S03E28 - Is Social Media Defining Beauty in Plastic Surgery? Part 2

If we constantly see "beautiful" images on social media, does that change what we think is "beauty" in plastic surgery?

We conclude our deep dive into social media and plastic surgery by looking at what is "normal" and "beautiful," and how social media influences what we think and want.

Special guest is @dr.christian.j.vercler Dr. Christian Vercler, MD, MA, HEC-C, Clinical Associate Professor of Pediatric Plastic Surgery at the University of Michigan C.S. Mott Children’s Hospital. He serves as Co-Chief of the Clinical Ethics Service of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. Dr. Vercler is a board certified plastic surgeon who specializes in craniofacial surgery.

Dr. Vercler has written extensively about the complex ethical issues regarding social media and plastic surgery, and how Instagram, Snapchat and Tik Tok may lead (or mislead) both surgeons AND patients into choices which may result in problems.

You can get every episode of Botox and Burpees wherever you listen to podcasts, YouTube, or go to botoxandburpees.com. Thanks for watching and listening!

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S03E28 IS SOCIAL MEDIA DEFINING BEAUTY IN PLASTIC SURGERY VERCLER PT 2

[00:29:09] Dr. Sam Rhee: Let's talk about the surgeon's role in providing or pressuring patients into normative appearances. So part of what social media and the argument is, is that we're pressing people to adhere or we're telling people, this is the standard of beauty, this is what this body parts should look like.

And I know you discussed this about aesthetic generals genital surgery as well as all types of surgery in general, you know, that that's been an ongoing issue. I think for society, for plastic surgeons who do aesthetic surgery or non aesthetic surgery, even we are certainly even in reconstructive surgery trying to maintain an aesthetic ideal and are we pressuring patients to achieve that aesthetic ideal?

Let's, let's start with that. And, and how is social media making that worse in some ways? Yeah.

[00:29:57] Dr. Christian Vercler: Yeah, that's tough. That's cause you know, as you mentioned, I do pediatric craniofacial surgery. So I take care of a lot of kids with cleft lip and cleft palate and one of my mentors at Boston children's hospital, there was every single kid he could, he would say, let me make your face look better.

And he'd book him for surgery. And then these kids would get lots of revisions and they looked great. But I remember as a trainee going does, but if it's not bothering them, maybe we shouldn't do it. And so just from a very early age, thinking like we should be operating for patients, not just on them.

And I, the line I always use to parents too, is that, look, I can find something wrong with anybody's face. The question is whether or not it's bothering them and whether or not we can make their lives better by addressing it. We know that there's a phenomenon. This psychologists have studied this, that, that people viewing content on social media feel bad about themselves afterwards. There's a, there's some, several studies that show I'll be like college age women, you know? okay. Scroll on social media for half an hour and then take this wellness exam or whatever, and it drops. And so there is something about how the algorithm feeds stuff to you that can put people into these looking at highly curated photos of things makes them feel bad about themselves.

The thing about reinforcing norms is just a big philosophical issue that, that I always bring up to students when I'm teaching them. Does the existence of our specialty, is it, is it somehow a bad thing for society? Right. And undergrads, I used to teach an undergrad class called the philosophy.

And that really would blow their minds right, to think about. And obviously we're not going to stop doing what we do, but I think it is an interesting philosophical question of, of what does it mean to be human and what does it mean for us to make people look more human or less human and better than average?

Very, very, a lot better than average, and, and why would we do those things and when is it appropriate? When is it not appropriate?

[00:32:01] Dr. Sam Rhee: Yeah. I feel

[00:32:02] Dr. Christian Vercler: those are, yeah,

[00:32:03] Dr. Sam Rhee: no, I feel like these are issues I grappled with when I was doing cleft craniofacial surgery. I'd had it both ways where patients or parents would say, I want my kid to be normal. And you're like, normal, wait, what's normal. And your kid looks pretty, pretty normal to me. I, or alternatively, I would feel like, you know what, I could make this look a lot better.

