Dr. EmerVaginal rejuvenation has gone from hush-hush to trending. The scenario will likely be much the same for men. They, too, want sexual parts to look and feel better, and men are starting to make those desires known, according to Beverly Hills, Calif., dermatologic surgeon Jason Emer, M.D.

“I have many younger male patients who are interested in this,” Dr. Emer says. “As the vaginal rejuvenation market is skyrocketing, men are seeking their own type of rejuvenation. Who wouldn’t want to be a little bit longer, thicker, or have more sensitivity and a better sex life? These men are also becoming interested in the cosmetic appearance of the actual penis and scrotum itself.”

The potential patient population also includes older men, who might have erectile dysfunction, resulting from age or health issues, such as prostate cancer treatment or high blood pressure, as well as cosmetic concerns that keep them from feeling good during intimacy or being comfortable naked, according to Dr. Emer.

Dr. Emer started doing penile enhancement treatments about three years ago. Until recently, most procedures involved using hyaluronic acid fillers or fat injections for penile enlargement. But injecting fillers and fat into the penis can be risky business. There are concerns, according to Dr. Emer, that small area, like the penis, fingers and noses, which have less blood circulation, could be at risk for serious complications from injectables, such as impending necrosis or vascular occlusion injuries.

So, Dr. Emer looked into other options — things he could do externally to the penis and scrotum to achieve desired outcomes with less risk. He found lasers and shock therapy are potential options in penile rejuvenation.

“These [modalities] stimulate the blood flow and theoretically can improve erectile dysfunction and, in turn, sexual stamina,” he says.

NEXT: Penile Enhancement Research

Penile Enhancement Research

Dr. Emer says he has been contacting companies to conduct trials on the use of lasers and shock therapy on penile enhancement with an overwhelmingly positive response. 

“I had been performing hair removal treatments in the genital area with a device called LightPod Neo, made by Aerolase. It’s a microsecond Nd: YAG laser which is virtually painless and requires no direct contract. It’s very quick, high-energy pulsing, so that you can damage the hair follicle without risk to the the skin,” Dr. Emer says. “When I started doing hair removal on the scrotum and around the penis, patients reported the appearance of their scrotum and penis improved. The skin was less wrinkly, it was smoother, and some even reported it wasn’t as veiny.” 

Dr. Emer says that wasn’t too much of a surprise, given the LightPod device has been used for facial rejuvenation.  Passes with the device cause deep heating of the tissue promoting collagen formation and tightening. It may also be increasing blood supply to the penile area, he says, which would improve sexual function, sensitivity and size.

After using the LightPod Neo on about 10 patients, Dr. Emer says none have reported negative outcomes or complications. All have mentioned that they’re more sensitive in the area since treatment.

“They’ve noticed at least a short-term increase in size, and I have a couple of patients who were unable to get erections easily and now are having them uncontrollably,” Dr. Emer says. “We’ve done similar testing now with another device called Cellutone by BTL Aesthetics which uses shock waves to stimulate blood flow and cause an acute short-term inflammation in the area treated, that, when it repairs itself, heals with improved local function. Not only have patients reported improvement in erectile dysfunction and size, we’ve also noticed improvements using this technology among men who have curved penises and are looking for a more straight appearance.”

Another treatment that is promising is the use of platelet-rich plasma, or PRP, according to Dr. Emer.

“We initially began seeing increased thickness with PRP injections, but then men were not only getting reporting increased erections, better sex, more ejaculations and heightened sensitivity,” he says.

The problem for surgeons who want to start incorporating penile rejuvenation into their practices is the lack of data and information about best practices, according to Dr. Emer. For now, there are a few researchers conducting trials on penile enhancement — Dr. Emer being one.

“There really isn’t much out there. I’m one of the innovators. I hope to be a pioneer in this field. I am trying treatments to meet the demand of my patient population and heighten awareness in this field. I hope that one day this will be mainstream like vaginal rejuvenation has so quickly become. For now, surgeons are going to have to watch what I [and a few others] discover as we try different methods,” he says.

NEXT: Penis Pumps & Scrotox

Penis Pumps & Scrotox

Dr. Emer is studying not only individual therapies, but also combinations of devices and injections, as well as how dermatologists and cosmetic surgeons can work with urologists to improve results of treatments. For example, Dr. Emer advocates the use of patient controlled penis pumps at home, immediately after treatments. Dr. Emer says combining what the urologist does with pumps with laser or other injectable treatments further increases blood flow, stimulates new blood vessel growth and could improve overall outcomes.

He is investigating the use of Botox to the genitals.

“Botox decreases sweating, improves wrinkling and may in some cases make the scrotum appear larger by relaxing the muscles in the area,” says Dr. Emer.

Dr. Emer says he uses the term “Scrotox” for this manly treatment, a term which has been used elsewhere, including a Saturday Night Live spoof on rejuvenation of the scrotum.

“It’s not only cosmetic, my marathon runners and cyclists who get inner thigh rubbing and irritation from sweat, benefit from this treatment as it decreases skin burn,” he says.

Now is the time for aesthetic physicians to consider looking into offering these alternative options to male patients, according to Dr. Emer.

“I think it’s a trend that people will start hearing more about, as there is significant demand. Hopefully, companies will start doing research with me and other interested doctors, so we can get data out to the medical community,” Dr. Emer says.

The timing is right. Men are paying more attention to their looks. They are having skin rejuvenation procedures, body contouring, teeth and hair treatments. They are man grooming more than ever, he says.

