Paging Dr. Internet, we need a diagnosis. In this series, Mashable examines the online world's influence on our health and prescribes new ways forward.
It seemed like the cosmetic dermatology appointment of dreams: Patients could find "champagne and snacks" at the ready in the "luxurious and clean" atmosphere, while longstanding-acne made way for "tighter, smoother" skin with just one procedure.
That's all from a glowing Yelp review of a Beverly Hills cosmetic surgeon. Too bad it's totally fake.
The review was purchased on a shady online marketplace, and it's just one example of a widespread issue in the medical community. Just as the desire for cosmetic surgery and minimally invasive procedures has increased — fueled in large part by influencers like Kylie Jenner, social media filters, FDA approval, and lower prices — so have fake online reviews.
And when fake reviews and cosmetic surgery merge, it makes for an especially potent, potentially dangerous cocktail, considering that patients trust review sites more than government ratings when choosing doctors.
If online reviews are where people turn before a cosmetic procedure, they'd better be legit — which is what makes it so troubling anytime they aren't.
A recent lawsuit involving a plastic surgeon linked to the Kardashians and a sweeping investigation into fake reviews reveals that some online reviews for cosmetic surgery practices are just as fake as the lip fillers they inject.
When the user reviews aren't by actual users
The Kardashian stronghold on current beauty ideals is powerful enough that, if someone were looking to get, oh, say, lip fillers, it's not a stretch to think they might take a look at the social media presence and online reviews of a cosmetic dermatologist publicly affiliated with them, Dr. Simon Ourian.
Thanks to repeat appearances on Keeping Up With the Kardashians, in which various members of the Kardashian clan received procedures from Ourian, he's built a formidable social media following, with 3.5 million Instagram followers and over 82,000 TikTok followers all likely eager to know more about the man helping shape the features that sparked the nickname "Instagram Face" (high cheekbones, pouty lips, come-hither eyes, and crystal clear skin).
But Ourian has also been looped into an investigation into the fake review marketplace and its troubling overlap with those who perform cosmetic procedures.
Kay Dean, a former fraud investigator for the Department of Education in the '80s who now operates Fake Review Watch, a YouTube channel dedicated to identifying instances of fraud on review platforms, recently pinpointed fishy online reviews about Ourian and Miami-based plastic surgeon Dr. Adam Rubinstein.
Dean's discovery stemmed from another venture. She uncovered a network of more than 1,200 businesses across North America that she says used fake reviews. Her work inspired a CBC investigation about the network, which confirmed her reporting.
A few years ago, Rubinstein noticed an influx of one-star reviews on his online review profiles from patients he'd never heard of before. He had an assumption about where the negative reviews from the mysterious patients might be coming from: Not long before they started popping up, Rubinstein had posted a video about Ourian on his own website as part of a series in which he analyzes the trustworthiness of other cosmetic surgeons.
Rubinstein alleged Ourian paid for fake negative reviews as retaliation for the video in a defamation lawsuit filed last year. Ourian also sued Rubinstein for defamation over the video. In September, a federal judge in Miami ruled Rubinstein didn't have enough admissible evidence to prove Ourian coordinated the negative reviews and struck down Ourian's defamation claims over the video too.
Ourian says his ability to comment on the lawsuit is limited but says, "I never understood the allegations except for the fact that I think he just wanted to have some type of a connection to say we're competitors, which we are not."
Rubinstein says he contacted Google to remove the fake reviews, but described the process as laborious. "I had to keep contacting Google and say, 'Hey, this has not been taken down. Here's your email saying that you know that they're fake, you're going to have them removed, and they're still not removed,'" Rubinstein says. A Google spokesperson says the company had identified and removed "policy-violating reviews" on Rubinstein's profile, but wouldn't confirm whether or not Rubinstein had contacted the company about removing reviews.
That wasn't Rubinstein's only brush with potentially fraudulent reviews. Dean found other potentially fake Google reviews for Rubinstein, too — but these reviews praised Rubinstein. Rubinstein analyzed the reviews Dean identified based on his patient records and concluded that some were indeed fake, while others turned out to be legitimate.
Meanwhile, Rubinstein vehemently denies that his practice paid for fake reviews. "Beyond the shadow of any doubt, without any confusion, I have never, I would never, and will never pay, solicit anyone to write a fake review about my business or anyone else's business," he says. He alleges that a few fake positive reviews could have been thrown in to tarnish his credibility.
Ourian also says his practice, Epione Beverly Hills, has never purchased online reviews. He adds that Epione is in high demand, and that most of Epione's clients likely don't read the practice's online reviews, instead choosing to go to Epione based on word of mouth and celebrity clients.
For the bulk of Dean's investigations, she's been unable to prove the businesses themselves solicited fake reviews, only that fake reviews appeared on their Google, Yelp, Vitals, or other review pages.
Still, she speculates that the businesses receiving fake positive reviews are the ones soliciting the service of online brokers, because they're the ones who benefit. "They may say, 'I had nothing to do with it,' but it's your practice," Dean says.
Dean's investigations typically hinge on identifying profiles that review businesses too geographically disparate for believability in such large numbers — and then digging deeper, with interviews when possible, into where these reviews are coming from. In the case of Rubinstein's practice, Dean identified 40 accounts with suspicious activity that posted reviews: Thirty-two of them happened to review the same nationwide lawn care company, 30 reviewed the same home security system, 14 reviewed the same Orlando pediatrics practice, while 10 reviewed the same pizza shop in Toronto.
Patterns like this are the red flag, in Dean's experience, that suggests a broker solicited fake reviews on social media, then provided scripts for reviewers to upload. Fake reviews are often first generated in large, private groups on Facebook, where brokers, usually operating overseas, buy, sell, and trade them.
