Aesthetic Medicine in 2020: A Year in Review

COVID-19 shook the foundation of cosmetic practices worldwide in 2020. In the span of eight months, the pandemic forced aesthetic medicine offices to close, stay afloat, then rev up to accommodate pent-up demand for injectable treatments and more.

With one swift viral kick, aesthetic practices are looking through a different lens at 2021, according to Chicago-based facial plastic surgeon Steven Dayan, MD. But it is not with trepidation that experts are looking toward the future. Rather, Dr. Dayan calls this the Roaring ‘20s.

“There is going to be an explosion in aesthetics,” said Dr. Dayan, who launched the educational series “Thriving in Aesthetics” with Sabrina Fabi, MD, in October. “I think we will come back stronger.”

In support of this theory, despite the pandemic, there were advances and launches in technology in 2020, including QWO, from Endo Pharmaceuticals, the first FDA- approved injectable treatment for cellulite, Galderma’s hyaluronic acid filler Restylane Kysse and Revance launched its RHA dermal filler line.

More important than the products and devices, however, are the strides aesthetic medicine clinicians are making to adapt and thrive in the new environment, according to Dr. Dayan.

Get Ready for an Influx of Patients

Aesthetic physicians might expect an increase in business in 2021. People are spending more time looking at themselves in virtual meetings and less money on travel and entertainment. This, according to Dr. Dayan, explained the big demand for nonsurgical procedures when practices first reopened. “But now that consumers have settled into their lives and realize they can recover at home, they are booking more and more cosmetic surgeries,” he said.

“That’s the biggest story in aesthetic medi- cine this year. Nobody predicted that. We all thought there would be a huge dearth, and everything would drop off, but it has been the opposite,” he expressed.

Injectable Update

In 2020, Teoxane Laboratories (Geneva, Switzerland) received FDA approval of its RHA-based dermal fillers and announced a partnership with Revance Therapeutics (Newark, Calif.), giving the company exclusive U.S. distribution rights of the product line, which includes RHA 2, RHA 3 and RHA 4. Indications for RHA 2 and RHA 3 are for injection into the mid-to-deep dermis for correction of moderate to severe dynamic facial wrinkles and folds, while RHA 4 is for injection into the deep dermis to superficial subcutaneous tissue for correction of moderate to severe dynamic facial wrinkles and folds.

Lori Robertson, MSN, FNP-C, clinical director of Skin Perfect in Brea, Calif., has been using RHA 2, 3 and 4 samples and said these fillers are much-needed competitors in the limited U.S. injectables market.

“These products are very easy to work with,” said Ms. Robertson. “RHA 2 is similar to the Refyne line from Galderma (Fort Worth, Texas). It is soft and very stretchy. It integrates very easily into the tissue and is very user friendly. It is hard to make a mistake with it. If you get a lump, you just press on it and it flattens right out.”

According to Ms. Robertson, RHA 4, which is not nearly as firm of a filler as Lyft (Galderma), but more like the Defyne (Galderma) or Voluma from Allergan (Irvine, Calif.) lines, may be ideal for hands.

Another entry into the market is Restylane Kysse from Galderma. Having received approval for lips and perioral lines, it is making a big splash, according to Ms. Robertson.

“Kysse is a stretchy filler,” Ms. Robertson noted. “You have Refyne that is the softest filler out there, next to Belotero from Merz (Raleigh, N.C.). Then you have Kysse that does not stretch quite as much, but is still very soft. Then you have Defyne in that same line which is firmer,” Ms. Robertson expressed. “Kysse has been a true game changer in lips. Those of us who have tried it have been obsessed with it. We can achieve a simple lip that is plumper in size and hydration with a naturally augmented look.”

In other filler news, this year Allergan announced that it entered into an agreement with Israel-based Luminera, a company with an extensive filler portfolio, including HArmonyCa, a dermal filler combining hyaluronic acid (HA) and calcium hydroxyapatite (CaHA). Allergan will acquire Luminera’s fillers and filler pipeline.

