Why Should Young Aesthetic Plastic Surgeons Care About Aesthetic Medicine? (2024)

Abstract

Young plastic surgeons who graduated from training in the last 10 years have trained in an era very different from their predecessors, largely due to the efforts of aesthetic surgery educators and mentors. A core part of any plastic surgery residency, aesthetic surgery has seen a 3-fold increase in the required minimum number of procedures to be performed by a trainee.¹ This highlights just how important aesthetic surgery is to plastic surgery education. Nonsurgical procedures like soft tissue filler, injection of neurotoxin, and laser treatments are all core plastic surgery procedures that residents must learn to perform prior to graduation. But even 20 years ago, these procedures either did not exist or were not considered “core” plastic surgery. The rise of aesthetic surgery fellowships endorsed by the American Society for Aesthetic Plastic Surgery (ASAPS) has further supported the differentiation of trainees into aesthetic surgery leaders. However, despite these changes, young plastic surgeons may wonder why and how best to incorporate aesthetic medicine and nonsurgical services into a budding surgical career.

Nonsurgical aesthetic services may be viewed as a “disruptive technology” because they are a set of services that happen outside of the familiar operating room. These services are rapidly growing and expanding and accounted for nearly $2 billion in 2017 according to the ASAPS Cosmetic Surgery Data Bank.² They may commonly be thought of as just injectables like soft tissue filler or neurotoxin, which in the last 5 years have experienced a 40% increase in utilization. But nonsurgical procedures and aesthetic services are more than injectables. The top 5 nonsurgical procedures in 2017 were neurotoxin, filler, nonsurgical fat reduction, hair removal, and chemical peel.² Areas of major growth include micro-ablative skin resurfacing and nonsurgical skin-tightening procedures. It behooves young plastic surgeons to look at these disruptive technologies and see how they can help build a surgical practice.

In 2007, a landmark study from the Cosmetic Medicine Task Force of the American Society of Aesthetic Plastic Surgery and American Society of Plastic Surgery highlighted prevailing perceptions and trends in cosmetic medicine.³ The task force was established to address the disruption caused by noncore providers entering the aesthetic field, the growing popularity of nonsurgical procedures, and emergence of medical grade spas. The most significant finding was what is now called the “747 effect.”

When surveyed, women were asked who they would choose to perform their cosmetic surgery: 93% responded a plastic surgeon and 7% responded a noncore doctor or dermatologist. When asked who they would choose to perform a minimally invasive procedure (laser, injectables, peels, microdermabrasion, etc.), 42% would choose a dermatologist, 33% a noncore physician, and only 25% would choose a plastic surgeon. A total of 47% of patients who underwent a noninvasive procedure with a nonplastic surgeon (either a dermatologist or noncore physician) and had a positive experience would stay with the nonplastic surgeon for a cosmetic surgery.³

The Cosmetic Medicine Task Force conclusion was obvious: demand for surgical procedures could be in jeopardy if aesthetic plastic surgeons do not capture new patients early in their experiences with aesthetic medicine. Indeed, the impact of such sentiments could drastically affect the flow of patients into the operating rooms. To preserve aesthetic plastic surgery, young aesthetic surgeons must be willing to incorporate “disruptive technologies” like nonsurgical procedures and aesthetic medicine into their practices.

THE FIVE PRINCIPLES OF AESTHETIC MEDICINE

Our personal experience and a growing body of evidence demonstrate several compelling reasons for aesthetic plastic surgeons to offer these services. These 5 principles of aesthetic medicine are all centered on patient care (Figure 1): patient acquisition, patient retention, patient optimization, patient education, and patient conversion. The goal for any young aesthetic surgeon should be building a practice with patients for life, where a well-trained surgeon can take care of the full range of surgical and nonsurgical needs of a patient as he or she ages.

Patient Acquisition

Nonsurgical fat reduction was one of the top 5 nonsurgical procedures performed in 2017, and cryolipolysis is an ideal example of how a nonsurgical aesthetic service leads to patient acquisition.² In 2013, Stevens et al described their clinical and business experience with cryolipolysis: 66% of the more than 500 new patients to the practice came specifically seeking cryolipolysis with Coolsculpting (Allergan, Dublin, Ireland) and 62% had never had an aesthetic procedure.⁴ This provided an opportunity to introduce patients to other offerings within the practice such as injectables, skin care, laser hair removal, and even surgical procedures performed by the aesthetic plastic surgeons in the practice. A total of 40% of these patients returned to the practice to receive other aesthetic treatments. These same patients previously never underwent aesthetic surgery or a nonsurgical treatment at the practice. Interestingly, 95% of patients had never had an injectable treatment utilizing either neurotoxin or soft tissue filler, and the practice found that the most commonly availed service by returning cryolipolysis patients was for injectables.⁴

The study also found that offering nonsurgical procedures expanded the male demographics of the practice. After a targeted marketing campaign specifically tailored for men, nearly 42% of all cryolipolysis clients were men.⁴ This demonstrates that nonsurgical aesthetic services bring patients into a surgical practice that may have otherwise never been considered. This can be a powerful tool for new practices seeking to establish themselves or mature practices that seek to expand their demographic, which might include male clientele.

