Nice summary of 2009 plastic surgery trends in the Wall Street Journal, showing the effect of hard economic times on elective plastic surgery volume.

I’ve reproduced it, below. I’ve added some editorial comments in parentheses.

In addition, you can see the latest ASAPS statistics on plastic surgery, by clicking the link here.


By ANJALI ATHAVALEY, Wall Street Journal

The number of cosmetic-surgery procedures in the U.S. sagged for the second year in a row in 2009, according to an annual survey released Tuesday by a plastic surgeons’ association.

There were 10 million surgical and nonsurgical procedures last year, down 2% from 2008, according to a survey of 928 board-certified physicians by the American Society for Aesthetic Plastic Surgery, a Garden Grove, Calif., group of plastic surgeons specializing in cosmetic surgery. (ASAPS is the largest, most important group of cosmetically-oriented plastic surgeons.)

Driving the decline was a 17% drop in surgical procedures, to 1.5 million surgeries. “People just couldn’t go for the big items,” said Renato Saltz, the association’s president.

Tummy tucks, rhinosplasty and other surgical procedures can cost thousands of dollars more than nonsurgical measures, and they require a longer recovery. (But of course, the surgeries do much more than any non-surgical alternative.)

Indeed, fear of job loss is the main reason people are putting off their surgeries, says Phil Haeck, president-elect of the American Society of Plastic Surgeons, a separate group that has yet to release its annual survey. Dr. Haeck, a plastic surgeon in Seattle, said that marks a shift from last year when consumers cited cost as a primary hurdle. This year, “job priority is number one, cosmetic surgery is number two,” he said.

Breast augmentation beat out liposuction as the most popular surgical procedure for the second year in a row. Dr. Saltz attributes renewed popularity of breast augmentation to the 2006 Food and Drug Administration decision to lift the ban on cosmetic use of silicone breast implants. Breast augmentations numbered 311,957 last year, down 12% from 2008; liposuctions numbered 283,735, down 17%.

Nonsurgical procedures, such as injections of Botox or hyaluronic acid to fill facial wrinkles, were flat, inching up 0.6% to 8.5 million.

Two surgeries are surging in popularity. Buttock lifts, which involve reshaping of the bottom, increased 25% to 3,024 procedures, and buttock augmentations increased 37%, to 4,996. Increasingly, people want to reshape their rears after losing weight, Dr. Saltz said.

The procedures, costing from $4,000 to $5,000, are fairly new, with both benefiting from recent technique improvements, he added. As the economy recovers, more baby boomers are expected to seek procedures, and more physicians will likely offer nonsurgical options. Surgical procedures have increased by 50% since 1997, while non-surgical procedures grew 231%. Places like health clubs and spas are already offering minimally invasive procedures. (Not recommended!) Cosmetic-surgery associations recommend that consumers seek out procedures that are conducted under the supervision of a board-certified physician.

They should also do research before going overseas for cheaper rates for surgical procedures, which physicians say is a growing trend. “Right now, there is not an association that verifies that the physician is appropriately trained to do what they are doing,” said Dr. Haeck. “Very few of the countries where these are being offered have anything that approximates the rigorous boards in the United States.” (Canada is one exception – their training standards are equivalent to the U.S.)

It’s not uncommon for women who have already had a breast augmentation some years ago to come and consult with us about an implant exchange. Most commonly, this is for reasons of wanting a different size; most often a little bit larger, sometimes a little smaller. People do change their minds about the look they want, compared to their original implant choice, and we understand that.

In situations like these, where the breast is soft (doesn’t have capsular contracture) and the pocket where the implant sits is in good shape, we can do what’s termed a “simple” implant exchange surgery.

This involves helping the patient select the desired new size and shape, and going to surgery to replace the older implants. There’s definitely a skill to selecting the new implant – and we’ve got a few little tricks for this!

With the resurgence in popularity of silicone gel implants, many women who first had breast implant surgery back in the “saline-only” era often consider switching to silicone gel implants. Here at our Orlando practice, four out of five patients who have experienced both types of breast implants tell me that they far prefer the gel implants. Gel implants also help to reduce wrinkle and ripple problems in the slender patient with saline implants. Using a different implant shape can also be a helpful suggestion. This keeps the implant width proportional to the patient’s frame, but allows more (or less) fill up front, where most patients want it.

