These less invasive procedures are often done under local anesthesia with less pain and scarring, and a shorter recovery time. This is due in part to specially designed surgical tools that allow treatments to be performed without the need for open surgeries.Robert Dorfman, MD, a plastic surgeon and hair transplant surgeon at Ziering Medical Hair Restoration in New York City, N.Y., believes that minimally invasive surgeries are the future of aesthetics, and for good reason. “Patients want results, and they want them fast. They also look for no downtime and they want minimal risk and minimal scars. In the past, the technology just was not there to achieve this, but as we progress into the 21st century things are finally catching up,” he explained. “For example, current research in hair cloning may lead to a future in which we may not need to do any punches or strip procedures. We may just be able to culture hairs in a petri dish and then implant them!”
More Innovative Advancements in Aesthetics
The latest technological advancements have contributed to the shift from traditional plastic surgeries to minimally invasive alternatives. Some of these include new ways to emulsify fat, like cryotherapy and laser lipolysis. CO2 lasers can replace or assist the scalpel in procedures like facelifts and blepharoplasty. Smaller surgical tools allow for smaller incisions with less scarring and downtime, while blades that cut and cauterize at the same time help reduce bruising and bleeding.
Cécile Winter, MD, a plastic and reconstructive surgeon in Nice, France, uses minimally invasive surgeries in her practice, and feels the demand will continue to rise. “Currently, many people regularly use fillers and injections to preserve their facial features,” she stated. “There will come a point when these become less effective and the skin will start sagging, which is the perfect time for minimally invasive surgery like anatomical composite facelift or blepharoplasty.
“I am particularly passionate about rhinoplasty and minimally invasive surgery because of the natural enhanced look we can achieve,” Dr. Winter continued. “The aim of anatomically conservative rhinoplasty (ACR) is to reduce the amount of tissue damage from surgery. ARC is a philosophy of making rhinoplasty indetectable by keeping certain points of the nose/face balanced and by preserving some of its specific features. Also, the preservation of the soft tissue and ligaments preserves the respiratory function and allows the nose to age well.”
Ideal Candidates for Minimally Invasive Aesthetic Surgeries
Patient demographics often determine which treatments a provider uses. Desmer Destang, DDS, MSc(Aesth Med), a board certified aesthetic physician and medical director at Dermalogics Aesthetic Dermatology (St. Lucia, Caribbean) incorporates a specialized approach to nonsurgical rhinoplasty that suits the facial features and skin type of her patients. “My practice is located in the Caribbean so a lot of my patients are black. Fillers, especially if you have patients with flatter noses, are not a good option because of migration. Threads are by far the best option with the African-Carib patient,” she clarified. “I often need to reconstruct the nose bridge, the tip, and the alar flare, which is where I ‘dissect’ a wedge from the inside of the nose. One should be cautious about knowing the anatomy of the facial vessels, and you have to be careful to mark correctly so as not to create any asymmetries of the face.
According to Joe Niamtu, III, DMD, founder of Niamtu Cosmetic Facial Surgery (Midlothian, Va.), the type of procedures used also depends on the nature of the practice. “I have a surgical practice and my patients expect to look different after surgery. I do endoscopic brow and forehead lifts and my incisions are small, but it is an aggressive technique. “My least invasive procedures are cheek and chin implants. Each procedure takes a half hour and is permanent,” he reported. “Alternatively, my colleague uses cheek and chin fillers. The results may be the same, but fillers can cost $5k and last a year, creating the need for repeat treatments to maintain the look versus permanent implants.
“I also do buccal fat removal, which is a very popular procedure today,” Dr. Niamtu continued. “I have done this procedure for over three decades, originally for grafting, but now patients do it to slim the face. The fat pads in the cheeks are lateral to the corner of the mouth, so in a very simple procedure that can be done under local anesthesia, an incision can be made to remove some of the fat to slim that part of the face, but it is not for all patients. Unfortunately, unstandardized photography used on social media has created unrealistic patient expectations. It is up to the provider to communicate to the patient and be honest about the outcome.”
Dr. Destang agrees that providers should make an effort to communicate openly with patients and use a pre-treatment consultation to select the ideal patients. “For any minimally invasive surgery, patient selection and patient assessment are important for ideal outcomes. Because minimally invasive means the procedure will be done with local anesthesia, the patient has to be calm because the face is highly vascular. If they panic in the middle of a procedure, blood pressure goes up and you can get significant bleeding.” She also feels it is important to inform the patient that they may not see the full outcome until two to three months post-procedure.
Patient Knowledge and Combination Treatments for Enhanced Success
In Dr. Winter’s opinion, advanced knowledge of the aging process and technologies like facial vascular mapping have helped physicians refine their nonsurgical techniques. Her passion for facial anatomy has led her to create a customized technique of Viscosculpture using a combination of treatments for facial rejuvenation. “I take the time to really analyze the patient, their face and how it moves. For example, I feel it is important to palpate the face to feel the firmness of the cartilage for a rhinoplasty, find the position of the hyoid bone for a facelift, or to test the elasticity of the lower eyelid for blepharoplasty.
