Today's Trends, Tomorrow's Future: What's new, what's hot and what's evolving in cosmetic enhancements

On a recent episode of Will and Grace, Canadian actor Eric McCormick has Botox to minimize the frown lines he's been obsessing about. And who can forget Marge Simpson's industrial-strength breast augmentation, or the clever writing that distinguishes Nip/Tuck? When cosmetic procedures become creative fodder for popular TV shows, it's a sure sign esthetic enhancement has gone mainstream.

"There's been a real shift in attitude," remarks plastic surgeon Dr. Michael Kreidstein. "People used to be afraid they would be considered vain. Now they're much more comfortable about making a change, and they're demanding low-risk, effective procedures with minimal downtime."

Not surprisingly, women lead the charge. Cosmetic plastic surgeon Dr. Stephen Mulholland says society encourages women to maintain their looks - "And in Canada today, a woman is turning 50 every 16 seconds." Dr. Peter Adamson has noticed that many women who come to him for cosmetic facial surgery give career concerns as the reason. "They're competing with younger people in fields like Information Technology, and they're not waiting until their 50s to have the procedures they want." He also finds patients are increasingly interested in their overall look rather than focused on one thing in particular. "Advances in surgical and esthetic specialties mean that there are more options available," explains Adamson, singling out endoscopic surgery and Botox as two of the major players.

Endoscopic surgery is directed by a miniature camera, incisions are smaller, and can sometimes be closed with adhesive glue rather than sutures. Both the endoscopic forehead lift and the mid-face lift have become popular in recent years, but did you know that an endoscopic tummy tuck is now available too? "In combination with a little liposuction, it works well for women who have a small pot of the lower tummy, healthy abdominal skin and no stretch marks," says Mulholland. 

There has also been a major change in treating leg veins. "We no longer have to use painful 'stripping' procedures for varicose veins," explains Mulholland. "Using a tiny internal laser, a procedure called the 'ELAS', we can cure varicose veins and large unsightly spiders in a simple office visit."

"The use of teardrop-shaped cohesive gel implants has skyrocketed as well," remarks Mulholland who says that a year ago 80 per cent of the breast augmentations performed in his practice were saline, but that now they are cohesive gel. They're softer, more lifelike and don't ripple the way saline implants can do."

Most of Kreidstein's patients have cohesive gel implants, which he inserts through an incision made in the fold underneath the breast, and then places over the pectoral muscle. He finds saline implants are best for women in their late teens or 20s with minimal breast development; these implants are usually inserted through the armpit and placed under the muscle.

According to Kreidstein, liposuction is still the most popular invasive surgery, but body-contouring procedures, performed after dramatic weight loss from gastric bypass surgery, have become an important part of his practice. "These patients may have liposuction, an abdominoplasty, a breast lift and augmentation, as well as additional surgeries to correct the batwing deformity under their arms and to tighten loose skin inside the thighs. It's gratifying to see what a difference this makes to a patient's self-esteem and quality of life," remarks Kreidstein.

When it comes to facelifts, there are plenty of options available. "We are able to offer far more than we did twenty years ago," notes Adamson. "The trend is definitely towards a minimalist approach - hence the popularity of the short scar and endoscopic mid-face lift. But patients need to be aware that the less you have done, the less noticeable the results."

Adamson explains that the short scar facelift works best on patients with a modest amount of lax skin. The so-called "SMAS" facelift is more extensive. "If an incision is made behind the ear, it can give good improvement to the jowl and upper neck. However, it won't completely solve the problem of 'wattles' or the banding of the platysma muscles which run vertically in the neck." In Adamson's opinion, the deep-plane facelift gives patients the best result. "Because it addresses all the tissues, the skin tends to look much better," he observes.

Adamson says surgeons are aiming for a more natural look today and that they combine the best of various procedures in order to achieve this. Patients also find combining surgeries saves them money and down time. For example: a patient may decide to have a submentoplasty or a forehead lift in conjunction with a facelift. A submentoplasty involves lipo-sculpting under the jaw line and tightening the platysmal bands. "An endoscopic forehead lift works best for younger patients who have normal hairlines and few wrinkles. But for those who have more wrinkles and a higher forehead, I'll use trichophytic incisions instead; this kind of incision enables me to remove excess skin and preserves the hairline without disturbing hair growth."

