S05E76 What are the Top Plastic Surgery Procedures? Decoding the Latest Trends

Unlock the secrets of the ever-evolving beauty industry as we convene with Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, Dr. Sam Jejurikar @samjejurikar and Dr. Sam Rhee @bergencosmetic to decode the latest American Society of Plastic Surgeons' statistics and their direct impact on patients.

Discover why liposuction has become the frontrunner in cosmetic procedures, and delve into the surging interest in breast lifts and eyelid surgeries. We'll also shed light on the unexpected boom in cosmetic surgery during the pandemic era, probing into the nuances of hospital access limitations and the changing currents of reimbursement practices. Our discourse extends beyond the operating room, examining the financial and societal pressures that are reshaping the landscape of cosmetic enhancement today.

Step into the rapidly expanding universe of med spas and witness the meteoric rise in demand for minimally invasive treatments with a staggering 300% revenue increase over the past five years. This episode peels back the curtain on the allure of Botox, fillers, and laser therapies, and confronts the reality that these services are often performed by professionals outside of board-certified plastic surgeons.

Listen as we, a panel of industry-leading surgeons, share our personal experiences and insights on integrating these non-surgical advancements into our practices. Together, we embrace the shifts within our field, recognizing the critical balance between innovation and maintaining our unwavering commitment to surgical excellence.

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S05E76 TOP PLASTIC SURGERY PROCEDURES

TRANSSCRIPT

[00:00:00]

Dr. Salvatore Pacella: Welcome everybody. We're back with uh, three plastic surgeons and a microphone. Actually four. Um, doesn't count because he's Canadian from Toronto. Dr. Tong is joining us. Okay. So as always, I'm Dr. Sal Pacella from San Diego, California. We've got Dr. Sam Jejurikar from Dallas, Texas. Dr. Sam Rhee from Northern New Jersey, New York City area.

And of course, my good friend Dr. Larry Tong from the beautiful city of Toronto, Ontario. How are you guys today?

Dr. Lawrence Tong: Great.

Dr. Sam Jejurikar: Doing great.

Dr. Lawrence Tong: Year. Happy New Year.

Dr. Salvatore Pacella: Awesome. Well, great to, uh, great to catch up with you guys again. Fantastic. Um, today we're gonna, we've got a really fantastic topic. We're talking about the latest statistics from our main society in plastic surgery, the American Society, uh, of Plastic Surgeons. We're going to go over a few of the results, um, for the top five [00:01:00] procedures, uh, that are performed in the United States.

Prior to that, we're just going to go through a regular disclaimer. Dr. J.

Dr. Sam Jejurikar: All right. So, uh, for our listeners, this show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment. After appropriate discussion, always seek the advice of your surgeon or other qualified health provider.

With any questions you may have regarding medical care, never disregard professional medical advice or delay seeking advice because of something you may see in this show. Back to you, Dr. Pacella.

Dr. Salvatore Pacella: Alright, so I'm just going to give you guys a list of the top five procedures here, and then we can dive a little bit into the statistics. So, uh, before we do that, I just want to tell you, so the ASPS is the main, uh, society organization for governed plastic surgery. So, um, it sets ethical standards, it sets, uh, Processes for how we evaluate [00:02:00] patients, uh, safety standards.

So it is, it is the kind of cream of the crop society that most of us are belong to, or most of us belong to as plastic surgeons. So every year they sent out a survey for ASPS members to describe their practice and give generalized numbers of types of procedures we perform. And these are kind of interesting and fun to go through because it really hints at what the trends are across the country.

Um, and you know, we're a microcosm of the world, so we may, we may really kind of gel with things that are occurring in other parts of the world. So, uh, the, uh, so I'm going to give you the top five in order. So there are roughly about 1. 5 million cosmetic procedures, surgical procedures performed in 2022.

The top one is liposuction. The second one is breast augmentation. The third is tummy tucks or abdominoplasty. The fourth is breast lift. And the fifth is eyelid [00:03:00] surgery. So, um, we can kind of dive into the numbers a little bit here, but why don't we go around the, uh, around the screen here and talk about just, uh, you know, how this gels or how this reflects your specific practice. Maybe, uh, maybe we'll start with Dr. T. Dr.

Dr. Lawrence Tong: right. Well, thank you very much, Sal. Um, so yeah, this, this, you know, this trend follows very closely with, I guess, most of our practices. I think one of the interesting things, uh, that you'll see is that, um, that you didn't mention, Sal, but I'm sure you'll probably touch on, is that, um, during the last several years, The growth in cosmetic surgery or, um, or aesthetic surgery has really outpaced reconstructive surgery.

And, um, I think that, um, maybe has to do with, uh, the pandemic and I'm not sure if you guys saw that as well, but, uh, [00:04:00] during the pandemic, there was a very significant increase in cosmetic surgery, uh, procedures. And I'm just wondering if you guys noted the same thing.

