Emerging trends in social media and plastic surgery

Neurosurgery and Social Media: A Bibliometric Analysis of Scientific Production from 2004 to 2023

BACKGROUND

Neurosurgery is a rapidly advancing surgical specialty. Social media has significantly impacted the landscape of advancements in the field of neurosurgery. Research on the subject of neurosurgery and social media plays a vital role in combating disability and mortality due to neurological diseases, especially in trauma-affected individuals by increasing cooperation and sharing of clinical experiences between neurosurgeons via social media. This study aimed to evaluate the global neurosurgery and social media research performance from 2004 to 2023.

METHODS

All the data for neurosurgery and social media-related research publications from 2004 to 2023 were extracted from the Web of Science database and a comprehensive analysis was performed on the R-bibliometrix package.

RESULTS

An increasing number of publications with an annual growth rate of 22.04% was observed, with >91% of total articles published in the last decade. The United States, the United Kingdom, Italy, France, Canada, and India made up of more than 67% of the global contribution. Out of 1449 authors, Chaurasia B was the most productive with 14 publications and the most globally cited document was JEAN WC, 2020 with 117 citations. The University of Cambridge was the leading institutional affiliation. World Neurosurgery was the most productive with >60 articles.

CONCLUSIONS

Exploring neurosurgery on social media enhances global collaboration, utilizing dynamic platforms for real-time knowledge exchange and holds immense potential for the field's global advancement.

Understanding Public Perceptions of Nipple and Scar Characteristics After Chest Wall Masculinization Surgery

BACKGROUND

Surgical chest masculinization procedures, especially gender-affirming top surgery (GATS), are becoming increasingly prevalent in the USA. While a variety of surgical techniques have been established as both safe and effective, there is limited research examining ideal aesthetic nipple appearance and incision scar pattern. This study employs patient images to understand the public's perception on top surgery outcomes when adjusting for BMI ranges and Fitzpatrick skin types.

METHODS

Images from RealSelf modified via Adobe Photoshop depicted various scar types and nipple-areolar complex (NAC) sizes/positions. A Qualtrics survey was distributed utilizing Amazon Mechanical Turk. Statistical analysis was performed through JMP Pro 17 for ordinal and categorical values, with a p value less than or equal to 0.05 statistically significant.

RESULTS

A moderately sized and laterally placed NAC was preferred. A transverse scar that resembles the pectoral border between the level of the inframammary fold and pectoral insertion was deemed most masculine and aesthetic. Majority of results demonstrated that this is unaffected by Fitzpatrick skin types. Increased BMI images impacted public preferences, as a nipple placed farther from the transverse incision (p = 0.04) and a transverse scar position closer to the IMF was preferred in higher BMI patients.

CONCLUSIONS

An understanding of the most popular NAC and scar choices, as well as how these factors may differ when considering a Fitzpatrick skin type or BMI categorization was attained. This validates the importance of patient-centered approach when employing surgical techniques in GATS. Future studies intend to obtain reports from actual patients considering GATS.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable.

Gynecomastia Surgery Patient Education: An Information Quality Assessment of YouTube Videos

BACKGROUND

YouTube is a platform for many topics, including plastic surgery. Previous studies have shown poor educational value in YouTube videos of plastic surgery procedures. The purpose of this study was to evaluate the quality and accuracy of YouTube videos concerning gynecomastia surgery (GS).

METHODS

The phrases "gynecomastia surgery" (GS) and "man boobs surgery" (MB) were queried on YouTube. The first 50 videos for each search term were examined. The videos were rated using our novel Gynecomastia Surgery Specific Score to measure gynecomastia-specific information, the Patient Education Materials Assessment Tool (PEMAT) to measure understandability and actionability, and the Global Quality Scale to measure general quality.

RESULTS

The most common upload source was a board-certified plastic surgeon (35%), and content category was surgery techniques and consultations (51%). Average scores for the Global Quality Scale (x̄ = 2.25), Gynecomastia Surgery Specific Score (x̄ = 3.50), and PEMAT Actionability (x̄ = 44.8%) were low, whereas PEMAT Understandability (x̄ = 77.4%) was moderate to high. There was no difference in all scoring modalities between the GS and MB groups. Internationally uploaded MB videos tended to originate from Asian countries, whereas GS videos tended to originate from non-US Western countries. Patient uploaders had higher PEMAT Actionability scores than plastic surgeon uploaders.

CONCLUSIONS

The quality and amount of gynecomastia-specific information in GS videos on YouTube are low and contain few practical, take-home points for patients. However, understandability is adequate. Plastic surgeons and professional societies should strive to create high-quality medical media on platforms such as YouTube.

Primary care doctor's perception about the scope of plastic surgeons: A national survey

BACKGROUND

Plastic surgery is characterized by a broad spectrum of aesthetic and reconstructive surgical expertise that is not defined by an anatomic area. The authors sought to identify primary care doctors' perceptions of different fields of plastic surgery.

METHODS

A short, anonymous, web-based survey was administered to primary care doctors in Portugal. Respondents were asked to choose the specialist they perceived to be an expert for 29 specific clinical areas, including 20 that are the core of plastic surgery practice. Specialists for selection included the following choices: dermatologist, general surgeon, maxillofacial surgeon, vascular surgeon, neurosurgeon, orthopedic surgeon, otolaryngologist, and plastic surgeon.

RESULTS

A total of 430 complete answers to the survey were collected. Out of the 20 clinical cases related to plastic surgery, only nine were attributed to plastic surgery in the majority of the answers: thumb reimplantation (64,2%), abdominoplasty (93%), breast reduction (94%), otoplasty (62,3%), skin graft for a burn (97,7%), breast reconstruction (94,9%), complex open wound (57,2%), facial reanimation (36,7%) and first web space contracture of the hand (78,6%).

CONCLUSIONS

There is a clear underestimation of the role of plastic surgery in a wide range of conditions, which may lead to the downsizing of plastic surgery departments in the national health system. It is of utmost importance to educate primary care doctors so that patients are referred correctly and in a timely manner.

Social Media Popularity and Academic Productivity in Academic Plastic Surgery: A Positive Correlation

BACKGROUND

Social media is a powerful tool that has empowered plastic surgeons to easily collaborate with one another and rapidly publicize research progression. The present study investigates the relationship between academic productivity and social media presence among both integrated and independent plastic surgery programs and their faculty.

