“If it is now asked whether we at present live in an enlightened age, the answer is: No, but we do live in an age of enlightenment.”
This is the time of year when we're presented with endless “Year-in-Review” stories on everything from world events to best and worst movies or hairstyles. So how shall we describe the year in aesthetics? Drug and device launches included new indication categories and new options for old indications, including an injectable to dissolve fat and a noninvasive device to reduce cellulite. Procedures we've done ‘off label' for years got ‘on label' approval, opening the way for direct-to-consumer advertising to use filler for hands and more. Many of us spend our days doing procedures that didn't exist during our residency or fellowship training. But to paraphrase Kant, have we really emerged from our immaturity? Has aesthetic medicine passed puberty?
The first modern lasers were built two decades ago on the theory of selective photothermolysis. The target was known and the device built to deliver a strictly defined wavelength, pulse width, and fluence. But for a while after, progress seemed more about finding more indications for machines we had. And just about every device producing heat was touted as helping wrinkles or scars. Unfortunately, theory and histology didn't always match clinical results so doctors and patients were left frustrated. The development curve rose steeply in the last decade as those preliminary ideas were built upon to produce stronger science and more consistent results. Noninvasive skin tightening and fat reduction was routinely denounced as quackery, but now it is hard to find an aesthetic physician's office without at least one device to treat those diagnoses.
Whether it is for science or because only FDA indications can be promoted by industry, more drugs and devices are being studied rigorously to gain those approvals. Traditional media outlets compete to be the first to present what's new and exciting to pull viewers or readers from the fast pace of information flow in cyberspace. And certainly almost universal access to the Internet in developed countries has increased the pool of potential patients by presenting what is available and altering their aesthetic expectations. Forty is not the new thirty. Sixty is.
The anatomy and pathophysiology of aging is also better understood. Phrases like localized fat pads, volume loss, and deflation, once shocking, are commonplace in lectures and articles. Use of stem cells and tissue stimulators, once the stuff of sci-fi, are routine. Details of the anatomy of beauty across cultures, once discussed by small groups of anthropologists and sociologists, is now required study for anyone entering aesthetics. And our measurement of outcomes is shifting from physician measured to patient satisfaction. As physicians we are asking not only what we can do, but what we should do to help our patients look and feel better longer. Even the FDA has acknowledged this trend, as it has increasingly incorporated PRO patient-reported outcomes as a metric of evaluation. As we move forward, we likely will see more attention devoted to PROs and the lifestyle effects of our treatments.
Another byproduct of this evolution is how the core cosmetic specialties interact. In particular, we are seeing a gradual convergence of interest. Territorial disputes among core specialties are eroding as we and our leaders realize that not only can we learn from each other but we are stronger together than apart.
So where are we as we move into 2016? We the editors suggest aesthetics is in its adolescence. We have come a long way but are on the cusp of maturity. There will be new challenges and new opportunities. The core cosmetic specialties must be ready not only to identify trends but to participate in shaping them, as well. Let us all make the resolution for 2016 to continue to mold this great experiment of aesthetic medicine into a place of high creativity, expertise, and satisfaction for both ourselves and our patients.
Steven Dayan, MD, FACS, and Heidi Waldorf, MD, FAAD