What’s Natural?

One of the most common words in aesthetic consultations in recent years has been “natural.” Practitioners all over the US advertise it. What does “natural” really mean, though, and how is the look successfully achieved in treatments?

“Everyone has their own sense of what looks natural to their eyes, but compared to 5 to 10 years ago, when the zeitgeist for women was leaning very much toward an exaggerated, Jessica Rabbit type of look with large cheeks, full lips, an exaggerated waist-to-hip ratio, and excessively large breast implants, most patients now have backed away from those types of requests and prefer a subtle and understated outcome,” said Lara Devgan, MD, MPH, FACS, a plastic surgeon in New York, New York. “There has been a huge increase in demand for a more natural look. In plastic surgery, we think about this concept of being undetectable. Patients do not want to lead with their aesthetic ‘work;’ they want to lead with their aesthetic ‘outcome.’”

Most of the blame for unnatural aesthetic outcomes has been placed on fillers, but leading aesthetic practitioners say fillers still have a place when used correctly.

“A lot of patients say, ‘I can do Botox, but I am nervous about fillers,’ and I need to explain to them that there are certain parts of the face, especially in the bony areas, where enhancing with fillers looks natural and does a lot to structure the shape,” said Jennifer Y. Lin, MD, an associate professor of dermatology at UC San Diego Health in San Diego, California. “You put a little bit everywhere because the natural aging process is to lose fat from the entire face. Bone gets resorbed. That happens everywhere, not just in your cheeks, so you cannot just put filler in the cheeks.”

Managing patients’ expectations is critical when pursuing natural-looking aesthetic improvements, Dr. Lin added.

“The practitioner needs to know when to say, ‘Adding more filler in this location just will look unnatural,’” she said. “If someone who is 60 wants to look 30, you likely will achieve an unnatural-looking result. Setting expectations is important, and I aim for a 10-year improvement or looking their best at whatever age they are.”

The overarching objective is to restore the patient’s own self.

“Youthfulness is not a fleeting quality tied to age but rather a manifestation of vitality and balance in form and function,” said Modern Aesthetics Chief Medical Editor Saami Khalifian, MD. “Our role as aesthetic providers is not to chase an idealized version of beauty or to follow trends, but to restore the tissues that gave lost integrity or volume over time and to replace like with like whenever possible.”

DIFFERING PERCEPTIONS

Defining “natural” is not as simple as many other trends. Nature is diverse, as are perceptions of beauty.

“There is a huge degree of customizability,” Dr. Devgan said. “Everyone has their own sense of what looks natural to their eyes.”

Dr. Lin said she has observed both regional and generational variability in perceptions of what looks natural.

“I have had many older patients, especially on the East Coast, who do not want surgical intervention because, in their mind, it looks less natural,” Dr. Lin said.

Accounting for different concepts of natural beauty also requires an understanding of ethnic differences.

“To me, ‘natural’ is about staying true to yourself, both individually and culturally,” said Sam Rizk, MD, a facial plastic surgeon in New York, New York. “From a surgical perspective, it’s incredibly important that I take a patient’s ethnicity into consideration. Some surgeons might say a nose job is a nose job, but to me, a rhinoplasty on a woman of African descent is an entirely different surgery than what I would perform on a man of Scandinavian descent. My goal is to give each patient the look they desire without losing the nuances that are unique to their culture and, ultimately, their identity.”

Dr. Devgan said the nose provides an opportunity to retain distinctive features.

“The nose is a feature that not only tells you about your ethnicity, your parents, your heritage, your race, and your background but also can speak to fineness and refinement in facial outcomes,” Dr. Devgan said. “It has been common for patients to request to adjust some but not all of the features of their nose—for example, to keep a little hint of the bump that reminds them of their parent, but to straighten or lift the tip because that feels less aesthetic to them. It is really all about the art of restraint; achieving a natural look is often about knowing when to stop. For me, true artistry lies in subtlety—enhancing features rather than overhauling them. I think of it as a whisper rather than a shout, where the work is seamless and quietly effective.”

