[ Feature ]
What’s New in
Aesthetic Plastic Surgery?
by David S. Kung, MD, FACS and Lee L.Q. Pu, MD, PhD, FACS
Despite the economic downturn,
aesthetic plastic surgery remains an
industry that has managed to stay
afloat. According to the most recent
national statistics report from the
American Society of Plastic Surgeons
(ASPS), in 2008 total cosmetic
plastic surgery procedures were
up 3 percent from 2007 at 12.1
millions.1
One major reason for the
positive increase was the surge
in minimally-invasive cosmetic
procedures, up 5 percent from
2007, as opposed to surgical
c o s m e t i c p r o c e d u r e s, w h i c h
fell 9 percent. In 2008, popular
surgical cosmetic procedures
such as breast augmentations,
liposuction and rhinoplasties all
experienced declines not only when
compared to the previous year,
but also when compared to the
year 2000. Meanwhile, minimallyinvasive procedures such as Botox
and filler injections are up in both
comparisons.1 The authors believe
that this trend is in accordance with
rising hot topics in aesthetic plastic
surgery today and wide acceptance
by consumers to have minimalinvasive cosmetic procedures as their
initial or repeated means for facial
rejuvenation.
What’s New in Botox?
Botox, or botulinum toxin treatment,
is by far the most popular minimallyinvasive cosmetic procedure with
5 million cases performed in 2008.
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The number of Botox procedures
increased a monumental 537 percent
from 2000 and 8 percent from
2007, respectively. Botox injections
are effective in treating dynamic
animation lines of the face without
the patient having to undergo a
surgical facelift.1
This increase in consumer
demand has warranted the
development of several new subtypes,
such as PurTox and Reloxin, now
known as Dysport. PurTox is
currently under development by
Mentor Corporation, a medical
supplier for the aesthetic surgery
market that Johnson & Johnson
acquired last December.
Prior to that, Mentor announced
the successful completion of the
first of three Phase 3 clinical trials in
October 2008. The study measured
subjects’ satisfaction with the use
of PurTox to treat glabellar rhytids
(frown lines). Four hundred subjects
at 10 sites in the United States
received either a single treatment of
PurTox or a placebo.2
Investigators, independent
reviewers, and the subjects themselves
scored their reduction in line severity
over the course of six months using
a 4-point photo scale; satisfaction
was measured using a standard
global assessment tool. The study
found a high degree of satisfaction
with the treatment outcome by a
large percentage of participants. The
results will be used to spur PurTox’s
Biologics License Application (BLA)
filing with the U.S. Food and Drug
Administration. PurTox is expected
to launch in 2012. 2
While Pur Tox has been
pending, Dysport obtained FDA
approval in April and made its way
into doctor’s offices shortly thereafter,
marking it as the first U.S. rival to
Botox. Dysport, formally referred
to as Reloxin, is already popular
internationally – it is approved and
used in the European Union, Brazil,
Argentina, and more than 26 other
countries worldwide.3
Dysport is marketed in the U.S.
by Medicis, an independent specialty
pharmaceutical company known for
its popular Restylane and Perlane
facial fillers. This product addition
places Medicis on a similar playing
field as Allergan, the company that
markets Botox and the Juvéderm
hyaluronic acid filler. Although Botox
sales are consistently strong, an FDA
ruling for stronger Botox product
safety warnings may give Dysport a
head start.3
According to physicians who
have worked with both injections,
differences between the two products
may lead to preference of one over
the other in certain facial areas.
Dysport may have a faster effect
and a greater spread, , while Botox
has a more localized effect, allowing
greater precision and predictability.
It is suggested by some that Dysport
may take fewer injections and provide
a longer result than Botox of up to
a month or two.3 Studies on both
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[ Feature ]
products are continuing.
What’s New about Fillers?
Fillers are beneficial for static, rather
than dynamic facial depressions,
lines and furrows, and can last up to
six months and longer. Hyaluronic
acid has quickly become the most
popular of eight types of fillers
available. They are the second most
popular minimally-invasive cosmetic
procedure, with 1.1 million cases
performed in 2008, experiencing a 6
percent increase from 2007.1
Nearly 20 fillers are available
and approved by the FDA. Two of
the most popular dermal fillers are
currently Juvéderm and Restylane,
as mentioned earlier. Fillers are
distinguished by the level of dermis
and hypodermis the injection is
intended for. Restylane and Juvéderm
Ultra are injected into the mid to
deep dermis, while Juvéderm Ultra
Plus and Perlane are injected into
even deeper rhytids. The more
superficial a filler is injected, the
greater the development of superficial
irregularity, but the more apparent
the result.4
Eyelash Rejuvenation
Latisse is the first and only FDA
approved prescription treatment for
eyelash hypotrichosis, or inadequate
e y e l a s h e s. T h e b i m a t o p r o s t
ophthalmic solution 0.03 percent
is applied once a day to the base of
the upper eyelashes. This stimulates
eyelash growth, making them longer,
darker and fuller, with full results at
12 to 16 weeks. Latisse was clinically
tested in a Phase III study, which
assessed its safety and efficacy. The
solution’s effectiveness in all areas
– improved eyelash prominence,
length, thickness and darkness –
were met. Bimatoprost, the active
ingredient, was first approved in 2001
to treat an eye condition; eyelash
26 ■ Volume 13 > Number 12 > 2009
growth was merely a side effect.
