You could say nonsurgical cosmetic procedures have come a long way since the late 1990s. According to the American Society for Aesthetic Plastic Surgery’s 2014 statistics, nonsurgical procedures totalled 740,751 in 1997. In 2014, there were nearly 8.9 million procedures performed.
D. NiamtuSurgeons who have practiced cosmetic surgery for many years have witnessed significant paradigm changes, according to Joe Niamtu, III, D.M.D., an oral and maxillofacial surgeon with a practice limited to cosmetic facial surgery, in Richmond, Va.
“Twenty years ago, a cosmetic surgeon was just that: a surgeon. Nonsurgical procedures basically consisted of dermabrasion, and filler treatment was limited to bovine collagen [both of which were performed mostly by dermatologists]. It wasn’t that surgeons did not want to perform nonsurgical treatments; there just weren’t many that existed,” Dr. Niamtu says.
All that changed beginning in the mid-1990s, when nonsurgical and minimally invasive procedures blossomed. This, coupled with the public’s thirst for cosmetic procedures and instant gratification, opened aesthetic medicine to a mix of specialties, including not only plastic surgery but also dermatology, otolaryngology, oral and maxillofacial surgery, ophthalmology and others, Dr. Niamtu says.
Will the trend continue? We asked our Editorial Advisory Board to comment on how they think the big picture of less invasive procedures will take shape in 2016.
In This Article:
The Neck Down
Dr. EmerBeverly Hills, Calif., dermatologic surgeon Jason Emer, M.D., says noninvasive devices have changed fat removal into a comprehensive result, including skin tightening, shaping and skin smoothing. That trend will continue, he says. Because, while the cosmetic surgery trend five and 10 years ago focused on filling lines and facial re-volumization, today’s patients are looking down at their necks, chests, hands, elbows, ankles and more.
Celebrities in skin-tight clothes and fitness trends are helping to fuel the consumer focus on body contouring. And companies are following the lead, according to Dr. Emer.
“I think companies are realizing they can’t just create devices for one thing. They want to create devices that either complement the other things that we have in those categories or [devices that do] a multitude of things, noninvasively with the least amount of downtime,” he says.
Dr. Emer says patients don’t just want fat removal in the traditional areas, including the stomach and thighs. They’re also looking into more shapely hands, elbows and knees. And they want tighter skin and less cellulite.
“For example, CoolSculpting (Zeltiq) is popular and effective for fat reduction, noninvasively. However it doesn’t really tighten much of the skin. If you combine CoolSculpting with other skin tightening devices — VelaShape (Syneron-Candela), Venus Legacy (Venus Concept) or even Thermi (Thermi) — you can get not only fat reduction, but you can get skin tightening. You can even get definition. In the case of the arms or the inner thighs, where people would typically have to go through more invasive procedures, they can do in the office and nobody would know they’ve had much done,” Dr. Emer says.
Dr. Emer says he might also combine devices, such as UtraShape (Syneron-Candela), which is fractional ultrasound for fat reduction, with CoolSculpting to enhance CoolSculpting’s effect and tighten the skin.
Balance Is Best
Dr. HirschCambridge, Mass.-based dermatologist and past president of the American Society of Cosmetic Dermatology and Aesthetic Surgery, Ranella Hirsch, M.D., says today’s patients want balance. And, often, one procedure, product or device isn’t enough to achieve patients’ goals.
“The idea isn’t to look tighter. The idea isn’t necessarily to look younger. The idea is to look better, and that’s a very different thought process. Five years ago, people would walk in and say, I want to look 10 years younger. Now, people often just want to look the best they can, but appropriate for who they are and what they are,” Dr. Hirsch says.
Take fillers, for example. More targeted filler applications address specific changes in appearance, which have the ability to impact how people are perceived, according to Dr. Hirsch. The dermatologist used that targeted approach when she recently treated a 50-plus-year-old woman who had unsightly nasal-jugal folds.
“There was a tremendous amount of puffiness, asymmetry and discoloration, and it really was bothersome to her because it really gave the impression of exhaustion and being sad all the time. And it wasn’t accurate [to how she felt or who she was],” she says. “Between judiciously selected soft tissue fillers and targeted laser treatments, she had a spectacular outcome and just looked like a rested, happy version of herself.”
With today’s array of fillers and more in the pipeline, cosmetic physicians use fillers at different planes of the skin, to address specific concerns. Some fillers are more oriented toward fine lines, others to volumization and still others to structure, according to Dr. Hirsch.
“Very rarely now do you find that you’re using one product across the face. You have this beautiful assortment of products and that’s just going to continue,” she says.
Another advance on the filler and toxin front is product longevity, according to Boca Raton plastic surgeon Jason Pozner, M.D.
“We are getting to a more mature place with toxins and fillers. We have a nice bunch of products now. The next advance will be longer lasting toxins, like [products by Revance Therapeutics],” Dr. Pozner says.
Quick Fix Meets Reality
Dr. FagienBoca Raton, Fla., oculoplastic surgeon Steven Fagien, M.D., says the hype of a quick fix is being tempered with the reality of expectations.