And they would say, it's okay, we're done. We're happy. And I would feel like, but I didn't really. Do the job I was supposed to do. And I feel like if I did, I could, I could get there. And, and so I felt like, it, it went both ways and oftentimes it's great if you and your patient or your patient's family could come to an agreement on, on what the goal is and achieve that goal.

But, but oftentimes, and this is often the time in aesthetic surgery too. If you're not harmonious with that goal, it, it can be a huge problem. I

[00:33:00] Dr. Christian Vercler: Yeah, absolutely. And you're totally right. It's like the hardest thing in the world to look at a kid and go, I know I could make that better. Please let me make that better. But I don't say that out loud. I know. I try to, I, cause I, yeah, I don't want to be that guy. I just, I just don't want to live that life where I'm telling people, please let me make you look.

I want them to, as you say, you want their goals to be harmonious with what we deliver. And I think that's the best way to get the best outcomes.

[00:33:24] Dr. Sam Rhee: So let's flip it into aesthetic surgery. So are we, for example, and we were talking about aesthetic general genital surgery, like labioplasty are we reinforcing or imposing our perspective on what normal genitalia is by posting these types of procedures or pictures on social media?

[00:33:46] Dr. Christian Vercler: Yeah. I wrote an article about this cause I think it's, I think so. I think it's really interesting. I have some in my wife's a urologist, a pediatric urologist and I'm friends with some of the gynecologists here and, and there's some gynecologists who are really, really angry about.

Labioplasty and one of, one of my colleagues has a book called pedals. It's by some photographer, it's just have a picture of like hundreds of genitalia of labia. And she has that book in her office and she hands it to patients who come in seeking labioplasty and says, look, what you have is normal.

See you later, w w so you, and I know that there's some patients who have functional problems or minor functional problems. That's I don't think that the operation is a bad operation, but I do worry about having a significant, like, if let's say someone's Instagram feed, I guess it wouldn't be Instagram, let's say their, their Snapchat feed or even their website is just a series of photos of normal female Tanner stage four genitalia pre-op and then post-op looking Tanner stage.

Hairless with visit with the menorah, unable to be seen. It starts you start and then it's so it's, pre-op, post-op, pre-op, post-op that ingrains in you, abnormal, normal, abnormal, normal pathological corrected. And so I don't know what that does on a social media feed when we know that women have worse feel bad, worse about themselves when they view certain kinds of images on social media.

And I'm not the only person to bring this up. I think there's, there's plenty of, of authors have had done studies on this to say, Hey, are we contributing to, or are we pathologizing normal? It,

[00:35:34] Dr. Sam Rhee: let me ask this first. So I think our first assumption is, is that female genitalia as a aesthetic part of the anatomy is somehow different, special then say aesthetic breasts or aesthetic face. And I felt also reading article that it was because it was intimate, it was hidden. It was not something that is typically displayed.

Although I don't know how often breasts are really displayed, but and so people. Should treat this subject of surgery on women's genitals to be somehow held to a different standard. Is that true? Because like you said, there are, and I do know some gynecologist and we've actually had a recent conference where several of them were very adamant that any aesthetic labioplasty or genital surgery is mutilation, it's not appropriate.

And like you said but isn't that them imposing their thoughts about what appropriate is, because they're just basically saying anything is appropriate which is in its own way, imposing a viewpoint about the appearance of women's genitals.

[00:36:43] Dr. Christian Vercler: Well, I think if they don't want to do it, I think that's fine. I think the idea is that if you are putting out into the. If your message is that normal is abnormal and that people consume media in certain ways, that's going to make them. So they'll internalize that maybe what you don't want to do is induce feelings.

That what they have is abnormal. So they must seek out surgery. I think we can agree that that that shouldn't be okay. That the idea that if you're fine and then you're scrolling through social media and you start to get this sense of, like, I think there's something wrong with me.