Now, as the exclusive patent owner,
Allergan is the only company with
the right to use bimatoprost, other
prostaglandins and prostaglandin
analogs to stimulate eyelash
growth.5
While Latisse was just launched
this year, RevitaLash Eyelash
Conditioner from Athena Cosmetics,
Inc., has been on the market for
two years. RevitaLash is now the
cosmetic alternative to Latisse and
does not require a prescription. As
a cosmetic product, its purpose is to
enhance the appearance and beauty
of a person’s existing eyelashes,
rather than treat a medical condition.
Like Latisse, RevitaLash is also a
solution applied once a day to the
base of the upper eyelashes.6
long as several months. There is also
risk of infection if the patient fails to
follow the post-treatment regimen.
Combining the two technologies will
enable a deeper treatment into the
dermis than the minimally-ablative
fractional treatments alone can
provide. Meanwhile, the inherent
risks, longer recovery and excess skin
pigmentation associated with the
CO2 laser are minimized.9
Laser Skin Resurfacing
Currently, laser skin resurfacing
experienced the largest increase
of all minimally-invasive cosmetic
procedures at 15 percent from
2007 to 2008. Fractional laser
resurfacing is a treatment used to
alleviate wrinkles, acne scarring,
hyperpigmentation and other skin
conditions. While earlier laser
technologies used blanket ablation,
fractional lasers deliver isolated laser
spots in an even distribution across
the skin, thus preserving the healthy
skin in between. Rather than have
one large burn, the skin contains
microscopic surface wounds,
enabling rapid recovery.7-9
Fractional laser technology has
now merged with the CO2 laser,
used for deep wrinkling and skin
damage. The CO2 laser vaporizes
the outermost layers of the skin to
produce new skin that is smoother
and suppler. However, the treatment
requires a longer recovery time of
10 to 14 days and the skin tends to
retain a pinkish/reddish hue for as
Figure 1. Laser-rejuvenation of the face. Pretreatment and two week post-treatment‘s
photographs of laser-assisted facial skin
rejuvenation for hyperpigmentation with
fractional technology after one treatment.
(Photographs courtesy of Dr. David Kung)
Liposuction
Water-assisted liposuction is a new
FDA-approved body-contouring
modality that utilizes water to gently
free fat from its attachments so it can
be removed from the body. Since preinfiltration with tumescent fluid is not
necessary with this technique, there
is less distortion and swelling in the
tissues, allowing for more accurate
contouring results. Local anesthetic is
placed in the water so the technique
is not very painful. In fact, this is one
of the few liposuction modalities
that can be performed in an office
setting without general anesthesia
or sedation. There is also increasing
data showing that recovery is faster
with little bruising or swelling when
compared to traditional liposuction.
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[ Feature ]
The body collects fat in both a
superficial and deep plane. Waterassisted liposuction works well for
deep plane fat and is especially
effective for “pockets of fat” that are
hard to get rid of naturally.
Figure 2. Water-assisted liposuction. Preoperative and one month post-operative
photographs of water-assisted lipoplasty of the
abdomen and flanks performed under local
anesthesia in an office setting. (Photographs
courtesy of Dr. David Kung)
Cell-assisted Lipotransfer
Although autogenous fat
transplantation has been used by many
surgeons for cosmetic rejuvenation in
the face, hands, and buttock and even
for the breasts, the overall success of
this procedure has been questioned
by other surgeons because of its
unpredictable long-term results due
to a lower rate of fat graft survival.
In order to address the problem
of autogenous fat transplantation,
Dr. Yoshimura’s group from Japan
has pioneered a new strategy of
autogenous fat transplantation called
cell-assisted lipotransfer (CAL).
