Social media platforms such as Facebook, Instagram, and Twitter are examples of a new generation of powerful online tools that enable people to communicate and interact instantly with a potentially limitless audience. These online networks began as a medium for social connection; in recent years, however, social media platforms have been recognized as effective and inexpensive ways to reach a wide variety of target audiences. Social media platforms have since found their way into the toolboxes of medical students, residents, physicians, and medical professionals worldwide.1 Plastic surgeons in particular embraced creating and implementing social media, and use them to enhance their clinical practice through advertising, marketing, and sharing education-related information. The use of social media in plastic surgery is not limited to individuals; both the American Society for Aesthetic Plastic Surgery and the American Society of Plastic Surgeons2 have endorsed social media by incorporating Twitter, Facebook, and YouTube applications into their websites and national meetings.
The most recent U.S. Census reveals that the racial composition of the majority of Americans is white. African Americans are the largest racial minority, accounting for an estimated 13.4 percent of the population. Hispanics and Latino Americans are the largest ethnic minority, constituting an estimated 18.3 percent of the population, whereas Asians constitute 5.9 percent of the population.3 The data from the 2012 plastic surgery statistics report show a total of 91,655 breast reconstruction procedures undertaken in the United States in 2012. Of those patients, 72.3 percent were Caucasians, 15.1 percent were African Americans, 10 percent were Hispanics, and 2.3 percent were Asian Americans.4 The number of women undergoing breast reconstruction appears to be increasing; according to the latest report, more than 101,657 women underwent breast reconstruction in the United States in 2018, an increase of 29 percent over a 6-year period. Of those, 71 percent were Caucasians, 13 percent were African Americans, 11 percent were Hispanics, and 4 percent were Asians/Pacific Islanders.5 Asian and Hispanic/Latina patients are underrepresented among breast reconstruction patients. Hispanic/Latina patients make up 18.3 percent of the population, whereas Asian patients make up 5.9 percent of the population. In 2012, Hispanic/Latina patients represented 10 percent of breast reconstruction patients, whereas Asians represented 2.3 percent. In 2018, Hispanics/Latinas represented 11 percent of breast reconstruction patients, whereas Asians represented 4 percent. African Americans make up 13.4 percent of the population. They were overrepresented among breast reconstruction patients in 2012 (15.1 percent) and dropped to only slightly below their general population representation in 2018 (13 percent). These statistics highlight disparities in access to breast reconstruction in women of color, the reasons for which remain unclear.
Despite the overall increase in breast reconstruction during the past decade, it appears that breast reconstruction among African American patients shows a concerning downward trend, decreasing 2.1 percent over a 6-year period. The purpose of this study was to analyze the inclusion of African American patients in social media posts for breast reconstruction as a potential to identify the contributing factor for the decreasing rate of breast reconstruction in this population. One potential reason for this may be a disparity in representation of African American patients in social media channels of plastic surgeons performing breast reconstruction.
PATIENTS AND METHODS
This study conforms to the Declaration of Helsinki. Data from several platforms, including Instagram, Facebook, RealSelf, and Twitter, were obtained manually on December 1, 2019. We surveyed the top trending hashtags for breast reconstruction in social media. The following hashtags were inquired: [#breastreconstruction #breastcancer #breastcancerreconstruction #breastcancercare #breastcancerjourney #breastcancerawareness #mastectomy #mastectomyreconstruction].
The selection and inclusion of photographs were performed manually in a randomized and blinded fashion by five independent reviewers. Each image was analyzed using the Fitzpatrick scale6 as a guide. The Fitzpatrick scale is a numeric classification scheme for human skin color, which remains a recognized tool for human skin pigmentation research.7 It serves as a semiquantitative scale made up of six phototypes that describe skin color by basal complexion.8 Only Fitzpatrick type 5 and type 6 were included in our analysis. Therefore, the definition of “nonwhite” for this study is Fitzpatrick type 5 or 6. After the first round, the picture pool was reviewed once again by the authors for the final decision. Social media posts involving educational or self-promotional before-and-after photographs for patients who underwent breast reconstruction were included.
We further recorded data from each post by analyzing the profile of each user. Recorded data include the surgeon’s name, skin color, location of practice, and board certification. We also recorded data from a random sample of 10 surgeons from the top plastic surgery social media influencers.9 Duplicate posts and posts not relevant to plastic surgery were excluded.
Under the eight hashtags sampled in this study, more than 5.6 million posts were found. Of these posts, we included the latest 2580 posts that met our criteria. Of 2580 patients, only 172 (6.7 percent) were nonwhite patients (Fitzpatrick type 5 or 6). This study surveyed 543 surgeons, 5 percent of whom were nonwhite.
The distribution of photographs by skin color is illustrated in Figure 1. Thirty percent of surgeons did not have any photographs of nonwhite patients uploaded (Fitzpatrick type >4). White surgeons were more likely than nonwhite surgeons to upload photographs featuring minority women (74 percent versus 24 percent). The analysis of the results from the random sample of the top plastic surgery social media influencers showed that only 22 photographs (5 percent) uploaded were nonwhite patients.