METHODS

Plastic surgery programs on the American Council of Academic Plastic Surgeons website were included. Faculty were identified via review of each program's website. Following metrics of academic productivity were collected for each faculty member: h-index, i10-index, number of publications, and number of citations. Online review was then conducted to identify faculty and program Instagram and Twitter accounts, and the number of associated followers and posts.

RESULTS

Integrated plastic surgery programs were more likely to have an Instagram account (p < 0.001), have higher average faculty h-index (p = 0.027), i10-index (p = 0.027), and number of publications (p = 0.042). A number of Instagram followers were significantly associated with average faculty h-index (p < 0.001), i10-index (p < 0.001), and number of publications (p < 0.001). The number of posts on a program's Instagram significantly predicted average faculty h-index (p < 0.001), i10-index (p < 0.001), and number of publications (p < 0.001). Twitter followers were significantly associated with average faculty h-index (p = 0.0397), i10-index (p = 0.0432), and number of citations (p = 0.00737).

CONCLUSIONS

The present study reveals a correlation between metrics of social media popularity and academic productivity of plastic surgeons. We propose that Instagram and Twitter are effective tools with which plastic surgeons may not only publicize their clinical practice, but also rapidly disseminate important innovations among the medical community. Integrated plastic surgery programs and their faculty have significantly higher utilization of social media platforms. The number of followers and posts on a program's Instagram have a significantly positive correlation with average faculty's academic productivity. Social media platforms may empower academic plastic surgeons to disseminate their innovations on a larger scale.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Content and Readability of Online Recommendations for Breast Implant Size Selection

Breast augmentation is one of the most frequently performed aesthetic procedures in the United States. Online information is often used by patients to make decisions when undergoing cosmetic procedures. It is vital that online medical information includes relevant decision-making factors and uses language that is understandable to broad patient audiences. Ideally, online resources should aid patient decisions in aesthetic surgical planning, especially implant size selection for breast augmentation. We describe patient decision-making factors and readability of breast implant size selection recommended by private practice plastic surgery webpages.

Methods

Using a depersonalized, anonymous query to Google search engine, the terms "breast implant size factors" and "breast implant size decision" were searched, and 52 plastic surgery private practice webpages were identified. Webpages were analyzed for reported decision-making factors of implant size selection. Readability analyses of webpages were performed with Readability Studio and Hemingway Editor.

Results

The two major decision-making factors for implant size selection reported by webpages were body/tissue-based measurements and surgeon input. Ten factors related to patient lifestyle, surgical goals, and procedural options were also identified. Average webpage scores for five readability measures exceeded recommended levels for medical information.

Conclusions

Reported decision-making factors for implant size selection emphasize a plastic surgeon's expertise but may enhance the patient's role in preoperative planning. Webpages describing breast implant size selection exceed the sixth and eighth grade reading levels recommended by the AMA and NIH, respectively. Improving the readability of webpages will refine the role of online medical information in preoperative planning of breast augmentation.

#CosmeticsTwitter: Predicting Public Interest in Nonsurgical Cosmetic Procedures Using Twitter Data

BACKGROUND

The utilization of social media in plastic surgery is expanding. The Twitter Academic Research Product Tract (TARPT) database provides plastic surgeons the opportunity to monitor public interest in plastic surgery procedures. Previously, TARPT was shown to be effective in tracking public interest in surgical cosmetic facial and body procedures.

OBJECTIVES

The authors sought to determine the ability of the TARPT tool to track and predict public interest in nonsurgical cosmetic procedures and to examine temporal public interest trends in nonsurgical cosmetic procedures.

METHODS

The authors employed the TARPT tool to calculate the total number of tweets containing keywords related to 15 nonsurgical cosmetic procedures from 2010 to 2020. Annual case volumes were obtained for each of the 15 procedures from annual reports provided by the American Society of Plastic Surgeons. Univariate linear regression was employed to compare tweet volumes and procedure volumes, with P < 0.05 as a threshold for significance.

RESULTS

Univariate linear regression revealed significant positive correlations between tweet volumes and American Society of Plastic Surgeons procedure volumes for 10 search terms representing 6 nonsurgical cosmetic procedures: "xeomin," "microdermabrasion," "facial filler," "fat filler," "fat injections," "fat transfer," "hyaluronic acid filler," "hyaluronic acid injection," "HA filler," and "PRP filler." Thirty-two search terms did not demonstrate a significant relationship.

CONCLUSIONS

The TARPT tool is an informative data source for plastic surgeons with the potential to guide marketing and advertising strategies, and monitor public interest in nonsurgical cosmetic procedures, helping surgeons respond to patients' evolving needs.

Role of Hashtags in Educating and Promoting the Field of Hand Surgery on Social Media

Purpose

This study identifies the hand surgery content being posted on Instagram, how hashtags are being used, and those posting to determine what is reaching the public.

Methods

Top hand surgery-related hashtags on Instagram from June 2020 to August 2020 were identified by searching "hand surgery" and sorting by relevance. Hashtags were quantified by number and qualitatively assessed. Posts without a clear relationship were excluded. Hashtags relevant to hand surgery were analyzed by educational merit, medical specialty, patient or nonpatient, and demographics.

Results

The top 25 hashtags contained 325,400 posts. The 3 hashtags with the highest number of posts were #carpaltunnel (64,700), #handsurgery (50,500), and #handtherapy (48,300). Most posts were educational (53.2%). Nonsurgical fields (66.5%) posted the most, followed by orthopedic (25.9%), and plastic hand surgeons (7.7%). Nonpatients (68.8%) posted more than patients. The top 3 languages of the posts were English (67.7%), Russian (9.4%), and Spanish (7.1%). However, when looking at the hashtags with more than half of the posts being made by hand surgeons, we observed that most (62.9%) of the posts were noneducational in content.

Conclusions

Instagram posts on hand surgery topics are largely posted by nonexperts and are educational in content. There is a major opportunity for hand surgeons to educate and market effectively using hand surgery-related hashtags. Given the number of hand surgeries performed annually, one would hope to see more representation by hand surgeons on social media. More active participation and provision of educational content by specialists is warranted.