Botox is often used before facial surgery to relax the muscles, and it can even provide a short term and very modest lift to the brow area. Adamson also likes to use Botox before laser resurfacing. While the trend today is towards gentler, non-ablative lasers, he still finds the best effect is produced by the more invasive CO₂ laser.

Upper and lower eyelid surgery continues to be the most popular facial surgery, and Adamson says that he's noticed a definite increase in the number of male patients seeking these procedures. He also performs many rhinoplasties, and recently completed a study that compares the closed technique (where the surgeon works inside the nose), to the open technique (where the incision is made at the base of the nostrils). "The closed technique was used for a long time, but now we're finding an external incision gives the surgeon a better view, and frequently provides patients with the best esthetic result."

One hot new area in the world of esthetic enhancement is the growing number of non-surgical options. "Surveys show that only 2 per cent of women would consider a facelift, but that most of them are definitely interested in less invasive procedures," says Mulholland. In his SpaMedica practice, patients can choose from a wide range of options including the latest rage, the ThreadLift (also known as the FeatherLift). Using local freezing, Mulholland gently inserts barbed 'Aptos' threads to support and integrate the soft tissues of the face. "You will see 30 to 40 per cent of the effects you would with facelift surgery, and the results last about 5 years."

Other options include Pan G Myofacials, which provide a deep lift to the muscles of the face by means of electrical and radio waves, and Therma Lift - a high frequency electrical current that heats facial skin creating a significant increase in collagen and elastin, as well as firming up loose skin. The Therma Lift is often combined with the FotoFacial RF - a combination of Intense Pulsed Light (IPL), diode laser and RadioFrequency energy. "Over 10,000 FotoFacials are done every day in the U.S.," Mulholland observes. "They tighten skin nicely, handling 70 per cent of sun damage and rosacea, as well as reducing wrinkling by 30 per cent." IPL is also used by many practitioners as a safe method of hair removal.

With Mulholland's popular non-surgical lift, the Pan G, patients gain 30 to 40 per cent of the benefits they would get from a facelift. This four-step/20-visit system incorporates a SonoPeel, hydrating serums, Fotofacials and Myofacials. The SonoPeel - a form of ultrasonic microdermabrasion - removes the layers of dead skin and 95 percent of blackheads eliminating the need for most extractions. It is also helpful for acne. Alternatively, acne patients can be treated with passive blue light for milder cases, or pulsed blue light for more resistant conditions. In the majority of cases, these new treatments eliminate the use of Accutane.

Fillers - both short and long term - continue to be the method of choice for minimizing wrinkles and augmenting the lips. Mulholland has been obtaining good results recently with a new filler called "Radiance" which contains tiny beads of calcium and lasts for 3 to 5 years. And we can't overlook the impact of Botox. Kreidstein observes that it's common now to use Botox as a preventative, and there are no signs that its use is slowing down. "You're less likely to develop wrinkles when you have Botox on an on-going basis," notes Kreidstein. "Still, used long term this can be much more expensive for a patient than having facial surgery."

Adamson reveals that when patients do have a facelift, however, they want to maintain the look. So: "While there is minimal downtime with procedures like photo facials and short term fillers, be aware that you will need multiple treatments in order to keep up the results." Both Adamson and Mulholland state there is a definite trend towards providing patients with topical and oral anti-aging solutions particularly with regard to skincare. In fact, Mulholland has recently added an esthetic nutritionist to his staff. "The idea here is to make skin better from the inside out through diet and a constellation of supplements. Topical DNA and growth factors, which encourage the growth of younger, newer skin, is another hot area. We can use chemical extracts like DMAE to stimulate collagen and hydrate the skin. There's even a topical amino acid called L-argereline that helps Botox to work even more effectively; it can also be used on its own to relax wrinkles."

Adamson believes that cosmetic practitioners are not only becoming better at choosing from all the options available, but are also more skilled at combining them to achieve the best effects possible. "And I'm sure we'll see continued development of various aspects of surgery like the endoscope and non-ablative procedures like radio frequency and intense pulsed light for skincare." Kreidstein agrees. Though he cautions: "Don't expect a revolution in cosmetic enhancement; what we're really looking at is a constant evolution of what is presently available." As for Mulholland, he is upbeat about the future. "Technological improvements never seem to end, so we're always expanding our services seeking new ways to help our patients look and feel their best."