Earlier this week there was a post by a journalist Jolene Edgar who writes on all things medical aesthetics, about the effects of non surgical procedures on future face/neck lifts and a forum which has plastic surgeons weighing in on their experience of this. 

Here's what she said 

"Interesting discussion over the weekend on the topic of nonsurgical treatments (like certain energy based devices, threads and injections) complicating facelift surgery by creating scar tissue, fusing natural tissue planes, obscuring landmarks that guide dissection and so forth.

As with nearly every topic in aesthetics, there's debate surrounding these claims - debate over which nonsurgical treatments are the worst offenders, how much damage they actually do, and what the repercussions of said damage may be (increased risk of nerve injury during a facelift, a less-than-ideal cosmetic outcome, longer/tougher recovery). 

And as some pointed out, surgery itself is the ultimate scar maker and can therefore compromise the results of any nonsurgical treatments that may follow facial surgery." 

As expected, there was a wide variety of opinions, from uber conservative surgeons who actively dissuade everyone from non surgical aesthetics in favour of surgery “at any age” and as young as their 20s, to surgeons who were more balanced in their view that given that face/neck lift and associated plethora of procedures costs upwards of $50,000 and easily much more ($100k and upwards) if we add in fat transfer, eye surgery, brow lifts and more, that this is not something most people will be able to budget for or afford, and as such it behoves  all of us to be more cautious about our recommendations of non surgical and minimally invasive procedures including steering patients away from certain procedures that are notorious for poor results on the table and post surgery, notably, Ulthera, Thermage, HIFU and similar options as well as arguably, threads. 

For me, watching and commenting where able, it was an interesting insight into what I see over and over in the field of medical aesthetics, which, without the fence of sound and evidence based medical scaffolding, can often seem very much like the Wild Wild West - since this is a very new field, and fueled by want rather than need and since health care workers are only human, with little to no basic understanding of business (we are not taught that in medical school) it's no surprise that some of us fall into unethical and questionable practices with the lure of big bucks. 

It is a big part of why I work the way I do. When I began, like many others, I began in a chain clinic and very quickly learnt how I did NOT want to work. Opening my own practice even pre Covid was a big risk, but it aligned with my ethical and moral values as a doctor who wanted longterm patient centered care that focused on longterm goals and realistic expectations, as opposed to on-demand, quick fixes that ultimately did not fix much at all. 

So, as someone who was a trainee in a surgical field between 2002-2011 and is now a Fellow of the College of GPs, and has been doing procedural work for most of my career, what are my thoughts and experiences based on aesthetic work since 2016 since I do non surgical and minimally invasive surgical work in my rooms including FaceTite and skin cancer surgery? 

• these concerns are not new, but they are newly being discussed which can only be a good thing. It is a big part of why I have never offered, nor seriously ever been tempted to offer, certain energy based devices such as Ulthera, HIFU and Thermage. Aside from scant evidence suggesting they are highly operator dependent for results, and results only lasting around 6 months, I worry about the crude methods used to provide "lift" and what layers are being destroyed in the process. It would seem some of my concerns based on theory and logic, are possibly true. 
• in my experience, biostimulatory fillers that work by triggering collagen through inflammation, do not have quite the same effects for two main reasons - the filler is usually placed far more superficially, just below the skin, unlike the layers that surgeons usually work for deep plane surgery. Additionally, in my experience, since biostimulatory fillers need an initial course of treatments followed by annual maintenance, I've had the opportunity to revisit skin I've treated over the years and have not found any significant degree of scarring when I've done so. In saying that, anytime the skin is penetrated by sharp objects, there is the potential for scarring. 
• I love radiofrequency (RF) microneedling as well as its corollary, RF Assisted Lipolysis aka FaceTite and AccuTite for small pockets of fact and collagen induction and to date, have not found it induces any appreciable degree of scarring or access issues for other procedures. 
• a popular fat dissolving injection on the other hand, does cause significant scarring, and on the rare occasions when I've performed FaceTite following fat dissolving injections, it has been hard going and tough work which has led me to be far more selective about who might be suitable for these injections and where eg bra fat, back fat, fat pad over the neck as opposed to double chin etc especially if they are open to the idea of FaceTite or surgery at some later stage. 

Obviously opinions and experiences are like noses in that everyone has one and barring a scientific trial, there's not much to be said except that this is one person's experience. 

It does however, inform me in terms of what procedures I am more and less likely to do and to offer my patients, especially if they are likely to be open to the idea of surgery down the track because as always, the first adage ought to be, "First do no harm". 

For these and many other reasons I believe it is so important to have a comprehensive consultation when you begin your aesthetic journey with someone who can form a longterm therapeutic realationship with you and guide you appropriately towards or away from certain treatments that are in your best interests, now and in the long run instead of simply saying yes. 

Equally, as some of the more balanced surgeons point out, while face/neck lifts are commonly quoted as being between $25,000-$50,000, it's rare that most people presenting for these will stop at "just" a face/necklift - many will go on to add on fat transfer, liposuction, upper and lower eyelid surgery, laser resurfacing and more, such that the total bill ends up being closer to $50,000- 100,000. If you have the money to spend on this, great, but many if not most people do not, and so it is foolish to assume that most of us should simply bypass non surgical options for surgery in the first instance. 

So as with all manner of discretionary spending, caveat emptor - buyer beware. Look for potential COI (conflict of interest); look at whether they stand to make money by selling you something because they have bills to pay, or whether it is in your best interests. Health care workers are human too, with bills to pay. Choose someone who can say no, set healthy boundaries, screen you for unrealistic expectations as well as a personality that tends to panic, worry or need a lot of hand holding because most medical aesthetics needs time, patience and the ability to show up when nothing seems to be happening.