- One surgeon contemplates the factors that are driving interest in nonsurgical cosmetic approaches
In the January-February 2007 issue of
Cosmetic Surgery Times
, Dr. Sam Hamra editorialized about nonsurgical approaches to facial volume ("$32,500 and Still Counting"). He reiterated an argument that he had made in a letter to the editor of Plastic and Reconstructive Surgery.1 I replied2 to Dr. Hamra's letter to the editor referring to my article,3 and I would like to repeat here some of the points that I made in that letter. Dr. Hamra argues that periorbital surgery for volume creates long-lasting results and, in that way, provides a better value for patients.
Certainly the long-term results that he presents are excellent. In my hands, and frankly from what I have learned from many aesthetic surgeons across disciplines, surgery longevity varies, ranging from excellent to poor. Surgery will usually last longer than synthetic fillers, even if all patients don't show profound persistent effects at 10-year follow-up. However, in my practice and in many others, there has been a dramatic shift from open surgical approaches to minimally invasive and nonsurgical approaches. So, what drives all the interest in the nonsurgical approach?
IS IT SUBSPECIALTY DRIVEN? Although subspecialists such as facial plastic, dermatologic or oculofacial surgeons bring their own particular, unique perspectives to aesthetic facial surgery, in my experience those who have taken advanced training and made a commitment to the discipline are typically experienced and versatile in the variations of facial surgeries. Of course, nonsurgical physicians will need to refer patients to surgeons for surgery. And (at least in Los Angeles) there is no severe shortage of aesthetic surgeons. I don't think that the shift towards minimally invasive and nonsurgical approaches is subspecialty based.
IS IT FINANCIALLY DRIVEN? Similar to the metaphor used in the title of this article of buying versus leasing a car, many factors have to be considered when comparing the cost of one big surgery compared to multiple office procedures. Naturally, some patients find it easier to afford a single small procedure, even repeated annually, compared to the expense of a larger surgery. But I find that most patients' decisions are not overwhelmingly driven financially. And to my relief, I continue to note that the overwhelming majority of physicians respect the sanctity of their position and successfully separate themselves from their own financial interest when counseling patients. I don't think that the shift towards minimally invasive and nonsurgical approaches is primarily financially based.
IS IT PATIENT DRIVEN? Yes, I believe that the trend is patient driven. Surgery intimidates patients. They don't want to take time off of work or from activities. They are worried about complications — and not without reason. My referral practice in revision blepharoplasty is "Grand Central Station" for complications of aesthetic surgery. I see complications from surgeries performed by pretty much everybody, across specialties, from recent graduates to famous plastic surgeons. Not all of the eyelid complications are treatable, and the worst cases are devastating for the patient. Fortunately, the risk of devastating surgical complications is low, particularly in the hands of so-called "masters." But patients understand that the risk of surgical complications is not zero.
Figure 1. 48-year-old woman before (left) and 3 months after(right) endoscopic forehead lift and lower periorbital hyaluronic acid gel (Restylane) filling. The contours are improved, but there is a color change (no improvement in her dark circles), and slight "boggy" character to the filler.