Allergan announced June 1 that the FDA had approved its Volbella XC filler for use in the lips and perioral rhytids. The filler was found in a study to increase lip fullness and soften perioral lines through one year.

Juvéderm Volbella XC will be available to U.S. patients in October 2016, according to Allergan.

The FDA describes Volbella XC as “a sterile, biodegradable, non-pyrogenic, viscoelastic, clear, colorless, homogeneous gel implant. It consists of cross-linked hyaluronic acid (HA) produced by Streptococcus species of bacteria, formulated to a concentration of 15 mg/mL and 0.3% w/w lidocaine in a physiologic buffer.”

The Clinical Trial

Researchers conducted a prospective, double-blind, randomized, controlled, multicenter clinical study evaluating Volbella’s safety and effectiveness compared to a control for injection into the lips and perioral area. In the study, 168 subjects received Volbella XC and 56 were in the control group. If considered necessary for optimal correction, researchers could do a touch-up treatment about one month after the first treatment.

Researchers then followed subjects at 1, 3, 6, 9 and 12 months after the last treatment.

The primary endpoint was the analysis of non-inferiority of Volbella XC relative to control in terms of change from baseline to month 3 in mean lip fullness based on Evaluating Investigator assessments using the validated 5-point Allergan Lip Fullness Scale (LFS), according to the FDA.

The average volume of Volbella XC injected to achieve optimal results was 2.6 mL. Researchers injected a median volume of 1.0 mL in the upper lip, 0.8 mL in the lower lip, 0.3 mL in perioral lines, 0.5 mL in oral commissures and 0.1 mL in philtral columns.

Injections into the upper and lower vermilion tended to be subdermal, while injections into the vermilion border, Cupid’s bow, philtral columns, perioral lines and oral commissures were generally intradermal. Injectors used these or a combination of techniques to achieve optimal results: tunneling technique, serial puncture technique and fanning technique.

They found the mean change from baseline to month 3 on the Allergan Lip Fullness Scale (LFS) was 1.1 for subjects treated with Volbella XC versus 1.0 for subjects in the control arm.

NEXT: VYCROSS Technology

VYCROSS Technology

Bill Meury, Allergan’s chief commercial officer, says in a press release about the approval that Volbella XC is the first such product in the U.S. to be formulated with VYCROSS, a proprietary filler technology, engineered to address specific patient concerns such as lip fullness, age-related volume loss in the cheek area or perioral rhytids. VYCROSS blends different molecular weights of hyaluronic acid which contributes to the gel's duration.

Charlotte, N.C., based facial plastic surgeon Jonathan Kulbersh, M.D., says in a press release responding to the approval that the VYCROSS technology is said to result in less pain from injection, less swelling and a more natural looking result.

“From what I understand, Volbella was developed to become the first-choice filler to be used for the lips. I’ve heard nothing but good things about the product. The majority of patients, even when you warn them that there will most likely be swelling after having lip injections, are surprised by how inflated their lips become, so the minimal swelling attribute alone will likely make Volbella the most popular lip filler once it is released,” says Dr. Kulbersh in the release.

The news isn’t all positive, however. Researchers reported January 2016 in Dermatologic Surgery on a higher-than-expected rate of late cutaneous reactions post Volbella injection into the tear trough area or lips. Broad-spectrum antibiotics along with repeated high-dose hyaluronidase injections into the inflammatory nodules effectively treated the cutaneous reactions, they write.

Dr. Kulbersh reports no relevant disclosures.

Dr. NahaiIt’s a question without a definitive answer. But, according to an editorial by plastic surgeon and Editor-in-Chief of the Aesthetic Surgery Journal, Foad Nahai, M.D., there are clues that suggest a link may exist and answers are worth pursuing.

Dr. Nahai, who is the Maurice J. Jurkiewicz chair in plastic surgery and professor of surgery at Emory University School of Medicine, in Atlanta, Ga., says he started to connect the potential dots when he read an editorial published in the Journal last year in June by Steven H. Dayan, M.D. In it, Dr. Dayan, who has shared his work with Cosmetic Surgery Times, suggests that aesthetic medicine can improve not only patients’ moods, but also the moods of those around them.

Related: Subliminal beauty theory 

Other studies, according to Dr. Nahai, suggest toxin treatments that relax the face benefit people with depression.

