Aesthetic practices around the U.S. – from South Florida to Park City, Utah, to New York City, N.Y. and Los Angeles, Calif. – are reporting trends that could signal long-term and robust business through 2021 and beyond.
Sachin M. Shridharani, MD Plastic Surgeon
Shino Bay Aguilera, DO Dermatologist
Kian Karimi MD, FACS Facial Plastic Surgeon
Renato Saltz, MD
Aesthetic procedures, in general, seem to be trending. In 2020 patients spent more than $9.3 billion on aesthetic procedures, including more than $6 billion on surgical options and more than $3 billion on nonsurgical therapies, according to The Aesthetic Society statistics. This represents an increase from the $8.2 billion consumers spent on aesthetic procedures in 2019, nearly 80% of which was spent on surgery, according to The Aesthetic Society.
“We have seen an all-time high in surgical procedures ranging from facelifts to significant body contouring procedures,” said plastic surgeon Sachin M. Shridharani, MD, whose practice LUXURGERY is on Fifth Avenue in New York City, N.Y. “The perfect storm of limited travel for work or personal reasons, decreased entertainment venues, and more flexibility to work from home has led to a unique opportunity for patients to undergo surgical proceduresand take the time they need to recover in the privacy and comfort of their homes, respectively. We have also seen a surge in demand for nonsurgical treatments, especially injectables.”
According to dermatologist Shino Bay Aguilera, DO, of Shino Bay Cosmetic Dermatology, in Fort Lauderdale, Fla., while some in-demand procedures are here to stay, others are more fleeting fads. For example, Bella Hadid is among the celebrities who helped stir young people’s desire for “fox eyes.” Many can achieve the lifted, almond-shaped look of the eyes with makeup, while others are visiting aesthetic practices for a more permanent option, he elaborated.
“Instead of using makeup, you can use polydioxanone (PDO) threads to pull the eyes for so-called ‘fox eyes,’” Dr. Aguilera said. “That will last maybe three months.”
However, this is one trend that Dr. Aguilera does not encourage. The skin around the eyes is thin, so while patients in their 20s might be producing the collagen and elastin to pull off the look, the already stretched skin could be more prone to wrinkling by the mid-40s when the skin is naturally less elastic.
“I think that by putting this tension on the skin, the 40-year-old versions of these young girls that are getting fox eyes will be sorry that they did it. They are going to need that upper blepharoplasty a lot earlier,” Dr. Aguilera said.
Trends like this tend to come and go. Another example, according to Dr. Aguilera, is the now waning demand for “Russian lips.”
“At least in the U.S., I think demand for the oversized lips is decreasing. People are moving towards natural is better,” Dr. Aguilera said.
Here to Stay: Everything for the Face
Mask wearing has fueled high demand for procedures around the eyes. Even if the vaccine eradicates COVID-19, mask wearing could be long term. When wearing a mask, “You can only see the upper third of the face, so a lot of treatments today focus on the eyes,” Dr. Aguilera said.
That is not to say that people do not want to address the lower face. Zoom and other virtual platforms are thought to have driven demand for aesthetic fixes for the lower third of the face and neck as well. In essence, the pandemic has spiked demand for facial aesthetic procedures.
To address aging concerns of the upper third of the face nonsurgically, Dr. Aguilera performs a “frontoplasty,” a high-risk, high- reward procedure that addresses volume loss with fillers. “It is an advanced technique that is really needed because if you look at a woman’s skull and a man’s skull, the woman’s skull is more convex. She has more soft tissue, more fat. The eyebrows are arched because they have more fat under the brow. The eyes are bigger,” Dr. Aguilera explained.
“As a woman ages, this is an area that changes with volume loss, when the forehead starts to drop and looks more masculine. We only know how to treat the upper third of the face with neurotoxins, but many of our female patients are still not happy with their faces and do not realize that the unhappiness is because the upper third of their face is becoming more masculine.”
Facial plastic surgeon Kian Karimi, MD, medical director and founder of Rejuva Medical Aesthetics in Los Angeles, Calif., said he is seeing two nonsurgical facial aesthetic trends in California.
“Threads are becoming a very popular option to subtly and beautifully lift the cheeks and jowls and can be a way to achieve the look one desires without relying on filler,” he began. “As well, chin filler is an extremely popular and hot treatment, especially with the recent FDA approval of two products for the chin, Juvedérm Voluma (Allergan Aesthetics) and Restylane Defyne (Galderma). Filler to the chin can make one’s face appear slimmer and can give a lot of harmony to the overall face, especially if the chin is delicate or deficient.”
Dr. Karimi often combines threads with either Restylane Defyne or Juvedérm Voluma. “The combination is extremely effective at giving an immediate and dramatic effect. Results typically last a year or longer,” he said.
“I see threads becoming a mainstay in the aesthetic armamentarium, as the thread technology improves and more dramatic results are able to be achieved without additional downtime or discomfort for the patient,” Dr. Karimi noted.
“In addition, as fillers achieve increasing indications for different facial areas, they will also become more popular for targeted areas. For example, there will be three fillers that are indicated for under eye circles within the next one to two years so I predict this will become a hot topic when that happens.”
While these nonsurgical options are making waves, interestingly, demand for minimally invasive procedures was down by 9% compared to the previous year. As a result, three-quarters of the work done in 2020 by members of The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) was facial plastic surgery – rhinoplasty, facelifts, eye lifts and neck lifts increased the most in 2020, thus facial plastic surgeons are among those reaping the real benefits. AAFPRS’s 2020 statistics revealed increased bookings and treatments for 70% of AAFPRS surgeons, with 90% of those reporting a more than 10% increase in business.
