What are the hottest plastic surgical and non-surgical procedures for 2019?

The last few years has seen a huge increase in popularity in injectables in all age groups and people are starting younger than ever before. Curves are in with the Brazilian butt lift being increasingly requested (outside Brazil!). Even Madonna has been rumoured to have undergone one to which she responded brilliantly “Desperately seeking no one’s approval and entitled to free agency over my body” Always ahead of the trend, Madonna’s quote encompasses the attitude of most people today towards cosmetic enhancements- if you want to do it and improves your body confidence go ahead.

How much is too much and how young is it safe to start? Be warned, not all procedures look good forever, especially the more extreme which are often not without long term consequences. The bigger it is, the more it sags, and the harder it is to go back to normal if you don’t like it. What looks good on an airbrushed celebrity may not look so good in the harsh light of day. While reversing ageing and improving self confidence are desired effects of well executed procedures, no one should end up looking different rather than better. Certain celebrities have gained attention for extreme procedures which has and unfortunately meant the “done look” is not altogether uncommon with grossly exaggerated curves and giant lips.

Achieving sustainable believable beauty should be the trend for 2019, small improvements here and there; subtle enhancements and maintenance rather than drastic changes.

Non-surgical treatments for the face and neck

 

Threadlift or PDO threads

Facelift-Sydney-Australia

The latest in minimal or “lunchtime facelift” are PDO threads. A thread lift is a type of procedure where temporary absorbable sutures are used to produce usually a subtle lift in the skin and neck under local anaesthesia through small incisions and cannulas.

The patient’s excess skin is not removed in this procedure, only the deeper portions of the skin are resuspended. Threads not only lift the skin however induce collagen formation through their placement.

Recovery is fast and it the procedure is much more minimal than a full facelift and therefore gives more modest results. Occasionally people react to the stitch material and visible lumps can be seen on the skin surface if not placed correctly and require removal. As loose skin is not removed, these are not suitable in older patients with significant skin laxity.

PDO-threads-facelift

PDO threads are made from a biocompatible material which is dissolved by the body over time. The threads remain for about 4-6 months after which they slowly dissolve. The threads themselves come in different types; barbed stitches (which have spikes and have greater skin gathering capacity) or smooth stitches (for collagen stimulation). Barbed sutures are inserted through a tiny hairline incision and lift the jowls or cheeks and work more by lifting. Smooth sutures are placed along the jawline, neck or corner of the mouth and work more by stimulating new collagen formation.

The surface of the skin can be addressed with a laser to get rid of skin irregularity, fine lines and pigment and induce skin tightening in combination with a thread lift for more dramatic results.

Neck fat removal in the office with fat dissolution

 Injecting a  synthetic form of a bile salt (deoxycholic acid) which occurs naturally in the human body has been shown to be effective in breaking  down fat cells. Currently it is only approved for use in the neck area (for pockets of fat under the chin or a double chin).

It is an office procedure performed under local anaesthetic. The treatment is delivered through multiple small injections and takes a short time and is well tolerated. People typically need two (and sometimes up to 4) treatments. Initially there is swelling and firmness in the area after the procedure for some days with fat dissolution taking some weeks. Results start to be visible by 1 month and final results by 3 months.

It is only useful for patients with small to moderate amounts of excess fat without skin laxity and platysmal banding (these are bands that occur down the centre when tensing the neck muscles). Patients with lots of loose skin or platysmal bands will need skin tightening devices or a neck lift. Laser liposuction is an alternative to in these situations.

Injectables for maintenance rather than extreme change

Lip-filler-Sydney

Lip-augmentation

Despite improvements in filler technologies, patients still worry about looking artificial. Looking weird does not relate to the product itself; well done fillers or botulinum toxin injections should be imperceptible.

Having small injections to address fine lines and replace areas of volume loss can slow the process of ageing and the need for surgical procedures.

Advances in filler technologies mean there are more area specific fillers available than ever before. They vary according to their cross linking which affects how long they last, where they are injected (deep or closer to the skin) and their consistency. The longer lasting fillers can remain in areas such as the cheeks, nose and chin for up to 2 years. Even once the product is dissolved, the area never completely goes back to its original state as the injection stimulates collagen synthesis. “Skin boosters” are injectables that hydrate the skin rather than for volume changes. These are the most recently released injectables by the major filler companies.  Whether they have a significant enough effect on the skin compared to other therapies such as light treatments and skin care remains to be seen,.