Yet another study propelled the scientific journal editor’s questioning. He came across the Baltimore Longitudinal Study on Aging, in which researchers suggested that young and middle-age adults who had negative age stereotypes were far more likely to have Alzheimer’s later in life compared to those with positive stereotypes. In that study, researchers found adults who earlier in life had more negative age stereotypes had steeper hippocampal-volume loss and greater accumulation of neurofibrillary tangles and amyloid plaques.

“That sort of stuck with me. If cosmetic treatments improve somebody’s mood; help someone’s depression, is this something that we should look at?” Dr. Nahai says. “Would there ever be a possibility that if individuals somehow changed their stereotype of aging, either through what they see in the media or what they see in the mirror, would that lead to their having less likelihood of Alzheimer’s when they’re older?”

No doubt that asking the question in the editorial, which was published online in March and will be in the printed Journal this summer, would fuel controversy, Dr. Nahai says.

“Basically, this [editorial] is to challenge my colleagues and me to think beyond what we do,” he says. 

Related: Dr. Feel Good

Dr. Nahai writes that his intention is not to promote a nationwide marketing campaign suggesting aesthetic surgery might prevent Alzheimer’s disease. But he believes that asking the question about whether aesthetic surgery could impact Alzheimer’s risk is worthy of a broader discussion. He says he’s also hoping to stimulate research.

“Frankly, I think the study that could come out of this would be to look at individuals who had routinely had cosmetic treatments — maybe even a facelift — going back to age 40 up to age 70, and compare them to those who have not had those treatments to see if there is any difference in the incidence of Alzheimer’s,” Dr. Nahai tells Cosmetic Surgery Times.

Dr. Nahai reports no relevant disclosures.

Dr. SclafaniInjecting platelet-rich fibrin matrix (PRFM) to restore facial volume and fill lines can be a patient-pleaser, but surgeons need to select the right patients and the right facial areas to treat, according to facial plastic surgeon Anthony P. Sclafani, M.D., who co-authored a study on PRFM in May/April 2012. The study, called “Induction of dermal collagenesis, angiogenesis, and adipogenesis in human skin by injection of platelet-rich fibrin matrix,” published in the Archives of Facial Plastic Surgery remains the most-read article on the Journal’s RSS feed today.

Dr. Sclafani, director of facial plastic surgery and professor of otolaryngology at Weill Cornell Medicine and New York Presbyterian, tells Cosmetic Surgery Times that surgeons’ interest is probably high because patients are enthralled with the concept of what they’ve come to know as PRP. Surgeons, however, are just starting to embrace the facial augmentation approach because, until recent years, the literature has been inconsistent and spotty.

The body of evidence in support of PRFM is growing, he says. But there remain some misconceptions even among cosmetic surgeons, according to Dr. Sclafani.

PRFM is different than what surgeons consider standard, or pure, PRP.

“With PRP, there is a very high concentration of platelets in a very small volume, and the platelets are induced to release the growth factors immediately. PRFM is somewhat enriched. It’s a much higher volume. It includes the plasma and incorporates fibrin,” Dr. Sclafani says.

The concept is this: The injected platelets from PRFM induce some sort of reparative function, releasing growth factors. This starts a wound healing cascade, which, basically, stimulates collagen production.

NEXT: Fat and Collagen Production

Fat and Collagen Production

Dr. Sclafani says he has been using PRFM for about eight years and has seen positive effects. The study provided a scientific and physiologic foundation to what he had been seeing clinically. And since, he has refined his patient selection process and better determined where PRFM works and where it doesn’t on the face.

The study involved injecting PRFM (The Selphyl System, Aesthetic Factors Inc.) into the forearms of four adult volunteers. The point of the study was to look qualitatively at changes in the skin and sub-dermis from PRFM.

“We injected into the dermis; we injected below the dermis; then, did serial biopsies over a course of time,” he says. “What we saw was new collagen being produced in about a week. By 2 to 2.5 weeks, there was a significant amount of collagen being produced. At by about 2.5 weeks, we started to notice fat cells, where there normally wouldn’t be fat cells in the area where we injected.”

The collagen produced post-injection turned into mature collagen by about week 10, according to Dr. Sclafani.

The researchers noted localized fat cell production, which wasn’t aggressive within the dermis but was more pronounced below the dermis, where fat cells are more likely to exist.

NEXT: Patient, Physician Expectations

Patient, Physician Expectations

PRFM is not a filler or media like Restylane or Juvéderm, he says. It doesn’t produce a tremendous amount of volume like a filler.