Mara Weinstein Velez, MD, FAAD, notes that non-Hispanic whites are expected to account for less than half of the population by 2050.¹

“When we think about natural aesthetic,” Dr. Weinstein said, “we need to realize that what we learned in the past about proportions of the face for a Caucasian person may not apply to our patients of mixed ethnicities.”

Regardless of ethnicity, embracing the natural look requires seeing the natural beauty in every patient and using that as a base.

“I call it the perfect imperfection,” Dr. Devgan said. “It’s the small individual quirks that make faces memorable and beautiful. With any aesthetic treatment, but with fillers in particular, people sometimes try to chase something that should be left alone. We should be preserving distinctive traits and enhancing them, rather than erasing imperfections, so people feel like a perfected version of themselves rather than a different person.”

Dr. Weinstein said the key remains listening to what the patient wants.

“Perhaps have them bring in a photo of what they looked like 10 or 20 years younger, and try to match that and work together with the patient to achieve their natural aesthetic rather than imposing our own ideals on them,” Dr. Weinstein said.

BIOSTIMULATORS

Perhaps the most obvious way to achieve a natural-looking aesthetic improvement is by stimulating the body to produce what otherwise might be injected during an aesthetic treatment.

“In the pursuit of natural aesthetics, biostimulators play a pivotal role by harnessing the body’s intrinsic ability to rejuvenate,” Dr. Khalifian said. “Unlike merely masking signs of aging, these treatments restore the structural and biochemical integrity of tissues, which is key to achieving results that feel both authentic and timeless.”

The term biostimulators has been used primarily to encompass treatments that stimulate collagen production, but it also can include platelet-rich plasma (PRP), among other procedures.

“There has been a huge uptick in patients who are interested in the use of platelet rich plasma, which is rich in growth factors that help ramp up stem cell activity,” Dr. Devgan said. “People also are extremely interested in autologous fat grafting, or nano fat, which brings not only natural volume to the recipient area tissue bed but also pluripotent stem cells to rejuvenate the tissue overall. And we’re always thinking about how to hold on to the collagen we have and how to get more of it, because that is the main diminishing natural resource in the face.”

Dr. Lin noted that long-term data on extensive use of collagen biostimulators is lacking, but that two to three treatments typically last more than a year.

“Collagen biostimulators can provide a more natural look, especially in the non-bony areas of the face, like the buccal cheeks,” Dr. Lin said. “I almost always use them in conjunction with hyaluronic acid fillers.”

POLYNUCLEOTIDES

One of the most exciting new options is the polynucleotide category. Polynucleotides regulate gene expression and promote tissue regeneration. Kay Durairaj, MD, FACS, a plastic surgeon in Los Angeles, California, and Executive Editor of Modern Aesthetics, said polynucleotides are especially popular in Asia and can provide an immediate glow for instant gratification.

“Bioregenerative therapies are trending in my practice,” Dr. Durairaj said. “I believe using the body’s regenerative potential will be a powerful treatment for patients who want to look natural and refreshed without fillers. They help to promote neocollagenesis, and elastin production, and improve skin structure and foundation.”

Polynucleotides are an ultra-purified derivative of sperm from Pacific salmon or trout that has been processed to remove any remnants of proteins, peptides, and other impurities, resulting in a DNA nucleotide-based product.

“These products are being used to improve the texture, tone, elasticity and glow of the skin,” Dr. Durairaj said. “As we transition to having patients want more natural results, this will be an incredible tool to be administered topically after microneedling. It super-activates the ability of the fibroblasts to grow collagen. It creates longevity of our filler results; recent research has shown that using filler or biostimulators in combination with polynucleotides produces synergistic amplification of collagen and elastin production, and much longer-term results. Sometimes, using a polynucleotide by itself on top of a previous biostimulator treatment can reactivate the existing biostimulatory effect of prior treatments as well. It is a real value-add for patients, and it is minimally invasive.”