The distribution of photographs by location is illustrated in Figure 2. Most of the photographs came from the United States, with the following regional distribution: West, 38 percent; South, 37 percent; Midwest, 14 percent; and Northeast, 11 percent. The photograph pool has been collected from 37 states (Table 1), with most photographs coming from California (28 percent), followed by Texas (14 percent) and Florida (7 percent).
Table 1. -
Geographic Distribution of Photographs within the United States
As illustrated in Figure 3, 96 percent of surgeons were certified by the American Board of Plastic Surgery, followed by the Royal Australasian College of Surgeons and the Royal College of Physicians and Surgeons of Canada.
Our study reported data from various platforms across 37 states during one selected date in December of 2019. Most of the surgeons were certified by the American Board of Plastic Surgery, followed by the Royal Australasian College of Surgeons and the Royal College of Physicians and Surgeons of Canada. African Americans and Latino Americans made up 3.6 percent and 5.7 percent of all plastic surgeons in the United States in 2004, but only 1.4 percent and 3.6 percent of plastic academics in 2008, respectively.10 In our sample, 21 percent of posts were featured by nonwhite surgeons. Thus, our results show that the presence of nonwhite surgeons in social media is overrepresented among plastic surgeons.
One might think nonwhite surgeons from different ethnic backgrounds are more likely to feature African American patients. However, our results show that only 24 percent of nonwhite surgeons uploaded photographs of African American patients. In contrast, of the white surgeons surveyed in this study, 74 percent uploaded photographs of African American patients. Thus, nonwhite surgeons were less likely to feature African American patients in their social media platforms. However, the difference was not found to be statistically significant because of the smaller sample size of nonwhite surgeons surveyed in this study (5 percent).
Only 5 percent of a random sample of the top plastic surgery influencers uploaded photographs of nonwhite patients. Furthermore, 30 percent did not have any photographs uploaded. These results show an underrepresentation of nonwhite patients in social media for breast reconstruction. It remains to be seen whether this may be a contributing factor to the trend toward less breast reconstruction seen in African Americans. It is appreciated that social media can play an influential role in exposing patients to procedures and trends in plastic surgery. It would be useful to investigate in future studies whether a disparity in representation of African American patients in social media may result in decreased awareness of the breadth of breast reconstruction. Numerous factors can contribute to the disparity between the growing trend of white patients seeking reconstructive surgery and their social media presence, compared to the decreasing trend of African American patients and their social media presence.
African Americans, as compared to their Caucasian counterparts, have strikingly lower reconstruction rates after mastectomy.11 With insurance and access to plastic surgeons accounted for, these rates remain significantly lower in African Americans compared with Caucasian women.11 In a research article from the American Journal of Surgery, the team from Philadelphia reported white women are 24 percent more likely to undergo reconstruction than black women; 26 percent more likely than Asians, Pacific Islanders, and Native Americans; and 19 percent more likely than Hispanics, even if the number of plastic surgeons in the region is the same and the patient has private insurance.12 In populations with ready access to plastic surgeons, Caucasians have a 59 percent reconstruction rate, whereas African American women had a 42 percent reconstruction rate. In terms of insurance, the disparity is much more significant. Eighty-four percent of Caucasian women with private insurance underwent reconstruction, whereas 60 percent of African Americans with private insurance underwent reconstruction.11 Considering public insurance (Medicare or Medicaid), the overall rate of reconstruction was lower, but the difference between races is still evident. Caucasians here had a rate of 34 percent, whereas African Americans had a rate of reconstruction of 24 percent.11 Such factors indicate that African Americans are pursuing and undergoing much less breast reconstruction than Caucasians, and this concerning trend mirrors the likewise concerning difference in their presence on social media.
A lack of appropriate preoperative consultation in women who are unfamiliar with breast reconstruction may deter these patients from seeking breast reconstruction. This is particularly impactful in circles of women who do not openly discuss plastic surgery.13 It has been shown that 68 percent of African American women would lie about getting work done out of fear of being judged, 28 percent believe plastic surgery is a private matter, and 9 percent are embarrassed about undergoing/having undergone plastic surgery.13 In a study by Alderman et al., African American women were significantly less likely than white women to see a plastic surgeon before initial surgery and were more likely to desire more information about reconstruction. Their study also showed that receipt of reconstruction varied significantly by patient race/ethnicity—40.9 percent of whites, 33.5 percent of African Americans, 27.4 percent of Latinas.14
In addition to socioeconomic differences, this disparity in the pursuit of breast reconstruction in African Americans may be attributable to other factors. One possible theory revolves around the difference in scar tissue formation. It has been hypothesized that pigment cells in highly melanated skin are more active, leading to darker and more aggressive scar formation in people of color.8 We are investigating whether this results in a less attractive reconstruction as compared to reconstruction in patients with lighter skin color, where the scar and fibrosis is less severe particularly after radiation therapy. Cultural differences may also account for the disparity in reconstruction. Plastic surgery has long been tabooed in ethnic communities and might be misbelieved as cosmetic only, which might lead to negative associations. Although these trends are slowly reversing, remnants of this anti–plastic surgery sentiment may still play a role in the decision to undergo reconstruction.11
The disparity in the presence of nonwhite patients on social media may also derive from patients’ preferences and comfort with public sharing of their photographs. Fewer women of darker skin color, seeking or undergoing breast reconstruction, may be willing to allow surgeons to include their images in this limited space for social media. This remains to be investigated.