I need to go seek out this surgeon to fix me that that's not really, that really shouldn't be what physicians are about. . If we can agree on that, then, then I think we think, well maybe there should be some ways about advertising about that or the way we label before and afters to try to minimize that potential trap or, or pitfall.

[00:37:39] Dr. Sam Rhee: I wonder because I feel like this issue is not something I've needed to deal. And I'm an N of one. So it really, it's not a very valid scientific viewpoint, but I will say in my experience, patients will have their own issue about their dissatisfaction with the appearance of their own genitalia.

An oftentimes if you really dig into it, it's, it's a partner or, some casual hurtful comment or something in their life that was traumatic, just that, that really instilled a great deal of insecurity in general about their body. And that's when they will approach, they, then they consume a lot of images about genitals online on social media in it, and let's face it. It's also good and bad all, they're all available now because, before they had nothing to use in terms of looking at resources and now they have what, maybe an overabundance of resources out there, like you said, that might be skewed, but at least then they will generally come to a surgeon and ask what it is that can be done, what their thoughts are about the surgery.

And most of the time I will give them my honest opinion about what's technically possible. And is that technically advisable, not aesthetically advisable, but is it technically advisable? And I have seen a wide variety of anatomic wants and. Patients in my experience have been fairly specific.

And in a few cases I will, or, or a fair number of cases, I will not necessarily recommend surgery, but I know that they will go find someone else, probably to do what they want. I just don't feel comfortable doing it, but, but in the end, the patient it's patient driven and the patient will find somebody.

So I wonder how much of this is really in our hands and how much of it is our responsibility. And ultimately like you said, social media is so difficult for us to control. How do we actually display the, these procedures? If not on social media, we can't really post them anywhere else, even on social media.

There's only a very, like you mentioned on your article, there are only a very few number of programs that will allow you to show nudity at all. And what if you are someone who is interested in it legitimately, I think you have to take the good with the bad, right? So maybe you do see a lot of genitals and that's available to you.

Unfortunately, maybe a large majority of them have some sort of normative value that someone else is imposing on on them. But but shouldn't, we trust the patient ultimately to make that choice because we see stuff that's skewed all the time. Everything is skewed in terms of the, our media consumption.

And this is just one more thing that's skewed as well.

[00:40:34] Dr. Christian Vercler: Right. Yeah. So I think, yeah, I think this is having the female genitalia, being an object of aesthetic scrutiny by society. I'm not the first person to think that that might. We call the patriarchy there needs to be overthrown, that idea that, that the male gaze of the female body is normative.

And that we should be okay with it. Or should we bring up that it could be problematic and that may be and that maybe also consuming images of augmented breasts is also pathologizing normal breasts. And maybe that could be problematic as well. So I think that the kind of arguments that I wrote up in that paper are more along these kind of feminist critiques of society where the idea that like women's bodies are normal the way they're made, and that it's a specific a specific way of consuming images of female bodies. That that's what that would be. The court considered the male gaze a very male way of looking or consuming a woman's body visually is finds it lacking in certain ways. And that women internalize that feel bad about it and then seek out cosmetic surgery so that they can fulfill this standards of the male gaze.

And so, again, that's a larger feminist critique. I'm not the author of that, but I think it's, it's definitely out there. It's definitely not anything that we talk about as plastic surgeons very much because it's, again, kind of a larger social critique of, the winds of style in our society.

So I think it's reasonable though, to, for us to know about those things. And I have three daughters. I don't want them to feel bad about the way they are and see stuff on social media that makes them feel not good enough that they would have to seek things out. That's just again, my viewpoint, but I think it's definitely a viewpoint that's out there as well, that we should kind of maybe be cognizant of.

