Board Forum: A Practical Assessment of Minimally Invasive Approaches

What is your favorite minimally invasive procedure to perform in your practice today? How has this procedure changed your practice?

Sachin Shridharani, MD: My favorite minimally invasive procedure to perform today is Kybella. This procedure has changed the nature of my practice by being able to help contour the face and body permanently by destroying focal areas of fat. Ten years ago, if you told me that I would have a safe, FDA-approved fat-destroying injectable, I would have felt that was science fiction. Now we have it, so I'm using it.

Adam Scheiner, MD: My Full Face Sculptra, injectable nose job, and Broad Based Light (BBL) Forever Young light treatments are my favorite procedures that are minimally invasive.

I've had many more young patients coming in for the five minute nose job this year.

Looking at the current injectables (neurotoxins and/or fillers) market, what pipeline agents are you most excited about? Where do you see ongoing need? Please explain.

Dr. Scheiner: Revenesse Versa is a new hyaluronic acid filler with a much lower price point. There aren't too many differences between the hyaluronic acids in the face. It is more an issue of how much volume is placed. The lower price point would allow us to put in more volume while remaining in the range of affordability of our patients.

Dr. Shridharani: There are a few newer treatments on the horizon that are exciting. Certainly, new neuromodulators with possible greater longevity are exciting. New fillers from tried and true companies that have approvals in Europe and Asia are on the horizon in the US.

Finally, topical fat reducing agents are moving along in the FDA process. This is really exciting and will change the way we practice plastic surgery.

Among energy-based devices, which of the “newer” indications/applications are you most excited about? What is the most significant unmet need in this arena?

Dr. Shridharani: Newer indications for energy-based devices are exciting for purposes of building muscle. Burning fat and building muscle are a winning combination, clearly. There is an unmet need for destroying deeper fat pockets. Right now, there is improvement in superficial fat, but we are limited by the depth of penetration and zone of injury to fat, while balancing lack of injury to the skin.

Dr. Scheiner: BBL Forever Young with research from Stanford is a great treatment to help with skin quality issues with an out-patient treatment that has long term benefits as well for patients.

Do you feel any surgical techniques have become underutilized in the current treatment landscape?

Dr. Shridharani: I think brow lifting has become underutilized/overlooked. No question that neuromodulator use in the forehead, glabella, and lateral peri-orbital region is exceedingly helpful in rejuvenation of the upper third of the face. In addition, energy-based treatments to the dermis can firm the skin and improve skin quality, which conceptually may increase brow position. Finally, dermal fillers in the temples and peri-orbital region can help “lift” the brow a few millimeters, but true brow ptosis is best addressed with a well-executed surgical brow lift.

The scar burden, downtime, and longevity associated with brow lifting techniques has made many patients and surgeons take pause prior to having or performing this sound surgical technique.

Dr. Scheiner: My RESET for Sun Damage procedure can make skin look much better and remove years of past irregular precancerous cells as well.

(Editor's note: Get information on the procedure at adamscheinermd.com/facial-plastic-surgery-in-tampa/reset-skin-resurfacing.)

Do you find that the range of tools and techniques available can make marketing and patient education more or less challenging? What are some key considerations for setting expectations?

Dr. Scheiner: One challenge is the breadth of treatments we can offer our patients. It can be challenging to give too many choices and makes it difficult for patients to choose one, even with guidance.

Also, budget and effectiveness of treatment can be an issue. Patients want the best results, but if their budget can't afford those results, sometimes it's best to have them save and come back when they can afford it rather than do a partial job and have them be disappointed.

Dr. Shridharani: Patient education is key, and I find that our patients are very well-informed. Unfortunately, being well-informed does not always translate to informed with the correct information.

There is tremendous dissemination of false or misleading information in the aesthetic surgery and dermatology world. Several times per week, I have patients who show me something on Instagram or Facebook or other social media platforms of procedures that are unsafe or marketed as “one of a kind.”

There are certainly several challenges to overcome false information, because it seems so official when it is online or in writing. Or, if a doctor with tens of thousands of followers makes a claim, it must be correct, right?