Social media are arguably the most powerful marketing tool for a surgeon’s practice. The surgeon’s online presence can significantly project their status as an expert, irrespective of his or her training or years in practice. Social media presence is the single largest tool for patients to research a surgeon. Patients seeking surgical and nonsurgical interventions research the physician’s practice extensively before deciding. This trend increased 3.9 times in patients younger than 35 years.15 Considering the magnitude of this effect, plastic surgeons, either themselves or through paid consultants, are refining and polishing their social media pages. These are aimed at patients seeking consultations and interventions while maintaining academic and aesthetic sensitivities in a business/revenue model.16 Most patients tend to compare results from photographs on social media, and often the decision to go through the operation, and choosing the surgeon, is based on how relevant these photographs are. Thus, it is arguable that patients expect similar outcomes from photographs of the same race. For the discussed reasons, plastic surgeons may prefer to feature only photographs that are more representative of the most common demographics, as this is an effective marketing strategy.
Furthermore, African American patients experience more severe physical reactions to radiation therapy than white patients, including hyperpigmentation and adverse scarring. It has been suggested that these differences in response to radiation therapy may have a genetic basis, as single nucleotide polymorphisms may potentially play a role in radiation toxicity.17–19 This negative postsurgical result may act as a deterrent to reconstructive surgery for people of darker skin color. Moreover, in our previous report, there was also a statistically significant difference in the way that African American patients rated the appearance of their skin when compared with white patients. It is possible that despite having similar objective measures of cosmesis, African American patients themselves perceive and are perceived by others as having worse cosmetic outcomes than white patients.18
Women with breast cancer use social media, where they have a high likelihood of encountering information about breast cancer, ranging from science news reports to stories about celebrities with breast cancer.20 To date, several authors have asserted that social media affect patients’ surgical choices, but there has been little attention to this influence, especially among minority patients.21 A study of women seeking breast augmentation showed that more than half of the patients started looking for information on the Internet, whereas only 11 percent searched the website of a plastic surgeon, and only 10 percent first went to a plastic surgeon. Therefore, when patients come for consultation for the first time, they can have unrealistic expectations, goals, or concerns based on misinformation that must be addressed.22 African Americans are particularly more likely to be on social media than other racial groups. According to a late 2014 survey, 38 percent of African Americans use Instagram, as do 34 percent of Hispanics. By comparison, only 21 percent of whites use the network.23 This illustrates the need to promote African American patients’ inclusion in social media to encourage more attention and outreach to make sure all women who desire breast reconstruction are aware they have access to this care with the ultimate goal of ensuring equal access to care for those patients.
One of the limitations of this study is the lack of standardized methods in capturing patients’ images, where different factors can influence the color of skin, such as lighting. The manual classification of patients using the Fitzpatrick scale might have resulted in reviewer bias. To mitigate this bias, the selection process was random and blinded between the authors. Our study reported the underrepresentation of Fitzpatrick type 5 and type 6 skin among breast reconstruction patients in social media. This finding might not represent a significant correlation in breast reconstruction numbers by race. Another limitation was the presence of some patients that could not clearly be defined using the Fitzpatrick scale. A list of those patients was combined and reviewed by all the authors again for a final decision. Some African Americans might fall lower on the Fitzpatrick scale (lower than type 5). However, the focus of this study is the inclusion of patients who fall on the darkest end of the skin color spectrum using the Fitzpatrick scale. Future studies looking at the exact representation using different methodologies might be needed to overcome the scale error present in this study.
Lastly, the pool of photographs uploaded can change over time, and therefore the pool is dynamic. Our study is just a snapshot of the patient population at a static moment. Future studies can help to monitor the changes in the representation of African American patients in social media related to breast reconstruction.
As with African Americans, Asians and Hispanics/Latinas are underrepresented among breast reconstruction patients as compared to the general population. Future studies are needed to explore their underrepresentation and to investigate their presence in social media.
Numerous factors can contribute to the disparity between the growing trend of white patients seeking reconstructive surgery and their social media presence, compared to the decreasing trend of African American patients and their social media presence. Patient-related factors include lower reconstruction rates after mastectomy, darker and more aggressive scar formation, patient preferences, and cultural differences. Surgeon related factors might also play a role and include preferences in marketing and featuring the most common patient population. This disparity illustrates the need to promote African American patients’ inclusion in social media to encourage more attention and outreach to make sure all women who desire breast reconstruction are aware they have access to this care with the ultimate goal of ensuring equal access to care for those patients.
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