In this podcast, Alexander Zuriarrain, MD, FACS, joins Plastic Surgery Practice Co-Chief Editors Keri Stephens and Alison Werner to talk about ethics in plastic surgery—a subject Zuriarrian recently wrote about for Plastic Surgery Practice.
The three discuss how social media and the way plastic surgeons are using it are raising some ethical questions. Zuriarrian—a board-certified plastic surgeon and owner of Zuri Plastic Surgery in Miami—talks about how he’s seeing plastic surgeons post altered and airbrushed images on social media platforms like Instagram and TikTok and how these posts raise concerns. He talks about how photos showcasing certain procedures are more easy to manipulate and give patients unrealistic expectations.
When it comes down to it, Zuriarrian contends that this is one of the reasons patients should search out board-certified plastic surgeons. He points out that the American Board of Plastic Surgery certification process is not just about how good a surgeon’s technique is, but also about ethical behavior—and that includes the ethics around their marketing practices. Zuriarrian specifically points to board guidance on website content and how images are used to illustrate procedures.
The fact is social media is a whole new frontier and there are ethical issues that need to be addressed. And while the conversation has started around the responsibilities of board-certified plastic surgeons, it’s going to take time to create guidelines.
In the meantime, Zuriarrian reminds listeners of the four guiding principles of medical ethics and talks about why it’s important as a plastic surgeon to look to one’s conscience and always focus on what is in the best interest of the patient. PSP
Hello, my name is Keri Stephens, and I’m joined today by my co-host, Alison Werner. We are the co-chief editors of Plastic Surgery Practice. Thank you for joining us for today’s podcast.
Today we are joined by Dr. Alex Zuriarrain to discuss the ethics of plastic surgery. It’s a topic he recently covered in an article for PSP. Dr. Zuriarrain is the founder of Zuri Plastic Surgery in Miami, where he specializes in aesthetic procedures of the face and body, including the facelift, eyelid surgery, rhinoplasty, breast augmentation, breast reduction, abdominoplasty, liposuction, and the Brazilian butt lift.
Dr. Zuriarrain, thank you for joining us today.
Thank you. Thank you for always having me on. It’s always a pleasure.
We love to have you on. So let’s be honest, there’s a lot of media coverage these days about trends and procedures that raise some ethical questions within the plastic surgery field. What’s your take on where we are?
Yeah, I think it’s quite disturbing where we are nowadays with plastic surgery and with what’s happened on social media. I particularly have seen some very disturbing images that have come across my feed on whatever platform you want to name. Not to single out a particular platform, but the Instagrams and the TikToks are probably highest on the list that most people are viewing nowadays. Especially the younger generations that are really heavily on TikTok more than anything else.
So, yeah. They’re getting a lot of images that are altered. They’re getting images that are airbrushed. They’re getting images that are supposed celebrity results, but they’ve been changed or modified on social media. So it is very scary. It’s very alarming. It’s very concerning what’s happening in that realm.
Do you think that there are specific procedures that raise some ethical questions? And maybe that ties into that social media question. Patients coming to you, seeing these possibly fabricated results, or hitting on some trend that they get captivated by on Instagram, TikTok, et cetera. Do you think that’s at play here too, certain procedures?
Oh, yeah. I think there’s certain procedures that definitely are easier to manipulate, Photoshop to create a certain type of look and result. I mean, a quick one to discuss would be the BBL, or the liposuction. It doesn’t take much to alter on Photoshop the results. You can make someone’s waist look smaller, you can make someone’s buttock look larger, you can give them more of an hourglass, you can give them more hips. You can make their bellies look flatter.
And yeah, I’ve seen that. I’ve seen that, it does happen, especially in ultra-competitive markets. I would say Beverly Hills, Manhattan, Miami, you could even say maybe Houston or Dallas. These are meccas of plastic surgery. And so it does happen a lot, where you look at photos and you really question whether or not that is a true result.
Well, and it seems like a lot of that is tied into these doctors wanting to promote themselves and be competitive. And so where’s the line in terms of your ethical responsibility as a surgeon, and then marketing your practice and marketing yourself as a doctor?
Yeah. And part of that really comes down to when you go and visit a board certified plastic surgeon by the American Board of Plastic Surgery, you are seeing a surgeon who’s gone through all of the rigorous training that is required nationally to become a board certified plastic surgeon. But it’s not about his or her technique or how brilliant they are with the science of plastic surgery or of medicine or how artistic they are with their surgical designs, but also what type of ethical behavior are do they embody?
And I will tell you from personal experience, having gone through the multi-step process of becoming board certified, I know the American Board of Plastic Surgeries extraordinarily rigorous in its attempts to ensure that surgeons are ethical. And one of the ways they do that is they make you, as a candidate to the board, they have you present all of the cases that you’ve performed within the last year. And they, at random, select cases from that list. And they require you to produce a series of documentation related to each surgery that they select at random.
And then they test you orally on each one of those cases. And they review all of your documentation for ethical documentation, ethical billing. How did you deal with certain types of complications? Did you overcharge patients? Did you say you did things that you really didn’t do? So it really comes down … a lot of times, candidates don’t pass. Not because of their scientific background or how brilliant they are, it’s just because they are involved in a lot of unethical behavior.
When you’re a board certified plastic surgeon, you go through … they review your cases for ethics. So ethics is this broader issue of how patients are being billed, the care provided. And now we’re getting to social media.
Do you think there needs to be a conversation within the profession, whether it be the board or when you’re doing residencies or in medical school, about where ethics lay today with everything that’s going on? Do you think there needs to be a new conversation? Or is there one?
