A Comparative Analysis of Online Reporting of Possible Complications for Minimally Invasive Cosmetic Procedures

Botulinum toxin type A (Botox), soft tissue fillers, and chemical peels were the most popular and fastest growing cosmetic minimally invasive procedures in 2018.¹ Although office-based procedures, such as Botox rejuvenation, soft tissue fillers, and chemical peels, are regarded to be reliable and effective, complications can arise that must be addressed.² With Botox and soft tissue filler injections, the most common complications are bruising, erythema, and pain.^2-4 However, more severe associated complications can occur, such as muscle paralysis, lagophthalmos, orbicularis oris muscle incompetence, anaphylactic reactions, and dysphagia from Botox toxin spread and granuloma formation, blindness, and vascular occlusion from soft tissue fillers.^2,5-7 Chemical peels can lead to erythema, irritation, and burning, as well as more serious scarring.² These complications can emerge even with the most precise technique and must be mentioned to patients in the informed consent process as well as on providers’ websites.^2,8

Effective risk information disclosure is necessary during the promotion of prescription drugs and medical devices, and omitting or minimizing the information is described as a violation of advertising and promotion regulations.^9,10 The US Food and Drug Administration (FDA) articulates that appropriate disclosure informs consumers of potential side effects they may experience and safety precautions that they may have to take.¹⁰ Similarly, in the case Canterbury v. Spence, the court declared that physicians are required to disclose all risks to patients to help them make an informed decision.¹¹ Websites offering cosmetic procedures and private practice physicians may benefit from upholding standards of full disclosure online similar to those of pharmaceutical companies because such regulations were put into place to ensure the safety of consumers and patients. While the informed consent process is traditionally performed in the presence of a physician, the expanding role of technology, the internet, and virtual information sharing underscores the importance of sharing information about a procedure earlier in the patient’s decision-making process. This may be the moment a patient begins learning about a treatment, which may be from online sources.

A 2015 literature review on the accessibility of online information for cosmetic procedures found that 95% of patients collected information from the internet before their physician consultation.¹² Patients most often sought after details regarding surgical procedures and preoperative and postoperative photos.¹² Patients are using the internet more extensively to help inform decisions regarding high-risk procedures, and it is the second most common source of medical information after physicians themselves.^13,14 This provides cosmetic physicians with the unique opportunity to educate patients not only through in-office visits but also online with written and visual materials. Furthermore, if internet sources provided more information about risks and complications, it may help enhance the informed consent process. Such information may increase transparency surrounding the risks of procedures and allow patients to have more realistic expectations before the consultation and ask more informed questions.

The objective of this study is to evaluate what complications are described for Botox, soft tissue fillers, and chemical peel procedures in online sources and to compare the level of reporting from various sources to understand how to fill some of the existing gaps.¹⁰

A cross-sectional search was performed in July 2020 to identify the top 50 Google search results for the 3 most popular cosmetic procedures. The search terms used were similar to what a patient might search for: “Botox,” “fillers,” and “chemical peel.” Location filter and ad-personalization were disabled, and incognito mode was used to identify the most accessible websites. Duplicate, video-based, and irrelevant websites were excluded.

Websites were categorized as “academic/hospital,” “commercial,” “private practice board-certified,” “private practice not-board-certified,” “online heath reference,” and “other” websites. The “other” category consisted of government, reference, news, social media accounts, or online magazine sites. Board-certified practices were defined as practices employing physicians with a board certification in plastic surgery, dermatology, facial plastic surgery (ie, ear, nose, and throat [ENT] specialty), oculoplastic surgery, or oral maxillofacial surgery. Non–board-certified practices included any practice headed by a health professional or physician without a certification in these fields or any specialty at all.

Each website was analyzed for the most relevant complications related to each treatment and was given an overall complication, prevention, prevalence, management, and disclaimer score by 3 different reviewers (Table 1). Relevant side effects included both common and serious that would be important to disclose to a patient. These side effects were determined by medication guides published by the FDA as well as a review of the Botox, fillers, and chemical peel literature.^2,15-19

Statistical Analysis

The Kruskal-Wallis test was used to compare scores across different website categories because the data were non-normally distributed and consisted of unequal sample sizes. A statistically significant result was further investigated by multiple pairwise-comparisons, using the Wilcoxon rank sum test. P-value adjustments were made using the Benjamini-Hochberg correction to reduce the false discovery rate. A chi-square test with Yates correction was used to compare common side effects reporting to serious side effects. A P value < .05 was deemed statistically significant. Descriptive statistics, including the mean, standard deviation, and median scores, were tabulated for each website group. All data analysis was conducted in R software v4.0.2 (R Core Team).