“I discuss this at length with patients,” he says. “This is not something where they see an immediate result. If they want to see an immediate result, PRFM is not for them. It’s not for the patient who has a really significant volume need. It would just take too many treatments and too long to really give them that correction.”

PRFM for the face, Dr. Sclafani says, works best to correct the hollows under the eyes.

“I think it blends very well. It’s not going to produce a lumpy correction,” Dr. Sclafani says. “That’s an area that I find patients are willing to incrementally improve over the course of two or three treatments.”

He also uses it to slightly augment the cheeks and to fill nasolabial folds.

“I don’t use it at all in the lips. I’ve been very disappointed with it in the lips,” he says. “I use it cautiously in the nose for secondary rhinoplasty.”

Results often last a year or more. And when patients return for touchups, they generally still look improved compared to how they looked in photos taken prior to treatment, according to Dr. Sclafani.

Surgeons who decide to offer PRFM should brace for the time spent educating patients that while fillers offer an immediate result after one treatment, results from PRFM take time and multiple treatments are usually required. That wait is even challenging for Dr. Sclafani, who says PRFM tends to be less gratifying than procedures that offer more immediate results.

Nevertheless, Dr. Sclafani says the option is important for patients because PRFM is their own tissue and it induces a natural healing process for a sustained effect. 

Disclosure: Dr. Sclafani’s study was supported by Aesthetic Factors Inc. and he is a former consultant for the company.

Reference

Sclafani AP, McCormick SA. Induction of dermal collagenesis, angiogenesis, and adipogenesis in human skin by injection of platelet-rich fibrin matrix. Arch Facial Plast Surg. 2012 Mar-Apr;14(2):132-6.

Capsular contracture remains a dreaded complication of breast augmentation and reconstructive surgeries. A new study published in the Aesthetic Surgery Journal suggests the Keller Funnel (Keller Medical) can reduce those rates by more than 50%.

Dr. Baxter“The Keller Funnel is a device used to insert silicone breast implants in a way that eliminates contact with the skin. So, it really facilitates what we think of as a no-touch technique,” study co-author Richard A. Baxter, M.D., a plastic surgeon, Seattle, Wash., tells Cosmetic Surgery Times. “The reason for doing that is that capsular contracture, which is a hardening of the scar capsule, is thought to relate in many cases to what are called biofilms, which originate from bacteria. The idea of the funnel I think appeals to a lot of us who do a high volume of breast implant surgery.”

NEXT: Study Details, Results, Implications

Study Details, Results, Implications

Plastic surgeon researchers compared 1,177 breast augmentations performed without the insertion funnel to 1,620 breast augmentations performed with the insertion funnel. In the study, seven centers retrospectively reviewed their surgical records from March 2006 to December 2012 for female patients who had undergone primary breast augmentation with silicone gel implants. In group 1, consecutive augmentations were performed without the insertion funnel. In group 2, consecutive augmentations were performed with the insertion funnel. The researchers looked for the development of grade III or IV capsular contracture that led to reoperation within 12 months.

They found that the insertion funnel group had a significantly lower incidence of reoperations performed due to capsular contracture within 12 months of primary breast augmentation with silicone gel implants. The rate of reoperation due to capsular contracture was 1.49% without the funnel and 0.68% with it, which is a 54% reduction in grades III and IV capsule detection.

“All of the practices going in had a low level of capsular contracture to begin with, but averaged together the incidence dropped by about half,” Dr. Baxter says.

Related: Laser therapy for capsular contracture?

The study suggests to plastic and cosmetic surgeons that there’s significant benefit to using the Keller Funnel, according to Dr. Baxter.

“It does add cost — about $100 for each case,” he says. “We’re balancing that against the cost of having to re-operate on patients. And reoperation for capsular contracture is not a trivial situation. It usually requires a capsulectomy, which involves removing the entire scar capsule and inserting a new implant, so it’s a big recovery for the patient and a significant expense. Even if it’s one patient out of 100 in a year, avoiding having to operate on them justifies use of the funnel.”

Dr. Baxter says the rate of biofilm-related capsular contracture depends on patient type.

“For example, in breast reconstruction there may be other confounding issues like radiation treatment and so forth. But for breast augmentation it’s likely that the majority of patients relate to biofilm,” he says.

Today, Dr. Baxter uses the funnel on all his breast augmentation and reconstruction patients receiving silicone gel-filled implants.

