BB&T Contributing Editor

CHICAGO — Once thought to be a competitor to plastic surgery, or at the least an alternative to, minimally invasive cosmetic procedures are now recognized as being a critical and valuable adjunct to providing the best cosmetic result for plastic surgeons' patients. This sentiment pervaded the lecture halls as well as the exhibits at the annual scientific meeting of the American Society of Plastic Surgeons (ASPS; Arlington Heights, Illinois) here last fall.

According to ASPS 2007 statistics, while the number of invasive cosmetic surgery procedures remained flat (and are believed by analysts to be down in 2008); the number of minimally invasive cosmetic procedures experienced a double-digit growth rate. All the more reason for plastic surgeons to jump on the cosmetic bandwagon. Cosmetic procedures include Botox injections, cellulite treatment, and injectable wrinkle fillers, to name a few, and totaled nearly 11.7 million in 2007 – an increase of 457% in the last 10 years.

Richard D'Amico, MD, current president of ASPS and medical director of the Plastic Surgery Skin Care Center (Englewood, New Jersey), presented "Cosmetic Medicine In Today's Economy" and shared results of a public survey conducted by ASPS that found 97% of its members now provide Botox, fillers and peels.

He also said that "the public perceives injectable fillers as having a higher risk than minimally invasive surgery, but not as much as surgery. Although 93% of the public surveyed said they would go to a ASPS member for invasive surgery, only 40% would go to a plastic surgeon for an injectable filler, with another 40% going to a dermatologist, and 20% going to a non-core provider."

The message of this survey was that plastic surgeons need to capture patients early with minimally invasive procedures so that they can keep them later for surgery. If not, there seems to be no strong feeling about which type of doctor patients will go to for minimally invasive procedures.

In a panel discussion, "Modern Facelift: What I Now Do Differently and Why," four plastic surgeons defined the hallmark of a good facelift to be a natural subtle result and explained how it is achieved through a combination of less invasive facial rejuvenation techniques coupled with surgery.

Not only are these found to provide a superior outcome when used in conjunction with plastic surgery, "It is becoming crucial to the economic growth and possibly even survival of a plastic surgeon's practice," said Mark Jewell, MD, of Jewell Plastic Surgery Center (Eugene, Oregon). "Patients want the least-invasive procedure that meets their goal."

He added, "Surgical and non-surgical are not mutually exclusive," noting that it is important for plastic surgeons to stay abreast of new technologies that are being developed. Jewell cited the following as examples:

• Revance Therapeutics (Mountain View, California) is in clinical trials for a topically delivered botulinum toxin type A gel for the treatment of facial lines and wrinkles.

• Elastin Products (Owensville, Missouri) is developing collagen and elastin products.

• Allergan (Irvine, California) and Athena Cosmetics (Henderson, Nevada) both are producing bimaprost for eyelash growth.

• Kythera (Calabassas, California) has several products in development for adipolysis, dermal contouring, pigmentation modulation, photoaging, and topical neuromodulation.

In today's market, the top two cosmetic procedures being performed are Botox injections and facial fillers. Miles Graivier, MD, of North Atlanta Plastic and Reconstructive Surgery (Roswell, Georgia), co-directed an instructional course, "Injectable Agents for Facial Shaping: The Art and Science of Botulinim Toxin Type A and the new Hyaluronic Acid Fillers," where he listed all the fillers currently on the market or in development. He continued with a discussion on which one to select and why, often using combinations of fillers and/or neurotoxins for the best outcome.

Graivier cautioned the audience, "If you are using neurotoxins in the upper one-third of the face, and fillers in the lower two-thirds, you must create harmony between the two."

Other new less-invasive products were being demonstrated here as well. Injectable fillers have been used in lips with mixed results often citing the lack of longevity; causing the patient to suffer repetitive, painful, and costly procedures.

New on the market and launched at this meeting was the PermaLip by SurgiSil (Plano, Texas), an implantable silicone implant for permanent yet reversible lip augmentation. The soft solid silicone elastomer cannot rupture, deflate or degrade over time and is resistant to tissue ingrowth.

The surgical procedure takes less than 30 minutes to perform under local anesthesia in an office setting and patients can resume normal activity the following day. Some 60 doctors ordered these lip implants in the first six months that they have been available in the U.S., with more than 2,000 patients having had the implant worldwide.

Evera Medical (Foster City, California) has a lip implant in development that is similar to a breast implant in that it is filled with saline and can be filled or emptied to obtain the patient's desired effect at anytime. This also is an office-based procedure performed using local anesthesia.

Cellulite treatments accounted for close to 40,000 procedures in 2007, up 15% from the prior year. Many companies have products that claim to treat cellulite, but because it is not considered a medical condition, FDA clearance is not required, and those claims are not always validated.

Two companies have gone to the trouble and expense of gaining FDA clearance to be able to make the claim that their product reduces cellulite. Elemé Medical (Merrimack, New Hampshire) has developed the FDA-cleared SmoothShapes system, a technology that combines laser energy with mechanical massage and vacuum to improve the appearance of the skin surface.

Syneron (Irvine, California) received its FDA clearance last year for both circumferential reduction and cellulite treatment using a combination of bipolar RF energy, infrared light, and vacuum. The company has placed more than 500 units in the U.S. An industry analyst has predicted that the number of body reshaping procedures will grow from 14 million treatments in 2005 to 33 million in 2010, and both of these cellulite-reduction companies should enjoy that growth.

Bioform Medical (San Mateo, California), which manufactures Radiesse, a long-lasting wrinkle filler, purchased Advanced Cosmetic Intervention (ACI; Denver) in April 2008, adding neuromodulation to its line of fillers. ACI's device, also referred to as the GFX device, is currently cleared via a 510(k) by FDA to create RF heat lesions in nerve tissue.

The ACI device uses minimally invasive bi-polar radio frequency energy selectively to weaken nerve signal transduction to the muscles causing the frown. The use of this technology on nerves that control the muscles of the forehead may reduce the appearance of glabellar furrows, making it a direct competitor to Botox. The promise is that blocking out the nerves that control the frown muscles with RF energy should last much longer than Botox. The company has seen some patients have a lasting outcome for up to 17 months, but is hoping for even longer.

The term "plastic surgery" is no longer confined to the use of scalpels. The politically correct term is now "cosmetic medicine" and has been re-defined by D'Amico as "medical and surgical treatments that enhance appearance," which includes a complete armamentarium of non-, minimally, and invasive procedures.