A total of 136 websites were analyzed, including 42 for “Botox,” 44 for “filler,” and 50 for “chemical peel.” Fifteen websites were excluded as irrelevant, duplicate, or video-based. From the selected sites, 46 (34.1%) were private practice, board-certified physician-based. Twenty-three (17.0%) were developed from online health reference sites. Twenty-three (17.0%) were categorized as “other” sites that included online magazine articles, government-based sites, and general reference sites. Twenty-one sites (15.6%) were developed by either an academic board or a hospital. Twelve sites (8.9%) were categorized as commercial. Ten sites (7.4%) were published by private practice, not–board-certified physicians (Figure 1). Of the 136 websites, 31 (22.7%) did not mention any complications or risks associated with the treatment.

The most commonly reported complications were bruising (67.0%) for Botox, swelling (79.0%) for fillers, and redness (58%) for chemical peels (Figures 2, 3, and 4). The least-reported serious complications were toxin spread effects (31.0%) for Botox, vision loss (23.0%) for fillers, and allergic reaction for chemical peel (18.0%).

The frequency of reports of serious and rare side effects was significantly lower than that of common side effects for Botox (P = .001), fillers (P = .004), and chemical peels (P < .001) (Table 2).

The overall mean (standard deviation) complication score across all websites was 2.81/5(1.31) (Table 3). Approximately half (49.6%) of all sites mentioned ways to prevent complications before treatment. Even fewer (43.7%) mentioned strategies on how to manage complications after they occur. When comparing categories of websites, online health reference sites and academic/hospital sites outperformed other sites in overall complication scores (Tables 3 and 4).

The increasing popularity of Botox, fillers, and chemical peels warrants high-quality online information where patients are not only educated on all possible benefits and alternative treatments but also informed of all aspects of risks and complications. Multiple quality and readability studies have shown deficiencies in online health information, but none have specifically analyzed risks and complications.^20-24 To the best of the authors’ knowledge, this is the first study to evaluate online sites and their reporting of specific complications of the top 3 cosmetic procedures performed in the US. Overall, the reporting of cosmetic complications for the top cosmetic procedures is scarce and highly variable.

The results of this study showed that many cosmetic websites were not disclosing any associated risks or side effects, and among those that did, there were discrepancies in the criteria for which complications were reported. This points to an informational gap and lack of consensus on complication disclosure online. Furthermore, fewer than half of sites indicated the prevalence associated with each side effect, which may misinform patients about which side effects are common and which are rare. From online sources, patients may therefore be left with a vague understanding of the risks involved before electing to undergo a procedure and confusion as to what to expect after treatment. This lack of reporting may undermine the informed consent process as a patient’s medical decision-making is influenced by online health content.²⁵

Additionally, rare and serious side effects of all 3 treatments were underreported online in comparison to the more common side effects, which further obfuscated the informed consent process. The informed consent literature has shown that a contextualized informed consent should be achieved, which includes the most relevant common and serious side effects.^26,27 About half of the sites reviewed failed to mention anything related to complication prevention, such as icing postoperatively or refraining from high-intensity physical workouts. More than half failed to mention ways to manage complications if they arose, which is a patient safety concern. For example, while vision loss due to fillers is a rare side effect, urgent action is required. Patients need to be aware of the appropriate next steps to emergently receive hyaluronidase.⁷ While cosmetic websites may not disclose all complications due to the fear of overwhelming patients, a disclaimer or source to another website to find additional information may benefit patients while displaying full transparency. The low disclaimer scores further suggest that cosmetic websites are not only omitting information valuable to patients but also not clarifying their role as a source. Does the medical information on these websites reflect the recommendations of a physician or merely the advice of a well-intentioned writer?

Although there is a wide discrepancy in quality of complication information, online health reference websites and academic/hospital sites tend to be better than most. These websites more often list the correct common and serious side effects and estimate their likelihood. They offer information on ways to prevent treatment complications and manage complications, and they direct readers to additional sources of information on complications surrounding that procedure. These websites should serve as a model to private practice cosmetic physician–based sites, which may benefit from improvement. Private practice physicians are often regarded as the experts because they are the ones performing the procedures, but this may not be reflected by the incompleteness of their websites. The results of this study highlight a unique opportunity for physicians and all online health contributors to collaborate in an effort to fill the gap of underreporting of risks and complications and to raise the overall standard of online health education.

