Nonsurgical or minimally invasive techniques for fat reduction have grown significantly in popularity over the past 10 years1 with patients now having a variety of modalities to choose from including radiofrequency, high-intensity ultrasound, injectables with deoxycholic acid, and cryolipolysis. These procedures are less invasive and offer shorter recovery times compared with traditional liposuction. As elective procedures paid for out of pocket, provider selection for fat reduction procedures are influenced by social media and real-world consumer experience. More than 60% of health care consumers consult social media before selecting a provider.2 In one study, 69% of patients note the quality of preoperative information as the most important factor in choosing a cosmetic surgeon.3 Online reviews may be the primary source of information for many patients. Previous works have shown the value of online patient reviews to inform practice management for general dermatology practices, Mohs micrographic surgery, rhinoplasty, and laser procedures.4–7 The authors' objective was to assess real-world online reviews of the emerging field of minimally invasive fat reduction to better inform practice management.
RealSelf.com (Seattle, WA) is a major online platform that compiles patient ratings and reviews for a wide range of aesthetic procedures. The site has more than 35 million unique yearly visitors and drives more than $249 million in cosmetic procedures annually.8 On March 12, 2017, the authors extracted patient reviews of “worth it,” “not worth it,” and “not sure” ratings of all minimally invasive fat reduction techniques and liposuction. Ratings of minimally invasive techniques were grouped by modality (e.g., Vanquish and Exilis as types of radiofrequency body contouring). The total number of reviews and cost were also collected. The authors determined the overall satisfaction and dissatisfaction percentages by dividing the number of “worth it” or “not worth it” reviews by the total number of reviews (positive, negative, and neutral) for each procedure. This is in contrast to the percentages by RealSelf, which does not include “not sure” ratings in their percentages. A chi-square test was used to assess for differences in proportion of “worth it” and “not worth it” ratings among 5 minimally invasive fat reduction techniques (laser, radiofrequency, injectables, cryolipolysis, and ultrasound) and traditional liposuction. The Marascuilo procedure was used to conduct pairwise comparisons of proportions between procedures. The study involved only publically available data and was exempt from institutional review board approval by Northwestern University.
Procedures were categorized into brand names (e.g., Zerona) as well as general terms (e.g., liposuction). In the data set, there were 13 unique minimally invasive fat reduction procedures. These were grouped into 5 types of minimally invasive body contouring modalities (laser, radiofrequency, injectables, cryolipolysis, and ultrasound) and compared with invasive body contouring (liposuction). In total, there were 11,871 reviews with a median of 166 reviews per fat reduction technique. The median global rating for all procedures was 81%.
When comparing techniques, patient satisfaction was highest for UltraShape Power (91%). However, this device also had the fewest number of reviews (n = 22). Patient satisfaction was lowest for Liposonix (n = 131, 37%) and Zerona (n = 157, 43%) (Figure 1). The median cost reported was $2,450 (range $1,350–$6,025). Dissatisfaction was highest for Zerona (n = 157, 50%) and lowest for liposuction (n = 4,645, 8%), UltraShape Power (n = 22, 9%), and Kybella (n = 316, 10%) (Figure 2). Cryolipolysis (CoolSculpting) had 2,707 reviews with a total patient satisfaction of 55%.
When comparing the broader 5 categories, liposuction had statistically significantly higher patient satisfaction (p < .05) than cryolipolysis, laser therapies (61% worth it, n = 3,565 reviews), and injectables (49% worth it, n = 319 reviews) (Figure 3). Injectables and cryolipolysis had statistically significantly lower patient satisfaction than radiofrequency therapies (63% worth it, n = 314 reviews) and laser therapies (p < .05).