Dr. Salvatore Pacella: Right, so just, just before we, uh, just before we talk about that, let me, uh, sorry, sorry, Sam. Um, just before, just from the numbers standpoint, 1. 5 million cosmetic surgical procedures and 1. 02 reconstructive procedures. So, cosmetic procedures have outpaced reconstructive surgery. So, go ahead. Sorry.

Dr. Sam Jejurikar: no, I, I think, um, I think Dr. Tong is right. What he's referring to during the pandemic is the access to do cases in hospitals, largely, um, at various times sort of went away. And so. Many of us had to, um, had to make alternate plans or, you know, sort of change our practices. And so for me specifically during the pandemic was the time I basically gave up doing reconstructive surgery.

I had still sort of done some during that time, but the [00:05:00] pandemic made it. Nearly impossible. The other thing too, which, you know, you hate to talk about it, but reimbursement in general across the board in the U. S. for reconstructive surgery is slowly trickling down every year and with the increase in demand for aesthetic surgery, I think most plastic surgeons are finding that it's, you know, not in their financial best interest to do, uh, as much reconstructive surgery as they had done, at least relative to aesthetic surgery.

So I think those two, those two trends, at least, you know, in my mind would explain why we're seeing this. Thanks.

Dr. Sam Rhee: This tracks with me. I, uh, stopped taking ER call and stopped doing reconstructive surgeries probably, uh, five years ago. And it was because it was a lifestyle choice on one hand, because taking call for 20 some years as you know, ever since I was an intern, uh, and After a while that stuff gets old pretty quick to have to come in at three in the morning for some Ditzel thing and then the [00:06:00] other thing is is the reimbursements going down?

And if you look at it that it kind of blows me away if you ask people in the world what is more common? Tumor removal, hand surgery, breast reconstruction, scar revisions or cosmetic stuff like Breast lifts, breast augmentations, liposuction, you would think there would be more reconstructive, there's more of a reconstructive need out there, but it's really not.

I mean, there's 50 percent more cosmetic procedures that were performed in 2022. Yes, the pandemic played a big role in that, but let's face it, We're going where the money is, and this is where the money is. It's crazy how much demand there is for cosmetic surgery, but we're just following what people are looking for.

And we're also following what society is reimbursing us for. And If people don't like these numbers, if they don't like this trend, if they feel like this is [00:07:00] not what we should be doing as plastic surgeons, well then the game needs to change, the rules need to change, the way they set up medicine in the United States needs to change.

So, so you could hate the What does it say? Don't hate the playa, hate the game, or whatever it is. Like, I don't know, Larry would know better. He's, he's more of a basketball fan,

Dr. Lawrence Tong: Oh, thank you, yes. I

Dr. Sam Rhee: would say this, like, what do you expect us to do as plastic surgeons? Like, we are fulfilling what is out there as, as needs.

And to me, lipo, breast dog, tummy tuck, breast lift, eyelid surgery, they track for me as my top five types of procedures, too.

Dr. Salvatore Pacella: So, a couple comments, you know, so, I, of anybody in this group here, I probably do the most amount of reconstructive surgery, um, and, you know, I, I have a kind of a unique perspective on it. I think, you know, I look at the, the ethical concerns and then, of course, the practical concerns with [00:08:00] this. So, can you make much more doing cosmetic surgery?

Yes, but maybe yes and no. Okay, um, I think depending on the situation you're in, um, economically or financially, depending on the, um, reimbursement, um, group that you're with, um, the payer profile, reconstructive surgery can be quite lucrative if you dive into it the right way. Okay, um, and so, um, You know, in my practice, you know, I do a tremendous amount of skin cancer reconstruction, and those cases are relatively short, uh, periods of time, an hour or so.

Um, we can do a lot of them in a series, um, and the reimbursement is not Um, but it's not fantastic. So I, I've been able to find a really good niche with doing reconstructive surgery. And, and from an ethical perspective, you know, I would say, you know, I, I sort of look at this like a. Uh, uh, [00:09:00] uh, a continuum, okay?

And specifically with related to eyelid surgery, you know? So, let's say we have eyelid complications. There's a fine line between cosmetic complications in the eyelid and functional complications in the eyelid. And so, you know, an ectropion can be cosmetically displeasing. Uh, meaning drooping of the eye, but it can also be very functional.

And so, you know, we sort of work with patients based on their symptomatology, their insurance plan, etc. And so I sort of see this as, you know, as plastic surgeons, we need to own anatomic areas. You know, we need to own the face, we need to own the nose, we need to own the breasts, right? And in my mind, there's not a way to really own that unless you're really able to deal with disease, trauma, and complications.

And so, you know, and I, I think, you know, I think we have to be cautious as plastic surgeons, uh, because on the outskirts of the community, there are Providers infringing on [00:10:00] reconstructive surgery. You know, there are breast surgeons that are now sort of doing implant reconstructions. Um, there are general surgeons doing large abdominal wall reconstructions.