[00:42:35] Dr. Sam Rhee: I agree. I would say there's no doubt that society, in my opinion, shows a lot of, I guess you could call that patriarchical perspectives on what. Women's bodies should look like a lot of businesses like Hooters are based on it. What w what we see in the media shows what these proportions are either exaggerated or idealized in a lot of ways, Barbie, you name it.

has been ongoing for decades, and this is not something I think us as plastic surgeons can really fix. I don't even know if we can really fight against it, honestly. And unfortunately we are probably we're profiting from it. Let's just put it that way. There's no doubt that we're profiting from it, and that's a bad thing, but, , it's difficult to address on an individual level.

I think some of the things that we can do as plastic surgeons, one is it's always typically been a male dominated profession. And the fact that we have more and more women entering our specialty is going to be one appropriate way of addressing this. I think if you look at how society is, a lot of higher education is becoming more at least equal in terms of gender.

And probably I think if you look at the new undergraduate classes in a lot of colleges, there's, there's more women than, than men in, in some of these colleges. And I think that that's going to reflect in medical school and then eventually in our surgical specialties. And then just having that, that diversity of viewpoint in terms of gender will hopefully help to change these things, because most of the people in positions of power who often determined.

These things are no longer just men. And I think that we're seeing a societal shift in terms of sexual harassment, what's appropriate behavior. And I think plastic surgery will also catch up in some ways in the year 2021. I don't know as me as an individual, I can necessarily say, well, I'm not doing breast augmentations anymore because I feel like I'm giving into the patriarchical viewpoint of w what an idealized breast should be like.

That, that I, I don't think I can realistically do what I think I can do is speak individually with each of my patients and try to harmonize what their goals and what can technically be done and achieve something that is satisfactory in a long-term. Like, I know there are a lot of patients out there that don't necessarily know what they want, and I'm very careful not to. A particular viewpoint or opinion, or thought in terms of what they should do. I'm very, very particular about that. And I think as plastic surgeons, if we do have patients who are unsure, I think that's very helpful. Rather than just say, well, everyone is getting this, so you should, you should do this.

[00:45:17] Dr. Christian Vercler: Right. For sure.

[00:45:19] Dr. Sam Rhee: and I feel like that's, that's, that's only a little bit of scratching the surface.

[00:45:24] Dr. Christian Vercler: what I'd say to that's cause this is about social media. I think, how, how we, what we put on social media is, is that's where we can kind of express that. I would say, I know you probably, you probably know Sheila Nazarian. She's got a great social media following. So, so, Sheila calls herself the small brown.

Right. And so she, her posts are always have very subtle breast augmentations. And I think that's her way of saying you don't have to put in 500 CC implants, she's, she's trying to show a different aesthetic. And I think that's, I think that's interesting and, and kind of cool. And so again, how we, what we choose to post and how we post it and, she brands herself as that.

That's one way I think of potentially, being in conversation with that larger issue that we just talked about.

[00:46:11] Dr. Sam Rhee: So I do know that there are some private practice, plastic surgeons who livestream labioplasty is they will actually have their patients almost self record as they're doing procedures. Is that appropriate? Is that, is that okay?

[00:46:27] Dr. Christian Vercler: yeah, I think it's, yeah. I guess that's the one.

I, I, I'm a trained ethicist, so it's always, the answer is like, it depends. Right. So you know, all the details matter if it's I, I saw a live stream of that one time. And the patient was speaking Spanish in the physician was speaking English to the PE Spanish speaking patient. And I thought to myself, what was the Hinson foreign, Spanish? What does she understand? What's actually happening? You just think about like, does, do people really understand what they're signing up for that, that idea?

Again, there's so many what I call them ethical pitfalls that you can get into in these situations. Like, is it bad? Full-stop no like the very few things that we might say like I said, if he did it without consent, that's bad, full stop. But if the patient consents to it, do they really know what they're doing?

Do they know what the intention is? Do they know what format it's going to be in? The problem with Snapchat is that it's the, it is the one where you can do show anything on it, but the average age of the users as well, below age 18. So the, and so you're basically putting pornographic stuff in one context that would be considered pornographic, but it's on Snapchat.