Clinical relevance

There is an opportunity for hand surgeons to educate those searching upper extremity conditions and seeking out expertise in a domain where information is largely driven by nonsurgeons and the quality of information is not vetted. This study identifies the need for more hand surgeon involvement to expand knowledge and communication efforts within the specialty and with the public through the evolving world of social media.

Quantitative Analysis of Preoperative and Postoperative Photographs Posted on Social Media by Oculoplastic Surgeons

PURPOSE

To investigate and quantitatively analyze preoperative and postoperative photographs posted on social media by oculoplastic surgeons.

METHODS

Pre- and postoperative blepharoplasty photographs posted by oculoplastic surgeons on the social media platform Instagram were identified over a 4-month period. Photographs demonstrating a frontal pose of the periocular region were selected, and image analysis was performed to compare the preoperative and postoperative photographs. Quantitative image analysis was performed with a semiautomated script using ImageJ (v1.52k) software. Image analysis compared magnification, patient position, luminosity, relative color profiles, and edge detection/sharpness. Three oculoplastic surgeons graded these imaging metrics for the same photoset and the consensus grade was assigned to each category. Finally, the quantitative calculations were then compared with the consensus grades to develop receiver operating characteristic curves for further analysis.

RESULTS

The study included 104 posts from 35 members of ASOPRS. Regarding patient positioning, 9 postings were 5%-10% offset from the patients' center, and 6 postings were more than 10% from the patients' center. The majority of photosets demonstrated less than or equal to 2.5% difference in magnification (69/104), with 7 postings demonstrating a greater than 5% difference, and 3 postings exhibiting greater than 10% difference in magnification. In the periocular region, 17.3% (18/104) of postings were found to have a greater than 10% difference in luminosity (>25.5 pixel-value). A more than 5% difference (>12.75 pixel-value) in pre- and postoperative edge-detection measurements was identified in 12 of 104 postings. In 22 of 104 photosets, the mean absolute deviation in color channel ratios was more than 0.01 and 15 of 104 photosets were found to have a mean absolute deviation more than 0.05.

CONCLUSIONS

Numerous quantifiable photographic inconsistencies were identified in surgical photographs posted on social media by members of ASOPRS. Adoption of an automated image analysis tool that compares before-and-after surgical photographs could promote standardized oculoplastic surgery photography on social media.

Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery

BACKGROUND

Despite high rates of online misinformation, transgender and gender diverse (TGD) patients frequently utilize online resources to identify suitable providers of gender-affirming surgical care.

AIM

The objective of this study was to analyze the webpages of United States academic plastic surgery programs for the types of gender-affirming surgery (GAS) procedures offered and to determine how this correlates with the presence of an institutional transgender health program and geographic region in order to identify potential gaps for improvement.

METHODS

Online institutional webpages of 82 accredited academic plastic surgery programs were analyzed for the presence of the following: GAS services, specification of type of GAS by facial, chest, body and genital surgery, and presence of a concomitant institutional transgender health program. This data was analyzed for correlations with geographic region and assessed for any significant associations.

OUTCOMES

Frequencies of GAS services, specification of the type of GAS by facial, chest, body and genital surgery, presence of a concomitant institutional transgender health program, and statistical correlations between these items are the primary outcomes.

RESULTS

Overall, 43 of 82 (52%) academic institutions offered GAS. Whether an institution offered GAS varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .329). Whether institutions that offer GAS specified which anatomic category of GAS procedures were offered varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .235).

CLINICAL IMPLICATIONS

This identifies gaps for improved transparency in the practice of communication around GAS for both physicians and academic medical institutions.

STRENGTHS & LIMITATIONS

This is the first study analyzing the quality, content, and accessibility of online information pertaining to GAS in academic institutions. The primary limitation of this study is the nature and accuracy of online information, as current data may be outdated and not reflect actuality.

CONCLUSION

Based on our analysis of online information, many gaps currently exist in information pertaining to GAS in academic settings, and with a clear and expanding need, increased representation and online availability of information regarding all GAS procedure types, as well as coordination with comprehensive transgender healthcare programs, is ideal. Aryanpour Z, Nguyen CT, Blunck CK, et al., Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022;19:846-851.

#PlasticsTwitter: The Use of Twitter Data as a Tool for Evaluating Public Interest in Cosmetic Surgery Procedures

BACKGROUND

Plastic surgeons are increasingly turning to social media to market their services. The newly released Twitter Academic Research Product Track (TARPT) database provides free, customizable analysis of keywords that are included in tweets on the Twitter platform. The TARPT tool may provide valuable insight into public interest in cosmetic surgery procedures.

OBJECTIVES

The aim of this study was to determine TARPT's utility in tracking and predicting public interest in cosmetic surgery procedures and to examine temporal trends in tweets related to cosmetic facial and body procedures.

METHODS

The TARPT tool was used to calculate the total number of tweets containing keywords related to 10 facial cosmetic procedures and 7 cosmetic body procedures from 2010 to 2020. Annual volumes for respective procedures were obtained from annual statistics reports of The Aesthetic Society from 2010 to 2020. Tweet volumes and procedure volumes were compared by univariate linear regression, taking P < 0.05 as the cutoff for significance.

RESULTS

Variations in tweet volume were observed. Univariate linear regression analysis demonstrated statistically significant positive correlations between tweet volumes and procedure volumes for 7 search terms: "eyelid lift," "facelift," "lip injections," "mastopexy," "butt lift," "butt implants," and "liposuction." Many procedure-related keywords were not significant, demonstrating the importance of careful selection of Twitter search terms.

CONCLUSIONS

The TARPT database represents a promising novel source of information for plastic surgeons, with the potential to inform marketing and advertising decisions for emerging trends in plastic surgery interest before these patterns become apparent in surgical or clinical volumes.

RealSelf Social Media Analysis of Rhinoplasty Patient Reviews

BACKGROUND

Social media has become increasingly important for patients when deciding whether they should undergo rhinoplasty. The purpose of this study is to analyze patient satisfaction of rhinoplasty procedures through RealSelf social media reviews.

METHODS

We collected data from 583 rhinoplasty reviews published on the RealSelf portal. In posts dated between 2016 and 2020, we included those which were labeled as "Worth It" and "Not Worth It." Posts that were labeled as "Unsure" or were left unlabeled were excluded from the study. In addition, posts not including the cost of their rhinoplasty were excluded. Taking into account patient demographics and cost of the procedure, we analyzed reasons for choosing to undergo surgery, reasons for choosing surgeons, and reasons for liking or disliking their procedure.

