Dirk Brandl, Jürgen Ellwanger
Controversies in aesthetic medicine Framework conditions 2: The new challenges of aesthetic medicine
Looking at aesthetics' history we are able to detect a clear tendency towards more and more minimal invasive treatment options. Today our new aims are focused on further and more minimal invasive interventions. This movement leads to new challenges: To find a better philosophical approach which is able to reflect the developments and to revise an old fundament of aesthetic philosophy which was based on the improvement and maintenance of a status and not of an aesthetic and continuous supervision of the aging process and therefore age related treatment strategies.
During many training sessions, where surgeons were often present, we noticed a passion for operative work. The activity of surgery leads to satisfaction, sometimes euphoria and is considered an experience that one would not want to miss. A non-physician can only comprehend this satisfaction if he transfers it to other fields of activity; the best way to compare it is to work as a craftsman: A carpenter who has built a beautiful table in one day radiates a similar satisfaction. The activity leads to a result, and this result has its value when the work has been done well.
Against this background, the surgeon’s enthusiasm is understandable, certainly not to be criticized. Nevertheless, it should be noted that in the surgical craft we are dealing with the material of human or patient, who ultimately does not care about the satisfaction of the physician, but who has completely different desires and needs, which are sometimes even opposed to this medical need. “What is in the foreground” is the question of all questions for the aesthetic physician working with body and soul, which is dealt with in the second part of the article series.
The patient and aesthetic medicine
The introduction of minimally and minimally invasive procedures into aesthetics has undoubtedly increased patient acceptance and thus the number of aesthetic treatments. A large number of patients rejected and reject the risks of surgery for aesthetic reasons, rightly or wrongly. In any case, fears of anesthesia errors are understandable, as are treatment errors that cannot be corrected or can only be corrected with great effort, or which in rare cases even have fatal consequences. A faulty Botox treatment disappears after 3 months at the latest, a faulty liposuction or a facelift has to be endured by the patient until the end of his life.
Looking at pictures of the first liposuction performed, today makes you sick. From today’s point of view these results are not to be accepted at all, although they were at that time “State of the Art” and represented an actual progress. Thus, there has also been a development in surgical procedures, which we can characterize as a tendency towards minimally invasive surgical techniques.
Curiously enough, aesthetics has an advantage over other medical disciplines because it has been excluded from the outset by the health insurance funds. It has always been a self-payer service since its introduction. This turned a patient into a customer and a purely medical activity into an economic transaction. We say advantage here, because thereby the normal rules of such transactions have become valid for aesthetics as well. Sentences like “The customer is always right” are only valid up to a certain limit. But if we do not look at the pathological aberrations of mentally disturbed dysmorphophobia patients here, but at the quite “normal” patients, then we have to state that the doctor is a service provider who helps his patients to recognize their own ideas about their appearance and then implement necessary changes.
This fact increases the importance of doctor-patient communication. Here aesthetic medicine has a clear pioneering role, which would also be good to see in other medical disciplines, in which communication is still considered a necessary evil today, which prevents the doctor from the “actual” activity.
So, if the patient prefers a minimally invasive procedure to surgery, but the doctor prefers surgery because he enjoys it more, there is a contradiction that the doctor, not the patient, must resolve, because he wants to do something for the patient and not vice versa.
|First treatments Liposuction||1970s by Prof. Kesselring a.o.|
|Improvement of the cannulas for aspiration||Dr. Sattler, Dr. Fatemi a.o.|
|Introduction of tumescence local anaesthesia||Dr. Sattler a.o.|
|Since 2000 new combinations of suction techniques e.g. with ultrasound||e.g. Vaser Liposuction|
|Development of injection lipolysis||1995-2005 Dr. Rittes (BR), Dr. Hasengschwandtner (A) with NETWORK Lipolysis and Dr. Duncan (USA)|
|Development of devices for laser lipolysis, ultrasound lipolysis and cryo-lipolysis||Since 2005, more and more equipment manufacturers have been pushing into this lucrative market|
|Development of more gentle combinations for fat reduction||2013 Half-sidecomparative study by Prof. Tausch, Kiel with injection lipolysis versus injection lipolysis + LDM ultrasound.|
Tab. 1: Because NETWORK lipolysis has a great competence in this field, here is a brief history of the volume reducing procedures of fat tissue, illustrating the tendency towards minimal invasiveness. The same development can be seen in wrinkle treatment or skin tightening.