“With the saline implants you probably don’t need it, but we do so few of those now,” he says. 

Disclosure: Dr. Baxter reports no relevant disclosures.

In January 2016, Illusio Imaging launched a virtual mirror imaging system for breast augmentation patients. Used to enhance the patient experience during breast augmentation consultation, Illusio 3D imaging features a real-time image of the patient’s face and body with superimposed breasts (the size they would be post-surgery), so the patient can see how she'd look from different angles.

Mr. WinnerEthan Winner, chief executive officer and co-founder of San Clemente, Calif.-based Illusio Imaging says it’s all about the patient experience. "As a surgeon describes possible outcomes, he can now visually show her exactly what he's talking about, while she’s looking at herself in real time on a wall mounted large screen display. The patient is looking at herself in a virtual mirror and seeing virtual breasts instead of her breasts, but they look like hers," Winner says.

Winner and plastic surgeon Kyle Song, M.D., developed the software, which uses an iPad interface that projects onto a large monitor. The patient can see the virtual breasts on her body from different angles and from close and far.

"The technology that we use is called augmented reality. Augmented reality refers to any time you take a virtual image and superimpose it on the real world," Winner says. "That marker is simply a mechanism so the application knows where to place that image."

According to Winner, Dr. Song has used the technology on close to 150 patients and his rate of conversion has gone from about 60% before Illusio to more than 80% with Illusio.

NEXT: How It Works, What It Costs

How It Works, What It Costs 

The Illusio app can be downloaded from the app store and can be run on the iPad Air and iPad Pro. A tablet comes with the initial set up, according to Illusio.com.

"We encourage our physicians to stream it onto a monitor, just so there is a larger interface with the patient," Winner says.

The virtual mirror imaging system provides a strap for patients to wear, which not only serves as a marker, but also offers coverage. Photo courtesy of Illusio Imaging.Plastic surgeons who sign up also get a strap that patients wear, which serves as a marker and has the added benefit of making patients more comfortable because it covers their breasts (see image).

The cost to surgeons who use Illusio is about $1,000 for the setup and $499 a month for licensing, according to Winner. The monthly fee covers all future versions of the breast software, including a scar simulation in development, which will allow patients to see what different incisions look like over time, as well as a version with virtual clothing, so patients can see what their new breasts will look like in a bikini, blouse, etc.

Related: 3D printing creates 'mock' post-surgery noses

Winner says the company plans to innovate the technology to include an application focusing on abdominoplasty, which cosmetic and plastic surgeons would use to show tummy tucks and mommy makeover patients what they'll look like after surgery. That could be out later in 2016, according to Winner.

"Then we'll look at the next up, with facial procedures, [which could be the] beginning next year,' Winner says. 

It’s the device that could be paving the way to a thread lift comeback. But what do cosmetic surgeons really think about the recently FDA-approved Silhouette Instalift? We asked; they answered.

The Technology

The Silhouette InstaLift (Sinclair Pharmaceuticals) uses a resorbable suspension suture with bidirectional cones for anchoring to lift and reposition subdermal tissue of the mid-face, with minimal downtime.

Dr. BlinskiMade from polyglycolide/L-lactide, the implanted Silhouette InstaLift mechanically fixates the tissue until collagen production and encapsulation of the suture in collagen occurs. According to company literature, this results in a gradual increase in facial volume and shapeliness. The procedure, which typically takes 45 minutes, is done as an in-office/outpatient basis, under local anesthetic.

Sinclair announced in April 2015 that the Silhouette InstaLift had been FDA approved for mid-face suspension surgery to fixate the cheek sub dermis in an elevated position.

Miami, Fla., plastic surgeon Darryl J. Blinski, M.D., who tells Cosmetic Surgery Times that he has done 40 Silhouette InstaLift procedures since he started using the approach in February of this year, says the InstaLift works and patient satisfaction is high. It lasts from 18 months to two years, in most cases without involving incisions or causing preauricular scars.

38-year-old female patient with Silhouette InstaLift mid face suspension, submental liposuction and Thermi Tight RF. Photos courtesy Dr. Darryl J. Blinski.