RESULTS

Of the 583 reviews analyzed, most (45.4%) were categorized from the 18-24 years age group and there was an overall 93.8% satisfaction rate. While there was no statistically significant difference in the cost of rhinoplasty surgeries between "Worth It" and "Not Worth It" groups, the average cost of recorded rhinoplasties was US$ 8043 with a standard deviation ± $3296. According to our analysis, younger patients aged 18-24 years relied more on social media to choose their surgeons and desired a more natural appearance to their nose while older ones preferred compatible physician personalities and increased self-esteem for rhinoplasty.

CONCLUSION

This study offers a unique perspective into the distinguishing characteristics of different age groups and the values they place in pursuing rhinoplasty, choosing their surgeons, and why they like/dislike their surgical outcomes.

Websites or Videos: Which Offer Better Information for Patients? A Comparative Analysis of the Quality of YouTube Videos and Websites for Cosmetic Injectables

BACKGROUND

YouTube is used by more than 70 percent of adults and 81 percent of 15- to 25-year-olds. The information quality of videos related to the two most performed aesthetic procedures-botulinum toxin type A (Botox) and soft-tissue filler injections-has not been assessed or compared to that of websites.

METHODS

A YouTube search for "Botox" and "fillers" was performed in July of 2020, identifying the most popular health information videos. Quality was assessed using the validated Journal of American Medical Association, Health on the Net principles, and the DISCERN criteria in addition to a procedure-specific content score. Quality scores were compared between different groups of video contributors and against websites.

RESULTS

A total of 720 measurements of quality were performed across 95 YouTube videos and 85 websites. The mean quality scores were as follows: Journal of the American Medical Association, 1.74/4 ± 0.718; Health on the Net, 6.66/16 ± 2.07; DISCERN, 40.0/80 ± 9.25; and content, 39.1/100 ± 11.9. Physician, nonphysician health professionals, and other (news, magazine channels, and influencers) were all of higher quality than patient-based videos (p < 0.001). The mean DISCERN percentage score for videos was 50.04 ± 11.57 and significantly less than that of websites, 55.46 ± 15.74 (p = 0.010). The mean content scores showed a similar result, 39.06 ± 11.92 versus 60.76 ± 17.65 (p < 0.001), respectively.

CONCLUSIONS

Improvement is needed in the quality of YouTube videos related to aesthetic injectables. Plastic surgeons, who are the most frequent video contributors, are most qualified to provide this change. Plastic surgeons should include videos as part of their online presence, as they may help facilitate a greater viewership.

Representation of African American Patients in Social Media for Breast Reconstruction

BACKGROUND

Social media use by plastic surgeons may contribute to the overall increase in breast reconstruction in the United States. However, recent data show a concerning decrease in breast reconstruction in African American women. The purpose of this study was to analyze the inclusion of African American women in social media posts for breast reconstruction, with the premise that this may be a possible contributing factor to decreasing rates of breast reconstruction in this population.

METHODS

Data from several social media platforms were obtained manually on December 1, 2019. Each image was analyzed using the Fitzpatrick scale as a guide.

RESULTS

A total of 2580 photographs were included that met the authors' criteria. Only 172 photographs (6.7 percent) were nonwhite. This study surveyed 543 surgeons, 5 percent of whom were nonwhite. The analysis of the results from the random sample of the top plastic surgery social media influencers showed that only 22 (5 percent) of the photographs uploaded were nonwhite patients. Furthermore, 30 percent of surgeons did not have any photographs of nonwhite patients uploaded.

CONCLUSIONS

Numerous factors can contribute to the disparity between the growing trend of white patients seeking reconstructive surgery compared to the decreasing trend of African American patients, one of which may be the disparity in their representation in social media, particularly among common platforms and social media influencers. This study highlights the evolving factors that may impair African American breast cancer patients' access to safe, effective breast reconstruction, which must be identified and resolved.

How cosmetic surgeons portray cosmetic procedures through Instagram? A content analysis on cosmetic surgeons' posts on Instagram

The present study intends to explore the visual and textual content of posts cosmetic surgeons shared on Instagram pages in order to present their cosmetic surgical or non-surgical procedures. To do so, this study employed a qualitative approach using textual and visual content analysis on 200 Instagram posts shared by cosmetic surgeons. The results demonstrated that the content of analyzed posts can be categorized as 12 sub-themes which are clustered around four main themes; "You have got some body imperfections," "Body imperfections are worrisome," "Cosmetic procedure is the solution; we provide it for you" and "It's not a real surgery!."

Analysis of social media use by European plastic surgery societies: A missing link for #PlasticSurgery

PURPOSE

The field of Plastic Surgery is prominent on social media around the world. Board certified plastic surgeons and societies of plastic surgery play a role in providing accurate, evidence-based information to the public, patients, and colleagues. The aim of this study was to explore the use of social media by European Plastic Surgery Societies.

METHODS AND MATERIALS

A retrospective analysis of the presence and activity of European Plastic Surgery Societies on Facebook, Twitter and Instagram was conducted between December 12th 2018 and December 12th 2019. The results have been compared to the American Society of Plastic Surgeons.

RESULTS

Twenty, eleven and nine European societies yielded an active account on Facebook, Twitter and Instagram respectively. Only seven European societies had an account on all three platforms and were therefore considered polypresent. The amount of followers of those seven societies was significantly higher than of the others (p-value = 0.02). Their activity yielded significantly more posts on Facebook (p-value = 0.02). The American Society of Plastic Surgeons had more followers on all three platforms than all European societies combined.

CONCLUSION

Social media are still rather unexploited by European Plastic Surgery Societies. A tendency towards increased visibility can be observed, yet a higher penetration is required to further educate and engage through social media. The quantitative data provided serve as reasonable foundation for further studies and a guide for growth of #PlasticSurgery.

Social Media and Retinal Detachment: Perspectives of Providers and Patients on Instagram

BACKGROUND AND OBJECTIVE

To evaluate the social media interactions of patients who experience retinal detachment and/or repair and how ophthalmic medical providers utilize social media.