We would even like to claim here that aesthetic medicine has an innovative function compared to other disciplines. Particularly in the case of “non-medically necessary procedures”, the surgeon will do everything in his power to ensure that the procedure is as gentle as possible and that the wound heals as quickly and with as few complications as possible. Examples include pre- and post-treatment with LDM ultrasound, which shortens the wound healing time and reduces the risk of scarring, or vitamin C high-dose infusion therapy during and after surgery, which produces several improvements: supporting collagen formation, reducing pain and promoting wound healing. What patients do not (yet) receive in a normal hospital, they first receive in aesthetic medicine, precisely because the patient is also a customer.
Surgery as a static treatment model
Before we start to look at the philosophy behind surgical procedures, we would like to mention that some aesthetic corrections can only be performed by surgery: Breast corrections, rhinoplasties and otopexies are the most important, but also bags under the eyes can still be treated better by blepharoplasty than by unconvincing alternatives. And, of course, liposuction is still the procedure of first choice for large fat compartments.
We must also state here that there can and must be no standstill in the aesthetics of your procedures, because some indications can only be treated to a very limited extent – with slight improvements, when it comes up. We want to address the topics of cellulite, striae and melasma here. If we are honest, we have to admit that these 3 indications still lacking convincing therapeutic possibilities, even though there is a lot of research on them at the moment and there are some options available that promise solutions.
Let us now come to the philosophy, which we can describe very well with the help of the surgical activity without wanting to limit it to this. As we have mentioned, the satisfaction of a well performed surgery, which is the basis of surgical activity, is more than understandable and can even increase the identity of aesthetic medicine. However, it should be supplemented and corrected where necessary, if it has been used to justify surgical activities. This justification leads to a misjudgment and “ideologization” of one’s own behavior: the estimation that one can produce a static result. The meaning of the concept of process, which is gaining more and more philosophical acceptance and thus many sciences and also influencing medicine, is also of outstanding importance in aesthetics.
We are never dealing with a state, we are always in a processual happening as this was so aptly intuitively anticipated by the ancient Greek expression Panta Rhei (Everything flows). If we look at the human being, then the idea of a state preservation is absurd. The process of aging begins immediately after birth and only ends when we have taken our last breath. To stick to the example of the carpenter: He can be very satisfied with his table, knowing that it will change already the next day and will show the traces of life after the first use.
A new philosophy of aesthetic medicine
Aesthetic medicine is forced to revise its philosophical foundations by the ever-increasing potential of minimal invasiveness. The notion that one can bring about a new state of satisfaction for the patient through a single intervention or an intervention that only treats one indication should be replaced by a new philosophy.
The philosophy is to accompany each patient according to their current status in their aesthetic aging process and to always have the right instruments available at the right time to make this accompaniment appear meaningful: The younger patient is supported by preventive measures to maintain his weight, to relax the mimic musculature and thus prevent wrinkles or to protect the skin surface against intrinsic and extrinsic skin aging by infiltrating vitamins. The middle-aged patient is accompanied by gentle procedures to smooth wrinkles, reduce excess fat at the base or replenish volume, in the case of breasts also by minimally invasive surgical measures. The elderly patient is supported systemically by anti-aging medicine, the aesthetics maintain the radiance of healthy old age instead of youthfulness and vitalize where it seems appropriate. Surgical procedures are not excluded, but should be used when the degree of intervention requires them to achieve a result, but only then.
The goal: As gentle and less invasive as possible
If the process is seen as an opportunity, then the new developments described should be taken into account as a definition of objectives. The goal should be to optimize all processes. The less invasive they are, the less the organism is systemically burdened. The more biological or ecological our interventions are, the more we are in harmony with the needs and physical conditions of the patients.