But not everyone has the first-hand experience with this newer technology. Thus, we asked cosmetic physicians how this evolution in minimally invasive facial lifting might compare to traditional thread-lifting techniques, as well as the more invasive facelift. This is what they had to say:

‘A Significant Advancement’

‘Concerned About Longevity’

‘Unlikely to Have Significant Impact’

NEXT: ‘A Significant Advancement’

‘A Significant Advancement’

Dr. PoznerCosmetic Surgery Times advisor plastic surgeon Jason N. Pozner, M.D., of Boca Raton, Fla., says he’s onboard with using the resorbable suspension sutures for facial lifting because, he says, they are a significant advancement with better lifting capability and absorbability than traditional sutures used in thread lifting. Time will tell, however, how patients and physicians perceive their use and results.

“This is another tool for the right patient: the younger patient, who is not yet ready for facelift, or older patient, who medically is not a candidate for surgery,” Dr. Pozner says. “As experience is gained, it might replace some facelifts.”

NEXT: ‘Concerned About Longevity’

‘Concerned About Longevity’

Dr. BossParamus, N.J., plastic surgeon William K. Boss, M.D., says he has been using thread lifts since they first came out about eight years ago and were known as the Contour threads. Although Dr. Boss has not used InstaLift threads, he says he is familiar with them.

“They are a modification of the silhouette sutures on an absorbable suture, whereas, the standard silhouette sutures are permanent sutures and require a small incision back in the hairline to anchor them. … the InstaLift threads dissolve over time and require no incision,” Dr. Boss says.

Dr. Boss says that while the procedure is minimally invasive and very quick, he is concerned about longevity with the absorbable sutures.

“In my experience with the permanent sutures, the effects only lasted two to three years at most,” he says. “It appears that the [InstaLift] procedure is most suitable for younger patients without a lot of skin laxity.”

“I really would like to see a comparative study between the InstaLift procedure compared to noninvasive skin tightening technologies, such as ultrasound and radiofrequency,” Dr. Boss says.

NEXT: ‘Unlikely to Have Significant Impact’

‘Unlikely to Have Significant Impact’

Dr. ThompsonLayton, Utah, facial plastic and reconstructive surgeon Scott K. Thompson, M.D., has his doubts about the InstaLift. Dr. Thompson, who specializes in the facelift and mini (MACSlift) facelift surgery, says he does not perform any thread lift procedures.

“Although there have been many variations of thread lifting over the years (the latest being the InstaLift), any technique that doesn’t separate the skin from the underlying muscle and, then, address the sagging muscle tissue directly is unlikely to have significant impact for more than a few months,” Dr. Thompson says. “Unfortunately, many of these procedures approach the cost of a minimally invasive facelift, such as the MACS lift (a technique that while less invasive than a standard facelift, lifts and tightens skin and muscle independently). Those looking for a non-surgical option may be better served by reconsidering the costs and benefits of surgery or sticking with injectables and laser resurfacing procedures.”

Disclosures

Drs. Thompson and Blinski report no relevant disclosures.

Dr. Pozner has attended an advisory board meeting for the Silhouette InstaLift.

Dr. Boss has a patented procedure which incorporates a subcutaneous laser and threads.

Sure, they might think it’s fine to tuck a tummy, broaden a bust or re-engineer a rear end. But some cosmetic surgeons think a single common procedure — the labiaplasty — goes over the line, and they’re not afraid to let their colleagues know it.

Audience responses to an electronic survey at the 2016 Aesthetic Meeting tell the story: 40% of those who performed labiaplasties acknowledged getting negative feedback from other physicians, with most saying some or all of the flak came from fellow cosmetic surgeons.

Indeed, there are plenty of critics within the cosmetic surgery industry and beyond. The obstetrician-gynecology establishment, feminists, bloggers and others continue to criticize the rapid growth in demand for labiaplasty.

But a few years after the procedure entered the public consciousness, are the negative feelings within the profession on the decline? It’s hard to know for sure, but cosmetic surgeons who specialize in the procedure say they’re seeing a change.

Dr. Jugenburg"The stigma around labiaplasties is evaporating rapidly," Toronto plastic surgeon Martin Jugenburg, M.D., tells Cosmetic Surgery Times. "I feel like the newer generation of plastic surgeons views this procedure as just another cosmetic procedure we normally offer because of the exposure it has been getting the last few years at plastic surgery conferences."

And there was plenty of conference chatter at this year’s The Aesthetic Meeting, the annual gathering of the American Society for Aesthetic Plastic Surgery, which featured at least four sessions about the topic with titles like "Cosmetic Vaginal Surgery: Labiaplasty and Beyond,” and “Why Patients Request Labiaplasty."