Off-the-face use of fillers exploded in 2020, according to Dr. Dayan, with hyper-dilute calcium hydroxyapatite and hyper-dilute poly-L-lactic acid being used with success in thighs, the chest, buttocks and arms. “Expect to see more of that,” he said.

Ms. Robertson agreed, and said hyper-dilute Radiesse (Merz) has been a gamechanger this year. “Providers in Brazil have been using hyper-dilute Radiesse for quite some time and have had beautiful results with it. Here in America, we have only had Sculptra poly-L-lactic acid (Galderma) to use as a bio-stimulant. Sculptra causes an immune response, and we have not been able to use that in people who have autoimmune disorders. Hyper-dilute Radiesse works in a similar way, but has a fibroblastic reaction rather than immune reaction,” Ms. Robertson explained.

Ms. Robertson has been using hyper-dilute Radiesse in the face, neck, décolleté, arms and knees to create volume and rejuvenate skin. She administers it in the same way as Sculptra, using a 22-guage cannula in the subdermal plane, superficially, where there are no big arteries to cause concern. She dilutes it with normal saline and lidocaine to a 1:2, 1:3 or 1:4 dilution.

However, in Ms. Robertson’s opinion, not everything was a homerun in 2020. Approved in 2019, the “newtox” botulinum toxin type A Jeuveau from Evolus (Irvine, Calif.) has not wowed her.

“At first, I noticed it kicked in really soon like Dysport abobutulinumtoxinA (Galderma) does. But then my patients came back and said it wore off too fast,” she reported. “I tried injecting more units and results still lasted from 2.5 to 3 months, while the cost of the procedure went up.”

With this in mind, improved longevity of outcomes is the future of neurotoxins. Examples of this include DAXI (Daxibotulinum toxin) from Revance, which seeks the FDA’s nod as a longer lasting toxin, and is already causing a stir, according to Dr. Dayan.

Another case in point, as Michael H. Gold, MD, recently presented at the American Society of Dermatologic Surgery (ASDS) 2020 annual meeting in October, Xeomin incobotulinumtoxinA from Merz demonstrated safety and prolonged duration of effect in a dose-ranging study for glabellar lines. “According to the data also published in the October issue of the Journal of Drugs and Dermatology¹, these results demonstrate a dose effect of at least six months duration with higher doses in the majority of [glabellar frown lines] subjects,” Dr. Gold reported.

Ms. Robertson pointed out the good and bad of a neurotoxin that lasts six months: Most patients will love not having to get injections as often, but those with neurotoxin-related blepharoptosis or an unsatisfactory outcome – not so much.

In regards to products that can improve the injector’s technique and treatment safety, the Medical Injector Ring (miRing) from miRing USA (Atlanta, Ga.), enables one-handed aspiration. This new device is an FDA registered, patent-pending, anti-microbial silver ring device that helps injectors gain more confidence with complicated injection sites, steady their patients with their free hand and have more control and precision with needle placement. miRing can be used with 99% of pre-packaged aesthetic syringes on the market and up to a 5 cc BD syringe.

Body Treatments Come Full Circle

Body treatments are coming full circle, with treatments that not only remove fat, but also tighten skin, diminish cellulite and increase muscle definition.

Endo Pharmaceuticals (Irvine, Calif.) announced in early July 2020 that the FDA approved QWO (collagenase clostridium histolyticum-aaes) as the first and only FDA-approved injectable for moderate to severe cellulite in the buttocks of adult women. QWO is expected to be available at U.S. aesthetic practices in Spring 2021.

“Improving the appearance of cellulite has been a huge unmet need in aesthetic medicine,” said Manhattan-based plastic surgeon Sachin M. Shridharani, MD, who was involved in QWO clinical trials. “The news about QWO’s approval is exciting for patients and represents a whole new category that we can treat. Up to 90% of women in the U.S. are afflicted with cellulite, and there haven’t been great options to treat it. So, this is going to be a gamechanger.”