At surgery, we can typically use the same surgical incision – so there are no new scars. And if the old scar has widened out, we get a chance to revise it during surgery, and hopefully get a nicer looking scar.

Most women are pleasantly surprised: the recovery from a “simple” implant exchange is usually very easy, with little pain, bruising or swelling. Since the pocket for the implant is already present, and only few small adjustments need to be made to the tissue pocket, the recovery is much quicker.

More complex implant exchange surgeries involve the correction of tissue stretch or pocket expansion, or the correction of scar tissue / capsular contracture issues. As the name suggests, these surgeries are much more involved. But that’s a topic for another day. Cheers!!

According to the readers poll over at, here is the “rogue’s gallery” as of today – the procedures at the bottom of the barrel on the “was it worth it” scale. The 20% satisfaction rating for lipodissolve, for example, means that 80% of people didn’t think it was worth the cost.You can see the full list here (link)Procedure………Percentage satisfied………Average cost


Mesotherapy …………32%………………………$2282

Lifestyle lift…………..28%……………………..$5470

Cellulite treatment……25%……………………..$2557


Astute readers of this blog will recognize many of these offenders from previous posts and discussions! Four out of five of these procedures have minimal science or proof of efficacy to back them up.

Interestingly, the Zerona non-invasive fat zapping laser was not on this list. But this device didn’t rate well either: Realself voters only gave the Zerona a 20% rating, which ties with Lipodissolve for last place. Ouch!!

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!

A lip lift is a procedure that pulls the red area of the lip, known as the “vermilion”, upward. Recently, I have been seeing some websites that advertise this procedure, to help the mouth area look more youthful.

First – some background. There are two main families of lip lifts. The first type of lip lift can be done with an excision of skin in the area where the lip joins the skin. This is called a “vermilion advancement”. The second type of lip lift is done with an excision of skin just beneath the bottom of the nose. This second type of procedure is sometimes called a “subnasal” or “bull-horn” lift, after the shape of the incision around the bottom of the nose. Both advance the vermilion upward. Lip lifts can be potentially useful for people that have an excessively long upper lip – either naturally or through aging.

The problem: like any incisional surgery, these lift operations do leave scars, which typically can look lighter than the surrounding tissue, making them hard to disguise. This is particularly true with the vermilion advancement method, in my opinion. With masterful surgical technique and perfect healing, the scars can look acceptable. With anything less, the scars may not turn out so well. It’s a bit of a a gamble.

One variation on the vermilion advancement lip lift idea involves only lifting the corners of the mouth. This gives a “happier” appearance for those people who naturally have a downturned mouth. Master surgeon Dr. Robert Flowers has written about this – he calls his operation the “Valentine anguloplasty”, because the tissue removed resembles a Valentine’s day heart shape. While he makes it look good, not all surgeons are in the same league… If overdone, it can make the lip shape look artificial or even Joker-like.

Lip lift operations have their fans. I’m not one of them. I personally do not perform this operation as a cosmetic procedure for young or middle-aged women, out of respect for the troublesome scars that can occur, even with good surgical technique. In most cases, I prefer to do lip improvement by using fillers and treating wrinkles around the mouth with either laser resurfacing or chemical peels. I would recommend caution if you are considering a lip lift.

Finnair, Finland’s biggest airline, has an offbeat new idea for frequent flyers: Exchange your air miles for plastic surgery!

According to the airline’s website, the cosmetic procedures are performed at the Nordstroem Hospital in Helsinki. All the usual procedures can be obtained with air miles – but it takes one heckuva lot of points! Earning the 3.18 million points for breast augmentation surgery requires 120 round-trip, business-class flights between Helsinki and New York, according to a points table on Finnair’s Web site.

Customers who want to redeem their air miles for cosmetic surgery must first book a 95-euro consultation at the hospital before using loyalty points for the surgery voucher.

This is prime material for late-night comics! What will they think of next?