The session "Incorporating Labiaplasty into Your Practice: Tips for Success" featured a survey-response system that asked hundreds in the audience if they perform the controversial procedure. More than 70% responded via electronic device that they do, but 3% agreed with this arch line: "Wouldn’t touch it if my life depended on it." And 2% agreed that the procedure should “Never be performed ever, don’t ask me again."

In fact, labiaplasties have long bDr. Streichereen an acceptable surgical procedure to improve comfort and functionality in areas like urination, says Lauren Streicher, M.D., associate clinical professor of Obstetrics and Gynecology with the Feinberg School of Medicine at Northwestern University. "Some women are born with or acquired very long labia which cause urine to spray all over the place and, quite frankly, just get in the way."

Over the past several years, however, "we’ve gotten much more into doing it for cosmetic reasons" as changes in pubic hair styles have uncovered female genitalia, she tells Cosmetic Surgery Times.

"Suddenly they are able to see their labia far more clearly, when 10 to 15 years ago, women couldn’t even see their labia, much less be critical of it. That’s when the plastic surgeons got on board."

Indeed, The American Society for Aesthetic Plastic Surgery estimates that 8,745 labiaplasties (excluding vaginal rejuvenation) were performed in 2015, including 400 in girls under the age of 18. At an average cost of $2,800 per procedure, the procedures accounts for more than $24 million in revenue, still far below the annual $1 billion-plus for breast implant surgery alone.

According to the 2015 statistics, labiaplasties jumped by 16% over 2014 and now rank as the 21st most popular cosmetic surgical procedure, just below lower body lift. The procedures weren’t ranked in 2010 or 2005.

NEXT: The Labiaplasty Critics

The Labiaplasty Critics

So who are the critics within the cosmetic surgery world? "There is an education gap with older plastic surgeons who have trouble understanding the need for such surgery," says Christine Hamori, M.D., FACS, a Boston plastic surgeon who spoke with Cosmetic Surgery Times. She’s performed more than 400 labiaplasties.

"Since most plastic surgeons are male and the concept of labiaplasty is driven by women, it is not surprising that some are critical of cosmetic vaginal procedures," she says. "They miss the fact that women do this for themselves to feel better and not to please men. Husbands and boyfriends are usually dismissive of labia hypertrophy, as to them it is not really an issue."

Dr. AlterGary Alter, M.D., a plastic surgeon in Beverly Hills and Manhattan, helped popularize labiaplasties and tells Cosmetic Surgery Times he’s performed 3,000 or 4,000 of the procedures. "I don't think there’s a stigma now," he says. "What you might have misinterpreted is that most plastic surgeons and, I’m sure, most gynecologists don’t feel comfortable doing them because they’re not really trained. They’re worried they’re not going to do a good job."

But critics of labiaplasty do exist, and they have powerful platforms. In 2007, a committee of the American Congress of Obstetricians and Gynecologists issued a statement warning about the lack of data regarding the safety and efficacy of "vaginal rejuvenation," "designer vaginoplasty" and similar procedures that are not medical necessary. The committee reaffirmed the statement in 2014.

Dr. Streicher, who has a public profile of her own, isn't entirely opposed to performing labiaplasties for non-medical reasons. "It’s a valid procedure in very specific women. I have a lot less problem with the 45 year old who comes to me and who’s had a couple of kids, is getting divorced, and is getting out there," she says. "I have a very different take regarding the 18 year old," especially if her labia is normal.

What about patients? Do they feel a stigma when they get labiaplasties? Their unwillingness to chat about their procedures with friends may provide a glimpse into their attitudes.

"Patient referrals are uncommon, and post-op patients do not talk," says John G. Hunter, M.D., FACS, a prominent labiaplasty surgeon in New York City, in his comments at The Aesthetic Meeting.

This level of reticence is unusual in the world of cosmetic surgery, he says, and requires surgeons to consider that "patients overwhelmingly get procedure information and seek consultations from the Internet."

What’s next? Boston’s Dr. Hamori says attitudes are changing, but slowly. "It is a long road," she says, "because of stern feminists who don’t understand that women themselves desire these procedures to feel better."

Picture this: You've just performed a perfect procedure. And then, even though everything went right, one thing after another begins to go wrong.

"Your patient hates the result, and the patient hates you," says plastic surgeon Mark B. Constantian, M.D., FACS. "You show her the preoperative photos and calmly explain what you did. She still hates you and thinks you're a liar and a crook, and she gets on the Internet and tells everyone."