Nonetheless, there is still a lot to learn about how patients with mild cellulite respond to treatment, if it treats significant skin laxity and how best to use it in conjunction with other body shaping procedures for optimal outcomes, according to Dr. Shridharani.

Aesthetic physicians and surgeons are getting more experience using new magnetic muscle stimulation devices, which created a lot of buzz in 2020.

Some of the leading non-invasive devices, like FDA-approved Emsculpt and Emtone from BTL (Marlborough, Mass.) and CoolTone (Allergan) are easy to perform and have created an opportunity for aesthetic practices that focus on the face to offer off-the-face treatments.

“I am a facial plastic surgeon, so these devices allow me to offer something that I have not offered in the past,” Dr. Dayan said.

There are two new options in this space. Cutera’s (Brisbane, Calif.) truBody is a complete body sculpting solution to remove fat, rebuild muscle and renew skin. By pairing the synergistic and complementary technology of truSculpt iD and truSculpt flex, truBody provides the benefits of 2 MHz monopolar RF with an average of 24% fat reduction and direct bio-electrical muscle stimulation with up to a 30% increase in muscle mass. Both technologies utilize truControl to maximize treatment outcomes and create long-lasting effects. Multiple handpieces simultaneously covering various areas combined with short treatment times, help to increase throughput and revenue.

Another newcomer, BodyTone from Rohrer Aesthetics (Homewood, Ala.) offers results comparable to the leading muscle stimulation devices on the market. BodyTone uses micro-energy pulses of “bio-electric” current to replicate the effects of normal exercise by flexing and contracting muscles. The Bioptic impulses are delivered through a series of different waveforms that stimulate and confuse the muscle, which helps to build mass. A BodyTone treatment takes 25 minutes, with no downtime.

Now, aesthetic clinicians are combining the spectrum of therapies with liposuction to transform bodies, Dr. Shridharani said.

“We have had great success combining liposuction with the Renuvion J-Plasma system from Apyx (Clearwater, Fla.), the helium plasma that tightens tissue. Combining that with muscle stimulation is also an advanced technique that gives us a harmonious outcome,” he said.

The new Ultracontour Ng from MedixSysteme AG (Ruggell, Liechtenstein), enables hands-free treatment of arms using three UMD belts applied to each arm. What makes Ultracontour unique is the final phase of the UMDs sonodynamic treatment which involves the application of six belts, each equipped with three UMD transducers in order to immediately drain the fat cells (triglycerides) that have been destroyed and liquefied by the intensive focused pulse. This accelerates the natural elimination process through the lymphatic and vascular system.

Another unique feature of the Ultracontour is the ability of the UMD system to create an internal cyclic massage. This action leaves the fat cells in passive sonification so that during the entire phase of the UMD massage the body does not reabsorb the fat that has been liquefied from the intensive ultrasound pulses. Instead, the body is forced to eliminate this fat through the lymphatic system. This is strategic to the success of the treatment, as without it, 80% of the liquids released after the intensive focused pulses would be reabsorbed.

Threads, Microneedling and Energy-Based Rejuvenation

Threads have had a complicated and circuitous past in the U.S., but thread technology will see an uptick in 2021, according to Dr. Dayan.

“It is not a facelift or a replacement for a facelift. If the price point for threads is as high as a facelift, it is going to be met with dissatisfaction. But if the price is lower and threads are marketed as an alternative to fillers, it will find a nice place in our portfolios. One area where I am particularly interested in threads is for the nose. We know the risk with fillers in the nose is high, so I expect to see interest in potential treatments in the nose,” he said.

Aesthetic practices will likely continue to offer microneedling in 2021, but to specific patients.