Just as a tummy tuck can really help people who have a lot of loose skin on their abdomen, a lower body lift is the corresponding operation for people that have significant amounts of excess skin on their lateral (outside) thighs or buttocks. It tightens the lax skin over the “saddlebag” area and buttock by removing the extra stuff, but it does not typically affect the inside of the thigh. Think of grabbing a fold of fabric on your pants in the saddlebag or upper buttock area, and pulling upwards, getting a nice, smooth result.

Most commonly, a lower body lift is done for people that have:
a) lost a major amount of weight through gastric bypass surgery or diet,
b) have had previous liposuction in the area, but have a deflated, loose result,
c) are just plain unlucky, and have a lot of loose skin in that area.

Yes, there is an incisional scar, which is designed so that it is hidden by a standard bikini or swimsuit. The scar is the trade-off for the major tightening of this procedure. So, in other words, this is not an operation for people that just have a little cellulite, related to minor degrees of skin laxity.

If the patient has already had an abdominoplasty, the lower body lift simply extends the incision around the back, curving over the top of the buttocks with a “heart-shaped” design. Some surgeons use a horizontal “belt” incision, but I feel that the curved design works better for women, as it emphasizes the buttock shape in a more attractive way. Most times, there is so much lifting on the sides of the abdomen that I have to re-do the outer portions of the tummy tuck scar!

If the patient has a little extra fat in these areas, some liposuction can be done at the same time. Generally, major liposuction of these areas is done as a separate procedure. Most experts do liposuction first (given decent skin elasticity), then we complete the reshaping of the outer thigh with the lower body lift.

Not all plastic surgeons do this operation routinely, so look for someone who does lower body lifts on a regular basis as part of their busy “body-work” type of practice.

You might need a breast lift (mastopexy) if one or more of these ten reasons sounds familiar to you:

1. You prefer the breast shape you get when you lift your breasts upwards with your hands.
2. You want your breasts to be “perkier”.
3. Your breast size is good, but they are “too low”.
4. When standing, one or both of your nipples point towards the ground.
5. When standing, one or both of your nipples are at or below the level of your breast crease.
6. You can’t go braless in any kind of top.
7. Your breast skin is loose, very stretchy, hangs or sags, because of weight fluctuations, pregnancy or breast feeding.
8. You like your breast shape when you stretch your arms above your head.
9. You look short-waisted because your breasts are covering your upper abdomen.
10. If you want your nipples to be positioned higher on the breasts.

Breast implants, by contrast, do not lift the breast. They can add volume, increase roundness, give more upper pole volume, increase projection and fill up loose breast skin – but implants do not lift.

If you have one of these 10 reasons, and want the breast to be larger as well – a combination of breast augmentation and lift may be an option for you.

Back in the dark ages, plastic surgeons recommended breast implants based only on their total volume.

Now, most modern surgeons realize that it is important to measure the patient’s rib cage width, and match the width of the implant to the width of the patient, in order to obtain a result that looks attractive, proportional, and avoids an overly wide cleavage gap or excessive lateral (side) fullness.

In addition to picking the right size, there are several choices of implant shapes available. These are called “profiles” by the manufacturers. Choosing the right profile makes a major difference in the final appearance of the breast shape.

Many patients are unaware of these possible choices before their consultation with us, and have only thought about the number of cc’s in the implant or the cup size they want. A useful question to consider is “How much fullness do you like in the upper part of the breast?” Someone who want a lot of fullness will pick a different implant than someone who just wants a little.

The most popular profile (implant shape) in our practice, whether it be silicone or saline filled, is a medium profile implant. About 70% of our patients choose this shape. It gives an attractive fullness in the upper part of the breast, but not “too much” for most people’s taste. I call this the “Victoria’s Secret catalogue model” look, and the proportions work well for most average frame patients.

The second most popular profile is the “high profile” implant. It gives more roundness and fullness in the upper part of the breast. For women that have a narrow ribcage and still want a generous implant volume, the high profile shape is worth considering. For women that want a larger, fuller implant without going to a wider implant, sometimes switching from a medium profile to a high profile implant is also a useful option. About 20%-25% of our patients choose this shape. But it’s a “love-it-or-hate-it shape”; some women think it looks a little too overdone or obvious, especially in the larger sizes, while some women find it sexy and attractive. It’s all personal taste.