Semi-permanent and permanent fillers need to be used with extreme caution as their removal in the event of problems can be difficult and require surgery rather than dissolution. These include calcium hydroxyapatite and poly-L-lactic acid.  Initially used in cases of severe facial atrophy seen with HIV they are FDA approved as a deeper filler in certain areas in the cheeks and hands. These have been used off label for buttock augmentation and body contouring with some success, however, are very pricey as large volumes are needed.

Microneedling

There are a large number of microneedling devices available on the market varying in the size and depth the needles penetrate. (Dermapen, Dermastamp). Some are combined with radiofrequency whilst others simply rely on microneedling alone to stimulate collagen formation. It has widespread uses with supposed improvements not only in skin wrinkles and texture but also acne scarring, other scars, hair loss and stretch marks.  It can be combined with anti-ageing treatments to increase skin penetration of actives.

 Due to its relative ease of use (there are home devices available) and minimal training required for use, it is important to determine which device you are having and how effective it is going to be, and any potential side effects.

It works through creating micropunctures with microneedles which produce a controlled skin injury. These lead to small areas of surface bleeding like pinpricks on the skin (the amount depends on the depth of the puncture). This microtrauma and set up a wound healing cascade and releases various growth factors which lead to new collagen formation and improvement in ageing skin.

It is done under topical anaesthetic as an office procedure for deeper needling. More superficial needling (such as the home rollers) are essentially painless as they do not penetrate very deep.

Needle lengths vary from 0.13mm-2mm, the longer ones are used in acne scarring and home devices are less than 0.15mm.

Whilst it is considered safe in darker skin types, in any susceptible person microtrauma can induce pigmentation that can be difficult to eradicate.

Devices combined with radiofrequency release radiofrequency currents from the needle tips which also heats the skin in addition to the needling effects. These devices need to be used with extreme caution in the face as radiofrequency is known to cause fat atrophy or fat loss if it penetrates too deeply. The devices have been on the market only a short time and require an experienced operator that has good control over the depth of treatment.

Platelet rich plasma/ PRP 

Platelet-rich plasma, or PRP, is a substance that’s thought to promote healing when injected. Plasma is a component of the blood that contains special “factors,” that support cell growth. PRP is produced by taking your own blood and isolating the plasma component and concentrating it through centrifuging.

The theory behind PRP is that injecting it into tissues promotes healing. Platelets release growth factors and other proteins and by triggering the healing process could have an anti-aging effect.

There is, however, no standardisation of the techniques used to isolate platelets (centrifuging and activation of the platelets) in the scientific literature. PRP has been experimented with in diverse specialities not only plastic surgery, but in wound healing, orthopaedic injuries and sports medicine. Sample sizes are small and real effects are difficult to determine as before and afters can be subjective. Therefore no conclusions can currently be made about the best way to prepare PRP, the ideal concentrations or activating factors. More studies need to be done to prove it actually has significant effects.

The Vampire facelift or Vampire facial

Popularised some years ago by certain celebrities this utilises platelet rich plasma. The “facelift” involves injecting the platelet rich plasma isolated from a patient’s blood whereas the vampire facial involves a combination of microneedling and PRP being placed on the skin after needling.  The term Vampire facelift or facial itself is trademarked, however, there are many similar procedures on the market.

This comes back to the efficacy of PRP and whether it has any significant long term skin remodelling effects or simply works through temporarily causing skin swelling through its injection. How much is absorbed through the microneedling process is also not known.

Stem cells

The buzz around the term “stem cells” still remains despite it being some years since people first started using terms such as the “stem cell facelift”.

Stem-cell-facelift

Unfortunately, in terms of human studies into the anti-aging effects of stem cells, there have been no real randomised trials to suggest isolating stem cells has any additional benefits.  Many animal studies have been done which show promising effects in the future for wound healing and skin ageing, however, have yet to be replicated in humans.