PATIENTS AND METHODS

A cross-sectional study of public posts on Instagram was performed from September 2019 to January 2020, with filtering based on the following hashtags: #retinaldetachment, #detachedretina, #retinaldetachmentsurgery, and #scleralbuckle. A categorical classification system was used for each Instagram post to review descriptive variables.

RESULTS

Of the 1,797 Instagram posts analyzed, 697 (39%) were made by patients, of which 395 (57%) were positive in tone and 599 (86%) were in the postoperative period. Posts by ophthalmologists were most commonly centered on colleague education (446, 81%).

CONCLUSIONS

The majority of Instagram posts by patients were of a positive tone reflecting primarily on activities of daily living and rehabilitations. Retina specialists should consider providing more social media content directed toward patients, particularly regarding their rehabilitation course following retinal detachment repair. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:391-395.].

The Discrepancy Between Perceived Importance and Actual Delivery of Business Education in Residency: A Survey of Program Directors

BACKGROUND

In the contemporary healthcare environment, there is a need for physicians to understand business fundamentals. Nonsurgical residencies have implemented formal business education, but surgical training programs have been slower to adapt. Further research is needed to evaluate the status of business education in plastic surgery residency.

METHODS

A 12-question survey was created. Ninety program director (PD) e-mails were obtained and the survey was distributed using SurveyMonkey. The survey evaluated program demographics and current resources, commitments, and attitudes toward business training. The survey also identified the most important topics to include in a business curriculum.

RESULTS

Thirty-six surveys were completed (response rate = 40%). Whereas most PDs agreed that business education in plastic surgery residency was important (78%) and that their programs should have more business training (73%), only 39% currently offered business training. Only 42% of PDs believed that their chief residents were competent to handle the business aspects of plastic surgery upon graduation. No programs offered a formal gap year to pursue a professional business degree. The most important topics identified for a business curriculum were economics and finance (83.3%), management (64%), and marketing (53%).

CONCLUSIONS

There is disconnect between perceived importance and resources available for plastic surgery residents to receive business education. Increased attention is needed to resolve this discrepancy to ensure that future plastic surgeons are equipped to excel in their personal careers and stimulate the advancement of the field. Future research should aim to outline a business curriculum for plastic surgery trainees.

Building a Multidisciplinary Academic Surgical Gender-affirmation Program: Lessons Learned

Background:

Every day, we see more patients present to hospitals and clinics seeking gender-affirmation care to ameliorate the symptoms of gender dysphoria. However, to provide a multidisciplinary approach, it is important to offer an integrated clinical program that provides mental health assessment, endocrine therapy, physical therapy, research, and the full spectrum of surgical services devoted to transgender patients. This article describes our experience on building a specialized, multidisciplinary, academic state-of-the-art gender-affirmation program.

Methods:

Herein, we describe the main and critical components on how to build a multidisciplinary academic gender-affirmation program. We share our lessons learned from this experience and describe how to overcome some of the obstacles during the process.

Results:

Building a multidisciplinary academic gender-affirmation program requires an invested team, as each and every member is essential for feedback, referrals, and to improve patient’s experience. Institutional support is essential and by far the most important component to overcome some of the obstacles during the process. Having all team members working under the same institution provides all the critical components needed to improve outcomes and patient satisfaction. In addition, the collection of prospective data with a well-structured research team will provide information needed to improve clinical services and standardize clinical protocols, while leaving space for innovation.

Conclusions:

This article describes the steps and experience needed to build a multidisciplinary holistic academic gender-affirmation program. We provide our lessons learned during the process that will help guide those who intend to start an academic gender-affirmation program.

Demographic and Cultural Differences in the Acceptance and Pursuit of Cosmetic Surgery: A Systematic Literature Review

Worldwide, the numbers of cosmetic procedures continue to climb. However, cosmetic surgery (CS) continues to be plagued by negative stigmatization. This study reviews the literature to identify how attitudes toward CS vary by sex, age, race, culture, and nationality, and aims to determine how other factors like media exposure interact with demographics to influence how well CS is accepted.

METHODS

A PRISMA-guided systematic review of the literature was conducted to identify all English-language papers reporting on CS or plastic surgery acceptance, attitudes, or stigmatization, specifically examining for data on age, sex, race/ethnicity, culture, and media influence.

RESULTS

In total, 1515 abstracts were reviewed, of which 94 were deemed pertinent enough to warrant a full-text review. Among the potential demographic predictors of CS acceptance, the one with the most supportive data is sex, with women comprising roughly 90% of all CS patients in virtually all populations studied and consistently exhibiting greater CS knowledge and acceptance. Culturally, the pursuit of beauty through CS is a universal phenomenon, although different countries, races, and cultures differ in how willingly CS is embraced, and in the aesthetic goals of those choosing to have it. In countries with culturally diverse societies like the United States, non-Hispanic Whites continue to predominate among CS patients, but the number of CS patients of other races is rising disproportionately. In this trend, social media is playing a major role.

CONCLUSION

Healthcare practitioners performing cosmetic procedures need to consider demographic and cultural differences of the patients in order to enhance their understanding of their patients' aesthetic goals and expectations.

Insta-Grated Plastic Surgery Residencies: 2020 Update

BACKGROUND

Recent evidence shows accelerating worldwide adoption of social media and suggests a commensurate increase in social media use by integrated plastic surgery residency programs in the United States. Programs nationwide are now making strides to include a longitudinal social media component in their plastic surgery curriculum.

OBJECTIVES

The aim of this study was to investigate the use of Instagram by plastic surgery residency programs and to describe trends in adoption, volume, and content.

METHODS

Current active Instagram accounts affiliated to integrated plastic surgery residency programs were surveyed to identify date of first post, number of posts, number of followers, number of followings, engagement rate, most-liked posts, and content of posts. All data were collected on May 12, 2020.

RESULTS

Sixty-nine out of 81 (85.2%) integrated plastic surgery residency programs had Instagram accounts, totaling 5,544 posts. This represents an absolute increase in program accounts of 392% since 2018. The 100 most-liked posts were categorized as: promotion of the program/individual (46), resident life (32), promotion of plastic surgery (14), and education (8).