Repeated suspicious attempts to manipulate
In Facebook groups dedicated to exchanging fake reviews, someone with the username Robert Mishel was soliciting Yelp Elite members to post reviews for Epione Beverly Hills for payment, as seen in the screenshots below. (Ourian says he has "no idea" who Mishel is.)
Tiffany Phan, who at the time was a member of the Yelp Elite Squad, a community-oriented program for passionate and trustworthy reviewers, took Mishel up on his offer. She was unemployed and in college when she first joined groups on Facebook dedicated to trading fake reviews.
These groups exist for the sole purpose of exchanging online reviews, may have thousands of members, and frequently change names to avoid deletion, Dean points out. Meta, as the company formerly known as Facebook is now known, says that the groups at the center of Dean's investigation, such as Yelp Facebook Advertising, FB Review Exchange, and Yelp Review Exchange, have since been removed for violating fraud and deception policies.
For obvious reasons, it's tough to get at the exact number of fake reviews on the internet, but the number of fakes removed from review sites helps give a sense of scale. In 2020, Google said it removed or blocked 55 million reviews. Trustpilot, a consumer review website, said it removed 2.2 million. Yelp, which relies on a mix of software and human moderation for filtering out questionable reviews, hosted 18.1 million reviews in 2020, about 25 percent of which were "not recommended" by the platform's software, which separates out potentially unreliable and solicited reviews. (An additional 4 percent were removed by Yelp's user operations teams.)
"I can make $80 in five minutes."
Phan initially wrote Yelp reviews because she was a genuine foodie, but says "it became something else" when she discovered the quick and easy cash she could make in the fake review game. "I can make $80 in five minutes," Phan says. "I wasn't thinking much about it. I was still in college, and I was thinking, 'Oh, this might help a business out.'"
She re-posted the Epione review Mishel supplied, and got $50 via PayPal for her services from someone named Mohinul Khan in New Zealand, who Dean alleges is an offshore review broker likely using an alias.
In addition to Phan, Dean identified 10 other Epione reviewers on Yelp who reviewed suspiciously disparate businesses such as a moving company in Arizona and a law firm in Toronto.
At the time of writing, Epione's Yelp page has about 600 reviews, roughly 42 percent of which aren't recommended. Yelp has additionally removed 165 Epione reviews for violating its terms of service and placed Consumer Alerts, which warn of abnormal or misleading activity, on Epione's page three times.
For years, Yelp has "responded to suspicious attempts to manipulate Epione Beverly Hills' ratings and reviews on Yelp," a Yelp spokesperson said.
Yelp also put a Compensated Activity Alert on Epione's page in 2016 in order to "warn consumers that the business was caught incentivizing positive reviews for free lip augmentations," according to the spokesperson. "Yelp also placed Suspicious Review Activity Alerts on the business page in January 2020 and February 2021 after detecting reviews from users who may be connected to a group that coordinates incentivized fake reviews."
These alerts get removed from Yelp pages after 90 days if the offending behavior stops, which it did for Epione, the spokesperson says.
Yelp "has closed a total of 46 user accounts after confirming they were paid to review Epione Beverly Hills’ Yelp page," thus far, the Yelp spokesperson adds. Phan says she was banned by Yelp, and stopped providing reviews for brokers after talking to Dean for her investigation and realizing the harm her fake reviews could do to consumers.
Consumers in the wilderness
Regardless of a fake review's source, with people's health on the line, a major cleanup of online reviews is necessary, Dean says.
"There's a number of things that need to be done that aren't happening," Dean adds. For starters, she thinks prosecutors and regulators need to "step up and start holding the companies that are faking reviews accountable," for what amounts to false advertising.
She also wants to see tech companies held accountable for fraudulent reviews appearing on their platforms. To that end, Dean, like many others, thinks Congress should revise Section 230, part of a landmark piece of legislation from the '90s that shields "internet computer services" from legal liability for what their users post online.
That particular part of U.S. law serves as a cornerstone for the internet we have today and, while not everyone believes it should be repealed, Section 230 has come under increasing scrutiny in the face of Big Tech's largely unfettered power. Facebook whistleblower Frances Haugen has called for the company to be held accountable for its algorithm, not just the content of its users, in order to more completely ameliorate Facebook's negative impact on users. Haugen also exposed Facebook's internal discussions about the negative impact Meta-owned Instagram has on some teen girls.
"I think the safest thing at the moment that I can pretty confidently say...is to follow content that has nothing to do with appearance."
Academics largely can't draw a perfectly straight line between social media usage and one's desire for cosmetic procedures, but that's not to say there's no link, says Jasmine Fardouly, a research fellow at the University of New South Wales in Sydney who focuses on social media's impact on mental and physical health.
Researchers like Fardouly worry that social media filters could be "shifting facial beauty ideals into something that isn't attainable without surgery. Even with surgery, anecdotally, surgeons say, 'we can't even make them look like that, either.'" Minimally-invasive procedures like Botox and lip fillers are up 174 percent to 13.3 million in 2020 compared to 2000, according to the American Society of Plastic Surgeons. Google searches for lip fillers and botox are also climbing.
Fardouly agrees that platforms need to play a major part in addressing the mental health and body image issues they intensify. That said, she also concedes that any image-based social media environment would likely create similar conditions, if only because humans naturally want to put their best foot forward, so improving one platform won't eliminate the problem.
"I think the safest thing at the moment that I can pretty confidently say that shouldn't hurt body image is to follow content that has nothing to do with appearance," she adds. "We need to challenge the ideal."
And at the individual level? Before you patronize a business, especially for a medical procedure, take its online reviews with a grain of salt. Then, as with everything you read online, check your sources.
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