It's called it's educational for patients. But the vast majority of people who consume that content are probably not your patients.

[00:47:45] Dr. Sam Rhee: we be regularly? Should we be regulating these tech companies? Because this is this not their responsibility.

[00:47:52] Dr. Christian Vercler: I think that's what they were talking about in Congress. When they were, testifying and saying, Hey, Facebook is trying to do this stuff and it's aimed at kids. And, and so I think, I don't have the answer, but it seems, there's been some New York times articles recently just saying how dangerous, like they said, the most dangerous object in your house is your phone for your kid.

Right. Cause they can get on it and they can get, and they can start getting into content that can lead them down a rabbit hole, which is bad for their mental health. And so th so it was interesting that that particular article in the New York times tried to make some analogies to other products that you would never let a kid have access to, and then show that how much more dangerous certain aspects of social media are to a kid's psyche.

So I think it's probably gonna have to be, or, so that's the question is where should it be regulated? Should it be regulated. Professional level where we say I would never post any content that could be taken out of context that could potentially ever lead to some bad outcome or be consumed in a way that would not be consistent with my intention.

Or should that be coming top down from the government? Generally, a lot of people think top-down government approaches, not the best approach. But that's what they do if we don't regulate ourselves. The professionals are given a lot of leeway to self-regulate. And so if we don't regulate ourselves, then we get things come down from the top down, like the FDA warnings on breast implants.

Now, that's like, that's a very draconian way of like making sure we're really doing what we, what we said, we're doing this.

[00:49:22] Dr. Sam Rhee: Right. I feel like as a professional society, the surgeons that I know who are ASPS, who are plastic surgeons, generally are pretty good. There's always outliers. The issue is, is that it's the non board certified plastic surgeons, the people who are cosmetic surgeons, are not board certified who are not plastic surgeons, who I are really causing patient harm.

They're not even following the most basic responsibilities in terms of patient care. And those are the ones that are going to drive some of the most egregious outcomes. And I think generally speaking, even when it comes to physical harm, you always see that, right. There are some times, no, no specialty is I'm faultless, but I feel like it's very difficult for us as plastic surgeons when we are dealing with, and I don't want to keep pointing at others because, I understand that I have a bias I have my own self-interest here.

But I do think that there are a lot of non board certified surgeons out there that are causing significant issues on social media in terms of what they do. In misinforming patients which is problematic. And I think we can certainly hold ourselves to a higher standard, but short of not being able to help regulate these on art certified surgeons.

I don't think there's a whole lot. We can do. Just because I'm driving onto the highway properly and I'm observing the stop sign and the red lights and making all my proper right. Turns the guy next to me, who's driving like a maniac and smashing into five people. Like, I can't do anything about that.

And it's frustrating. I think.

[00:50:58] Dr. Christian Vercler: Yeah, no. So I think, I think that's a good case for w why the social media companies probably should take a more hands-on approach to regulating what gets posted.

[00:51:08] Dr. Sam Rhee: What do you do as a parent personally? Cause I have a son and a daughter. Are older, they're in, they're in high school. So honestly the horse probably left the barn for me at this point for social media. But what advice as an ethicist would you give to others about children and consuming social media?

Because short of, locking them away in a closet and hiding their phone, like there's really no way you can prevent them from being part of society.

[00:51:35] Dr. Christian Vercler: I don't think so. Yeah, I, my kids are always on a device. And so, I, I certainly don't personally have it figured out I try to watch what they're on and have the YouTube, whatever things set up. So they can't find crazy stuff there. Tik TOK, I try to only let them watch it while I'm around.

So, but that's difficult too, because you can, again, it feeds them stuff. And before too long, what the heck are you guys watching? Yeah, it's tough. I've, I've got some colleagues. I work in a children's hospital primarily, and so I have a lot of pediatric colleagues who say that there's lots of evidence that the longer that you can delay kids access to.

Constantly being bombarded with this the social media feeds the better and more resilient they're going to be emotionally.

