Commentary on: Patient Satisfaction With an Early Smartphone-Based Cosmetic Surgery Postoperative Follow-Up

Smartphones have become an integral part of daily life and have shaped the way people interact with the world around them. This societal paradigm shift has certainly impacted the practice of aesthetic surgery, with an increasing number of surgeons incorporating social media into their practices.1-3 Apps such as Snapchat and Instagram have allowed surgeons to connect with patients in novel and exciting ways. However, when it comes to directing patient care, an established role for the smartphone in aesthetic surgery has yet to be developed. Recent advancements in healthcare technology have focused on patient monitoring via smartphone-based follow up.4-10 Though data in the plastic surgery literature are limited, largely focused on free-flap monitoring, a recent study by Armstrong et al demonstrated that mobile follow up for breast reconstruction surgery patients can reduce the number of follow-up appointments postsurgery with no effect on complication rates or patient satisfaction.7,11-14 This is particularly beneficial for patients traveling long distances to undergo routine follow up for ambulatory procedures. It is critical, however, that patients do not misinterpret mobile follow up as a replacement for in-person follow up, as the line between convenience and perceived apathy can be very fine. For smartphone-based follow up to become viable in the aesthetic surgery setting, it must improve either postoperative recovery, monitoring, or the patient experience. In the study “Patient Satisfaction with an Early Smartphone-Based Cosmetic Surgery Postoperative Follow-Up,” the authors attempt to address these issues by investigating the effect of smartphone-based follow up on patient experience and postoperative monitoring.15 Fifty-seven patients undergoing outpatient aesthetic surgery were asked to send photographs of their operative site to their surgeon between 48 and 72 hours following surgery. Responses from the surgeon were provided via either phone call or text message. Overall this study demonstrates an innovative use for smartphone technology that aesthetic surgeons could easily adopt into their practice. However, instead of asking “can this be implemented?” the more important question is “should this be implemented?” To answer that question, one must reflect on three key factors of the intervention: Impact, Cost, and Risk. From the patient perspective, smartphone-based follow up primarily provides reassurance during the recovery period. This was demonstrated by a high overall patient satisfaction rate (96.2%), particularly for patients who had previously undergone an aesthetic surgical procedure (100%). This finding was impressive given that the average patient age in the study was sixty including multiple patients in their seventies, a cohort of individuals who may not be as adept with smartphone use. In addition to patient satisfaction, smartphone-based follow up has the potential to detect early complications and improve patient safety, though the three postoperative complications from this study were all discovered over one-week following surgery and following the first in-person visit. Both these factors make smartphone-based follow up attractive to patients, and this technology could be used as a marketing tool to attract patients to your office. From the surgeon perspective, the primary benefit of smartphone-based follow up, besides discovering potential complications, is improved efficiency. This technology could reduce office phone calls and avoid unplanned follow-up visits, both of which interrupt the daily routine and work flow. If implemented in its full capacity, the technology could actually reduce the need for in-person postoperative follow-up visits altogether, which would not only streamline office efficiency but also significantly help patients traveling from afar by reducing the required number of required in-person visits.7 Smartphone-based follow up takes time, and not an insignificant amount. Imagine yourself at the end of a busy operative day, facing a pile of paperwork and a long to-do list, having to sit down to assess and respond to patients who had sent photographs over the course of that day. It is not hard to imagine that some messages may be lost, forgotten, or accidentally deleted during a busy day, which could have serious implications (see the Risk section below). Even once it becomes a part of your daily routine, smartphone-based follow up becomes an additional daily task to be completed. First and foremost, one of the most time-consuming aspects of smartphone-based follow up is that many photographs submitted by patients are not of sufficient quality to provide meaningful interpretation. In my experience, it is very rare that patient submitted photographs are of the quality depicted in this study. Common errors I have experienced include: Photographs that are out of focus Photographs so zoomed-in there is no perspective Photographs so zoomed-out there is insufficient detail Dimly lit or overexposed photographs due to use of a flash Distracting backgrounds (eg, bathroom mirrors, animals) Image inversion from photographs taken of mirror reflections Lower resolution images from older generations of smartphones and front-facing cameras Furthermore, to obtain adequate images for breast and body procedures (or true laterals for facial procedures) photographs typically need to be taken by somebody else. This can be embarrassing for patients, or even impossible for individuals who either live alone or are alone at the time that concern of a complication arises. Low-quality photographs not only make image interpretation more difficult (both over-calling or under-calling potential complications), they waste time in the subsequent back and forth with the patient to get better quality images.16 This certainly may change as the “Selfie Generation” (ie, individuals comfortable using smartphone technology for personal image capture) matures, however, the wide age range of aesthetic surgery patients will likely affect smartphone image quality for the foreseeable future.17 The preeminent risk with smartphone-based follow up is privacy. From the patient perspective, this is certainly a concern given the private, personal, and identifiable nature of the images being shared. The potential for images to be sent to an incorrect number also exists, and though this is beyond surgeon control, remains a potential embarrassment for patients. From the physician perspective, an entirely different set of privacy risks exist. Although a photograph sent by a patient to their physician does demonstrate implied consent, it is how that photograph is managed by the physician that may lead to potential risk, particularly violations of the Health Insurance Portability and Accountability Act (HIPAA). Even on a device that is encrypted and secured, images may be automatically backed up to a cloud-based server, stored on the device, or available through an unsecured wireless network without the recipients’ knowledge.18,19 Physicians must know exactly how their smartphone is configured and their data are managed to ensure the security of patient photographs and avoid HIPAA violations.20 I recommend reading the article “Digital Photograph Security: What Plastic Surgeons Need to Know” by Thomas et al as a primer for the management of digital photograph in practice.19 Yet, perhaps the most concerning result in this study was the 2 patients who were not contacted to acknowledge receipt of their photographs. It is no surprise these were the only patients that did not report a positive experience. However, these missed replies represent a much more significant problem; it speaks to the bigger issue of digital communication between physicians and patients. E-mail and text messaging have created communication channels that are open 24 hours a day, 7 days a week. With constant access, we have become an impatient society; we expect that important messages will be read and responded to promptly. But what defines “prompt” may vary significantly between individuals. At present, there is no definition of appropriate response times for digital communication, and unfortunately, unlike e-mail, standard text messaging does not offer automated replies. While the American Medical Association has created guidelines for e-mail communication with patients, similar guidelines for text messaging remain under development.21,22 This lack of guidelines and recommendations leaves the door open for liability. One must consider the potential medicolegal implications of smartphone-based follow up before embarking into this new frontier of patient interaction. For example, what happens if a patient sends a photograph showing a significant complication developing and they do not receive a response? One would hope that if a problem existed, the individual would persist in their communication efforts. However, for various reasons, the patient may instead wait for a response prior to seeking medical care or assume the lack of communication was an indication that medical care was not required. Or what happens if a physician does not recognize a complication in a photograph, either due to poor image quality (see Cost section above) or the complication being either difficult or impossible to detect through a photograph (ie, deep vein thrombosis or pulmonary embolism). While these “What if…” scenarios may seem unlikely, it is important to considering these issues prospectively to avert medicolegal risk in the future.23 There is no doubt that the way we practice medicine will evolve as technology continues to develop. Smartphone-based follow up presents an innovative method for aesthetic surgeons to connect with their patients during the postoperative period. For any surgeon considering digital communication with patients, it is important to educate yourself as well as your patients on the rules, regulations, limitations, and potential complications associated with this method of communication. The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The author received no financial support for the research, authorship, and publication of this article.

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