“I love microneedling for the right patient, who is willing to undergo several treatments to get results,” Ms. Robertson shared. “If a patient has large pores, acne scars, if they have dark skin and cannot have CO₂ laser, microneedling is phenomenal. I notice about a 30% reduction of acne scar pits after about six months with five treatments of microneedling,” she said.

Ms. Robertson used to combine microneedling with platelet-rich plasma (PRP) because, she said, it is like adding fertilizer. But for the last eight months, she has instead used exosomes via Benev’s (Mission Viejo, Calif.) Exosome Regenerative Complex, which are harvested from the stem cell and are part of the stem cell that helps to grow new tissue.

“I have the exosomes in my fridge, mix them up and put them on the skin after I do a treatment that opens the skin, like CO₂, radiofrequency microneedling or regular microneedling,” she said. “It is like PRP amplified. It helps calm the skin. I use a little vial and send patients home with the vial and they keep using it for the next 24 hours to heal.”

Other skin rejuvenating technologies evolved in 2020. PlasmaMD from Aesthetics Biomedical (Phoenix, Ariz.) is among those. Plasma MD is a compact handheld device employing plasma technology for nonsurgical skin rejuvenation, using proprietary ARC Technology as the key differentiator. PlasmaMD and Plasma+ are FDA Class ll cleared for soft tissue coagulation and lesion removal. The treatment takes less than an hour between numbing, treatment and the beginning of the post-treatment experience. The plasma energy reacts with the air between the skin and the device to combat visible signs of facial aging. It targets improvement in skin laxity, resurfacing texture and the appearance of fine lines with minimal downtime and maximum results, according to the company.

With COVID-19 concerns, demand for at-home treatments are likely to increase. For example, Tina Alster, MD, a dermatologist in Washington, D.C., has The A Method line of products and recently introduced The AMAZING Peel Kit, an at-home, self-neutralizing TCA peel system that is suitable for all skin types. It is a safe and effective solution to address uneven texture, tone, hyperpigmentation and blemish-prone skin. The comprehensive kit features five medical grade products designed to bring uneven pigment up and out of the skin, brighten dark spots and naturally stimulate collagen production to correct texture, fine lines and wrinkles. Consistent, monthly use of the AMAZING Peel Kit will also visibly tighten and firm skin to improve elasticity and reduce pore size.

Coming in 2021 is Quanta System’s (Varese, Samarate, Italy) Chrome device, an expandable modular laser station based on a 1064 nm/532 nm Q-switched technology reinvented to outperform other skin treatments and focus on the patient’s desired aesthetic goals. This station has a wide range of applications, such as a pulsed 1064 nm Nd:YAG source, microbeam handpieces, IPL and 2940 Twain handpieces. The device’s exceptional expandability allows aesthetic clinicians to treat dermatological imperfections from pigmented lesions and tattoo removal to vascular lesions, wrinkles and fine lines, with a special focus on achieving glowing and radiant skin through non-invasive procedures, according to the company.

Perfect the Virtual You

Aesthetic practices that become proficient at virtual consults and visits will benefit in 2021, according to Dr. Dayan.

“Virtual consults will allow us to see more people in a shorter period of time and will be a better screening method. It will be a time-saver if done well,” Dr. Dayan said.

The virtual consult is here to stay, said Mark J. Tager, MD, a physician well versed in aesthetic, lifestyle, regenerative and integrative medicine, and CEO of ChangeWell (Rancho Santa Fe, Calif.), a company that helps healthcare professionals become both charismatic and powerful communicators on camera.
But like so much else, perfecting the virtual meeting is an art.

“In an ever-increasing virtual world, physicians must present themselves on- camera as caring, organized, engaging and thoughtful. This requires training and coaching for many doctors,” Dr. Tager indicated.