The clearly defined goal of an aesthetic intervention should be to carry out the desired change as invasively as possible. A further goal of aesthetic medicine should be to support all developments that offer alternatives to the previous procedures if they are more gentle than the older procedures. Unless the patient has other ideas, the necessity of several treatment sessions should be accepted in order to achieve an operative result with a more gentle method.
Non-Invasiveness and Process: A Hypothesis
If aesthetic medicine continues to develop as rapidly as in the past decades, we can assume that the development today is already in a new stage, which can be described as moving away from minimally invasive procedures and towards non or more minimally invasive procedures. While stormy developments towards minimal invasiveness have been observed since the 1990s, the next decades will be characterized as a stage towards non-invasiveness.
Some examples: The techniques of infiltrating substances have expanded significantly. In addition to iontophoresis, we would like to highlight the JetPeel and similar devices, which have a lot of infiltration and treatment potential by providing gentle peelings, needle-free infiltration of substances and various media of infiltration (air, oxygen, CO2). However, the term non-invasive is not correct here either. The same applies to therapeutic ultrasound, which has undergone powerful development steps towards gentle treatment, but only because the intervention via the medium of sound waves is not visible, is it nevertheless not necessarily gentle, as the fat-dissolving ultrasound has shown us in the past. The fractionated interventions also show in the laser and radiofrequency areas that invasiveness decreases significantly. Noninvasiveness is a goal that will never be fully achieved. We ourselves have been able to make concrete experiences with the fat-dissolving injectables: Whereas in 2003 the members of the NETWORK-Lipolysis were just accepted as exotics, today the situation looks quite different.
Our hypothesis is that in the future, there will be an ever wider range of minimally invasive techniques used in aesthetic medicine. The surgical techniques will concentrate on some important indications and refine their techniques there. The use of this new generation of techniques will be accompanied by a change in the course of treatment, away from single treatment and towards multiple treatment to achieve the same result. The consequence of these changes is that aesthetic practitioners should be prepared to prepare themselves and their patients to perform aesthetic and, in anti-aging medicine, systemic monitoring of the aging process rather than one-off, indication-only treatments.
The departure in many scientific disciplines – also in medicine – from a world view that has accompanied us for centuries and helped the sciences to gain significant insights, also applies to aesthetic medicine. What is meant here, is the renunciation of the Cartesian world view, which elevated a static analysis into ever smaller units for the outstanding acquisition of knowledge and thus manifested the separation of body and mind and regarded the human body and its functionality as machine-like. This “mechanistic” view of the world was associated with the old aesthetic treatment model aimed at states. Today’s world view of the unity of body and psyche, of observing processes instead of states, is more appropriate to the new treatment model.
Consequences of development
Assuming that the development outlined in this article prevails, of which we are deeply convinced, what consequences should we then prepare ourselves for?
We would particularly like to address the relationship between doctor and patient, which is made up of various aspects. In any case, this relationship will become more important. Doctor-patient communication is no longer characterised by the term “sale of a single service”, but much more by “building trust”. Every physician could become aware that a new patient is a candidate for aesthetic accompaniment in his continuous, age-related, physical process of change to harmonize his appearance. Any investment of time to get to know this new patient is therefore more than justified. The aesthetic physician who is able to match the patient’s wishes in his communication with the possibilities of aesthetic treatment, and who therefore sometimes has to change the patient’s ideas into a realistic view, will be successful. The long-term development of a patient base based on trust and understanding is at least as important as one’s own qualification and training in the new possibilities of aesthetic treatment. The crisis of the identity of the aesthetically working physician mentioned in the first article (Cosmetic Medicine 1-2019) can also be defused by these changes and help to replace the social image of the greedy physician who does not take care of the patient’s interests.
The adoption of a process-oriented philosophy can also give impulses for a better acceptance of aesthetics in the media and the population.
The development outlined in this article could lead operative physicians to believe that they will find worse conditions in the future. We believe that it depends on how the operating physicians deal with the development described:
Those who fight against it and continue to work on the old philosophical basis will certainly have a harder time in the future. But those who accept it as the right and necessary development can turn the supposed crisis into an opportunity. If the development is accepted, there is a chance that these physicians will be able to offer by far the broadest spectrum of possible aesthetic interventions.