Dr. Khalifian agreed that polynucleotides represent an exciting frontier in aesthetic medicine.

“By influencing gene expression and enhancing the extracellular matrix, these molecules promote skin regeneration, improve elasticity, and amplify collagen synthesis,” he said. “Current research underscores their synergy with biostimulators and fillers, where they act as catalysts, amplifying and prolonging results. However, as with any emerging technology, it’s critical to scrutinize their origin and antigenicity to ensure patient safety and efficacy.”

Dr. Khalifian added polynucleotides should be categorized as biochemical cues, along with growth factor, exosomes, peptides, and stem cells.

“Each category of biochemical cues—growth factors, polynucleotides, stem cells, exosomes, and peptides—plays a distinct role in tissue regeneration and rejuvenation,” Dr. Khalifian said. “Growth factors are signaling molecules that bind to specific receptors, initiating cellular processes like collagen production and repair. Polynucleotides, on the other hand, influence gene expression and promote the regeneration of the extracellular matrix, improving skin elasticity and hydration. Stem cells act as master regulators, not only differentiating into various cell types but also secreting growth factors, cytokines, and exosomes to enhance cellular communication and regeneration. Exosomes, which are extracellular vesicles, function as carriers of proteins, lipids, and RNA, facilitating intercellular communication and amplifying the regenerative effects of growth factors and stem cells. Lastly, peptides are short chains of amino acids that can stimulate collagen synthesis, improve skin barrier function, and modulate inflammation. Together, these components form a synergistic network that allows us to strategically target multiple pathways for natural, long-lasting aesthetic results.”

Dr. Khalifian said how these biochemical cues are leveraged can lead to different outcomes.

“This creates a lot of confusion,” he said. “The key to the difference is understanding where they come from, what’s in them, what is their stated benefit, and whether there is data in support of their use.”

Dr. Durairaj cautioned against injecting polynucleotides until more research has been conducted.

“Even the providers in Asia, where they are most popular, are not asking the correct questions,” she said. “What is the source? Where is it derived from? What is the sterility and antigenicity? If this is salmon sperm and not human DNA-related, does it create immune sensitivity and antigenicity later in life? We don’t know those answers, and until we do, we should not be injecting these products. Polynucleotides are currently only FDA-approved for topical cosmeceutical use and can be microneedled into the skin but they are not FDA-approved for injection purposes, although they could be used off-label by experienced providers.”

SURGICAL STRATEGIES

Plastic surgery may seem counter-intuitive for a natural look, but various strategies exist to accomplish subtle surgical modifications.

“With any aesthetic work, both surgical and nonsurgical, we’re thinking about how to maintain facial identity while optimizing facial attractiveness,” Dr. Devgan said. “Real anatomic expertise is needed along with a huge degree of customization. No two faces are the same, and neither should be any treatment plan, so a natural outcome requires an understanding of each individual’s unique bone structure, skin type, and facial proportions. This is how we can craft results that look as though they’ve always belonged on someone’s face.”

One strategy is the MicroLift that Philip Miller, MD, FACS, offers in New York, New York. The procedure is “designed to mimic the improved appearance that comes with pulled-back hair,” Dr. Miller’s website says.

Dr. Rizk has promoted a “vertical facelift,” which targets the entire facial structure from a vertical perspective, addressing not only sagging skin but also volume loss and tissue laxity. This strategy allows him to reposition loose jowls and define the neck and jawline without the tightness and pulling that often lead to an unnatural look.

“As a sculptor, I work with each patient’s unique bone structure, following its natural contours to enhance what’s already there,” Dr. Rizk said.

Incisions, of course, are a key element of making any surgical result appear natural.

“Incisions must be smaller, more discreet, and in more cosmetic locations,” Dr. Devgan said. “Specifically with regard to facelifts and neck lifts, I am often able to accomplish beautiful outcomes by keeping incisions completely hidden behind the ears and under the chin, with no extension into the hairline or onto the face. With specific reference to blepharoplasty, I use my signature approach to a zip stitch: a running, intracuticular stitch that allows the incision lines to kiss together without causing the appearance of track marks like traditional stitches.”