This new technique is based on the
findings that aspirated fat tissue
contains fewer vessels and adiposederived stem cells (ADSCs) than
that of intact fat tissue. It is also
based on their hypothesis that the
relative deficiency of tissue-specific
progenitor cells in aspirated fat
tissue might contribute to the low
survival rate and progressive atrophy
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of transplanted fat tissue. After
they confirmed their hypothesis in
an animal study,10 they proposed
a cell assisted lipotransfer strategy
because they believe the progenitor
deficiency can be compensated
by supplementation with stroma
vascular fraction isolated from a
separate volume of aspirated fat
tissue. They have speculated the
roles of adipose derived stem cells in
CAL to be: (1) to differentiate into
adipocytes and contribute to adipose
regeneration; (2) to differentiate into
vascular endothelial cells or mural
cells that may promote angiogenesis;
(3) to release angiogenic growth
factors; and (4) to survive as original
adipose derived stem cells which
serve as adipose tissue progenitors.
Since 2003 Dr. Yoshimura’s
group had pioneered this fat
transplantation technique and has
performed more than 230 clinical
cases, primarily for breast and facial
soft tissue augmentation.11,12 In the
CAL technique, fat is collected
via a conventional liposuction.
Approximately half of the collected
liposuction aspirates are used in
isolation of adipose derived stem
cells via collagenous digestion and
centrifugation. The process takes
about 90 minutes. While processing
the ADSCs, the other half of the fat
grafts is also harvested. Once the
ADSCs are mixed with aspirated
fat grafts, relatively progenitor poor
aspirate fat tissue can be converted
into progenitor enriched tissue. The
ADSCs enriched fat grafts are then
injected into the desired area of the
patient. The experience with the
CAL technique showed absorption
of transplanted ADSCs enriched
fat grafts is minimal and the clinical
results are generally satisfactory
without major complications. Dr.
Yoshimura estimates the surviving
volume of the fat graft taken range
from 40% - 80% among the patients.
Although the safety and efficacy
of the CAL technique needs to be
confirmed by others, some remarkable
results have been accomplished by
Dr. Yoshimura with this technique.
With a combination of stem cell
technology, the technique of fat
transfer pioneered by Dr. Yoshimura
and his colleagues in Japan may
represent a significant breakthrough
in aesthetic plastic surgery .
Figure 3. Concept of cell-assisted lipotransfer (CAL). Relatively progenitor-poor aspirated fat is
converted to progenitor-rich fat by supplement with the stromal vascular fraction (SVF) isolated
from one-half of the aspirated fat. SVF cells are attached to the aspirated fat, which acts a scaffold
in this transfer. (Photography courtesy of Dr. Kotaro Yoshimura)
Volume 13 > Number 12 > 2009
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[ Feature ]
Figure 4. A 26-year-old Asian woman, who had a hypoplastic breast along with thoracic deformity on the right side, underwent CAL augmentation
for both sides (325 ml and 105 ml on the right and left, respectively) Preoperative (left) and postoperative (right) views at 12 months. Pre- and
post-operative CT scans (bottom, left and right) show that adipose tissues were augmented not only subcutaneously but also under the mammary
glands with no abnormal nodules or calcifications detected.(Photographs courtesy of Dr. Kotaro Yoshimura)
Mini Facelifts
Mini facelifts have become an
attractive option for younger clientele
in their thirties to forties who are
just starting to experience the signs
of aging. This procedure is best for
addressing minor sagging and can
target problem areas customized
to the patient. Often known as
“weekend” facelifts, they can be
performed quickly and less invasively
than a standard facelift and are
associated with faster recovery.
Patients who choose this flexible
and less stressful treatment can enjoy
the mini facelift’s subtle changes
without feeling as great a burden in
their wallets.
Branded mini facelifts are also
available. The Lifestyle Lift (removal
of preauricular skin with some
suturing of the tissue beneath) is
specifically designed to tighten the
jowls and neck and address wrinkles
28 ■ Volume 13 > Number 12 > 2009
and frown lines in about an hourlong procedure. Nearly 100,000
patients received the Lifestyle Lift
in the last decade. The Quick Lift
is an improved version of the S-Lift
and devotes attention to the lower
face and neck. Both procedures
utilize local anesthesia and boast a
short recovery time. About 10,000
patients received Quick Lift since
2003. While these quick-fix options
may be desirable, some surgeons
are concerned that branded facelift
advertising will deter patients from
seeking a second opinion. Patients
should select a treatment course
from a range of options and fully
be aware of the limitations of the
branded mini facelift.7
or minimal invasive procedures
which are the fastest-expanding
segment of the cosmetic treatment
spectrum because of the lower
cost, faster recovery time and likely
noticeable results achieved by these
procedures. The authors predict that
minimal invasive cosmetic surgical
procedures will possibly replace the
most of “traditional” cosmetic surgical
procedures in the near future because
of a strong and popular demand by
patients.
