Body Versus Face: Minding the Divide

By Steven Dayan, MD, FACS

As aesthetic clinicians, we should always be weighing the value of different types of procedures within our practices. Meeting and anticipating patient demands is a critical element to staying ahead of the curve and maintaining the gold standard that we have rightfully earned as providers of cosmetic services. Over the last 10 years, we have seen increased emphasis on facial procedures, reflected in the number of dermal fillers and botulinum toxins that have reached the market. And yet, despite the rising prominence of procedures for the face, surgical procedures for the body remain among the top cosmetic procedures performed in the US each year.

The annual statistics teach us that no matter how much the pendulum appears to be shifting toward the face, we mustn't underestimate patients' desires to improve their bodies, as well. A number of psychosocial aspects may account for why the body remains a prime target for cosmetic surgery. For example, research in evolutionary biology has shown us that one of the first places a man's eye goes when viewing photos of a naked female is not her genitalia or breast or face, but rather her midriff section, highly defined by the waist-to-hip ratio. Interested heterosexual males are particularly focused on this curvy portion of a female body because it indicates fertility and the physical resources to carry a baby. A waist that is 30 percent smaller then the hips seems about right to the hunting male's subconscious palate.

So, what makes a body rejuvenation patient different than a facial rejuvenation patient? Are body rejuvenation patients more or less discerning? Are they willing to invest more to improve body or facial imperfections? Are they willing to take bigger risks? I have found that no patient ever wants to take a risk. However, on occasion patients may be a bit more willing to test out a new laser or treatment on a hidden body part before the face. So much of our identity and first impression that we project is tied to facial appearance and expression that skeptical patients may be hesitant to venture into uncomfortable terrain when it comes to sampling something new.

I am sure that each of us has different experiences and observations on the matter. What's most important is that we are engaged with this issue, as it will continue to be of pressing significance as the market takes shape.

Within the scope of body rejuvenation, several recent advances in technology and delivery have given body rejuvenation treatments a new edge. Procedures are becoming more nuanced and also much more accessible for patients. The “Holy Grail” for body procedures would be non-invasive body shaping and fat reduction or removal. This is one area in which we are seeing a lot of activity. From freezing fat with devices such as Zeltiq to shaping it with Venus and hopefully one day melting it with chemical lipolytic injections (now in phase 3 trials), it seems we are getting closer to identifying alternatives. But conventional wisdom seems to indicate we are still a distance off from when we can shelve our cannulas and suction machines.

Several of these newer and investigational technologies may well change how physicians approach and perform body rejuvenation. Moreover, this changing landscape of treatments has a number of implications for physicians. As patients are given many more options, physicians will have to be more discerning regarding what to offer in practice.

Now, to capture a different perspective, dermatologist Vivian Bucay, MD will tackle the differences of facial and non-facial patients in her own practice and discuss specific characteristics and contextual factors of common body rejuvenation procedures she performs.

Steven Dayan, MD, FACS, Co-Chief Editor, is in private practice in Chicago. He is a Clinical Assistant Professor at the University of Illinois and author of the new book Subliminally Exposed.

Body in Context: Navigating the Realm of Non-Facial Rejuvenation

By Vivian Bucay, MD

While the general contrast between the face and the body may yield very different clinical approaches, any concrete differences depend on what type of treatment is being performed. For example, if we are talking about a chemical peel to improve photo damage, the same strength of tricholoroacetic acid may not be equally effective when used on the face, as compared to the arms. Another factor to consider is weight; it is not much of an issue for filler treatments for facial rejuvenation, but it will be a factor in someone asking for non-invasive fat removal or a skin tightening procedure.

Facial rejuvenation often involves addressing the various contributing factors to the aging face: overactive muscles, volume loss, gravitational changes, and changes in the skin. A global approach can encompass a variety of treatments, including neuromodulators, fillers, resurfacing procedures such as chemical peels and lasers, and energy-based treatments like ultrasound and radio frequency. The timing and sequencing of combination treatments is important, as is the possible downtime associated with a given treatment, since the face cannot be covered by clothing. Other factors to consider are a patients' willingness to return for maintenance treatments for facial rejuvenation as well as a commitment to wearing sunscreen on a daily basis.