Most people advertising a “stem cell facelift” are referring to a standard fat graft which through centrifuging (purifying the fat prior to injection) concentrates stem cells to some extent. However, no additional stem cells are being added. The “lifting” is achieved by placement of the fat, however any additional skin tightening is achieved.

A fat graft is anti-aging mainly in its volume replacement capacity. Fat grafting certainly improves the appearance of scars and leads to improvements in the skin texture beyond the volume effect alone. However, the exact mechanism by which this occurs and if adding extra stem cells to a standard centrifuged fat graft has any additional benefit (without risk) has yet to be proven by large scale scientific studies.

The American society of plastic surgeon released a position statement on stem cells in 2011 and much of the document still stands and further studies are needed. Most studies are on animals with no randomised trials in humans. Although stem cells offer tremendous potential, exact cell interactions and possible risks and side effects are still not fully understood.

Laser- there is still no real substitute

It involves a week of downtime looking a bit like a burns victim but once the skin peels off and you come out after hiding at home the results are dramatic.  Ablative fractionated laser delivers more powerful results than non-ablative lasers (non-ablative means the skin is left intact).

Fractionated simply means that only a percentage of the skin is treated with untreated skin left in between the columns of lasered skin. It is the untreated islands of skin  which allow a faster recovery than lasering the entire skin surface.

This achieves a very significant reduction in wrinkles and improvement in skin texture, removing pigmentation irregularities and boosting collagen synthesis.

BBL facial or “forever young” maintenance

Imagine a treatment that you could have 3-4 times a year, with minimal downtime that actually makes you look younger over time and delays the process of skin ageing.

The BBL photofacial is such a treatment. Backed by scientific evidence a groundbreaking study on BBL from Stanford University showed that it can restore the gene expression pattern of aged human skin to resemble young skin. In fact over 1,000 gene expressions became “rejuvenated” to be more like youthful skin resulting in improvements in fine wrinkles and pigmentation.

Sciton’s broadband light is the most powerful device on the market. Its range of smart filters make it suitable for darker skin types and allow precise targeting of pigmented spots and broken capillaries and redness. This make the treatment customisable to each patient.

Having 3-4 BBL facials a year will have a dramatic impact on skin ageing and is one of the best treatments out there in terms of downtime and achieving significant effects. Swelling, minor bruising and darkening of pigmentation can occur immediately after treatment.

Botulinum toxin, not just for wrinkles- weird and wonderful uses

Botulinum toxin injections are not only useful for fighting wrinkles. Other uses are treatment of migraines, lazy eye, spasms and excessive sweating in the armpits and palms.

There are a couple of more recent uses for botulinum toxin that are new and off label uses. Blowtox is now an option to make your blowdry last longer. Scalp injections block sweat glands in the scalp and reduce sweating; long term effects on hair growth are unknown.

Calf reduction with injections into a part of the calf muscle with botulinum toxin is now being offered by some practitioners. Some people feel they have disproportionately large calves and the reasons for this are often excessive muscle bulk rather than fat. It’s long term efficacy and safety have not been tested. Since the muscles are essential for walking, sprinting and pumping blood back to the heart, injections could potentially impact these.

Non-surgical procedures for the body

 

Non-surgical fat reduction and skin tightening for the body- fat freezing vs fat heating 

There are numerous non-invasive alternatives to liposuction on the market. The majority only have moderate fat reduction capacity and skin tightening and usually require repeat treatments. Machines can work by fat freezing (cryolipolysis) or radiofrequency with magnetic pulse and laser to name a few.

Stretch marks and cellulite are still common problems for which only improvements can be seen with some treatments rather than disappearance. Unfortunately, no miracle cures have been found for these common problems. Stretch marks are essentially a scar in the dermis of the skin from overstretching where it has not sprung back. They are a sign of poor quality skin which might not respond well to fat removal in the area without additional skin tightening measures.

Cellulite can be the dimpled kind due to irregular fat deposition (cellulite of adiposity) or where it is due to skin sagging which occurs with ageing or sun damage (cellulite of laxity). The latter will respond to skin tightening treatments, the dimpled kind may improve slightly with fat reduction treatments.