To help turn these virtual consults to patients, QuotePRO from DermPRO (Dallas, Texas) is a cosmetic procedure quoting tool that incorporates powerful, automated lead nurturing to help you convert consults into patients. This solution addresses the challenges that practices face in converting patients after they have been quoted for a procedure. QuotePRO is built upon DermPRO’s e-commerce expertise, incorporating digital remarketing best practices and online purchasing. After the provider creates a quote, QuotePRO’s automated messages about the practice and procedure keep the practice and the quote easily accessible to the prospect. The prospect’s engagement and interaction with emails and texts they receive trigger lead segmenting, ensuring they receive just the right messages and information they find valuable. Finally, QuotePRO’s conversion sequence helps to close patients when their lead score surpasses certain thresholds. A dashboard keeps the provider informed of outstanding quotes along with the funnel of activity and stages.

Consider Practicing More Holistically

The pandemic showed many aesthetic practices that having more than one income stream might help hedge against future problems, like pandemics.

“I think we all have to look to diversify,” Dr. Dayan reflected.

The COVID era has placed a greater emphasis on selfcare and what one can do to prevent and optimize health and beauty, Dr. Tager pointed out.

“While aesthetic providers address patients’ desires to look younger or more beautiful on the outside, they are in an ideal position to also help patients optimize results with supplements, dietary counseling and cosmeceuticals,” he added.

The truth is that patients go to aesthetic practitioners not for procedures but rather for results, Dr. Tager emphasized. “If you are a practitioner who pays attention to the fact that your patients want results, the best way to get results is to combine health and beauty from the inside out and the outside in,” Dr. Tager said.

Dr. Tager, who co-authored the book Cash-Pay Healthcare: How to Start, Grow & Perfect Your Business with Stewart Gandolf, MBA, explained that the fields of aesthetic and functional/integrative medicine have things in common starting with the fact that both are cash-pay healthcare disciplines.

Another commonality is that chances are good that patients who go to aesthetic practices also have an interest in supplements and cosmeceuticals.

“More than two-thirds of patients today take nutritional supplements. The nutritional supplement business is a $50 billion business, of which $8 billion is purchased in physician offices. And it is growing rapidly,” Dr. Tager said.

For example, given COVID concerns, today’s patients are interested in what they can do for immune support.

“Healthcare professionals – no matter their discipline – are a knowledgeable source of information and guidance. I think there is an opportunity to forge a deeper, more compelling bond with the patient by meeting their needs around nutrition and wellbeing, immune support, wound healing, scar reduction and more,” Dr. Tager articulated.

The motivations for aesthetic practices to sell supplements and cosmeceuticals should be the belief and desire that by doing so, patient outcomes will improve; followed by a desire to increase revenue, Dr. Tager added.

There is a lot that goes into standing behind wellness products.

“Everything within a brand has to be contextualized. That means a practitioner cannot just say, ‘We’re selling immune support products,’” Dr. Tager explained.

But, if a physician believes in a product, has seen its benefits both personally and anecdotally, and has examined some of the literature, the physician likely will successfully integrate it into his or her plan for holistic patient care. And patients notice when their aesthetic clinicians take an interest in optimizing overall health. It can set practices apart from the competition, Dr. Tager noted.

Doctors interested in supplement and other product sales should expand their knowledge of these products. They should also educate staff members, so they too can counsel patients. Other options are hiring a nutritional specialist or lifestyle expert or referring to a nearby expert.

Reference:
1. Kerscher, Martina PhD, Fabi, Sabrina MD, Fischer, Tanja MD PhD, Gold, Michael MD, Joseph, John MD, Prager, Welf MD, Rzany, Berthold MD ScM, Yoelin, Steve MD, Roll, Susanna Dr. med, Klein, Gudrun PhD, Maas, Corey MD PhD. “IncobotulinumtoxinA Demonstrates Safety and Prolonged Duration of Effect in a Dose- Ranging Study for Glabellar Lines.” Journal of Drugs in Dermatology. 2020; 19(10): 985-991, 30 Sept. 2020, https://jddonline.com/articles/dermatology/ S1545961620P0985X