CONCLUSIONS

Instagram use by plastic surgery residency programs has drastically increased since it was first evaluated in 2018. This trend will continue as we reach near saturation of residency programs with accounts. We remain steadfast in our belief that the advantages of social media use by plastic surgeons and trainees are far outweighed by the potential community-wide impacts of violations of good social media practice on peers, patients, and the general public.

The Influence of Photo Editing Applications on Patients Seeking Facial Plastic Surgery Services

BACKGROUND

The utilization of the smartphone and social media have introduced paradigm shifts to cosmetic surgery. Much has been studied regarding social media and its influences in plastic surgery; however, little is known about facial editing applications and how these relate to plastic surgery practices.

OBJECTIVES

The authors sought to discover if face-editing applications influence patients' pursuit of plastic surgery, who utilizes these applications, and why.

METHODS

An anonymous survey was administered between September and December 2019, including questions about demographics, familiarity, and utilization of face-editing applications, motivations in utilization and influences towards pursuing cosmetic procedures, and attitudes towards applications.

RESULTS

Seventy patients completed the survey and 32.9% admitted to utilizing face-editing applications. Patients utilizing applications were significantly younger (36.9 years) than those who did not (54 years [P < 0.001]). Among those familiar with applications, women were significantly more likely than men to utilize them (100% vs 78.6%, respectively [P = 0.047]). Social media was the most common influence for utilizing apps (87%). The majority confirmed that these applications played a role in pursuing cosmetic procedures (56.5%). Most patients did not regret their utilization of these applications (87%).

CONCLUSIONS

Face-editing applications serve a role regarding patient decision-making to pursue cosmetic surgery. Several motivators exist for application utilization, the largest of which is social media. Younger females are the most likely demographic to utilize applications and generally do not express regret in doing so. Plastic surgeons would benefit by understanding patient motivations and expectations created by utilizing these applications.

Predicting Public Interest in Nonsurgical Cosmetic Procedures Using Google Trends

BACKGROUND

Google Trends (GT) provides cost-free, customizable analyses of search traffic for specified terms entered into Google's search engine. GT may inform plastic surgery marketing decisions and resource allocation.

OBJECTIVES

The aim of this study was to determine GT's utility in tracking and predicting public interest in nonsurgical cosmetic procedures and to examine trends over time of public interest in nonsurgical procedures.

METHODS

GT search volume for terms in 6 ASPS and ASAPS nonsurgical procedure categories (Botox injections, chemical peel, laser hair removal, laser skin resurfacing, microdermabrasion and soft tissue fillers [subcategories: collagen, fat, and hyaluronic acid]) were compared with ASPS and ASAPS case volumes for available dates between January 2004 and March 2019 with the use of univariate linear regression, taking P < 0.01 as the cutoff for significance.

RESULTS

Total search volume varied by search term within the United States and internationally. Significant positive correlations were demonstrated for 17 GT terms in all 6 ASPS and ASAPS categories: "Botox®," "collagen injections," "collagen lip injections" with both databases; and "chemical skin peel," "skin peel," "acne scar treatment," "CO2 laser treatment," "dermabrasion," "collagen injections," "collagen lip injections," "fat transfer," "hyaluronic acid fillers," "hyaluronic acid injection," "hyaluronic acid injections," "Juvederm®," and "fat transfer" with just 1 database. Many search terms were not significant, emphasizing the need for careful selection of search terms.

CONCLUSIONS

Our analysis further elaborates on recent characterization of GT as a powerful and intuitive data set for plastic surgeons, with the potential to accurately gauge global and national interest in topics and procedures related to nonsurgical cosmetic procedures.

Use of Social Media to Teach Global Reconstructive Surgery: Initiation of a Secret Facebook Group

The ReSurge Global Training Program (RGTP) is a model for building reconstructive surgery capacity in low- and middle-income countries.¹ The aim of this study is to assess attitudes toward social media, to develop an initial RGTP Facebook Education Group, and to assess the early results of the group’s implementation.

Analysis of #PlasticSurgery in Europe: An Opportunity for Education and Leadership

BACKGROUND

Prior studies demonstrate that social media are used by plastic surgeons to educate and engage. The hashtag #PlasticSurgery has been studied previously and is embraced by American plastic surgeons and journals; however, no studies have examined its use or adoption across Europe.

METHODS

A retrospective analysis of 800 tweets containing the words "plastic surgery" or the hashtag #PlasticSurgery in four of the most spoken European languages worldwide excluding English (Spanish, #CirugiaPlastica; French, #ChirurgiePlastique; Portuguese, #CirurgiaPlastica; and German, #PlastischeChirurgie) was performed. The following were assessed: identity of author, subject matter, use of the hashtag #PlasticSurgery in each language, whether posts by surgeons and academic institutions were self-promotional or educational, and whether a link to a journal article or a reference in PubMed was provided.

RESULTS

Seventeen percent and 3 percent of analyzed tweets came from plastic surgeons or academic institutions, respectively; only 17.5 percent of them were for educational purpose. None of them had any digital link to a peer-reviewed article or a scientific journal.

CONCLUSIONS

This study demonstrates the low participation of plastic surgeons and academic institutions in social media (especially for education) in four of the major world languages. Social media should be considered in Europe as an opportunity to increase leadership, improve education, and spread knowledge of plastic surgery by board-certified plastic surgeons.

Can You Trust What You Watch? An Assessment of the Quality of Information in Aesthetic Surgery Videos on YouTube

BACKGROUND

Videos on YouTube can be posted without regulation or content oversight. Unfortunately, many patients use YouTube as a resource on aesthetic surgery, leading to misinformation. Currently, there are no objective assessments of the quality of information on YouTube about aesthetic surgery.

METHODS

YouTube was queried for videos about the 12 most common aesthetic surgical procedures, identified from the 2015 American Society of Plastic Surgeons procedural statistics between May and June of 2016. The top 25 results for each search term were scored using the modified Ensuring Quality Information for Patients criteria based on video structure, content, and author identification. Average Ensuring Quality Information for Patients score, view count, and video duration were compared between authorship groups.

RESULTS

A total of 523 videos were graded after excluding duplicates. The mean modified Ensuring Quality Information for Patients score for all videos was 13.1 (SE, 0.18) of a possible 27. The videos under the search "nose reshaping" had the lowest mean score of 10.24 (SE, 0.74), whereas "breast augmentation" had the highest score of 15.96 (SE, 0.65). Physician authorship accounted for 59 percent of included videos and had a higher mean Ensuring Quality Information for Patients score than those by patients. Only three of the 21 search terms had a mean modified Ensuring Quality Information for Patients score meeting criteria for high-quality videos.