“I think every [man] is going to want to do this, as commonly as getting their hair cut or their teeth cleaned,” he says. “Men want to feel and look good. They want to have a better sex life and feel confident being naked.”

Disclosure: Dr. Emer has ties with Eclipse, Aerolase and BTL Aesthetics.

Sculptra Aesthetic (injectable poly-L-lactic acid [PLLA], Galderma) is gaining traction in off-the-face treatments, some say. But is the practice to use PLLA for the body in patients’ best interests? Surgeons on both sides weigh in.

Some surgeons tell Cosmetic Surgery Times that this PLLA-based treatment, which has been shown to last more than two years when used to reduce facial wrinkles and folds, can also be used, off label, to diminish cellulite, emphasize muscle definition and even treat plantar foot atrophy.

Dr. EviatarNew York City-based cosmetic surgeon Joseph Eviatar, M.D., uses Sculptra in men to create fuller and shapelier calves, pecks, butts and biceps. Final results from body sculpting with Sculptra take about three months, but outcomes are stellar and patients don’t need implants, he says.

“… the option of an implant can be scary, as they can harden over time, cause discomfort and often look drastic and unnatural. Sculptra appears to be a safe option providing natural results with minimal downtime,” Dr. Eviatar says.

Another off-label use of Sculptra that works, according to Dr. Eviatar, is to treat cellulite in the butt and thighs.

“We use the same concentration (8 cc sterile water, plus 1 cc lidocaine added to product) as we would in the face, but we need about six vials of product, whereas, with the face we use about two to three vials,” Dr. Eviatar says. “We inject the Sculptra at the deep dermis level to fill in the divots. We do not inject into the fat or near the bone, as you would with the face. The needle fanning technique creates damage to the top dermis layer and allows for a healing response, which also stimulates collagen production, making cellulite appear less obvious.”

Patients being treated for cellulite on the buttocks or thighs generally need about three treatments, spaced three weeks apart. The Sculptra continues to work three to four months after the last treatment and results are permanent with cellulite, according to Dr. Eviatar.

There’s more.

NEXT: Sculptra for Biceps & Breasts

Sculptra for Biceps & Breasts

“In regard to biceps and upper chest (in men), Sculptra seems to be a homerun,” he says.

Ideal patients for that indication are those who have little definition and want to accentuate the areas a little more, according to the cosmetic surgeon.

“We inject Sculptra just under the surface of the skin to make the area ‘pop.’ We use about one vial of product and perform two to three treatments,” Dr. Eviatar says.

Dr. Eviatar has used Sculptra and is conducting studies on Sculptra’s use for treating the décolletage, upper breast area and buttocks. 

“In general, injecting Sculptra in the body doesn’t require a large amount of time. Though the surface area is larger, it takes less or the same amount of time as injecting Sculptra in the face. We generally charge the same amount of money that the face would cost, yet we are using double the product,” Dr. Eviatar says.

Ideal candidates for body Sculptra treatments are people 40 to 60 years of age, who are in pretty good shape and just have problem areas, according to the cosmetic surgeon.

Dr. Eviatar says he has not seen any complications using Sculptra for these indications. Surgeons using the approach should let patients know to expect some bruising at the site, as with any injectable. 

“It is important that the dilution of the product is correct,” Dr. Eviatar says. “We find that less dilution can cause some lumps, so the 8 cc to 9 cc of sterile water appears to be optimal. Also, physicians must inject the correct layer of skin for different body parts. An example with cellulite: If Sculptra is injected into the fat layer, the outcome will not be very good.”

Dr. RodwellCharleston, SC-based facial plastic surgeon David W. Rodwell, III, M.D., says he prefers to focus on his area of anatomic expertise, so the only area outside of the face that he treats with Sculptra is the upper chest, or décolletage.

“I do not perform injections elsewhere, such as the hands or thighs/buttocks. However, there is some promising buzz in our community about transitioning Sculptra into use for areas of cellulite,” Dr. Rodwell says. “The upper chest is a perfect area for Sculptra and responds quite well with great patient satisfaction.”

Dr. Rodwell emphasizes dilution, as well.

“A few pearls for using Sculptra in this area are to use a more dilute solution, consider cannulas and combine with other treatment modalities,” Dr. Rodwell says. “My typical Sculptra dilution is 8 cc to 9 cc when used in the face, but for the décolleté area I prefer a 12 cc dilution for a more even distribution to a broad area. Although the skin is delicate in this area, it is still relatively thick and can be slow to show improvement, so a series of two to three Sculptra treatments spaced six weeks apart seems to be ideal for most patients.”

Dr. Rodwell says he achieves best results when he combines Sculptra with a series of moderately intense fractionated CO2 laser treatments. The combination approach results in even more collagen production to reverse the skin aging and sun damage in the upper chest.

NEXT: Sculptra for Hands & Feet

Dr. Ostad

Sculptra for Hands & Feet

New York City-based cosmetic dermatologist and dermatologic surgeon Ariel Ostad, M.D., tells Cosmetic Surgery Times that many people don’t know that Sculptra can be used to effectively treat plantar foot atrophy.

“It fills the flattened area and provides internal cushioning in the feet, creating padding between the skin and bones of the foot. This cushioning can prevent calluses from repetitive pressure,” Dr. Ostad says. “We have successfully used it on the bottoms of the feet to alleviate pain and pressure from standing, wearing high heels and running. We use it frequently on patients who run, in order to prevent Achilles tendinitis, runners’ knee and shin splints.”