“Also, one should understand the insertions and positions of the superficial musculoaponeurotic system (SMAS) of the face,” she added. “Injections and minimally invasive treatments are closely linked, especially in the rejuvenation process, and I find that to get the most effective and natural results, it is better to combine treatments such as hyaluronic acid (HA) treatments with laser, for example.”
Thread lifts continue to thrive in popularity, thanks to updated thread technologies, along with minimal downtime and scarring. To ensure her patients get longer lasting results, Dr. Destang combines thread lifting with laser treatments. “The issue with a lot of the minimally invasive options is that sometimes they fall short of patient expectations. For example, about three to four months after thread lifting, patients are disappointed that the results are not holding up the way that they would like. So, along with the threads, I go in with the laser and do a bit of skin tightening through the same portals that I use for the threads. Introducing heat energy shrinks and lifts the tissues and stimulates more collagen, so I am able to get a better and longer lasting lift.”
Some devices such as Endolift, by Eufoton (Trieste, Italy) use laser energy to create micro-tunnels into the skin to lift and tighten skin without incisions or local anesthesia, which helps Dr. Destang create a more sculpted look for her patients. “When you introduce the laser, you heat up the tissues, but threads are a bit sensitive to heat, so I take my time. I use this laser treatment to melt the fat as much as possible, then do a little bit of liposuction in the jowls under the chin area. I normally wait about 30 minutes, then I go in after and do the threads last. I find that when doing threads alone, patients would tell me they are not feeling the lift anymore within six months. But when I combine thread lifts with laser, results last about a year to a year and a half.”
Dr. Destang provides a number of highly popular minimally invasive treatments in her practice and has a word of caution for other physicians. “I do a short-scar facelift and a lot of upper eyelid blepharoplasty procedures,” she shared. “While these are treatments that can be done under local anesthesia, these are advanced procedures and specialized skills are essential, as the facial area is very vascular. If you hit a blood vessel and you do not have the correct suction, or if you do not have a proper surgical setup, you could see a lot of bleeding. You have to know your facial anatomy and you have to be artistic. Aftercare is very important to ensure quicker recovery and an optimal outcome.”
Advancements in Lasers and Lights
Lasers and light technologies have also taken a quantum leap in recent years, with improved efficacy and fewer side effects. “Lasers and Intense Pulsed Light (IPL) have huge advantages and they work great,” Dr. Niamtu stated. “When patients come in with spider veins or birth marks, I can just erase them. That was not an option 40 years ago.”
Energy-based lipolysis for body sculpting is also becoming more popular, thanks to no anesthesia and no downtime required. “I think there are advances in lipolysis,” Dr. Niamtu reported. “When you do liposuction, you can use the traditional method where you vacuum it out, or you can use laser lipolysis. A skilled and confident provider will do a good job; with observable improvement whether its energy-based or traditional lipo. I think the provider makes the difference with this treatment.”
Evolving Hair Treatment Techniques
Hair treatments and transplant surgery are also seeing advancements in minimally invasive therapies. “There are two classic procedures in hair transplant surgery that we offer,” Dr. Dorfman began. “The first is Follicular Unit Transplantation (FUT), also referred to as the “strip” procedure. The other is Follicular Unit Extraction (FUE). FUT is associated with a horizontal linear scar, whereas FUE is the minimally invasive alternative, leaving punctate scars that are generally not noticeable to the human eye when the procedure is performed correctly and no single area is overharvested. FUE is rapidly becoming the most popular form of hair transplant procedure, and in many patients, it can give excellent results.”
Dr. Dorfman clarified that while one is more invasive, it is in the patient’s best interest to provide both treatments. He is a firm believer in specializing in a particular niche. “There is a lot of artistry to hair transplant and creating recipient sites that mimic the natural flow of hair is critical,” Dr. Dorfman explained. “I encourage practitioners who are interested in hair restoration to attend meetings like Vegas Cosmetic Surgery, the Aesthetic & Anti-Aging Medicine World Congress, or anything put on by the International Society for Hair Restoration Surgery to learn more about techniques you can integrate into your practice.”
The Future of Aesthetic Surgeries
The strategy of ongoing, specialized education, skills and artistry are themes that come naturally to forward-thinking aesthetic physicians and providers. At the same time, patient education is necessary for patient satisfaction with any minimally invasive procedure. Dr. Dorfman summarized it well, “I believe minimally invasive surgery to be the surgery of the future, but I think there will always be a role for more invasive procedures in the right patient. I feel it all comes down to taking the time to sit down with your patients and understand their goals and objectives.” With new technology, products and devices creating more choices, coupled with advanced training and refined techniques, minimally invasive surgeries will continue to be a key player in shaping the future of aesthetics.