“Over the past few years, use of non- invasive procedures to forestall the signs of aging have been steadily on the rise. The pandemic flipped the switch, creating a surge in surgical demand not seen in recent years,” according to an AAFPRS press release.
Today’s aesthetic surgeons are doing more aggressive work on the neck, said Renato Saltz, MD (Park City & Salt Lake City, Utah), adjunct professor of Plastic Surgery, University of Utah, and past president of the American Society for Aesthetic Plastic Surgery (ASAPS) and International Society of Aesthetic Plastic Surgery (ISAPS).
“You see more and more surgeons going beyond the platysma. It used to be that the platysma was the safe layer to go to, but more and more people are going below that and addressing the submandibular glands and subplatysmal fat. They are getting much better contouring and more definition in the neck,” Dr. Saltz advised.
Demand for nonsurgical procedures aimed at off-the-face fat reduction, skin tightening and more is high, and likely will remain that way, Dr. Saltz indicated.
“The growth is clear, in Utah, in the U.S., in the world – popularity for nonsurgical aesthetic options for the body has been increasing for more than a decade, as the options like CoolSculpting (Allergan), became safer, more reliable and effective,” he continued.
“Being in practice for almost 30 years, it is a whole different world. Patients do not want to go through general anesthesia and if there is a viable option, why should they when they can sit and watch a movie while they get their flanks frozen?” Dr. Saltz said.
Dr. Saltz is seeing great results with radiofrequency (RF) microneedling. Early on, RF was applied superficially and providers saw some improvement. Now microneedling technology delivers the energy down into the dermis, resulting in much better skin tightening, he said.
Another technology to make its mark off the face is BroadBand Light (BBL), which is more effective than the old intense pulsed light (IPL) for skin tightening and improvement of sun damage, according to Dr. Saltz.
Treating cellulite seems to be all the rage lately with the recent launch of the world’s first injectable treatment for cellulite – QWO from Endo Aesthetics, according to Dr. Shridharani.
“We were fortunate enough to be involved in three of [QWO’s] clinical trials and have worked with the product enough to see amazing improvements in skin dimpling irregularities and reducing cellulite. We are seeing a huge demand for the treatment since its release,” Dr. Shridharani said.
“With the Brazilian Butt Lift trending as a popular procedure in recent years, we have helped patients achieve a better butt enhancement through nonsurgical buttocks rejuvenation, as well. Using QWO to smooth over any cellulite and skin dimpling irregularities and Sculptra (Galderma) to volumize and contour the shape of the buttocks has been a perfect partnership for nonsurgical buttock rejuvenation.”
The Brazilian Butt Lift is rising in popularity once again since the release of recommendations to make it a safer procedure, added Dr. Saltz, who is a co-chair of the multi-society Gluteal Fat Grafting Task Force.
“The Brazilian Butt Lift is much more popular in South America than it is here, but Florida and California see a lot, even Utah sees a lot,” Dr. Saltz stated. “The Taskforce studied cadavers and met with the coroners that did patient autopsies to create very safe guidelines.”
On the surgical side, Dr. Shridharani’s practice has noted an upswing in demand for J-Plasma with liposculpture cases, or as a stand-alone treatment for patients seeking skin tightening with less aggressive and invasive excisional procedures.
While breast augmentation demand is on the rise, so are the requests from patients to remove their implants, which has become big business for many plastic surgeons, according to Dr. Saltz. “I was talking to a colleague who has done over 200 explantations, but his augmentation practice is busy too,” he said.
“We finished 2020 with almost 200 breast implant cases, so it is not like the number of breast augmentations is going down,” he continued.
Pending better science to explain the possibility of breast implant illness and other concerns, surgeons should be open to discussing potential risks and supporting patients who want their implants removed, Dr. Saltz said.
Yet another off-face aesthetic category that continues to grow in popularity is vaginal rejuvenation. With combinations of laser treatment with surgical tightening and labial reconstruction, today’s providers who are trained in these procedures can help patients with function and appearance, Dr. Shridharani pointed out.
“This is very popular in the U.S., and certainly in South America,” Dr. Saltz added.
Patient & Practice Trends
Dr. Saltz recently chaired a practice management webinar featuring a panel of worldwide experts discussing various patient and practice developments. Among the trends revealed were changes in thinking about what brings patients to the office, according to Dr. Saltz.
“It is not the website. The website is just for credentials. It is reviews. Reviews are huge,” Dr. Saltz disclosed.
Zoom and similar platforms continue to drive referrals for facial procedures. “We are all participating in and becoming better at virtual communications and that will continue to drive patients to the office because we are looking at ourselves,” he said.
Conversely, Dr. Saltz and his colleagues are observing diminishing impact from social media influencers. “I see more and more referrals from podcasts that talk about aesthetics and beauty,” he shared.
Finally, demand for skincare, especially physician-dispensed cosmeceuticals that are based on science, continues to climb, Dr. Saltz revealed.
Today’s topicals have expanded indications, including for rejuvenating the neck and improving body contouring outcomes, he specified.
In Dr. Saltz’s opinion, incorporating the spectrum of options will be key to whether practices survive or close their doors in the months and years to come. “I think the comprehensive world of synergistic topical, nonsurgical and minimally invasive options that offer results is our future,” Dr. Saltz said.
Ten years ago, many of these aesthetic treatments did not exist. “It is an incredible time to be in aesthetics with the introduction of new technologies that have novel capacities to treat complex aesthetic issues with a minimal scar footprint on the body,” Dr. Shridharani said. “Not only will the technologies and capacities of these cutting-edge treatments continue to improve, but also expand indications and [enhance] optimal outcomes.”