Non-facial rejuvenation typically does not involve as many combination treatments, and in my practice, treatments tend to focus on the effects of photo damage, skin texture, uneven skin tone, and skin laxity. Wrinkles due to hyperactive muscles and the effects of volume loss are not really an issue here.

Interestingly, the facial patients I see in my practice need much more education regarding the options needed to address their concerns and those consultations take much longer. Our body patients are usually younger and tend to commit to a procedure much more quickly. Price and relative risks of adverse events do not appear to be major factors for these patients; however, one thing I have noticed is that the patients who insist that I perform any treatment related to their face have no problem with my delegating body treatments to someone else in my practice. For example, the same patient who insists that I perform fractional resurfacing on their face has no problem with my aesthetician performing the same treatment on their chest.

This may be attributable to the fact that patients are more protective over what everyone else can see, as opposed to the body being covered. Nevertheless, it bears mentioning that although our patients may approach the two differently, both facial and body rejuvenation are medical procedures and thus deserve the same care and attention, starting with patient evaluation and consultation. Both types of patients require education regarding their options, and the physician should still be the individual who evaluates and recommends treatment, regardless of who performs the procedure.

When selecting a specific treatment for the non-facial patient, everything depends on the indication. Whether you're treating photo damage, skin laxity, small pockets of unwanted fat, cellulite, etc., certain considerations should be made. These include: age, medical and medication history, psychological assessment (to ensure that there are not any unrealistic expectations), body mass index (for noninvasive fat reduction), and lifestyle habits such as smoking and tanning. For a peel or resurfacing procedure, skin type is also factor. For example, I would be careful about using a laser to treat stretch marks in a darker-skinned patient. Finally, another important factor is the ability to pay for a treatment, as some patients have no idea regarding cost and may not be eligible for credit; therefore it does not make sense to waste their time or to use office resources for a lengthy consultation.

When it comes to which procedures/products to offer in my practice, first and foremost considerations are safety and efficacy, and I will look for publications in peer-reviewed journals in support of these. Beyond these, before investing in a new device or offering a new procedure, I need to make sure that there is a demand for that service and that it makes sense to offer it. Many of the things I offer today have been patient-driven. For example, the request for non-invasive fat reduction was so frequent, that I finally purchased a device because there was only one such device in our city at the time I added it to my practice. Market saturation plays a role in decision making, and I may not have offered this treatment in my practice if there were already many of these devices in our market.

I have no problems referring patients to colleagues who offer a treatment that I don't have. It creates good will, and they often will refer a patient for a treatment that I offer and that they do not. Another consideration in offering a service is whether or not the treatment can be delegated to someone in my office. From a business standpoint, my time is limited and should be spent performing those procedures that no one else is qualified to do.

Looking ahead to the future of body rejuvenation, we will likely be seeing more devices that are more effective in addressing skin laxity so that skin off the face will be smoother and tighter to match that on the face. In addition, the “Holy Grail” of body rejuvenation, a long-term, non-invasive solution for cellulite, still remains elusive. As the field continues to take shape, physicians should be cognizant of how patients may differ when it comes to the areas of the body for which they seek treatment. Both types of rejuvenation require a thorough evaluation of the patient and an honest discussion regarding treatment options and expectations as well as the need for maintenance. After all, we can turn back the clock, but it will still keep ticking.

Finally, and perhaps most importantly, aesthetic medicine is still medicine, and patient safety is a priority. As physicians, our education never ends and staying current is a must, so that we can offer our patients the best care available.

Vivian Bucay, MD, FAAD, is in private practice in San Antonio. She is also Clinical Assistant Professor in the Department of Physician Assistant studies at the University of Texas Health Science Center.