Dr. Ostad says Sculptra can also be used on the hands. In appropriate candidates, he dilutes Sculptra in 7 cc of saline with 2 cc of lidocaine 1%. After injecting those patients, he says, it’s good to massage the area to avoid granuloma formation.

NEXT:  Sculptra for the Face Only

Dr. Freiman

Sculptra for the Face Only

But not everyone is a fan of using Sculptra off the face. In fact, Miami, Fla.-based plastic surgeon Jacob Freiman, M.D.,  says he feels strongly that Sculptra should not be used anywhere but the face.

“I believe the reason Sculptra has not been approved for other parts of the body is because it doesn't make sense,” Dr. Freiman says.

Dr. Freiman says that since Sculptra must be injected deep, surgeons would need massive amounts to see even the slightest difference. The massive injection would result in poor blood supply and may ultimately cause a seroma. If surgeons inject Sculptra on body area too close to the skin, small nodules will result. And the cost is prohibitive, he says.

“Consider that it could take over 1000 ccs of fat to perform the proverbial Brazilian Butt Lift,” Dr. Freiman says. “A similar amount of Sculptra would cost over a million dollars for only a temporary effect. Currently, I do not know of any board-certified plastic surgeons performing body Sculptra.”

Disclosures: Drs. Freiman, Ostad, Rodwell and Eviatar report no relevant disclosures. Dr. Eviatar's reserach is self-funded. 

Arnica montana has a history of medicinal use dating back to the 1500s. Ever searching for ways to improve patient recovery (and prompted by effective product marketing), we’ve seen Arnica become fairly well accepted as an option for reducing post-surgical swelling and bruising. But does it actually work? This is the question that prompted van Exsel et al. to design and perform their randomized, placebo-controlled trial that was published in the July issue of Plastic & Reconstructive Surgery.

The researchers randomized 136 bilateral upper blepharoplasty patients into two study arms: One received arnica ointment 10% and the other a placebo ointment. Patients in both arms had a treatment and non-treatment side designated. The periorbital area of the treatment side received either arnica or placebo ointment, while the non-treatment side received no ointment and served as an internal control. Overall periorbital appearance was the primary endpoint and assessed by a medical and nonmedical panel using light photography after 3 days, 7 days and 6 weeks. Secondary endpoints included swelling, pain, ecchymosis, erythema and patient satisfaction with recovery and outcome.

Does Arnica Work?

The study found no significant differences between arnica and placebo based on the panel’s assessment and nor did any of the secondary endpoints differ between arnica and placebo. Furthermore, there was no difference in outcome between treated and untreated eyelids in ether the arnica or placebo groups.

The researchers' conclusion: “…topical arnica ointment after upper blepharoplasty does not improve postoperative outcome.”  

Reference:

Van exsel DC, Pool SM, Van uchelen JH, Edens MA, Van der lei B, Melenhorst WB. Arnica Ointment 10% Does Not Improve Upper Blepharoplasty Outcome: A Randomized, Placebo-Controlled Trial. Plast Reconstr Surg. 2016;138(1):66-73.

Not only has the number of consumers who want to have cosmetic surgery doubled since 2013, but the top four treatments they want to have are all technology based, including energy for skin tightening, laser and light for skin imperfections, body sculpting and laser hair removal. That’s according to survey results released this week by The American Society for Dermatologic Surgery (ASDS).

The ASDS reports that they conducted a blind online survey April, 20, 2016 to May 1, 2016 using Survanta, a web-based service. They received a total of 7,322 responses. This is what they found:

Popularity Contest

Ranking highest are treatments to tighten skin or smooth wrinkles using ultrasound, laser, light or radiofrequency at 60%. Laser and light treatments come in second (51%), with body sculpting (50%) and laser hair removal (48%) in the third and fourth spot.

What a Bother

There are numerous physical “flaws” that the overall population would rather not have. The ASDS survey reports these as the top 5:

1. Excess weight 83%
2. Lines, wrinkles around and under the eyes 73%
3. Submental/neck fat 73%
4. Skin texture and/or discoloration 71%
5. Lines, wrinkles and/or folds in the mid-face, around the cheeks, mouth 67%

Related: A closer look at Sculpsure

One Satisfied Customer

Satisfaction is always the name of the game and for survey respondents who have had treatments, these top-scoring procedures all come in at 95% and above:

• Injectable wrinkle-relaxers
• Laser and light treatments for redness, tone, scars
• Skin tightening/Wrinkle smoothing using ultrasound, laser, light, radiofrequency
• Vein treatments
• Microdermabrasion
• Laser tattoo removal

And then, of course, there’s the question of why. What’s motivating the population to seek out medical aesthetic treatments? They want to feel more confident, appear more attractive and look as young as they feel or better for their age, reports the ASDS.

Finally, if you are an ASDS member, the association reports that you are the dermatologist of choice for cosmetic medical procedures. Other factors that influence consumer choice of provider include price, board-certified specialty, referral and licensure level.

A radio-frequency device that helps to tighten skin, including around the vagina.

A non-invasive fat removal device for sculpting.

A hair grafting device that promises rapid procedures.