Litigation studies surrounding Botox, fillers, and chemical peels involve both common and serious adverse events, with the unifying conclusion that some patients may benefit from a comprehensive preoperative informed consent process.^28-30 Botox litigation cases have involved those patients who experienced systemic toxin spread effects leading to muscle weakness, paralysis, respiratory problems, and severe pain.³⁰ Filler-related lawsuits have revolved heavily around swelling and infection.²⁸ Chemical peel–associated litigation has involved poor cosmetic outcome as the most cited factor for cause of suit.²⁹ Scarring, dyspigmentation, and disfigurement were the likely culprits. The results of the current study complement these findings as only 31% of Botox websites listed systemic toxin spread effects as a possible risk. Approximately 79% of websites did mention swelling as a possible side effect of fillers, but only 42% mentioned infection. Only 38% of chemical peel sites mentioned scarring, and only 48% mentioned dyspigmentation as possible complications. Raising the standard of disclosure online may actually even benefit cosmetic physicians by possibly preventing some litigation surrounding Botox, soft tissue fillers, and chemical peel complications; physicians could point to their online website as possible evidence for adequate informed consent. If patients are finding physicians through their websites, then it is plausible that they would see these possible complications online on their provider’s site. Transparency online may act as a deterrent to future lawsuits.

There is a lack of research on the effects of full transparency in complication disclosure on the physician-patient relationship; however, human behavior suggests that patients may actually trust their physicians more if they disclose even the rarest complications. They may view the honesty and transparency as a reflection of the physician’s overall expertise and experience. Further research is needed to understand patient-related behavioral changes associated with full disclosure.

Moreover, improving the standards of complication disclosure online may help vulnerable populations, such as the elderly and those of lower socioeconomic status. These groups have been found to trust information from physicians more and thus may be more likely to be misinformed when providers do not fully disclose complications in consultations or online.^31-33 Alternatively, these patients may seek treatments from health providers with lesser training or lack of board certification to avoid expensive consultation fees. For these patients, a more rigorous and complete reporting of risks and complications online may help protect them and inform their decision-making when selecting a cosmetic physician.

The authors of this study by no means claim that websites are the sole resource intended to provide informed consent or a comprehensive overview of complications to patients considering cosmetic procedures. Rather, online resources should serve as an adjunct to in-office visits where time is precious and preoperative discussion can often be limited. In an effort to improve the internet and online resources to benefit more patients exploring cosmetic surgery, the authors recommend the following for writers developing content for these sites: review FDA guidelines and the literature to display estimates of the common and serious adverse events of a treatment, discuss strategies to prevent and manage complications, provide sources of additional information, and offer a medical disclaimer to clarify a website’s role. A sample informed consent checklist has been provided to help practices refine their own informed consent processes (Table 5).

The results of this study are meant to only be interpreted in the context of Botox, filler, and chemical peel websites because websites describing other procedures may vary in their reporting of complications. Further study is needed to evaluate the quality of online content reporting on surgical procedures in which complications are even more severe. Additionally, a major limitation of this study is that only 1 search engine and a limited number of search phrases were used to identify websites. The resulting sites were confined to only the top 50 websites. Other search engines, phrases, and site rankings may have higher-quality websites that are not as popular due to financial implications.   Further, in the interest of consumerism, site designers often harness the assistance of skilled marketers in the development of their websites.  Such experts are often able to optimize site metadata to rank higher in search results even though the content itself may be lower quality.   For example, mobile device optimization and fast website speeds can both significantly improve a sites’ rank within major search engine algorithms.  

The disclosure of complications for Botox, fillers, and chemical peels online is highly variable, biased towards common side effects over more serious ones, and differs among website categories. Online health reference and academic/hospital websites are more comprehensive and should serve as a patient’s primary online source of education for risks and complications. Improvement of cosmetic websites and higher standards of complication disclosure are needed.

Affiliations: ¹Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Minnesota School of Medicine, Minneapolis, MN; ²Department of Surgery, Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Chicago, IL; ³Renaissance Plastic Surgery, Saint Peters, MO

Correspondce: Robert D Galiano, MD; rgaliano@nmh.org

Ethics: This study conforms to the Declaration of Helsinki.

Disclosures: The authors have no conflict of interest to disclose.