Plastic Surgery Predictions for 2010

Remember the old Johnny Carson sketch, "The Great Karnak"? Well, these predictions may prove to be about as accurate, but here goes...

1. Botox vs. Dysport. So far, this corporate shoot-out has been pretty low-key. But I expect the marketing and tug-of-war between the two corporate behemoths to increase significantly in 2010, as people (both patients and physicians) become more comfortable with Dysport. IMO, there's plenty of room for both in the ever-expanding non-surgical market. Of course, the real game changer is Revance Therapeutics' topical formulation - Botox cream. But that's probably a few years away yet.

2. Market Consolidation. I expect two forms of market consolidation in 2010, continuing what we were seeing in the rough economic waters of 2009. Smaller product lines will either drop out, or be absorbed by larger corporations. Mergers and buyouts of small to mid-size aesthetic companies will continue, as we've seen in the laser industry in 2009.

3. Increasing regulation of medi-spas. It's taken a while, but regulators at the State level are beginning to wise up that medi-spas are doing treatments and procedures that until recently, were only done in physicians' offices or surgery centers. So, they should have similar safety regulations and oversight. The recent med-spa related liposuction death in Florida has added fuel to this fire.

4. Pragmatism towards current minimally-invasive procedures. When ever any new technology is introduced, there are 3 phases: an excitement / hype phase, a reassessment phase, and the final "here's-the real-deal" phase. I'm hopeful that in 2010, we'll be approaching the pragmatic phase about laser-assisted liposuction (LAL), and that we'll see more good science about the degree of skin tightening that LAL really produces.

5. Continued interest in fat grafting. Especially once the technology for turbo-charging fat grafts with stem cells gets approved by the FDA, this is the next "big thing" in both aesthetic plastic and reconstructive surgery.

6. Will the "gummy-bear" breast implants arrive in 2010? Maybe in the second half of the year. The real question is whether American women will accept the trade-offs of larger incisions and the "super-firm" feeling of the implant for a possibly lower contracture rate and lower rate of gel migration. I think textured, standard gel implants will undergo a surge in popularity - especially for revisional cases.

7. More "me-too" products. Whether it's in the injectable filler, botox, or laser arena, I think companies will try to introduce their spin on currently existing products, to gain a share in the lucrative cosmetic market. There will be more HA fillers, more fractional lasers, more liposuction devices - each touting that their product is "just as good as Brand X". (The FDA 401 (k) equivalency process encourages imitation, rather than innovation.) This will, of course, be more confusing for consumers. If the new products don't catch on rapidly, I suspect, prediction # 2 will take place, and the product will sink out of sight, more rapidly than before. Better then, to stay with the tried-and-true / market leaders.

That's all Dr. F. has for now. Happy New Year, everybody!

Good Plastic Surgery

Why don't you ever see tabloid headlines about "Good Plastic Surgery" or "Great Botox"? Or maybe "Fantastic facelift" or "Tremendous Tummy tuck"?

Well, besides the fact that 1) sensationalist headlines sell papers, and 2) we all have an excessive sense of curiosity about all things related to celebrities, regardless of their actual talent level, good plastic surgery should be basically undetectable. It shouldn't be the first thing you notice when you look at someone for the first time.

Good plastic surgery is about restoring or enhancing what is known as "the beautiful normal" - that is, the attractive end of the bell curve distribution of normal anatomy. A good facelift, for example, should smooth the cheeks, eliminate the jowls and correct the neck, but without obvious scars, or any peculiar "pulled" appearance, so everything looks like it did five or ten years earlier.

"Good" botox should just soften the expression lines of the face, and not leave the person looking frozen, or devoid of expression. Nor should it drop the eyebrows, creating an appearance reminiscent of Mr. Spock. (the Vulcan, not the author-pediatrician!)

"Good" lip fillers make female lips look young and luscious, and not like two sausages next to one another.

"Good" breast implants do not look bolted on, or like two cantaloupes. There should be a soft-looking, flowing shape that is proportional to the woman's frame.

"Good" eyelid surgery doesn't make you look permanently surprised, gaunt, or feline. It merely removes overhanging skin or puffy fat, letting the natural beauty of the eye show through.

And none of it should be obvious. It should be a "Did she or didn't she?" and not "OMG! Look at her!"

Bad plastic surgery distorts a feature so that it stands out from the rest, but not in an attractive, harmonious way. As one of my professors used to say, "Bad plastic surgery shouts, but good plastic surgery only whispers..."

As for the answer to the enduring mystery of why so many Hollywood celebs get some bizarre-looking work done - well, I'm as stumped as you are. One would think that these celebs, with their money and connections, would know which plastic surgeons are the good ones in town...

When Bad Lips Happen to Good People

One of the hallmarks of unfortunate plastic surgery in many celebrity photos is the overdone lip augmentation. The lips in these photos generally appear overstuffed, like two tubes, or two sausages lying side by side.

The real reason that these results are bad is that the idea of creating a beautiful normal lip has gone out the window! Real lips have many subtle features in their shapes - and beautiful lips maintain these features. Unskilled practitioners just "pump in" fillers without regard for the details of the anatomy. Skilled practitioners shape and enhance the underlying forms.

For example, the upper lip and lower lip are not the same size. Usually, the lower lip is about twice the height of the upper lip. It's important to maintain this 2:1 ratio when enhancing lips. If the lips are made to be the same size, this will make the upper lip appear excessively large, which is not desirable.

Secondly, lips have subsections or segments to them. The upper lip has three segments, the lower lip has two. It's important to recognize these segments and maintain their individual shapes when performing lip enhancement with fillers. For example, since the lower lip should have two symmetric halves, with a slight depression in between - the plan for the filler treatment should be designed this way too.

The central portion of the upper lip and the adjoining skin is particularly unique, with features known as "cupid's bow" and the "philtral columns". A well done lip augmentation preserves and enhances these normal contours, rather than obliterating them through excessive filling. Plastic surgeons have a unique understanding of the anatomy of the lip, as the surgical repairs for children with congenital cleft lip problems also require the restoration of these same anatomic features with careful attention to subtle anatomic details.

In addition to enhancing the outline of the lips, adding volume to the lips is also helpful to restore a loss of lip fullness that happens with aging, or to enhance the look of lips that were naturally thin. Once again, respect for the segmental lip anatomy is key to getting a good result. So is restraint.

Excessively sized "pillow lips" will not look attractive, no matter how you do them. Sometimes patients get carried away with their desires for lip fullness... and the results may look peculiar. In these cases, a responsible physician will have to tell the patient, "No - that won't look good."

The bottom line:
1. Careful communication about the desired result with your practitioner is essential.
2. Start small / be conservative at first, using a more subtle approach.
3. Avoid long-lasting or permanent fillers, such as silicone, radiesse or artefill, in the lip. If there is an unsatisfactory result, you could be stuck with it. The options for correcting lumpy looking permanent fillers are very limited.
4. Look at lots of before and after photos when evaluating the previous results of your practitioner. Your injection specialist should have a light touch and an artistic eye. If you see some of the problems we've discussed here, go elesewhere!

Happy Father's Day!