Quality of information about liposuction for the lay public: A scoping review
Qualidade das informações sobre lipoaspiração para o público leigo: Uma revisão de escopo

INTRODUCTION

Introduced by Illouz in the early 1980s, liposuction is a surgical procedure that seeks to improve body contour by removing localized fat deposits^1,2.

Since the middle of the 20th century, there has been a focus by humans on physical appearance as a vehicle of identity and expression, currently even more intensified with the dissemination and popularization of digital social media. Therefore, there is a growing search for improvements in body contouring, including liposuction. According to data from the International Society of Aesthetic Plastic Surgery (ISAPS), in 2019, liposuction was the world’s second most-performed aesthetic surgical procedure, with around 1.7 million surgeries, and the most performed in Brazil, with 231 thousand surgeries^3-5.

Due to the growing understanding of the biochemical and physiological properties of the procedure, as well as biomedical technological advances, liposuction is constantly evolving, with improvements in technique, patient safety, and results. New equipment and surgeon training progressively refine the procedure, such as infiltration of solutions, advances in the design and shape of the cannula, ultrasound-assisted liposuction, vibroliposuction, Vaser-assisted liposuction, and laser-assisted liposuction^1,6.

Such innovations have even expanded the possibilities for improving body design, such as muscle definition liposuction. This technique, representing a highly fashionable topic among the lay public, consists of liposuction of more superficial layers of subcutaneous fat to define muscular contours in any body area, regardless of the equipment used. It is up to the plastic surgeon to fully assess the patient to recommend - or not - the use of this resource to improve the appearance of the body⁷.

Thus, over the last few decades, liposuction has evolved from a procedure that only removes small amounts of fat to a practically irreplaceable tool in the plastic surgery arsenal for improving body contouring. It has also become a useful complement in other areas of plastic surgery, such as breast reconstruction and postoperative contouring in the reconstruction of the neck and upper and lower extremities¹.

On the other hand, everyone should know that liposuction is not without risks. Some complications, such as skin irregularities, prolonged edema, ecchymosis, hyperpigmentation, changes in sensitivity, seromas, hematomas, ulcers, necrosis, visceral perforations, systemic infection, fat embolism, sepsis, and death, may occur. The estimated mortality rate from liposuction is 1 in every 5,000 procedures performed².

Currently, given the contractual model of the doctor-patient relationship, in which the patient participates in the decision-making process, most people who want to undergo liposuction actively seek information about the procedure even before the medical consultation⁸. In this case, the Internet and digital social networks offer content about plastic surgery quickly, directly, and accessible to most patients and, today, are the main search sources. However, the quality of content on the network is a cause for concern, with some studies demonstrating precarious information. However, so far, no scientific reviews have been found in the literature that evaluate this issue.

OBJECTIVE

Therefore, the present study consists of a scoping literature review measuring the quality of information disseminated to the lay public addressing liposuction.

METHOD

The present study is a scoping review of the literature. The PRISMA-Scre checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review) was used to guide this scoping review⁹. A literature search was carried out from November 18 to December 12, 2021, on the following database platforms: Medline, Cochrane, LILACS, Embase, and VHL.

The search strategy involved the combination of the following descriptors: (“abdominal etching” OR “aspiration lipectomy” OR “aspiration lipectomies” OR “aspiration lipolysis” OR “body sculpting” OR “lipectomies” OR “lipectomies, aspiration” OR “lipectomies, suction” OR lipectomy OR “lipectomy, aspiration” OR “lipectomy, suction” OR lipoabdominoplasty OR “lipolysis, aspiration” OR “lipolysis, suction” OR liposculpture OR liposuction OR liposuctions OR lipoplasty OR lipoplasties OR “suction lipectomy” OR “suction lipectomies” OR “suction lipolysis”) AND (“health communication” OR “educational communication” OR “health communications” OR “printed media” OR “population education” OR “health education” OR “patient education” OR “patient communication” OR “user information” OR “patient information” OR “information search” OR “information dissemination” OR “social media” OR Internet OR twitter OR “communications media” OR “search engine” OR “patient portals” OR comprehension OR “consumer health information” OR language OR reading OR instagram OR facebook OR “google trends” OR “Data Sharing” OR “Data Sharings” OR “Information Distribution” OR “Information Distribution” OR “Information Exchange” OR “Information Sharing” OR “Information Sharings” OR “Knowledge Dissemination” OR “Knowledge Sharing” OR “Sharing of Knowledge”). The bibliographic references of the selected studies were also checked to expand the list of articles of interest.

The inclusion criteria were articles of the type of randomized clinical trial, systematic review, or observational study in humans, with patients over 18 years of age, without publication date restrictions, in English, Portuguese, or Spanish, and studies with relevant results regarding the topic covered. The exclusion criteria included dissertations, theses, animal studies, and those not presenting outcomes relevant to the proposed topic.

Two independent investigators read the abstract of studies obtained using the search strategy to evaluate those that met the eligibility criteria. In cases of disagreement, a third investigator participated in the screening process. The selected articles were read in full, and data related to publication date, type of study, platform studied, and evaluated outcomes were transferred to a spreadsheet fed jointly by the researchers.