“Patient demand is somewhat dictating the direction of aesthetic medicine. People want minimally invasive procedures with minimal downtime and even reduced costs. And many of the options that are available have seen significant improvements in the way we’re rejuvenating faces. On one hand, that has driven the development of new products, which have fueled the industry. We’ve developed new products that are minimally invasive, injectable and even energy-based devices and procedures and so forth,” Dr. Fagien says. “However, the mixed message is that a lot of practitioners believe... that they’ve replaced some of the existing surgical procedures, which they simply do not.”
The attempt to respond to the public demand, according to Dr. Fagien, is somehow obfuscating the reality that something just cannot be corrected with a 30-gauge needle.
“And we’re seeing that not only in nonsurgical procedures, but also in minimally invasive surgical procedures, where surgeons trying to convince themselves and their patients that these are improvements over existing procedures or more extensive surgical procedures when they truly are not,” he says.
Blepharoplasty is one example.
“The attempt to rejuvenate eyes with fillers in my opinion, in some ways, has become a bit of a disaster. Many patients who get treated with injectables to the tear trough are not happy because it is not in many situations a sound solution to a very complicated problem. It is usually not a problem with the particular agent, per se, but rather a misunderstanding of the extent of what fillers can actually do here and what are the potential sequelae. Filling the lower lid with volume is not always rejuvenating. Yes, you can make some people look better. But you truly are not replacing or restoring or reversing the anatomic deficit,” he says.
Dr. Fagien says he sees patients daily who have been treated with fillers, including hyaluronic fillers or autologous fat, to the lower lid, and many of these patients are simply miserable and looking for better solutions.
“More often, they just want it out. The surgical procedures are often complex and it is not always easy to remove injected autologous fat. …Hyaluronic acid, fortunately, in most situations, you can reverse it with hyaluronidase, so you can cure some of the problems,” he says. “But another problem is sometimes people get dramatic eyelid swelling after they’ve had hyaluronic acid injected in the lower lid. Even if you remove the material, the swelling persists.”
The problem, according to Dr. Fagien, is that you’re taking a complicated problem of lower eyelid aging or tear troughs, which is not just a volume problem, and trying to solve it with just inflating it with filler.
Refining noninvasive techniques is helping to solve these issues, he says. The good news is newer fillers are being developed, which result in less swelling. And by using better techniques, physicians can avoid some of the problems of the older techniques in which practitioners injected tear troughs.
Dr. Niamtu says surgery remains king in his office.
“Many of my patients have been around the City and spent big bucks on noninvasive procedures only to remain disappointed with the result,” Dr. Niamtu says. “Other patients did appreciate small changes from noninvasive treatments, but now want a bigger change. Although, I go to meetings and hear lecturers say that noninvasive procedures are overtaking surgical procedures, it is not happening in my world or with many other surgeons.”
Dr. Niamtu says, for example, that while combined fat melting and skin tightening might someday rival surgery, we’re not there yet.
“In the meantime there exist many drawbacks. The biggest problem that I see with nonsurgical skin tightening [and] fat treatment, as well as Kybella [Allergan], is the inability to address excess neck skin. We can melt fat under the chin with freezing; we can melt fat under the chin with Kybella; but we can’t drastically affect the turkey gobbler skin and platysmal bands, and these are the main things patients want corrected,” Dr. Niamtu says. “I remain concerned about the over promotion of results from nonsurgical treatments.”
Evolving Techniques
Nonsurgical options continue to evolve for the better, experts say.
One example: The pendulum with neurotoxins and fillers is reaching a point of balance. The trends with neurotoxins, for example, have gone from overtreatment to undertreatment. Now and into 2016, it’s more in the middle, according to Dr. Fagien.
“When we used to do neurotoxins in the forehead, it was dropping everyone’s brows, and they were unhappy. Then we backed off to almost no injection to the forehead, and that’s not good either because patients complain that they still have animation lines to the forehead. So, it the pendulum has to swing to the center, again, going from overtreating to undertreating and back to the middle with better technique,” he says.
Kybella is another example. Dr. Fagien, who was involved in the FDA studies for Kybella, says he and the other investigators in the clinical trials began by treating patients with what now seems to be significantly hefty doses in an attempt to get an efficacy endpoint in a reasonably short period of time.
“The drug dosing was safe and we treated patients every month. We’ve now realized you don’t always have to treat them that heavily or that frequently, and you can still get the same results with less cost. So, I think we’ve now backed off,” he says.
In 2016, Dr. Fagien says he is looking forward to the anticipated approval of a topical neurotoxin. His excitement, he says, is more around a topical’s ability to improve skin quality.
“I think, in general, we know that neurotoxins do more than just chemo denervate muscles. We know that they have some effect on the qualitative improvement in the skin,” he says. “But a topical as a chemo denervation agent for areas like glabellar frown lines probably isn’t likely going to work very well.”
Disclosures:
Dr. Emer is a consultant/luminary and does clinical trials for Syneron/Candela, Venus, Thermi and Kythera.
Dr. Pozner owns stock in Revance.