Yeah, I think the board is very much interested. And I don’t speak on behalf of the board, I don’t represent the board. But as a member and as a board certified surgeon, I know that there is a strong push to work on rules and regulations for social media. I think we’ve done a really good job in the last, probably 15 to 20 years, on what is the websites. So having very specific content on your website that has to be approved by the board. You cannot use certain images without saying that they aren’t models, for example. You have to be very careful the content that you put forth on your website as being truthful, et cetera, et cetera.
But the social media world is a whole other frontier. And the board, I know is going through a lot of growing pains with how to regulate board certified plastic surgeons or board eligible plastic surgeons on how to somehow create ethical guidelines. And how to determine what is appropriate, what’s not appropriate to put on social media.
Your article also mentions the four guiding principles of ethics. Can you please list them and explain why plastic surgery should follow them?
Yeah. So the four guiding principles, they come out of just medical ethics in general. It’s not something that is particular to plastic surgery. And everybody who’s listening … I know a lot of physicians, a lot of colleagues of mine listen to the podcast. And autonomy is the first one. And it’s really being transparent. It’s being a surgeon who provides information that’s accurate, that’s truthful to their patients, so that their patients can make an autonomous decision on whether or not they want to proceed with a particular type of intervention.
The second one is beneficence. It’s basically providing benefit to the patient by considering the most appropriate treatment options. So you want to provide a benefit to the surgeries that you perform for the patient. That’s the goal. You want to get them to look better or feel better. And that’s critically important. The third one would be non-maleficence. Non-maleficence is basically trying to avoid risks and complications. And trying to help the patient go through a successful surgery and employing techniques that you know are going to help reduce any type of complication, post-surgery. That’s basically the Hippocratic Oath, to do no harm, essentially.
And then the fourth one is justice. Which is basically, you want to give the patient high quality services and resources available to them that is fair. You don’t want to overprice your surgeries. You don’t want to only reserve plastic surgery or treatments related to plastic surgery just to the wealthy or the elite. It should be available to the vast majority of patients. And those are the four guiding principles. And that should help surgeons figure out how to act in certain situations.
Also seems like patient education or public education around understanding the ethical requirements of a board certified … or what a board certified plastic surgeon brings to the table in terms of those ethical issues. Versus someone who’s not board certified, who is potentially doctoring photos and presenting you with an outcome that might not be feasible, realistic or feasible.
So it’s almost like there should be public education around what the ethical responsibilities for a plastic surgeon is, and board certified versus non-board certified. Because social media has taken it in a whole different direction.
Yes, it has. Yes, it has. And it’s almost like that fake news concept, whether you want to believe in that being real or not. But it’s almost … people are not stopping to look at the source of what they’re actually viewing on their phones. They’re just seeing before and after images coming at them at a rapid pace. But they’re not stopping to think, where is this coming from? Is this an actual board certified plastic surgeon? Is there any ethical backing on what I’m looking at? Or am I just looking at random pictures that people are posting?
And in Florida, interestingly enough, to be the owner of a plastic surgery practice, you do not have to be a physician.
Yes. Whereas in Georgia, for example, in Georgia, you have to have … majority ownership has to be by an actual physician. In Florida, it’s [inaudible 00:11:14]. Exactly. And so that’s a big deal because in Florida, you can be a used car salesman and you can open up a clinic, and there’s no ethical guidelines there. There’s no ethical principles being followed there in terms of your marketing and your advertising and the way that you position yourself in the market.
So that’s, I think, very unfortunate. Although I love Florida, I think it is a phenomenal state. I wouldn’t move anywhere else in the country, personally. But it’s tough down here.
Because the onus is almost on the patients to figure out, okay, this is board certified. This is just Joe Schmoe who set up a plastic surgery practice.
So in your article you wrote that plastic surgeons must be mothers at conscience. What exactly does that mean? I thought it was a really cool term, but …
Yeah, so that comes from a neuroscientist, Dr. Naskar. And he basically said, “A doctor must be a clown at heart, a scientist at brain, and a mother at conscience.” So I think that when you talk about mothers having a certain type of conscience … I’m not saying that fathers don’t, because I’m a father myself. But I will say that a mother does have a different angle or a different view when it comes to their conscientiousness regarding their children and their family, et cetera, et cetera.
And I think as a surgeon, you really have to have a well-developed part of your brain that focuses on being motherly or having those types of qualities to you, because it’s important. It’s important for the welfare of your patients, it’s important for the success of your surgeries, for your referrals that you get from other colleagues, and the way that patients feel about the experience that they’re having with you.
And so it’s not just about being brilliant and scientifically knowing all of the literature and all of the science, but you have to have a soft heart. You have to have a sense of humor. You have to go through life trying to help people the best way that you can. And having that motherly instinct to … which also means that sometimes you have to be tough. And mothers can be very tough. And they’re only doing that because they want what is in the best interest of their children. And as physicians, we want what is in the best interest of our patients. And sometimes our patients want certain things that we’re not in agreement with and is not the best option for them. And so you have to be able to have an honest conversation with your patients and let them know that that’s not a good idea.
Absolutely. Well, thank you so much, Dr. Zuriarrain. This was very informative, as always. And to our listeners, be sure to check back on the MEDQOR Podcast Network for the next episode of the Plastic Surgery Practice Podcast. And in the meantime, to catch up on the latest industry news, please check out plasticsurgerypractice.com. Until next time, take care. Thank you.