[00:52:23] Dr. Sam Rhee: So what

[00:52:24] Dr. Christian Vercler: So I don't know. I've I actually haven't met it's too late for me. I My four year old is on my phone from like the minute she wakes up, she walks in and says, dad, give me a breakfast and grabs my phone off the nightstand.

So, yeah, I, I, yeah, no one should follow my example in that regard, but it's scary. I don't, yeah, I don't have any easy answers for that, but I know that there's evidence that the longer you can delay and the more you can try to keep them off of it. The better they're going to be, but it's so hard.

It's a constant struggle and, especially, yeah, well, I was gonna say I've a good friend of mine. Her biggest lament of the Penn. Was that she said to me, I spent my whole life preventing my kids from there. They had a screen-free existence up until the pandemic, and our kids were like school age and she, it was so hardcore.

I I'm in Ann Arbor. So you can imagine there's some hippies here who really no screens for their kids. And now the kids gotta be on the screen all the time for all of their engagement. That's the only way they can engage is, is CRE. So it was undoing all the good that she thought she had done for the entire existence of her children was like gone in an instant with a pandemic.

So, I think we're all, all of us were sorting that out and I don't have any easy answers. And I certainly personally am probably not someone to hold up as an example, exemplar

[00:53:39] Dr. Sam Rhee: It's, it's funny. I think I don't have any really good ideas either. All I can tell you is I try to practice what I preach, but I still consume a lot of social media. And so I can't legitimately have any moral grounds to stopping my kids from a reasonable amount or unreasonable.

I don't know, whatever you want to say in terms of consumption, but I certainly want to practice my set an example. So in situations where I don't think it's appropriate, even if I want to use social media, or be on my phone, I'm not. And then the other thing is, is I try to offer experiences. That are positive, which don't necessarily involve social media, but involve our family.

And I hope that that helps. It probably is not enough. But the third thing that I have hope is is that our kids are resilient. As children, we've gone through a lot of crazy stuff and most of us are half okay. Having grown up. And I just have hope that my children will also find a way to navigate and be resilient.

And they've always surprised me in terms of what they can do. And I hope that they'll continue to navigate things and continue to surprise me. So that's, that's just really what I, that's what my hope is.

[00:54:47] Dr. Christian Vercler: Yeah, the ECC summarized it. Well. Yeah, exactly.

[00:54:53] Dr. Sam Rhee: Well, Christian is really a pleasure to talk to you about these issues. And it's so funny. I thought with an emphasis, I would have these clear guidelines about everything. And it's, it's refreshing to know that a lot of it is, is very situational and specific. And that, that gives me hope that as a plastic surgeon, I need to look at every situation make my best judgment in that situation, not apply a hard and fast rule to everything.

It's really about figuring out what is best in that particular situation. And a lot of it seems like it's common sense, honestly, as an ethicist. Is that the way it seems like, I don't know.

[00:55:30] Dr. Christian Vercler: so I think that I I get a lot of lectures on, on ethics in general, and there's a lot of different ways to define what is ethics. And I always say that my favorite one is that is disciplined reflection on moral ambiguity. And so that you're basically in, but disciplined also meaning taking a discipline that exists like philosophy and logic, and trying to apply that to these areas that are morally ambiguous.

Social media didn't exist 20 years ago or whatever. So we're, we're looking at so how do you answer these questions? We'll try to take some basic principles and apply them to the circumstances as they are existing in reality. And so I think that's, that's how we do it and try to.

It's morally ambiguous. It's neither. It's neither good nor bad. It's just, we have to try to struggle through these things.

[00:56:20] Dr. Sam Rhee: Well, thank you very much, Christian. I appreciate it. And I really hope I have a chance to talk to you again in the future about other issues. It's been really, really.

[00:56:29] Dr. Christian Vercler: Yeah. It's been a pleasure. Go blue.

[00:56:31] Dr. Sam Rhee: then go blue. Let's do it.