Guest Editorial: Challenging issues in aesthetic surgery
Department of Dermatology and STD, VM Medical College and Safdarjang Hospital, New Delhi - 110029
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Khunger N. Guest Editorial: Challenging issues in aesthetic surgery. Indian J Dermatol Venereol Leprol 2013;79:30-31
In recent times, there has been a massive boom in the demand for aesthetic surgery all over the world. It has been fuelled by several factors, the most notable being an increasing awareness ofaesthetic proceduresto enhance appearances, publicity in the media and internet and their widespread availability and social acceptance. The advent of several minimally invasive aesthetic procedures such as neurotoxins, fillers, chemical peels, fractional ablative and non-ablative laser systems and microneedling therapy, which are effective with minimal downtime,has further paved the way for increasing acceptance of rejuvenation procedures as opposed to the traditional surgical procedures such as face lifts and ablative resurfacing that involved considerable downtime and expense.
Ever since the first observation of the improvement of glabellar wrinkles by botulinum toxin used to treat blepharospasm and strabismus  and subsequent approval of the cosmetic use of the toxin for glabellar wrinkles this cosmetic procedure is the topmost among all aesthetic procedures. The evolving trend is moving away from fixed dose and fixed point injections towards a more customized approach depending on individual anatomic differences. The use of fillers for soft tissue augmentation has also brought into focus a simplified nonsurgical technique for rejuvenating the upper face, with minimal downtime. The article by Nanda and Bansal  published in this issue highlights the finer nuances of both these techniques for rejuvenation of the upper face as well as complications that can occur. The authors have detailed the procedures and rightly concluded that a thorough knowledge of the basic anatomy, proper patient selection and following proper guidelines makesthese procedures safe and effective for rejuvenation.
Aesthetic surgery has also now become an interface for specialties such as plastic surgery, dermatosurgery, oculoplastic surgery, dental aesthetic surgery and psychiatry. There is an overlapping of procedures done, particularly between plastic surgeons who are now embracing minimally invasive procedures such as fillers, neurotoxins, lasers and chemical peels due to market demand and cutaneous surgeons who are performing more invasive surgeries like liposuction, hair transplant surgery and blepharoplasty. Thus aesthetic surgery has become a meeting ground of these specialties. The need of the hour is learning from each other and working together for the common good of the aesthetic patient. The article by Naik  , an oculoplastic surgeon is an example in this direction. The eyes are an important component of facial aesthetics and often the first to show signs of aging such as droopy eyes, undereye bags, malar bags, tear trough deformity, periocular pigmentation and wrinkles. The technique of blepharoplasty should be mastered for upper eyelid rejuvenation, whereas the rejuvenation of the lower eyelid and midface is more complex, with several treatment options such as fillers, blepharoplasty, and skin resurfacing.The article highlights the finesse and precision of ophthalmic plastic surgery in addressing these various issues and emphasizes the need of a customized approach to eyelid surgery in which the specific anatomic problems are identified and the technique chosen is individualized to address these problems.
Aesthetic surgery is basically a wellness surgery and patients are often referred to as clients rather than patients. This grey zone of medicine has led to the explosive mushrooming of medi-spas and beauty centers run by non-physicians offering a plethora of services that also include procedures such as lasers, peels, fillers etc. that should ideally be performed by physicians. This has raised serious questions about ethical issues involved in aesthetic surgery.  Patients often come with unrealistic expectations fuelled by misleading advertisements and are pressurized to undergo procedures, which may or may not be beneficial to them. Complications following cosmetic surgery are on the rise, particularly when performed by inadequately trained staff.  More and more patients are presenting particularly with infectious complications fromunapproved injectable solutions administered by individuals with little to no medical education at places that do not followeven minimum basic principles of medical or surgical care. In a study by Narurkar  82% of complications that occurred were seen in facilities that had no direct physician supervision and 78% occurred in non-traditional medical facilities, such as free-standing medical spas and laser centers in shopping malls. The need of the hour is to practice aesthetic medicine and surgery in an ethical fashion, regulate the mushrooming medi-spas or face consequences of complications and potential medico legal liabilities.
Another challenging issue is the increasing incidence of elective cosmetic surgery in adolescents and young adults.  In the US in 2009 it is estimated that more than 209,000 cosmetic plastic surgery procedures were performed on adolescents aged 13-19 years.  Many such requests for cosmetic surgery in adolescents are emotionally or psychologically motivated, with peer pressure playing a major role. Psychiatric diseases such as body dysmorphophobic disorder, personality disorder or polysurgical addiction, often remain undiscovered.  These should be excluded in any patient demanding cosmetic surgery procedures for imagined or minor defects.  Such patients often ignore the possible risks and complications that can occur and put pressure on the surgeon to perform surgeries repeatedly, with increasing chances of involved risks. Ideally in cosmetic surgery, the patient and procedure selected should be risk free. The patient should be adequately counseled regarding the results expected, time taken for recovery and potential complications that can occur.  The physician should be precise, realistic and cautiously optimistic without exaggerating results. If required the help of a professional counselor should be taken.
Another important challenging issue in aesthetic surgery is the use of unapproved products. It is mandatory to use products which have obtained prior approval by a regulatory authority. Manufacturers create demands for products by extensive advertising, incentives andpromotion gimmicks, without obtaining proper approval of their products. Cheaper products with dubious credentials are also available freely on the internet. It is essential for the physician to not give in to temptation but check whether relevant certification has been obtained. In today′s demanding world, the use of interventional procedures to obtain quick and unexpectedly good resultshas made the ethicalpractice of cosmetic surgery increasingly difficult. The physicianhas to withstand pressure not only from patients, but also a hyperactive industry and finance companies to payinstalments of costly machines. In this scenario, today′s aesthetic surgeon faces many challenging issues and hence the physician must use experience and judgment to establish an ethical cosmetic practice.
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