Dr. DiBernardoBarry DiBernardo, M.D., FACS, director of New Jersey Plastic Surgery in Montclair, is praising all of these devices as “up-and-coming winners for this year.” Dr. DiBernardo, who’s a consultant, trainer and researcher for each of the device manufacturers, spoke about them during a session on Hot Devices in 2016 at The Aesthetic Meeting in Las Vegas, the annual meeting of the American Society for Aesthetic Plastic Surgery.

Here are the devices:

ThermiRF, an injectable radio frequency technology device that applies heat.

Dr. DiBernardo praises its ability to tighten skin in contrast to other devices. “There are a lot of devices that can reduce fat, but you can still have skin hanging there,” he tells Cosmetic Surgery Times.

According to Dr. DiBernardo, the device has shown success at tightening skin in the neck and around the eyelids. It can also be applied to abdominal, arm and breast skin.

Related: Nonsurgical neck tightening: What works best?

He also highlighted an add-on component of the machine known as ThermiVa, which provides vaginal tightening.

Plastic surgeons should be cautious about using the device at the correct temperature, he says. “The beauty is that a probe is monitoring the temperature under the skin and a thermal camera monitors the temperature above the skin.”

SculpSure, a laser treatment for non-invasive lipolysis of the flanks and abdomen.

“It works faster than previous devices and has more versatility for more parts of the body,” Dr. DiBernardo says. “The applicators are flat so you can use it almost anywhere in the body compared to those hose-curved applicators that had to fit certain curves and certain dimensions.”
 

Related: A closer look at Sculpsure

He cautions that SculpSure must be reserved for the proper patients. Someone who’s overweight should get liposuction or a tummy tuck instead, he says.

SmartGraft, a hair-grafting device that promises to do a better job of preserving hair until implantation.

“It’s added a lot of improvements over previous devices,” Dr. DiBernardo says, and streamlines several steps so the grafting procedure can be performed more quickly.

As for cautions, he advises that “you need to be experienced at hair transplants to use these kind of devices.”

Disclosures: Dr. DiBernardo reports being a consultant, trainer and researcher with ThermiAesthetics (ThermiRF), Cynosure (SculpSure) and Vision Medical (SmartGraft).

Like many of the technologies cosmetic surgeons buy and lease for their practices, hair removal lasers are evolving to cover more area, in less time and with less discomfort. We asked cosmetic surgery experts to name their favorite brands, share what’s important in hair removal technology and help colleagues decide whether what they have is enough or it’s time to upgrade.

Wavelength Winners

Hollywood, Fla.-based dermatologist Todd Minars, M.D., says that while newer lasers have color screens and more bells and whistles, the foundation of the technology is much the same. The most effective wavelengths for hair removal have not changed in many years, he says.

Dr. MinarsDr. Minars says he prefers the 755 nm Alexandrite Candela GentleLase Pro for light skin patients and Candela GentleYag 1064 nm Nd:YAG laser for dark skin.

Alexandrite lasers reign in permanent hair removal because of the technology’s 755 nm wavelength. The laser’s wavelength more easily targets coarse and finer hair, resulting in optimal hair reduction, according to Dr. Minars.

“Both the Alexandrite and the GentleYag are effective workhorse lasers,” Dr. Minars tells Cosmetic Surgery Times. “But you do need both if you want to treat hair in all skin types; the GentleLase cannot treat dark skin safely.”

Surgeons who have one or both of these lasers do not need to upgrade, according to Dr. Minars.

“The only advantage to some newer lasers is a faster pulse rate or a larger spot size which would allow you to finish a large case (like a leg or back) faster,” he says. “Candela has combined these two devices into one laser … but I prefer to have two separate lasers. Combining two lasers into one creates ‘traffic jams.’ When you have two separate lasers in two separate rooms, you can have two doctors treating two patients at the same time, allowing for physician efficiency and minimizing patient waiting time.”

Disclosure: Dr. Minars reports no disclosures.

NEXT: By the Business Model, Tanya Kormeili, M.D.

By the Business Model

“There are so many different laser companies that produce hair removal technology. The key is to determine the type of business model you might want to have as the cosmetic doctor,” says Santa Monica, Calif., dermatologist and UCLA clinical instructor of dermatology Tanya Kormeili, M.D. “If you plan to be (like our office) a high end office where the dermatologist provides the actual treatments, you need to go to the gold standards for laser technology, i.e. Alexandrite and Nd:YAG lasers.”

These devices, she says, are good for most lighter skin types. But as the skin gets darker, they’re less suitable.

“They are safe, fast and effective, but are limited by price, and the fact that they are not as suitable for darker skin types,” Dr. Kormeili says. “If one plans to run the practice by nurses, and be able to provide hair removal to most patients, diode lasers might be a better choice. They need more treatments but can be safer on most skin types.”

Disclosure: Dr. Kormeili reports no disclosures.

NEXT: Workhorses Win, Jason Pozner, M.D.

Workhorses Win

For hair removal, Boca Raton, Fla., plastic surgeon Jason Pozner, M.D., uses the Candela GentleMax Pro and Sciton’s BBL and ClearScan YAG 1064 nm Nd:YAG wavelength lasers.

Both company make good hair reduction systems, according to Dr. Pozner.

Dr. Pozner“The Candela is a workhorse — quick and not painful,” Dr. Pozner says. “I tell most docs to start hair removal with the Sciton BBL, as it is a very useful machine for light skin patients with dark hair and for so many other non-hair related applications.”

Dr. Pozner tells Cosmetic Surgery Times that he rarely upgrades hair removal lasers at his practice. Why? There isn’t an urgent need to upgrade because the advances haven’t been all that significant, he says. “… the devices we have are so good and are workhorses.”