Dr. Devgan also advocates for combination treatments rather than multiple single procedures at different times.

“I look at the face as a matter of harmonizing, rather than isolating,” Dr. Devgan said. “A natural result in the operating room comes often from treating the face holistically rather than isolating features. Every area of the face bears on the adjacent area. I often perform a mid-face lift, lower-face lift, neck lift, lip lift, blepharoplasty, and brow lift all together. This allows the artistry of aesthetic plastic surgery to come to the forefront.”

Dr. Rizk said one technology that has been transformational in helping to achieve a natural aesthetic is an ultrasonic device for rhinoplasty.

“We used to be limited to using tools that created a lot of trauma and swelling, but with the advent of the piezo ultrasonic rhinoplasty, that’s all changed,” Dr. Rizk said. “Unlike the irregular, inconsistent movement of rasps and knives, the piezo tool relies on the gentle pressure of sound vibrations to glide through the bone and cartilage, buffing and smoothing as it goes.”

For patients who refuse surgery or are too young but still want some minor improvements, another option is a new facial muscle stimulation treatment that exercises facial muscles to create instant lift-like effects.

“It is not quite a replacement for a surgical correction, but there is nothing more natural than strengthening your own muscle,” said Manuel Lopez, MD, FACS, a facial plastic surgeon in San Antonio, Texas.

A DIVERSE SET OF TOOLS

Of course, fillers remain a reliable, effective option that need not compromise a natural look.

“If you have many different tools in your toolbox, then you can accomplish many different kinds of very bespoke things,” Dr. Devgan said. “You can get into trouble with fillers when you try to accomplish more than is possible with them, but when used with care, they can have an amazing and powerful role.”

Doris Day, MD, FAAD, utilizes a vertical vectoring approach to fillers that she said hinges on having a deep enough understanding of anatomy to customize treatment for the specific concerns of each patient while also capitalizing on the reliable commonalities involved with aging that need to be addressed.

“My approach is affecting each specific layer of change that happens with age—from bone, muscles and ligaments, superficial and deep fat compartments, and all the layers of the skin itself,” Dr. Day said. “We cannot reconstruct exactly what you were at 20 because the architecture of the face is different, but what we can do is create balance. By taking into account vectoring, understanding the way the compartments of the face work, and using them to your advantage, you can vector to help achieve, essentially, an optimal lift and balance without overfilling the face. The vectoring I use takes advantage of hidden (less visible or obvious) areas of the face—under and behind the ear, along the hairline, along the scalp line—avoiding using too much product, and carefully layering products appropriately, understanding that the eyes are the rate-limiting factor. Overfilling or trying to eliminate every line or wrinkle with filler can make the eyes look more deep-set or smaller and should be avoided.”

Clearly, achieving a natural look is not as simple as avoiding or dissolving filler. Dr. Durairaj noted that the overuse of hyaluronidase resulting in post-hyaluronidase syndrome has become an issue as well.

The best strategies may involve early interventions to minimize the effects of aging before they even occur—everything from neuromodulators to biostimulators to simply prioritizing photoprotection.

“We need to educate the younger demographic so that they start with some of these procedures and even topical skincare much earlier, to help prevent the progression of that aging process,” Dr. Weinstein said. “People want to age, but they want to do it beautifully. We can start early with small amounts of injectables, neuromodulators, biostimulators, fillers, and very low-energy lasers to stimulate collagen. We can encourage proper skincare, including sunscreen and a retinoid and antioxidant starting early in adulthood to maintain their natural features. Over time, we will be able to help them with that process while doing less.”

1. Passel JS, Cohn D. U.S. Population Projections: 2005-2050. Pew Research Center. Published February 11, 2008. Accessed November 12, 2024. https://www.pewresearch.org/social-trends/2008/02/11/us-population-projections-2005-2050/