This scenario may sound familiar; you may be thinking body dysmorphic disorder (BDD).

Dr. ConstantianDr. Constantian, who practices in Nashua, N.H., offers a deeper take. According to his new research, extreme dissatisfaction with plastic surgery procedures may have roots in an extraordinarily high rate of childhood trauma among cosmetic patients in general.

"I've added a big piece about why some patients are obsessed with physical perfection or trying to fix problems that other people don't even see," Dr. Constantian tells Cosmetic Surgery Times. "It's not an unrecognized genetic abnormality or a neurotransmitter problem. They started off in an abusive situation."

Dr. Constantian's research expands on existing knowledge about the close connection between BDD and plastic surgery. He discussed it this year at The Aesthetic Meeting of the American Society for Aesthetic Plastic Surgery.

In This Article

BDD Background

Is BDD Linked to Childhood Trauma?

Body Dissatisfaction vs. Body Shame

NEXT: BDD Background

BDD Background

BDD causes sufferers to become preoccupied by perceived body flaws to the extent that they can't function properly. 'The flaw they perceive may be non-existent or very minor. They think it really looks terrible, and they want to have it fixed,' says Katharine Phillips, M.D., a professor at Warren Alpert Medical School of Brown University who runs a BDD clinic. 'The problem is with their tendency to focus on tiny details, to obsess and worry about how they look with an inability to see the big picture."

It's difficult to measure BDD, so estimates of the percentage of plastic surgery patients with the condition have varied widely. A study of 234 patients in JAMA Plastic Surgery last year put the numbers at 13% (cosmetic surgery patients) and 2% (reconstructive surgery patients).

Dr. Phillips tells Cosmetic Surgery Times that surgery is rarely a fix for these patients. Another 2010 study found that "overall BDD severity improved with only 2.3% of treatments."

Even worse, surgery can be risky for the patient, who may become suicidal, and the physician, who may be severely criticized, sued or even physically threatened by the patient, Dr. Phillips says.

In a previous study (part 1 and part 2) published in 2014, Dr. Constantian and a colleague studied 100 patients seeking a second rhinoplasty. The rate of childhood abuse was over 90% among those who'd had more than three previous procedures, had a normal nose shape before the first surgery and showed signs of depression and/or were demanding.

"Trauma (abuse/neglect) history was the most significant mediator between patient satisfaction and number of operations and the most prominent factor driving surgery in patients with milder deformities," the researchers wrote.

NEXT: Is BDD Linked to Childhood Trauma?

Is BDD Linked to Childhood Trauma?

For the new study, Dr. Constantian and colleagues sought to better understand the role of childhood trauma. "I wanted to be able to put my findings in context," he says.

The researchers studied 100 consecutive patients post-operatively: mean age 51 (21-77), 77% women, 92% Caucasian and 76% college or graduate school degree. Of the patients, 87% were undergoing aesthetic surgery while the other 13% underwent reconstructive surgery.

The patients answered questions from a 1995-1997 Kaiser Permanente/CDC survey into childhood trauma. 

The Kaiser/CDC study found that 67% of 17,433 general medical patients in Southern California gave at least one positive answer on the survey; the number was 81% in the plastic surgery survey. The number of patients who answered yes to more than 4 of 10 questions was also higher in the plastic surgery group at 54% compared to 16% in the Kaiser/CDC group.

In the plastic surgery group, the levels of reports of emotional abuse (49%), emotional neglect (43%) and experience living with drug/alcohol abuse (40%) were double those in the Kaiser/CDC group.

Dr. Phillips says other research links BDD to childhood trauma and also to childhood teasing. But it's difficult to know if they were actually teased more. They may be predisposed to be more sensitive to teasing and more likely to remember it when surveyed, she says.   

According to Dr. Constantian, childhood trauma can produce people who are perfectionists, obese, obsessive, untrusting, needy and dependent.

"If they end up in a plastic surgeon's office, it's because that's how they're trying to get self-esteem," he says. "When their wildest dreams aren’t realized — and they never are — they have a flashback to childhood, and their feelings of worthlessness have been reawakened. That's why they get so irrational. You can't reason with them, you can't calm them down."

NEXT: Body Dissatisfaction vs. Body Shame

Body Dissatisfaction vs. Body Shame

So could questions about childhood trauma be a screening tool for BDD? Dr. Constantian doesn't think so. "The patients you love to see didn't necessary have easy childhoods,” he says. “They just overcame them. Trauma doesn't do the same thing to everybody."