For surgeons who are considering a new hair reduction device, Dr. Pozner says the newer diode devices may be faster than older technologies.

Disclosure: Dr. Pozner consults with Sciton and Syneron Candela.

NEXT: Fast & Flexible, Chris Robb, M.D., PhD

Fast & Flexible

Chris Robb, M.D., Ph.D., cofounder of the Skin & Allergy Center Spring Hill (a suburb of Nashville), Tenn., says hair removal is a mainstay of any cosmetic practice.

Dr. Robb“… you need to be fast, efficient and have happy clients,” Dr. Robb says. “You also need to be flexible with different skin types, and platforms that offer dual wavelengths are often preferable.”

Dr. Robb uses the BBL Forever Bare (Sciton).

“We've found it’s painless and very effective. Large areas can be treated relatively quickly,” Dr. Robb says. “I also have recent experience with GentleMax [Syneron Candela], which I like for its spot size and flexibility. It’s important, whether you use an IPL or a laser, to have some flexibility in treating vascular or pigmented lesions. This is especially true if it’s your first laser.”

According to Dr. Robb, these are important considerations when deciding on a hair removal device: large spot sizes, safe cooling and increased speed.

Disclosure: Dr. Robb is a speaker for Sciton but reports no conflicts of interest with Syneron Candela.

NEXT: Speed & Comfort, Michael H. Gold, M.D.

Speed & Comfort

Nashville, Tenn., dermatologist and cosmetic surgeon Michael H. Gold, M.D., says his practice offers several different hair removal devices for patients depending on such things as their skin color and hair color.

Dr. Gold“Most of our patients are being treated today with either the 810 nm LightSheer Duet by Lumenis or the Soprano Ice by Alma Lasers,” Dr. Gold tells Cosmetic Surgery Times. “We do use the Cynosure Elite MPX 1064 nm device on darker skinned individuals, as well as the Aerolase [LightPod] Neo 1064 device.”

Dr. Gold says that while there are several new hair removal devices on the market that might prove to be better than what he has, he doesn’t feel compelled to keep up with every new hair removal device that comes to market. The array of technology he has had for several years has stood the test of time, has been upgraded when available and fits the needs of a diverse patient population, according to Dr. Gold.

“The most important things we look for are speed and patient comfort — making sure efficacy is always kept ahead of everything,” he says.

Among the new and potentially attractive features of today’s hair removal devices are speed and virtually pain-free treatment, according to Dr. Gold.

While hair removal has an important place in Dr. Gold’s busy practice, he says that he doesn’t view hair removal in the same breath as fractional laser resurfacing or microneedling. That’s mainly because hair removal has become a commodity and is being done virtually everywhere now, he says.

“In the past, when only laser doctors were offering this, we spent much more time with the technology. And as more and more people started doing it — whether for the good or bad — many doctors stopped paying attention to it, as they feel there is not enough money in it anymore for them,” Dr. Gold says.

Dr. Gold says his practice has maintained a successful hair removal business by focusing on quality and being the best choice for consumers.

Disclosure: Dr. Gold is a consultant for Aerolase Corporation and has ties to the other companies but not specifically in the area of hair removal.

NEXT: High-Tech Upgrades, Jack Zamora, M.D.

High-Tech Upgrades

Denver, Colo.-based plastic surgeon Jack Zamora, M.D., says there are many different types of lasers available for permanent hair reduction, which offer safe, effective treatment.

“Some use either laser or light energy, but with the correct modality and settings both can be effective,” Dr. Zamora says. “Finding the best device will depend on the patient's skin type, density of the hair and the melanin in the hair follicle. Even the best machines may not work well if the clinicians are inexperienced and uninformed about which device is best for that patient and which settings will yield the best result.”

Dr. Zamora recommends the Palomar Vectus and Lumenis LightSheer because they are safe options for patients with light and dark skin; they have the FHR technology (fast hair removal treatment time); and cooling chill tip to provide treatment with minimal discomfort.

The plastic surgeon says it is important for providers to update or change their devices to the latest advancements available.

“Older machines don't have larger spot sizes, so treatments take longer. Not all older devices have a cool chill tip and, therefore, treatments are more painful. Out of date devices cannot give the same level of energy or run as efficiently to provide a successful and speedy treatment,” he says. “The longevity of a device depends on how often it is used and it is important to keep your machine maintained through its lifespan.”

Disclosure: Dr. Zamora is a national trainer for Cynosure. 

“More butt, more money.” That’s how some of the butt augmentation patients at the Los Angeles clinic of plastic surgeon Dr. David Matlock describe their desire for a bigger derriere. 

Dr. Matlock“Some in various professions state that they make more money with a lot of junk in the trunk, as the song goes,” says Dr. Matlock, M.D., MBA, FACOG. 

Whatever happened to the days when slimmer female behinds were the ideal? Will they ever return? And what about implants, male patients and other butt augmentation statistics? 

As cosmetic surgeons embrace the surging interest in the gluteus maximus, here’s a look at the past, present and future on the butt front.

From the Pages of Playboy

Millions of American men may have, um, "studied" the history of American ideals of feminine beauty by reviewing old issues of Playboy. But few have actually been paid for it like San Diego journalist and author Damon Brown.