CONCLUSIONS

The information contained in aesthetic surgery videos on YouTube is low quality. Patients should be aware that the information has the potential to be inaccurate. Plastic surgeons should be encouraged to develop high-quality videos to educate patients.

Social Media Impact on Aesthetic Procedures Among Females in Riyadh, Saudi Arabia

Aesthetic procedures represent one of the most commonly performed procedures in the medical field. Such procedures have been growing in popularity. Social media is a term used to describe electronic platforms that promote the dissemination of information to targeted users. These platforms play a critical role in promoting aesthetic procedures. Objective The objective of this study was to assess the impact of social media on aesthetic procedures among the female population in Riyadh, Saudi Arabia. Methods A cross-sectional study was performed. A validated online questionnaire, consisting of 26 questions, was distributed among females visiting the facial plastic clinic at King Abdulaziz Medical City, in Riyadh, Saudi Arabia. Results Out of 1449 participants, 81% were aged between 25 and 34 years. The majority (78.8%) were aware of the complications that may follow aesthetic procedures. The decision to undergo such procedures was affected by the price in 77%. Overall, 97% thought that cosmetic specialized accounts on social media are helpful, yet 77.8% believed that such accounts do not provide sufficient information. The influence of social media upon participants was 68%; 31.9% claimed that social media had no influence. Instagram was the most influential application followed by Snapchat and then Twitter; 50% of the participants routinely apply Snapchat filters and 42% decided to undergo facial changes after applying Snapchat filters. Conclusion Social media is an important source of information with Instagram being the most influential platform. Facial filters have led to an increase in the number of aesthetic procedures carried out.

Assessing patient satisfaction among ABHRS surgeons: Opportunities to improve

BACKGROUND/OBJECTIVE

Online physician-rating websites are being increasingly used by patients to gauge physicians' quality of service. The objective of this study is to assess the impact of residency training background of hair restoration surgeons and to identify themes of patient reviews using online physician-rating portals.

METHOD

From July 1, 2018 to July 18, 2018, a list of American Board of Hair Restoration Surgery (ABHRS) physicians was compiled. Each member's name was searched on Healthgrades.com and Yelp.com websites, and profile reviews were analyzed for themes of patient satisfaction and dissatisfaction.

RESULTS

Eighty-six ABHRS-certified surgeons were identified on the ABHRS physician directory practicing in the United States. Eleven different residency training backgrounds are represented. Surgeons were given significantly higher ratings on Healthgrades (4.63 vs 3.77, P < 0.001), and nonsurgeons were given significantly higher ratings on Yelp (4.31 vs 4.11, P = 0.036). A total of 567 five-star reviews and 59 one-star reviews were analyzed for content across both physician review portals. The most commonly cited topics included results, office staff, physician's bedside manner, comfort during procedure, patient-perceived physician's honesty, patient-perceived physician's knowledge, cost/financing options, recovery time, and wait time/scheduling.

CONCLUSIONS

Significant, yet inconsistent differences in ratings were found between surgical and nonsurgical residency backgrounds across online physician-rating portals. Understanding drivers of positive and negative reviews may help surgeons improve patient satisfaction.

The Public's Preferences on Plastic Surgery Social Media Engagement and Professionalism: Demystifying the Impact of Demographics

BACKGROUND

Social media discussions are alive among plastic surgeons. This article represents a primer on beginning to understand how the public would seek out plastic surgeons and how demographics shape their preferences.

METHODS

An anonymous 31-question survey was crowdsourced by means of MTurk.

RESULTS

There were a total of 527 respondents. Of these respondents, 33 percent follow plastic surgeons on social media, with those aged younger than 35 years 3.9 times more likely to do so. Google was the first place people would look for a plastic surgeon (46 percent). When asked what was the most influential of all online methods for selecting a surgeon, practice website ranked first (25 percent), but social media platforms ranked higher as a whole (35 percent). Those considering surgical or noninvasive procedures are thee times more likely to select social media platforms as the most influential online method in selecting a surgeon and five times more likely to follow a plastic surgeon on social media. The majority would prefer not seeing the surgeon's private life displayed on social media (39 percent). Respondents were evenly split regarding whether graphic surgical images would lead them to unfollow accounts. Ninety-six percent of the general public were unclear of the type of board certification a plastic surgeon should hold.

CONCLUSIONS

Clear differences in engagement and perception exist in the public based on age, sex, parental status, and reported country of origin. Social media will soon become a critical strategy in outreach and engagement and a valuable tool in clearing misconceptions within plastic surgery.

The "Game of Implants": A Perspective on the Crisis-Prone History of Breast Implants

Since their introduction into the market, breast implants have been the subject of many controversies. It is timely to examine the forces that have shaped the breast implant industry to make it what it is today. This review will concentrate more on the use of implants in aesthetic surgery rather than their use in breast reconstruction, but some of the factors have relevance to both indications.

Patients' and Surgeons' Perceptions of Social Media's Role in the Decision Making for Primary Aesthetic Breast Augmentation

BACKGROUND

Social media (SoMe) has evolved to be a platform that patients use to seek information prior to an operation, share perioperative and postoperative journey, provide feedback, offer and receive support. While there have been studies looking at the evolution and usage of SoMe either by patients or by surgeons, there is no information that compares its usefulness for both the groups.

OBJECTIVES

The aim of this study was to compare the views held by patients and surgeons, towards social media and other internet resources, in relation to one commonly performed operation.

METHODS

A questionnaire was presented to 648 consecutive patients who attended our clinic for consultation for primary breast augmentation from September 2016 to March 2017. A separate "surgeons' questionnaire" was answered by a group of 138 plastic surgeons who were either practicing in branches of our clinic, had previously done fellowship with us, or were visiting the clinic.

RESULTS

All 138 surgeons and 648 patients responded to the questionnaire. A total of 91.4% of patients said that they had searched online and 61.4% had searched in specific online groups for information on breast augmentation. A total of 88.9% of patients had specifically looked for clinical photographs and 73.4% had specifically searched for unfavorable reviews of the surgeon. In comparison, 72.5% of surgeons thought that over three quarters of patients gather information on the internet while only 20.3% thought that over three quarters of patients use social media for their information. A total of 52.5% of surgeons have noticed that social media affected their consultations.