This study was developed with the support of the Professional Master’s Course in Science, Technology, and Management Applied to Tissue Regeneration at the Federal University of São Paulo (Unifesp). It was part of the research project entitled “Liposuction: preparation and validation of a book intended for the public layman.” This initiative was approved by the Unifesp Ethics and Research Committee on April 13, 2021, under opinion number 4,646,756 and CAAE 43920621.5.0000.5505.

RESULTS

Ten articles were selected for this scoping review. The processes of identification, screening, and inclusion of studies are represented in the flowchart in Figure 1.

Figure 1 - Flowchart for the selection of scoping review articles.

Figure 1 - Flowchart for the selection of scoping review articles.

To analyze the selected articles, Tables 1 to 3 were created.

Table 1 - Title, author, year, and country of articles.

Table 2 - Sample number, platform studied, and methodology of selected articles.

Table 3 - Results and conclusions of the articles.

DISCUSSION

Access to the Internet and digital social networks offers content about liposuction quickly, directly, and accessible to most patients, and currently, they are the main search sites for non-specialist audiences.

Montemurro et al.¹⁰ concluded that, in five of the studies analyzed in their research, 37 to 81.8% of patients search for data before the consultation, with the Internet being the first source of research in 38.6 to 72% of cases. It can also be observed that, in 2016, according to Sorice et al.¹¹, the social network with the highest engagement regarding posts related to aesthetic surgeries (including liposuction) was Facebook, with the lowest engagement being Twitter. It was revealed that the public was more interested in before versus after photos and, secondly, in information about the procedures. Furthermore, there is an increase in the popularity of online searches on social networks for non-invasive aesthetic procedures¹².

Regarding how advertisements about liposuction are presented, according to Sanan et al.¹³, the lay public prefers articles with little description, which balance images and words. No difference was shown between the use of real patients and models in the advertisements. For observers, the ideal would be a photograph of the professional “in action” in their work environment.

Although not included in this review, some articles provide relevant information about using the Internet for health education purposes. Vardanian et al.¹⁴ state that social networks are important tools for educating, engaging, publicizing, and communicating directly with patients and professional colleagues. Jejurikar et al.¹⁵ go further in their article and report that the Internet has enormous potential to provide the public with health information. They suggest doctors guide their patients about the procedure and warn them that most websites do not offer reliable and trustworthy surgery information. They also indicate that plastic surgeons should select specific Internet pages - considered reliable sources - and redirect their patients to these sites. They believe that, when used correctly and based on scientific content, the Internet can complement the dialogue in the doctor’s office.

It is also worth highlighting the content provided to the lay public regarding liposuction. Although Wong et al.¹⁶ concluded that plastic surgeons obtained the highest overall average scores from the American Society of Plastic Surgeons (ASPS) code of ethics regarding advertising and advertisements, there is an evident lack of information with high scientific content and accessible language among health professionals and the lay public.

Among the studies reviewed, the articles by Montemurro et al.¹⁰, Zuk et al.¹⁷, Vargas et al.¹⁸, Gray et al.¹⁹, Polonijo & Carpiano²⁰ and Ward et al.²¹ indicate that the considerations on aesthetic procedures provided to the lay public are very superficial and imprecise. It is therefore important to develop materials produced based on an elaborate scientific methodology to provide interested people with material of high scientific quality, which can help in understanding the procedure.

Furthermore, Montemurro et al.¹⁰ and Vargas et al.18 also state that the information published on websites is difficult for lay readers to understand due to the use of technical language. At this point, the authors could adapt medical jargon to colloquial and routine terms, disclosing the subject seriously but in a way easily understood by those interested.

It is also worth highlighting the use of biased images about liposuction, which often compare the results before and after the procedure, for example, published and shared by default on social networks. In these cases, tricks are often used to improve postoperative results: playing with lights and shadows, using Vaseline, taking photos at favorable angles.

Plastic surgeons mistakenly induce the lay public into a false sense of utopian results, unattainable for many patients, by publicizing their work in this way. In Brazil, the Federal Council of Medicine (CFM) currently does not allow the publication of “before and after” photographs (CFM Resolution nº 1,974/11)²²; however, the bad examples that occur abroad demonstrate the need for this topic to be discussed broadly and profoundly before any change in the CFM’s positioning occurs in the future.

This scoping review has some limitations to be highlighted: the inclusion of materials only in English, Spanish, and Portuguese and the lack of a tool to evaluate the methodological quality of the selected studies. On the other hand, this review followed the PRISMA-Scr⁹ checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review), which increased its methodological reliability.

In short, currently, there is a lack of quality information in accessible language for the lay public to make readers (potential patients in the future) more informed about the procedure. As liposuction is one of the most performed plastic surgeries in the world and, therefore, of great interest to the general public, the authors consider that greater robustness of information intended for patients is necessary, especially in terms of the surgical procedure, qualitative and quantitative benefits, risks, treatment of complications and preand postoperative care. The exploration of different surgical techniques and alternatives to surgery could also be better addressed¹⁷.

CONCLUSION

Among the ten articles selected in the present study, nine report poor and inaccurate information about liposuction. Improving the scientific quality of materials intended for the lay public on liposuction becomes imperative.