Mr. BrownBrown, who specializes in sexuality, is author of the 2012 book “Playboy's Greatest Covers.” He understands how Playboy always viewed the feminine form: With an emphasis on the front above the waist. “The focus has always been on the bust, not the behind,” he says. “Playboy’s emphasis has never been the behind.”

Even so, the archives of Playboy offer insight into changing American ideals of the female rear end. Brown sees trends in the curves and a bit of a return to the past in the present.

In the 1950s, the ideal was Marilyn Monroe. “Her body type isn’t much different than Kim Kardashian’s,” he says. “Kardashian is a bigger woman, but it’s the same kind of ideal.”

But a decade later, tiny waists and exaggerated hips were in. Then the 1970s brought a revolution. “You get into heroin chic and women being more svelte, thinner and less curvy,” he says. “It’s connected to Studio 54, not eating and doing a lot of cocaine. All that is reflected in Playboy.”

In the 1980s and 1990s, pornography and plastic surgery produced the “trifecta” of Jenny McCarthy, Anna Nicole Smith and Pamela Lee — augmented and proud of it. But these three women weren’t known for their well-equipped rears. What happened to move buttocks into our modern era of bigger-is-better?

NEXT: From Fringe to Mainstream

From Fringe to Mainstream

Brown, who also happens to be African American, points to an evolution in the influence of minorities in the U.S.

“Within Latino cultures and African-American cultures, we’ve always been accepting of — and even interested in — women who have a curvier body, a bigger chest and/or a bigger behind, perhaps because of the way women in our communities are built,” he says. “But as far as mainstream America goes, it’s been a more capricious relationship.”

Dr. MofidIndeed, a decade ago, butt augmentation patients made up a “pretty tight demographic,” recalls San Diego plastic surgeon Dr. M. Mark Mofid, a pioneer in butt augmentation. “They were primarily ethnic patients or patients that were within the gay community.”

Then things changed with the rise in popularity of stars like Jennifer Lopez and, later, Kim Kardashian. “It’s become much more mainstream now,” Dr. Mofid says. “You could have schoolteachers, soccer moms or male professionals in heterosexual relationships. That’s not something I would have expected.”

But, Dr. Mofid says, the trend makes sense in the history of plastic surgery. “Many procedures started out relatively fringe-like and became more mainstream,” such as breast augmentation, first performed on women in the entertainment industry like strippers, and rhinoplasty, largely used earlier on to alter ethnic-looking noses, says Dr. Mofid, M.D., FACS, associate clinical professor (voluntary) of plastic surgery at the University of California at San Diego.

NEXT: Butt Augmentation By the Numbers

Butt Augmentation By the Numbers

Interest in the derriere, which has been growing for years, shows no sign of hitting bottom. According to the American Society of Plastic Surgeons, in 2015 U.S.-based cosmetic surgeons performed buttock procedures, on average, once every 30 minutes of every day. Additionally, buttock augmentation with fat grafting procedures was up 28% from 2014 to 2015, reaching 14,705 procedures. While some plastic surgeons have left implants behind in today’s era of sophisticated and safe fat grafting, even buttock implant procedures are on the rise, up 36% to 2,540 in 2015.

So the question now is, what do patients want today? Dr. Matlock says 98% of his female liposculpture patients come in for Brazilian-style butt augmentation that makes the rear larger. Other plastic surgeons report similar interest in larger sizes.

Dr. Shureih“Patients wish for a sculpted narrow waist and round- or heart-shaped buttocks with significant projection,” says Samir Shureih, M.D., FACS, a plastic surgeon in Baltimore. According to him, patients often come in and pull up photos of celebrities to explain how they want to look.

Dr. Shureih performs butt augmentation procedures with implants when patients don’t have enough fat deposits for grafting. But there’s disagreement within the plastic surgery community about the wisdom of turning to implants in the age of fat grafts.

In Los Angeles, Dr. Matlock says he has never used implants because he thinks they look and feel unnatural. But he says about 20% of his patients don’t have enough fat for effective grafting in a butt augmentation. His fix? Make them fatter. “Now we have a regimen for the women to gain weight in a healthy manner,” he says.

NEXT: The Big Business of Butts

The Big Business of Butts

It’s not just young women — the mainstays of butt augmentation — who come to Dr. Matlock for better behinds. He says he also sees men who want what he calls “male pattern buttocks” that look more like footballs. “And we see older people coming in to enhance the fullness of a dropped buttocks,” he says. “They are not seeking the trends of the big screen and reality TV stars.”

But most of his butt augmentation patients continue to seek larger rear ends thanks to the influence of celebrities. “I have treated patients from all 50 states and over 70 countries. Over the past 5 years, I have operated in Dubai and Riyadh, Saudi Arabia,” he says. “I thank Jennifer Lopez, Kim Kardashian, Beyoncé, Vida Guerra, Nikki Mudarris, Nicki Minaj, Iggy Azalea, Ashanti, Jessica Biel, Sofía Vergara, etc., every day for the business.”

But is this a lasting trend? Will the interest in bigger rears ever come to an end and bring the demise of peak butt?

Brown, the author and journalist, says there may be a backlash similar to the one that arose when men began to debate the value of natural vs. artificial breasts: “Are you into real? Are you into fake? Or does it matter? Soon, if not already, that will be a discussion in regard to other parts of the body. I’ll guess the ass is the next one, and I think it’ll be a more heated argument.”

What will that mean for cosmetic surgery? “The impact of people being more self-conscious — about how their partners might feel about an exaggerated or augmented behind — might cause customers to get more subtle augmentation,” Brown says.