In a study by Kurkjian et al examining the impact of economic factors on facial aesthetic surgery, an overwhelming majority of patients preferred treatments that have a long-lasting effect over those with shorter duration.⁵ Only physicians’ training and expertise with the treatment superseded this as a treatment decision driver. Further, more than half of respondents said that their decisions to have an aesthetic facial treatment was affected by the economy. It is important for young plastic surgeons to consider offering diverse services with a range of price points for new patient acquisition. The study also suggests that well-trained aesthetic surgeons should consider offering nonsurgical treatments because one of the most important factors for patients choosing to have a treatment is a physician’s training and background.⁵ Indeed, ASAPS-endorsed aesthetic surgery fellowships are training aesthetic plastic surgeons to meet the growing need and expectation from patients for well-trained providers.

Patient Retention

It can cost more to acquire new patients than to retain existing ones seeking aesthetic services. Hence, building loyalty is paramount to any fledgling practice. The growth in nonsurgical procedures and the aesthetic medicine industry may not translate to increases in revenue for a new practice unable to retain patients. The issue is not that patients are no longer seeking treatment; rather, they are going elsewhere.

As many other physicians and nonphysicians increasingly become involved in aesthetic medicine, it is important that aesthetic surgical patients be retained in a new practice. The 2007 seminal study by the Cosmetic Medicine Task Force found that 47% of patients would be willing to return to a nonplastic surgeon for an invasive aesthetic procedure based on a prior positive noninvasive treatment with that provider. This could bode poorly for aesthetic surgeons as we try to maintain high quality and excellent outcomes in aesthetic surgery. Maintaining patients in a practice will lead to multiple encounters and potential procedures during their lifetime, leading to “patients for life.” For example, Stevens et al found with cryolipolysis that 40% of new patients who were seen remained in the practice for up to 4 years after their treatments, which was the longest follow-up available from the study at the time. Anecdotally, plastic surgeons with mature practices will recount stories of patients who first came to the practice seeking a breast augmentation in their young years, then a mommy makeover in their middle years, and finally facelifts and eyelid rejuvenation in their older years.

Nonsurgical treatments may also help patients gain confidence in a young plastic surgeon. By safely performing nonsurgical treatments and delivering consistent results, patients may grow to trust the provider and convert to a surgical patient. The continued exposure and developing a doctor-patient relationship should not be underestimated.

Patient Optimization

For young aesthetic surgeons, consistent, safe, and excellent outcomes are key. Aesthetic surgeons pride themselves in their results and want their patients to look as good as they can. Presurgical treatments with skin care, facials, and proper cosmeceuticals can prepare a patient for an optimal surgical outcome, particularly in facial aesthetic surgery. Interestingly, the concept of patient optimization for improved surgical outcomes is not a new concept. The use of tretinoin or hydroquinone prior to laser therapy or weight loss before an abdominoplasty are just a few examples of plastic surgery dogma in patient optimization. The use of noninvasive devices to enhance a facial surgical outcome is an extension of that same philosophy.

In our practice, the use of noninvasive aesthetic services to enhance surgical outcomes is called “the icing on the cake.” This includes laser resurfacing, microneedling, nonsurgical skin tightening, fillers, neuromodulators, skin care, facials, and biologically active cosmeceuticals. Aesthetic medical services and products optimize the appearance of our surgical patients, and this optimization leads to higher patient satisfaction as well as practice growth.

More than ever, attention is now being placed on the pretreatment period before a surgical procedure. Just like one would perform a surgical debridement before doing a flap, medical-grade skin products could be used to prepare the skin for a surgical procedure such as a facelift or lower eyelid blepharoplasty. We anticipate this to be a rapidly growing trend that could be the next paradigm shift in patient optimization and is a novel way for young plastic surgeons to think about optimizing their outcomes. It is a sort of “refining the sugar” before baking the cake and icing it.

