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nstagram is increasingly being used as an advertising platform for people and companies hawking medications, supplements, and even so-called “detox” teas. Occasionally, those advertisements cross the line; in 2015, the FDA warned one company about Kim Kardashian’s Instagram posts promoting its drug to treat morning sickness.

But findings in a new paper reveal another potential risk in user-driven photo advertising — a difficulty in discerning quality plastic surgery providers from uncertified or unscrupulous ones.

Researchers surveyed one day’s worth of top posts on Instagram — as defined by the site’s algorithm — for 21 plastic-surgery related hashtags, including #breastlift, #plasticsurgery, and #abdominoplasty. The 163 posts they analyzed included things that looked like advertisements you might see in a newspaper. Others were before-and-after shots from doctors or patients, often using emojis to cover sensitive areas.

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But the results of their analysis, published Wednesday in the Aesthetic Surgery Journal, showed that nearly a quarter of the uploads came from doctors who marketed themselves as cosmetic surgeons but who were not board-certified in the specialty by the American Board of Plastic Surgery or the Royal College of Physicians and Surgeons of Canada. (Surgeons certified through these boards are eligible for membership in the American Society for Aesthetic Plastic Surgery, which publishes the journal.)

More than half of the posts were uploaded by doctors based outside of those two countries. Dentists were responsible for four of the top posts; spas accounted for another four. One was even posted by a hair salon.

But the study included some posts that weren’t so much advertising a procedure as capitalizing on the popularity of a hashtag. In fact, said Dr. Clark Schierle, a plastic surgeon affiliated with Northwestern Medicine and the senior author on the paper, most of the posts appeared to be “hijacking” the hashtags to advertise different, non-invasive procedures.

“It’s leading to a sort of bait and switch where a consumer is looking for face-lift information but they’re getting Botox information — because this is a practitioner that can’t offer a face-lift,” he said.

The paper found that the largest group of non-board-certified plastic surgeons using related Instagram hashtags were otolaryngologists — more commonly referred to as ear, nose, and throat specialists. (Some ENTs can be receive a certification for plastic surgery involving the head and neck from their board.) And it may not be strictly illegal for doctors to do surgeries beyond their defined area of expertise.

“There are different layers of nuance in terms of who is actually qualified to do some of these procedures, and legally, there are no strict guidelines. The idea that this oral surgeon is doing breast implants is OK in the eyes of the law,” Schierle said.

Part of the problem is the licensing landscape for plastic surgeons. Of the 24 major medical specialty organizations affiliated with the American Board of Medical Specialties, just one oversees plastic surgeons. However, there are numerous other unaffiliated boards that purport to do the same thing, including the American Board of Cosmetic Surgery and the American Board of Facial Cosmetic Surgery. Training requirements, including the number of cases or the length of fellowships, can be different across boards. And not all state licensing agencies will recognize all of these boards.

“There are a lot of boards out there — you don’t know what’s real, what’s not,” said Dr. Samuel Lin, a professor of surgery at Harvard Medical School who was not involved in the paper.

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Both Schierle and Lin agreed it wasn’t Instagram’s job to patrol these posts. Not only are there censorship issues to consider, but it takes time to figure out a user’s credentials. “The providers won’t come out and say, ‘Hey, by the way, I’m a dentist,'” Schierle said.

Rather, the onus may fall on board-certified plastic surgeons to educate the public about this issue and improve their own social media skills. For example, Schierle said, using non-technical hashtags —#nosejob vs. #rhinoplasty — may improve a plastic surgeon’s social reach.

“We want to conduct ourselves with an air of respect for patients and decorum,” Schierle said, “but at least being aware of the language that’s being used and utilizing that language to the degree that we feel comfortable will allow us to engage more with patients that we’re trying to reach,” he said.

“We have to fight fire with fire.”

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  • Well done!! As a board-certified plastic surgeon also board certified in general surgery I have been fighting this confusion for for decades . My late wife’s first cousin, an oral surgeon, called me to find out how to do a nose job or rhinoplasty. I, of course, told him where to go. I’m retired but I inspect outpatient plastic surgical facilities since my retirement and even before. I have done over 70 in 20 states.

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