Minimally invasive fat reduction ranked as the 1 of the 5 most popular nonsurgical cosmetic procedures in 2015.1,9 Body sculpting procedures are among the top 4 procedures consumers are considering.10 Given the continued innovation in the field driven by growing consumer demand for minimally invasive cosmetic procedures,11 aesthetic providers have an impetus to understand the insights and pitfalls associated with real-world reviews of patients who have undergone minimally invasive fat reduction. Some have argued that online reviews may be even more transparent than published studies.8 However, patient reviews are also prone to bias and often lack important information.7
In fields outside medicine, online reviews have been shown to affect purchasing decisions within the entertainment sector.12 Moreover, the number of reviews directly correlates with popularity, consumer demand, and product awareness.13–15 Previous marketing studies have shown that online consumer behavior and subsequent reviews are positively or negatively affected by reviews from previous consumers.16
The authors' results show that liposuction still retains the highest patient satisfaction. Other highly rated minimally invasive procedures (e.g. UltraShape Power) demonstrate high patient satisfaction, but are subject to more bias, given the low number of reviews. Patient satisfaction for Kybella, a popular injectable technique, and CoolSculpting were lower but comparable with liposuction. The drivers behind this were beyond the scope of this study, but further work mining individual patient reviews may reveal whether the weight of factors such as procedural pain, or disappointing efficacy led to patient dissatisfaction for each treatment type. Although liposuction had the highest number of reviews, minimally invasive techniques offered comparable satisfaction at a lower cost point.
Aesthetic procedures are largely self-paid. Therefore, pricing is an important consideration, given the menu of choices for fat reduction. The authors' results show that there is both high satisfaction and dissatisfaction across a large range of pricing ($1,350–$6,025). However, the cost data are not delineated between a global fee or a per treatment cost. Providers should remind patients that there may be a minimum number of treatments required to achieve a certain result and that the final cost will vary accordingly. Nonetheless, patient-reported cost can provide useful benchmarks for providers in price setting.
Tumescent liposuction, developed by dermatologists, is an intermediately invasive fat reduction technique that is less invasive than traditional liposuction. On RealSelf, as of 2017, tumescent liposuction had a patient satisfaction of 63% (n = 393 reviews) comparable with laser therapies for fat reduction (61% patient satisfaction). This technique is more effective for larger volume procedures compared with noninvasive techniques. For problem areas such as the neck, tumescent liposuction performed by experienced providers can be safely and efficiently performed even in one setting.17 Consideration should be given on the cost of the procedure to both the provider and client. For instance, tumescent liposuction may offer cost advantages to the provider depending on the cost of consumables for the newer noninvasive techniques. Also, compared with traditional liposuction, tumescent liposuction also offers significant cost savings to the patient due to elimination of the need for an operating room and an anesthetist. Furthermore, providers may have to educate consumers that a minimally invasive procedure may be less dramatic and require more treatments at a total aggregate price to achieve equivalently satisfactory results.
There are several important limitations of this analysis. First, patients who elect for liposuction versus minimally invasive fat reduction procedures are very likely different in their characteristics and expectations. The authors did not analyze individual patient reviews for important demographic details such as baseline body mass index (BMI), age, and treatment goals. Previously, the authors showed that social media reviews often lacked important demographic and medical details of the reporter.6 Patients with a higher initial BMI may opt for liposuction more often than patients who select minimally invasive techniques. Although Kybella was noted to have high patient satisfaction and low reported cost when compared with other procedures, it is only Food and Drug Administration–approved for the treatment of submental fat. Nonetheless, benchmarking patient expectations for fat reduction is still useful to identify specific procedures that perform better or worse than average. Finally, the authors did not control for the time span of reviews with certain procedures having a longer historical time frame for reviews. The authors elected to include all reviews across time, as this is how the data are presented to potential patients.
Minimally invasive fat reduction procedures are extensively rated online and exhibit significant limitations. Overall, patient satisfaction rates were high across all fat reduction techniques with comparable rates to liposuction suggesting real-world efficacy. Aesthetic providers can use patient online reviews in guiding decision-making surrounding minimally invasive fat reduction techniques and price setting.
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© 2018 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
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