The low profile implant is the third choice. It works for women that have a broad ribcage, but for whom the other profiles would give an implant volume that would be excessively big. It’s a more conservative and “natural” look, and gives less projection or upper pole fullness compared to the other two profiles.

While some surgeons strongly recommend high profile implants for women considering a combination breast augmentation / breast lift surgery, I do not insist that women make that particular choice. It is true that a higher profile implant has a greater arc length over its highly curved surface, and so it fills up more loose skin compared to the lower profile implants. However, the patient may not want the size or shape that a properly selected high profile implant gives. I think its more important to the final result to pick the implant size and shape that the patient wants first, and then tailor the mastopexy around that as needed. In my opinion, this is much more likely to make the patient happy in the long run.

In our experience, there’s no substitute for proper measuring, followed by trying on actual implant sizers in a sports bra and T-shirt. Once women see how it looks in the mirror, it’s amazing how rapidly they are able to sort out the many different choices. Once they see the look they prefer, most women know it almost immediately! It’s kind of like trying on shoes: you know if they fit or not.

Everything evolves. When cosmetic fillers were first used, we applied them to the problems of wrinkles – and they worked pretty well. Then we used them to enhance lips, and then to enhance cheekbones, and to smooth out jawlines…and the list of uses kept on growing.

This ever-increasing use of fillers has directly led to the concept of the “liquid facelift”, which is simply the use of a significant volume of injectable filler agents to add volume to the face. When done appropriately, and done well – the technique can look good, restoring the lost contours of youth, at least for a time, until the costly products are absorbed by the body. But like anything, it can be overdone. And quite expensive.

Hype alert: the liquid facelift technique is not really “just like a regular facelift”, despite the marketing hype of some websites. The two methods work totally differently. Let’s review some of the basic differences:

– In a surgical facelift, you remove excess neck and cheek skin. Not possible with the liquid facelift technique, which works by inflation.

– In a surgical facelift, you can tighten the neck muscles and re-suspend the SMAS layer (the fibro-fatty anatomic layer between the skin and the muscles). Not possible with the liquid technique.

– Traditional facelifts (with the exception of those that use fat grafting techniques) work by tightening tissue planes. This can sometimes cause a flattening effect on soft-tissue facial curvature.

– The liquid techniques work by inflation or “re-volumizing”, and can add fullness to areas that would otherwise be difficult to correct. Traditional facelifts can sometimes shift soft tissue fullness by re-distributing or lifting tissues, but they don’t add new volume.

– Surgical facelifts typically have an effect of 8 to 10 years, on average. Injectable products, even the newer, longer-lasting ones, last 1-2 years at most.

So, the two procedures are not directly comparable. Don’t be fooled – choose the right procedure for your particular needs. If you have a lot of lax skin, get a surgical facelift. If you have loss of facial volume issues with minimal skin laxity, then you might be a candidate for re-volumizing with fillers. Your plastic surgeon can advise you.

I’m also starting to see patients who have been over-treated with the facial fillers. It used to be just the lip area – but now it’s the entire face that is involved. Since there isn’t an official name for this, I’ll call it “puffy-face syndrome”. Features of “Puffy face syndrome” that I’ve seen include:
– generalized swollen or bloated look to the face, due to the over-injection of filler agents, which is out of keeping with the pre-procedure appearance;
– excessive fullness in some or all of the injected areas: brow, cheekbones, paranasal and perioral areas;
– obliteration of normal naso-labial creases.

Interestingly, many of the patients that I feel are over-injected seem to be somewhat addicted to their filler treatments. When I tell them “no, you really don’t need any more volume” – they react with shock and disbelief!

So, while I think that facial fillers are useful, they are but one option among many for the treatment of facial aging. Too much filler can lead to Puffy Face Syndrome! This is another example of how aesthetic judgement is important.

Plastic Surgery In Florida