Patient optimization with noninvasive technologies is not limited to just facial aesthetic surgery. They have a role even on breast and body surgery with scar management, for example. Different devices that focus on lymphatic massage can also be adjuncts for patients who have had liposuction or other body contouring surgeries. Appropriately selected nonsurgical vagin*l rejuvenation devices can also be used as adjunct procedures when treating labiaplasty patients with sexual dysfunction or distress, which can be prevalent in plastic surgery patients.⁶

When the philosophy of a young surgeon’s practice is to deliver the optimum outcome for the patient, it requires the surgeon and the practice to use more than the just the scalpel; it requires adjunct technologies to deliver that result and complement what happens in the operating room.

Patient Education

When patients are treated with nonsurgical modalities, they are often in the office for extended periods of time, which can be a couple of hours. This time may include preprocedure numbing or postprocedure massage, depending on the nature of the treatment. Unlike in the operating room under a general anesthetic, patients availing nonsurgical aesthetic services are awake. This means there is an opportunity to engage patients and educate them about the aesthetic services the practice offers.

This time is a true teaching opportunity. Patients can be exposed to videos or photo books of before-and-after surgical and nonsurgical procedures. These visual cues often lead to questions that the surgeon and staff can answer and, in our experience, have been a real opportunity to dispel myths about surgery and outcomes. Many of our patients who avail nonsurgical services ultimately go on to become surgical patients because they have learned to trust the surgeon and the practice and feel empowered with the aesthetic medicine education they received in the office.

Patient Conversion

In a growing practice, the goals are ultimately happy patients and more surgical volume. The conversion of nonsurgical to surgical patients is key for any practice and follows the educational process. A single surgeon experience reported by Richards et al with injectables and facial aesthetic surgery identified more than 15% conversion of aesthetic naive, new patients who came to a practice for injectables and converted to surgical patients at an average of 19 months.⁷ On average, patients had 3 injectable sessions before converting to a surgical procedure at this practice, which included facelift, upper blepharoplasties, and browlifts. Other studies have also shown that patients who ultimately went on to have a facelift had previously undergone multiple noninvasive aesthetic procedures. Young surgeons can build the doctor-patient relationship by spending time with patients and performing nonsurgical procedures. Ultimately, patients will want to go to a surgeon they know and trust when they choose to have aesthetic surgery.

THE FUTURE OF AESTHETIC MEDICINE

Undoubtedly, the future of aesthetic medicine and its place in aesthetic plastic surgery is bright and exciting. Technological advancements with new devices for skin rejuvenation and fat reduction along with longer acting, more versatile injectables will continue to broaden options for patients. There are, however, likely paradigm shifts for the delivery of aesthetic medical services. The advent of subscription models for things like entertainment and shopping is also entering the aesthetic marketplace. The subscription model for aesthetic services has the potential to transform the way younger generation plastic surgery consumers view aesthetic medicine. Instead of purchasing a single treatment of filler or neuromodulator. for example, patients in a subscription model of aesthetic services could maintain a “look” over a period of time, potentially at a more sustainable cost paid out over a longer period of time. This has major implications for young plastic surgeons who seek to retain patients and optimize their results, which are parts of the five principles of aesthetic medicine.

The other major paradigm shift we may see is in the presurgical period of an aesthetic surgery procedure. It is practically dogma that a surgical wound bed needs to be prepared before a major reconstructive procedure. This has not been as pervasive in aesthetics. Slowly, we are beginning to see options to prime the skin and soft tissue of the face or eyelids before a facelift or blepharoplasty, for example. This is akin to hydroquinone or retinoid pretreatment before a peel or laser resurfacing procedure. Young plastic surgeons may be more willing to adopt strategies for patient optimization and begin the process of obtaining a superior outcome even before the surgical procedure.

As eloquently posited by Dr. Nahai, “Aesthetic surgeons, too, must contend with a new normal” and this new normal of aesthetic medicine must be included in training the next generation of plastic surgeons.⁸ Although nonsurgical education is a core part of accredited plastic surgery training today, there are opportunities to enhance resident and ASAPS-endorsed fellow education. Practice building and management strategies for young plastic surgeons deserve more attention. Partnerships between residency programs, ASAPS fellowships, academic institutions, and industry will be necessary to help transition young plastic surgeons into growing and thriving practices that provide the highest level of excellence in aesthetic medicine and surgery.

CONCLUSIONS

For young aesthetic surgeons to develop and grow their surgical practices, they must be willing to incorporate aesthetic medicine. The diversity of treatments, procedures, and price points allows practices to tailor a set of services to meet their clientele’s needs. Whether with the scalpel or the needle, the goal is to achieve the best result possible for each patient and help patients achieve their aesthetic ideals.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes

Dr Qureshi is an aesthetic surgery fellow at a private plastic surgical practice in Marina del Rey, CA.

© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com