So what can plastic surgeons do to help — and avoid — patients with BDD?

"The good patient has body dissatisfaction, and the bad patient has body shame," Dr. Constantian says. He cautions colleagues to keep an eye out for patients who want to fix body parts like noses that are normal because they "aren't perfect enough."

"That's a danger sign," he says. "The patient needs to understand there’s no such thing as perfect."

Dr. Phillips suggests using a survey designed to detect BDD. You can find examples here: www.rhodeislandhospital.org/services/body-dysmorphic-disorder-program/questionnaires.html.

If patients do show signs of deep-seated problems, Dr. Constantian says, trauma treatment is where they belong. The good news, Dr. Phillips says, is that BDD is a "very treatable condition" via medications and therapy. 

Difficult cosmetic surgery patients are usually one of four types, according to Brenton Koch, M.D., a facial plastic and reconstructive surgeon in West Des Moines, Iowa. Dr. Koch, who wrote the book "Raving Patients!,” presented on the topic of nightmare patients yesterday during the Vegas Cosmetic Surgery and Aesthetic Dermatology 2016 meeting in Las Vegas.

When it comes to defining those difficult patients, “Some are angry,” Dr. Koch says. And, usually, that has nothing to do with you, but is projected at you because you are something they think they can control when they can't control what's truly hurting them, Dr. Koch tells Cosmetic Surgery Times.

There are also uninformed patients. Their questions seem never-ending, and sometimes they realize they don’t know why they’re consulting with a cosmetic surgeon. Or they have gotten all their "information" from the Internet or a chat site.

“People should be reminded of the obvious selection bias going on with internet discussions and information,” Dr. Koch says.

Unrealistic patients wonder why their eyes are swollen one week after surgery. These patients, according to Dr. Koch, need education and are often most helped most by illustration, demonstration and information.

Finally, there are those patients with underlying psychological disorders, including body dysmorphic disorder, borderline personality disorder, codependency issues and depression.

Dr. Koch offered these tips for dealing with difficult patients:

1. Identify the type of patient and what's going on early in your interaction. Be specific with questions about why they’re consulting with you. Separate yourself from the interaction and evaluate that patient from a third-party perspective to identify underlying issues. It can be difficult for practitioners not to take comments and reactions from these patients personally, according to Dr. Koch. It's important to remember that their problems have nothing to do with you, and oftentimes an attempt to understand their pain will help you to keep perspective and even help.
2. Always, always, always remain positive in your discussions and resist the urge to argue — at all times.
3. Often, there comes a time to let go of problem patients. That time might even be at the first consultation. One luxury cosmetic practitioners have is the option of saying, "You look great just the way you are, and I don't recommend any intervention or treatment at all." Even not charging for a consultation that may include this interaction, frees you of prolonged attachment with regards to accepting money for making a patient unhappy, so to speak.

“To recap: identify, remain objective and positive, and don't be afraid to separate [yourself] from patients like this. No one procedure with a nightmare patient is worth the long-term frustration and damage to one's reputation that can result,” Dr. Koch says. 

Millennials by definition are born in the 1980s and ‘90s and have now surpassed the baby boomers as the largest generation. So as they continue to grow up (age), what exactly do cosmetic surgeons need to know to welcome and retain them as patients in their practice?

According to Chicago-based dermatologist Rachel Pritzker, M.D., millennials can be described as technology focused. They create networks through technology and represent themselves from a very young age with their online presence. Dr. Pritzker presented on the topic of millennials and initiating treatment with these younger patients yesterday during the Vegas Cosmetic Surgery and Aesthetic Dermatology 2016 meeting in Las Vegas.

“They are motivated by trends that they see online, and they are always up to date with their knowledge about potential procedures,” Dr. Pritzker tells Cosmetic Surgery Times. “Because of this knowledge, this generation comes into the office at an earlier age requesting treatments — either to make themselves look better in ‘selfies,’ to change an aspect of their appearance they do not like or to prevent the aging process.”

A word to the wise cosmetic surgeon regarding the successful treatment of millennial patients: A little goes a long way, according to Dr. Pritzker.

“Having this generation of consumers is beneficial, as they will be loyal and return frequently, but it is important to sense why they are seeking procedures and not treat a patient with a body dysmorphic syndrome at an early age,” she says. “Top three words of wisdom: marketing, creativity, caution.”

Disclosure: None