Acknowledgement
The authors greatly appreciate Dr.
Kotaro Yoshimura of University of
Tokyo, Japan who kindly provide the
photographs used in the article.
Conclusion
Many of these hot topics and emerging
technologies in aesthetic plastic
surgery stem from non-invasive
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[ Feature ]
Biography
Maryland plastic surgeon Dr. David
Kung is a multiple board certified plastic, reconstructive,
and maxillofacial surgeon. He holds doctorates with honors from both Harvard Medical School
and Columbia University, and has completed residencies with distinction at the Massachusetts
General Hospital as well as the University of North Carolina/Duke University Medical Center.
Dr. David Kung is a leading provider of cosmetic plastic surgery, at the forefront of several exciting
new techniques, and an innovator in his own right. He has written influential articles on cosmetic
eyelid incisions and the correction of rare congenital facial deformities, as well as a new book
entitled A New Face - The Art of Facial Enhancement. Dr. Kung has invented medical instruments
involved in wound closure that are awaiting patents and will soon be used by the US military. He
was also invited to speak at the Extreme Makeover Expo in Philadelphia and nominated for the
International Health Provider of the Year award in 2004. ■
Website: http://www.kungplasticsurgery.com/index.html
Biography
Dr. Lee L.Q. Pu is Board Certified by the American Board of Plastic Surgery and an active
member of the American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic
Plastic Surgery (ASAPS). Dr. Pu is physician first and his relationship with his patients and their
safety is a priority in his practice. Dr. Pu’s patients receive personalized care with compassion and
have the best possible results after surgery. As a surgeon, innovator, and educator, Dr. Pu possesses
a unique set of skills and always strives to be the best in a procedure of your choice. ■
E-Mail: [email protected]
www.asiabiotech.com
Volume 13 > Number 12 > 2009
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[ Feature ]
References
1. “2009 Report of the 2008 Statistics.” American Society of Plastic Surgeons. 10 June 2009 <http://www.
plasticsurgery.org/Media/Press_Kits/Procedural_Statistics.html/>.
2. “Mentor Corporation Announces Completion of PurTox® 3A Study.” Business Wire. 1 Oct 2008. 10 June
2009 <http://www.bnet.com/>.
3. American Health and Beauty. VC Cubed – Medical Marketing Specialists. 10 June 2009 <http://www.
americanhealthandbeauty.com/>.
4. Dhaliwal J and Friedman O. Injectables and Fillers in Male Patients.
Facial Plastic Surg Clin N Am. 2008;16:345-355.
5. Latisse. Allergan, Inc. 10 June 2009 <http://www.latisse.com/>.
6. RevitaLash. Athena Cosmetics, Inc. 10 June 2009 <http://www.revitalash.com/>.
7. Lewis W. “The Scoop on Lumixyl, the Newest Skin Lightener.” HealthNewsDigest.com. 31 May 2009. 11
June 2009 <http://www.healthnewsdigest.com/>.
8. Saint-Louis C. “Want a Mini-Facelift? Surgeons Advise Getting a Second Opinion.” The New York Times.
2 July 2009. 14 Aug 2009 <http://www.nytimes.com/>.
9. The American Society for Aesthetic Plastic Surgery. 13 Aug 2009 <http://www.surgery.org/>.
10. “The DOT CO2 Fractional: The Next Step in Laser Skin Resurfacing.” PRNewswire. 1 Mar 2008. 13 Aug
2009 <http://www.reuters.com/>.
12. “The DOT CO2 Fractional: The Next Step in Laser Skin Resurfacing.” PRNewswire. 1 Mar 2008.13 Aug
2009 <http://www.reuters.com/>.
13. Matsumoto D, Sato K, Gonda K, Takaki Y, Shigeura T, Sata T, Aiba-Kojima E, Iizuka F, Inoue K, Suga H,
and Yoshimura K. Cell-assisted lipotransfer: Supportive use of human adipose-derived cells for soft tissue
augmentation with lipoinjection. Tissue Eng 2006;12:3375-3382.
14. Yoshimura K, Sato K, Aio N, Kurita M, Hirohi T, Harii K. Cell-assisted lipotransfer for cosmetic breast
augmentation: Supportive use of adipose-derived stem/stromal cells. Aesth Plast Surg 2008;32:48-55.
15. Yoshimura K, Sato K, Aio N, Kurita M, Inoue K, Suga H, Eto H, Kato H, Hirohi T, and Harii K. Cellassisted lipotransfer for facial lipoatrophy: Efficacy of clinical use of adipose-derived stem cell.
Dermatological Surgery 2008;34:1178-1185.
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