Five Tips for Plastic Surgery Trainees Interested in Facial Rejuvenation

The path to today's fascination with facial aesthetic surgery and nonsurgical treatment has been a long one. For decades, pioneering surgeons such as Charles Miller, Adelbert Bettman, Suzanne Noel, Jaques Joseph, and many others, have pushed this area forward in the face of resistance from colleagues. The interest in aesthetic surgery by patients has long been present. However, the openness about aesthetic procedures has grown significantly with time—we have come from nearly all patients in Western societies prioritizing discretion and wanting to hide the fact that they have had surgery, to the year 2023 when young patients are likely to share their aesthetic journey with the world via social media. We have now reached a point where aesthetic surgery has been widely accepted by society and is encouraged as an area for specialization within plastic surgery. These are certainly victories that will lead to more discussion, more research, and ultimately further the development of the field. However, we must not allow the pendulum to swing so far that procedures are performed without proper consideration or training. With expert plastic surgeons reliably achieving exceptional results with low rates of complications, interest in facial rejuvenation has grown, leading to an increase in the numbers of practitioners who lack formal training in aesthetic surgery or potentially in plastic surgery. While this is certainly concerning for patients, compounding the issue is the fact that our plastic surgery trainees are coming through in an era where misinformation can spread via the internet at an alarming rate and the credibility of sources is difficult to gauge. To maintain the integrity of our field, the onus is on expert surgeons to provide training, mentorship, and guidance to learners so that they have the tools to succeed. With these thoughts in mind, and based on our experience, we have compiled the following 5 keys to success for plastic surgery trainees interested in facial rejuvenation. The first and most fundamental step to success in facial rejuvenation is to have the appropriate formal training for the job. This will naturally include residency training in plastic surgery, but we would recommend that those interested in establishing themselves in facial rejuvenation also seek out proper fellowship training in the area. Facial aesthetic surgery is extremely complex and the nuances are beyond the scope of plastic surgery residency training. Fellowship training should include the opportunity to operate independently on a large volume of facial aesthetic patients and be endorsed by The Aesthetic Society.1 Furthermore, we consider it mandatory to obtain certification in plastic surgery by the appropriate organization for a surgeon's country of practice, such as the American Board of Plastic Surgery in the United States, or the Royal College of Physicians and Surgeons in Canada. The credibility afforded to the young plastic surgeon by achieving proper certification is undeniable. We acknowledge that what is considered appropriate formal training and certification will vary by country; trainees would be wise to understand the expectations of their respective regional plastic surgery societies and medical professional regulatory bodies. With regards to the United States and Canada, certification by “boards” that are not members of the American Board of Medical Specialties/Royal College may detract from one's credibility. Appropriate formal training lays the foundation for success, but equally important is the informal education and guidance that one gains through mentorship. Interested trainees will need advice on all things from patient care to practice management, and having a reliable senior colleague to lean on is far more valuable than much of what can be found online, or even in the press. In our experience, and that of our colleagues, mentorship is a mutually beneficial relationship.2 We encourage senior surgeons to step up, be generous with their time, and help develop young talent. With the skills afforded them by the training detailed above, young surgeons will no doubt wish to push the envelope and achieve the best results for their patients. This drive to do better and adopt new techniques is exactly how our field grows. However, with the internet allowing almost anyone to share their techniques, and the amplification of this via social media, untested techniques may spread quickly. Young surgeons should have a cautious approach in adopting new techniques. We encourage an open mind and rigorous evaluation of all new techniques and procedures as some will no doubt have merit. One such technique is the incorporation of radiofrequency skin tightening (InMode Aesthetics, Lake Forest, CA) into facelift and necklift surgery by the present authors. If aiming for longevity in their career in facial aesthetic surgery, surgeons must avoid propagating fads. This means thinking critically about new techniques and treatments, and soliciting the expertise of experienced colleagues. Although some techniques are indeed new, many “innovations” in facial aesthetic surgery are in fact decades old and have come in and out of favor over time.3 One such example is the endoscopic facelift, which was first described in the early 1990s by surgeons such as Oscar Ramirez and Luis Vasconez and has recently seen a resurgence in popularity driven by social media.4,5 This approach is now marketed by other practitioners as being safer and associated with