Coolsculpting is for distinct fat bulges such as the stomach, bra line fat, arms and thighs. Skin quality needs to be taken into account and how it will spring back after fat removal. Extremely rare cases of  gradual enlargement in the treated area (paradoxical adipose hyperplasia) after coolsculpting have been reported. This adverse effect and has not been reported after other non-surgical fat reduction treatments.

Technologies that use heating such as radiofrequency and laser devices will have more effect on skin tightening than devices that work through freezing.

For larger volumes of fat removal, liposuction may be a faster way to get a greater result for people with significant fat deposits. Also contouring can be fine-tuned a little more with a fine liposuction cannula than with a surgical device. Microtrauma from liposuction also induces skin tightening in the affected area and for a greater skin tightening ultrasonic liposuction (which also heats the area) as well as removes fat is an option.

Non surgical treatment responses vary in people as it depends on fat stores, skin quality and number of treatments. There are many machines on the market, and it is hard to control for all these factors to compare different treatments and to determine which one gives the best results. It is best to expect only modest results from such treatments, Contour irregularities can occur the same way they might in liposuction but which much less risk with non-invasive treatments.

Surgical procedures

 

 Why fat is always in fashion

Breast implants have received a lot of bad publicity of late with albeit the very rare risk of breast cancer (anaplastic large cell lymphoma) and rumours of them causing breast implant illness.

There is still much investigation to ascertain the cause of the very rare blood cancer associated with breast implants. There have only been just over 400 cases worldwide and the majority of them have been treatable. One of the types of textured silicon implants associated with the cancer have been recently removed from the market in Europe until it is further investigated.

However, there is very little evidence that breast implants cause the wide range of often non specific symptoms described in breast implant illness and there is no way of proving the diagnosis through testing. Whilst some women may experience improvement with removal of breast implants (such as pain that can be associated with capsular contracture) few have experienced improvements in other non-specific symptoms.

Fat grafting is a great alternative to breast implants in those with enough body fat stores who feel uncomfortable with the concept of breast implants. Whilst it may not give the volume change possible with breast implants in one session, it has deemed to be well and truly safe with no increased incidence of breast cancer with fat injection to the breast in long term scientific studies.

Dr Simone was one of the first people to perform large volume fat grafting to the breast. Here’s an editorial article about her in Vogue when she had just started doing it .

Safe Brazilian Butt lift (BBL)

One of the most popular procedures last year received a lot of bad publicity due to a significant number of deaths associated with the procedure.

These sparked a review and a Task Force for Safety in Gluteal Fat Grafting was formed by the American Society of Plastic Surgeons (ASPS), the American Society for Aesthetic Plastic Surgery (ASAPS), International Society of Aesthetic Plastic Surgery (ISAPS), International Society of Plastic Regenerative Surgeons and the International Federation for Adipose Therapeutics and Science(iFATS).

Deaths were found to be due to unsafe practices in injecting under the gluteal muscle. Choosing a qualified plastic surgeon who has been trained in and understands anatomy should ensure your BBL is safe.

BBL is fast growing in popularity due to the number of celebrities that have had the procedure. However, there is such a thing is too much fat; placing too much and excessive liposuction can lead to sagging and distortion of normal anatomical landmarks (such as the gluteal crease).

Fat-graft-buttock

 Achieving tailored, believable and sustainable beauty

Unbalanced large lips, excessively small noses, obvious breast implants and butt lifts are giving way to more tweaking and improvements while maintaining individual features.

The secret to good plastic surgery is looking like you haven’t had it. Nothing demonstrates better than this video how there is no single feature that suits everyone. After images credited to artist Mat Maitland.

What looks good on Instagram does not necessarily look good in real life

Filters, Facetune, Photoshop, angles; it’s all quite different in the flesh and harsh light of day.

Remember extreme plastic surgery decisions may not be reversible

Whilst all surgical procedures carry risk, subtle tweaking and gradual small improvements are the safest way to go. Large implants, masses of fat transfer to the buttock can lead to significant skin stretching and eventually the heavier the tissues, the more they will sag under the influence of gravity. The greater the change, the harder it will be to reverse if one day you realise you don’t like it.