That kind of trend could make a big difference in the world of plastic surgery. But only time will tell if the current obsession with bigger butts is a temporary boom or a permanent boon.

The cosmetic surgery industry is watching closely as the Food & Drug Administration is considering the way it regulates autologous fat tissue. At stake: Will plastic surgeons be allowed to use fat grafting broadly for purposes that include shaping and contouring of the body and face?

Dr. Reisman“Most physicians would rather see a broadened use allowed that represents an increased knowledge of how fat is used safely,” says Neal R. Reisman, M.D., JD, FACS, chief of Plastic Surgery at Baylor-St. Luke’s Hospital and past president of the Aesthetic Surgery Education and Research Foundation. “But I don’t think anyone has a full handle about whether they’ll go beyond what we envision as protecting the patient.”

Related: Fat grafting and the facelift

Dr. Reisman spoke about legal issues regarding fat at this year’s The Aesthetic Meeting in Las Vegas, the annual meeting of the American Society for Aesthetic Plastic Surgery.

The FDA issued draft regulations about the use of adipose tissue in December 2014, and they have yet to be finalized. “They’ve been wise to let them be out there for a long time,” Dr. Reisman tells Cosmetic Surgery Times. “They sought and have received a lot of input.”

At issue is how the FDA’s final regulations will define the appropriate use of autologous fat, given that the use of fat injections has evolved. They’re now a major tool for plastic surgeons in areas like the face, hands, buttocks and breasts.

“I’ve been reluctant to put it in breast tissue until recently,” Dr. Reisman says. “But big studies have proven the safety and efficacy of fat injection throughout the body.”

The FDA draft rules say that autologous fat should be similar to the fat it replaces, and it defines adipose fat as “structural.” Under this perspective, the grafted tissue should serve a structural purpose. The uncertainty comes in with what is defined as “structural,” and therefore allowed under the FDA’s interpretation vs. what is “functional.”

Related: Abdominal dermal-fat grafts for buttock augmentation

Some things are clear, at least from Dr. Reisman’s perspective. On the “functional” front, “it certainly would be not following the guidelines to use fat to replicate or replace breast tissue with gland function and milk production,” he says.

But will the FDA go beyond that and impose additional limits that could affect the use of fat grafting in cosmetic surgery? “Hopefully the FDA will look at the studies showing the benefits of fat in a cosmetic patient,” Dr. Reisman says. 

In a recent study describing sensory changes post subfascial breast augmentation, Melbourne, Australia-based plastic surgeon Tim Brown, MChir, FRCS, FRCS (Plast), reports that based on his study of 162 consecutive patients, only 4% had sensory loss at the nipple-areolar complexes three months post-op, but more than 16% had diminished sensitivity in the lower outer breast quadrant.

The author assessed sensory changes using a Semmes Weinstein monofilament test prior to surgery and at two, six and 12 weeks postoperatively.

At 12 weeks, 92.5% of the women regained preoperative levels of sensation in all breast areas, except for the lower-outer quadrants — the most common area of diminished sensitivity and an issue related to the use of inframammary crease incisions. Sensory deficits were more likely among younger patients and patients with high BMIs and measurably thicker soft tissue envelopes. The calculated volume changes produced by implants in the series were from 12.1% to 102.7%, with no association between volume increase and sensory issues, according to the study.

Seattle, Wash., plastic surgeon Richard A. Baxter, M.D., tells Cosmetic Surgery Times that he found the study interesting, given he published the first article on the subfascial technique in North America, in the September-October 2005 Aesthetic Surgery Journal.

“The study confirms that the subfascial plane is equivalent to the submuscular plane in terms of risk of sensory change, which makes anatomic sense,” Dr. Baxter says. “I have not systematically measured sensory changes but my sense is that my results are in line with this report. I would have expected some correlation to larger implant sizes, but it is reassuring that this was not found. There does seem to be improvement with time when it does occur.”

Dr. SalzbergC. Andrew Salzberg, M.D., system chief of plastic surgery at Mount Sinai and associate professor of plastic surgery, Icahn School of Medicine Mount Sinai Health System, says temporary sensory change from breast augmentation, regardless of approach, is common and should be disclosed as part of the consultation with breast augmentation patients.

“…it’s common sense that for the first few weeks or month, there may be a change in sensation,” Dr. Salzberg says. “But I do have some major issues with this study.”

Next: Disagreements Among Doctors

Disagreements Among Doctors

Dr. Salzberg says that Dr. Brown’s description of the sensation changes as “objective” does not seem accurate.

“When I ask you if you feel something, that’s more a subjective response. What you say may not be the same as what some other person says. So, it’s not very objective,” Dr. Salzberg says.

Another issue: The entire paper was about the subfascial plane, which is an uncommon breast augmentation approach among U.S. surgeons, Dr. Salzberg says.

Most breast augmentations in this country are either [subpectoral or subglandular],” he says.

William P. Adams, Jr., M.D., associate clinical professor of plastic surgery at UT Southwestern Medical Center, University Park, Texas, says the sensory issues noted in Dr. Brown’s study are not a perceived issue with breast augmentation patients.

“The biggest issue for sensory issues post procedure is not the incision or pocket plane, but using tissue-based planning and an implant that ‘fits’ the breast,” Dr. Adams says.