fewer complications than a formal facelift. However, there is currently no strong published evidence to support this. Anecdotally, the senior author (S.J.A.) has seen multiple patients for a second opinion after they have had complications following an endoscopic facelift. These complications are not benign and include marginal mandibular nerve injury, frontal branch injury, facial deformity, and lack of appreciable results. Another example is the composite facelift. Although this has been modified slightly with time and recently gained significant popularity through social media, in our experience a dissection of only the deep plane does not yield optimal aesthetic results or longevity—to achieve the best results it is preferable for the surgeon to take the extra time and effort to perform a subcutaneous dissection as well as a deep plane dissection. It is tempting to participate in these fads to satisfy patient demand and give the appearance of being at the cutting edge of the field; however, this is likely a career-limiting approach if complications and dissatisfied patients begin to mount. As noted above, patients are now more motivated than ever to pursue facial aesthetic procedures—blepharoplasty was one of the top 5 procedures performed by Aesthetic Society member surgeons in 2021.6 For those starting their careers, the reasons to operate on a patient presenting to your practice are many. However, we would encourage careful patient selection and thorough patient education. With social media driving the trend cycle ever faster, it is crucial for surgeons to provide measured and realistic counseling with regards to the risks and expected results of surgery. The risk of inappropriate counseling is now greater than in the past: even if an expected result is achieved, patients may still become disappointed with their results as trends shift. Patients with unrealistic expectations or those who are seeking procedures that are inappropriate for them should be educated, and if a realistic plan cannot be achieved, then we would recommend that the patient be referred for a second opinion elsewhere. With the appropriate training, skills, and patients, one must ensure that care can be provided in the safest manner possible. Increasingly in our experience, aesthetic procedures are moving out of the hospital and into private offices. With this in mind, young surgeons must choose the optimal setting in which to offer care. We recommend seeking out an accredited facility7 with overnight monitoring capabilities—all patients undergoing facelift and necklift surgery are monitored overnight in our practice. Furthermore, we recommend that anesthesia for this type of surgery be provided by a board-certified anesthesiologist or certified nurse anesthetist. From a surgical perspective we could caution against operating on patients who are active smokers, who have medical conditions that would preclude facial aesthetic surgery such as significant bleeding diatheses, or who have wound-healing concerns such as uncontrolled diabetes mellitus. Patients with lupus, Sjögren's disease, Ehlers-Danlos and other connective tissue disorders exist on a broad spectrum and thus require extensive evaluation prior to deciding to proceed. In addition to the surgical concerns above, careful attention should be paid to the potential for body dysmorphia and any concerns with regards to this or other psychiatric issues should prompt evaluation by an appropriate mental health professional. Last but certainly not least for a successful career in facial aesthetic surgery is the surgeon's attitude. This is one of the most challenging and nuanced areas in plastic surgery. As experience in the area grows and consistent results are achieved, it is crucial for all surgeons to remain humble and kind to their colleagues. In every community, all surgeons in the area will have seen complications from their colleagues and one must never think they are the exception. The curiosity and openness that is felt by young surgeons is something to be cherished. The old adage that routine surgery is safe surgery holds true, but while the provision of care should be routine, surgeons must be critical of their results and always strive for better. That will mean carefully evaluating and adopting reliable techniques over the course of one's practice and avoiding unreasonable techniques. With time and dedication, many surgeons may achieve success in the field and remember the training and mentorship that contributed to their success. Naturally, they will want to share their experience with other surgeons and perhaps the public. We would encourage an earnest approach—the operating room is too small a place for dancing or otherwise making a spectacle of the profession. Young plastic surgeons are coming through in an exciting time for facial aesthetic surgery. There has never been more interest in, or dialogue about, the field or aesthetic surgery more broadly. Social media has changed much in terms of the pace of this dialogue and who can participate. The successful surgeons of the future will be those who can cut through the noise and misinformation of today to provide safe, high-quality, and reliable care for their patients. Dr Aston is a consultant for InMode Aesthetics (Irvine, CA); this did not impact the production of this manuscript. The remaining author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The authors received no financial support for the research, authorship, and publication of this article.

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