CONCLUSIONS

With the evolution of the internet and related technologies, the role of social media continues to increase. While patients use social media to help make their decisions, it is not the only deciding factor. Surgeons appear to underestimate the patients' use of these technologies. There is concern in each group about the amount of inaccurate information on the social media. This underlines the importance of providing factual, evidence-based information to the patients.

Insta-grated Plastic Surgery Residencies: The Rise of Social Media Use by Trainees and Responsible Guidelines for Use

BACKGROUND

Ethical guidelines for appropriate use of social media are beginning to be delineated. As social media becomes ingrained in plastic surgery culture, education of residents on appropriate use of social media is increasingly important. Recently, plastic surgery residency programs have begun to utilize social media.

OBJECTIVES

This study characterized the trends and content of plastic surgery residency-associated Instagram accounts.

METHODS

Active individual residency program Instagram accounts were identified for integrated plastic surgery programs. Metrics for each account were retrieved on September 16, 2017, including date of first post, number of posts, and followers. Individual posts were analyzed for content of post.

RESULTS

Fourteen of 67 (21%) integrated plastic surgery programs were found to have active Instagram accounts. There has been an exponential growth of programs adopting Instagram since August 2015. A total of 806 posts were created. Thirty-two (3.97%) posts had intraoperative photos and only one (0.12%) showed a patient image. There were 4466 followers of plastic surgery residency programs. A linear correlation was found between number of posts and number of followers, while there was no correlation of number of followers and time since account start.

CONCLUSIONS

Instagram use by plastic surgery integrated programs continues to grow exponentially, and programs are appropriately using the platform. Active use of the resident social media results in increased influence. Resident use of social media has many benefits. We propose social media guidelines for plastic surgery trainees and advocate for continued appropriate use and autoregulation by plastic surgery trainees.

Social Media Return on Investment: How Much is it Worth to My Practice?

BACKGROUND

Plastic surgeons are rapidly integrating social media into their practices and recent articles on the subject have exploded in the literature. Although social media is being evaluated as a tool, few have actually been able to quantify the impact of social media on a practice.

OBJECTIVES

To quantify the return on investment for social media in a plastic surgery practice.

METHODS

The ideal method for this type of study is a new practice, without preexisting clients and with a broad approach to marketing to examine the effects of multiple marketing tools. In this study, we profile a start-up plastic surgery practice in Beverly Hills, Los Angeles.

RESULTS

In this study, we report practice demographics as well as one year of income, broken down by the referral source for each patient. The dollar amount returned was reported for several social media resources and other internet-based marketing tools.

CONCLUSIONS

Social media has a relatively high return on investment, and to date this is the first study to transparently quantify the value of social media in plastic surgery.

Plastic Surgery-Related Hashtag Utilization on Instagram: Implications for Education and Marketing

BACKGROUND

Recent data suggest patients are seeking aesthetic surgery to improve their appearance on Instagram and other social media. Despite the rising influence of Instagram in plastic surgery, few academic publications address Instagram, let alone evaluate its utilization in plastic surgery.

OBJECTIVES

We set out to answer the following three questions: 1) what plastic surgery-related content is being posted to Instagram; 2) who is posting this content; and 3) what specific hashtags are they using?

METHODS

Our study queried 21 Instagram plastic surgery-related hashtags. Content analysis was used to qualitatively evaluate each of the nine "top" posts associated with each hashtag (189 posts). Duplicate posts and those not relevant to plastic surgery were excluded.

RESULTS

A total of 1,789,270 posts utilized the 21 hashtags sampled in this study. Of the top 189 posts for these 21 queried hashtags, 163 posts met inclusion criteria. Plastic surgeons eligible for membership in American Society for Aesthetic Plastic Surgery (ASAPS) accounted for only 17.8% of top posts, whereas noneligible physicians accounted for 26.4%. All nonplastic surgery trained physicians marketed themselves as "cosmetic surgeons." Nine top posts (5.5%) were by nonphysicians, including dentists, spas with no associated physician, and a hair salon. The majority of these posts were self-promotional (67.1%) as opposed to educational (32.9%). Board-certified plastic surgeons were significantly more likely to post educational content to Instagram as compared to nonplastic surgeons (62.1% vs 38.1%, P = 0.02).

CONCLUSIONS

ASAPS eligible board-certified plastic surgeons are underrepresented amongst physicians posting top plastic surgery-related content to Instagram.

Male medical students' perception of plastic surgery and its relationship with their cultural factors

Objectives

This study is an attempt to establish the knowledge of the medical students on the specialty of plastic surgery, in addition, to know their opinions about its relationship with their cultural factors.

Patients and Methods

This is a cross-sectional study; participants invited randomly from the college of medicine at King Khaled University to fill a questionnaire consisted of 20 questions regarding the basic knowledge, attitude, perception, and understanding of plastic surgery and its subspecialties.

Results

Medical student participated in our study; their perception towards plastic surgery specialty was positive as they believed that this is a specialty as any other medical specialties; Out of 201 (45.6%), 81 (18.4%) assured plastic surgery is a good specialty. The biggest concerns about joining to cosmetic surgery were a difficulty of accepting in this specialty (34.9%). There is a significant relationship between the plastic surgery and cultural factors (P < 0.05). On other hand, there is no significant relation between choosing plastic surgery specialist among medical students and community overview about plastic surgery specialty (P = 0.15).

Conclusion

Despite the confession of the importance of plastic surgery between Saudi medical students, a large portion of them refuses plastic surgeons due to cultural factors. Increasing knowledge of plastic surgery subspecialties deserves attention.

Getting Started: A Social Media Primer

Social media use has increased both in the general public and in the surgical profession. A variety of social media platforms have been used, with Twitter being one of the most common and interactive platforms. Common uses by surgeons and scientists for social media include dissemination of information, information exchange, education, research recruitment, community consultation for clinical trials, and hospital or surgeon ratings. As social media use increases, a new language as well as metrics has been developed to track impact and reach of research incorporating social media platforms. All surgeons should be encouraged to familiarize themselves with social media, regardless of whether or not they choose to actively engage in it.