Nevertheless, Dr. Salzberg says, there are positive points from Dr. Brown’s work for U.S. plastic surgeons. It highlights the issue of sensory changes, which serves as a reminder to surgeons that they should talk about the risk with breast augmentation patients. And Dr. Salzberg agrees that the 12-week mark is probably a good indicator of when those sensory changes should diminish.

“The article also refers to the inframammary incision, which is an incision underneath the breast in the fold. That’s where the nerves on the side are coming out. The area can be injured not just by stretching but also by either cutting the nerve directly (and that’s where you can get more permanent changes) or when surgeons use electrocautery… to cauterize the blood vessels. That can also temporarily injure the nerves and make it even longer, so patients might feel numb in certain areas for months to years,” Dr. Salzberg says.

There are things that surgeons can do and recommend that help avoid and treat sensory changes, according to these experts.

“… I would say that it is worth taking the time to elevate the fascia laterally even with subpectoral placement,” Dr. Baxter says.

Dr. Salzberg recommends that patients experiencing sensory changes should touch their breasts. The stimulation, he says, will help bring back normal sensation.

Note: We attempted to reach Dr. Brown to comment on his study but he was unable to respond. 

For years, Baby Boomers have been the driving force in cosmetic surgery trends and have directed most everything, from marketing strategies to the consult and the business overall. But according to one expert there’s a whole new generation that’s changing the face of cosmetic surgery — and they offer a lifetime of opportunity to the cosmetic practice.

“Millennials are becoming our largest patient base and that’s a good thing,” says Lauren Amico Reed, PA-C, who spoke at this year’s annual Vegas Cosmetic Surgery Meeting in Las Vegas. If you can capture them, she says, you’re likely to have them as lifetime patients.

In her presentation, “Move Over Baby-Boomers, The Millennials are Here!”, Ms. Reed pointed out that while there are around 75 million Baby Boomers in the U.S. — notably the wealthiest generation, there are more than 80 million Millennials — the most educated generation and widely in debt because of college expenses.

Translation: Your potential patient population has more than doubled in favor of the generation that currently spans ages 16 to 36. And while they may be smarter, they don’t have as much disposable income.

It’s no surprise then that the what, why’s and when’s of treat younger patients has quickly become a widespread topic of conversation, especially when 64% of cosmetic surgeons are seeing patients under the age of 30, according to Ms. Reed, a NCCPA board-certified PA and Aesthetic Specialist at the La Jolla Cosmetic Surgery Centre. And understanding this younger generation’s motivations is the first step to successfully folding them into your practice.

In This Article:

Millennial Motivations

Marketing to Millennials

Treatment Tips

NEXT: Millennial Motivations

Millennial Motivations

So what’s driving Millennials into the cosmetic surgery practice? The biggest motivating factor is that they simply don’t want to look like their mothers — or grandmothers, says Ms. Reed. And then there’s social media omnipresence: Profile pictures are the new first impression. “Self image is portrayed through social media,” she says.

Adding fuel to the fire, there’s also the fact that younger celebrities, like the Kardashians, have ushered the industry into a new, more “glamorous” era.

“Social media is the driving force of nonsurgical treatments,” says Ms. Reed. So the question becomes, how do you capture this younger generation?

NEXT: Marketing to Millennials

Marketing to Millennials

There’s no question that Millennials offer a high lifetime customer value. They are fiercely loyal to the brands they love. However, “Millennials only give you one shot. You fail? They don’t come back!” cautions Ms. Reed.

Millennials are also advertising goldmines, she says. “If they love you, they LOVE you,” and you will be rewarded by word of mouth referrals and in positive online reviews.

As for getting this younger generation into the office, you need to have a strong Internet presence. Here are Ms. Reed’s rules of thumb:

• SEO — Be on the first page for the combined search terms: “your city” and “Botox"
• Use plenty of before and after pictures
• Have lots of good patient reviews
• Use genuine or authentic content in social media, not just advertising

Once they’re in the office, there’s also the changing nature of the consult to consider.

“My consult has changed based on my experience with younger patients,” says Ms. Reed. “They come in and know a lot about you and your products. While they may be self-educated, however, they don’t always know what’s best,” she says.

Be sure you manage their expectations, she emphasizes: “They may expect miracles, but they don’t have a lot of money.” The opportunity with Millennials lies in gaining their trust early and keeping them as lifetime patients, so “Talk to them. Create a long-term plan,” advises Ms. Reed.

NEXT: Treatment Tips

Treatment Tips

Effectively treating the Millennial generation means understanding them.

For example, if your patient says she wants “natural” looking lips, don’t assume you’re speaking the same language.

“What I think is natural isn’t necessarily what they think is natural,” explains Ms. Reed, who says she speaks from personal experience. While her idea of “natural” may be Cameron Diaz, she says, her patient’s very well could be Khloe Kardashian. Therefore, Ms. Reed emphasizes the need to use common reference points to make sure you’re on the same page before treatment.

“Take lots of photos,” she adds. Explain what can be achieved and what cannot as well as duration — BEFORE treatment, Ms. Reed says. “If you tell them before, you’re a genius; if you tell them after, you’re lying.”

Ms. Reed also recommends what she calls the .2 cc Filler Rule. “When you’ve got .2 cc filler left, hand the patient a mirror and ask what else they want.” It’s smart, it’s efficient and it’s the perfect way to get their approval for the final result.

Finally, remind patients when to return and be sure to follow up with your patient. “If someone’s unhappy, you don’t want to find out about it on Yelp,” she says. By following up, you’re more likely to correct the situation and get a positive review in the end.