There's head and neck surgeons doing advanced facial, uh, reconstructive surgery. And I think as a society, we have to, we have to own that. Um, so, you know, my thoughts.

Dr. Sam Jejurikar: You know, I think you're right, Sal, but I, what I would also say is when it comes to the world of aesthetic surgery, we've seen this for a long time as well, where you see general surgeons, family practitioners, otolaryngologists that are, that are operating throughout the course of the body, doing, doing body and, you know, facial aesthetic surgery.

And so we've, we've, we've dealt with this for a while. I'll just say, you know, um, from my personal perspective, I love doing reconstructive surgery. I always have enjoyed doing it. My personal setup as basically a solo practitioner. And not having the benefit of facility [00:11:00] based reimbursement. So for, for our listeners, you know, whenever you get a reconstructive surgery, reconstructive surgery, that's reimbursed by your insurance company, the, the provider gets a small, a relatively small payment.

The majority of money actually goes to the facility. And so, um, not having, um, you know, not working for a large healthcare organization where. It's in their benefit to keep a large pipeline of those cases going through there. The financial reimbursement for me has always been largely limited to that small piece of the pie or the facility fee.

Meanwhile, you know, you look at what's going on with the economy. Inflation has run rampant the last two years. So the cost of running my business has gone up. My employee salaries have gone up. Um, the demand for aesthetic surgery has gone up. So what you can charge for that's gone up as well. Meanwhile, reimbursement for Reconstructive surgery has gone down.

And so it's been, it wasn't really a choice based off of the fact that I love doing aesthetic surgery that much more than a reconstructive surgery. I love doing reconstructive surgery, just like [00:12:00] I always have aesthetic surgery. The economic realities were in order for my employees to make more money in this inflationary environment, we needed to bring in more revenue and that just wasn't going to happen by doing reconstructive surgery.

Dr. Sam Rhee: I mean, I'll chime in there as well, because as you guys know, I trained as a craniofacial guy and I, and my first two jobs in practice were doing craniofacial surgery and pediatric plastic surgery. Uh, we all trained at Michigan and the amount of reconstructive training versus cosmetic training was Way, way, way over in the, in, you know, in favor of reconstructive training.

So you're right, Sal, we, we felt comfortable operating and we feel comfortable operating as plastic surgeons everywhere from head to toe. And that was something that our bosses sort of inculcated in us and sort of trained us to, to feel confident about. No matter where we were, we, they often told us over and over again, we were the surgeon, surgeon, the best surgeon, you know, the [00:13:00] best surgeon available out there because of the breadth and depth of our knowledge anatomically and where we operated.

But, um, for me as a craniofacial guy, I loved. Those procedures. I love doing clefts. I love doing big, um, head cases, but the economic reality is that you don't need nearly as many of those craniofacial guys as you do, uh, aesthetic. Let's just face it. And, um, the minute I felt like I couldn't live in Manhattan or I Couldn't stay in Manhattan, which is where the biggest centers were in my area.

I couldn't make a living doing that by myself. Like, I had to be part of a big system, like Sam said. And, uh, without that, I had to make real money. And the only way you're really going to make real money out there Uh, as a solo guy is you, you can try to find that, that special sort of situation where you're doing enough reconstructive to make real money.

But I would say the [00:14:00] majority of plastic surgeons are going to sort of skew aesthetic and, um, you know. Insurances and the hassle with reimbursement notwithstanding. Like you said, that's a big hassle and it's just, it's becoming more of a hassle probably every year. I mean, what my concern also is though, is with these younger surgeons, like let's face it, can you survive as a newly minted plastic surgeon out there by saying, You know, except for, you know, I mean, hand surgery, I think, is one thing that will always sort of help, uh, carry your practice when you start, but for everything else, like, as a maxillofacial guy, you know, as, uh, as some of these other specialty reconstructive guys, like, are you, you know, do we really need a million more of those guys?

Like, how can you survive without Uh, as a new plastic surgeon, I would say a lot of them are already looking at the economic reality and skewing faster towards aesthetics than, than ever before.

Dr. Salvatore Pacella: [00:15:00] Well, let's shift gears a

Dr. Lawrence Tong: well said.

Dr. Salvatore Pacella: to go back to the, uh, the, um, the stats here. So, you know, just from the numbers standpoint, liposuction versus breast augmentation. You got 325, 000 procedures in liposuction, about 300, 000 in breast augmentation. And what I'm curious about is Is liposuction listed as a primary procedure or as an additional procedure?

So it's, you know, if I'm doing a breast lift, I oftentimes do a little liposuction on the sides of the breast. If I'm doing, you know, a cosmetic facelift somewhere and I'm doing some liposuction around the neck, do you think that these numbers are indicative of liposuction as pure abdominal body contouring liposuction or as additional add ons?

Dr. Tong.

Dr. Lawrence Tong: Uh, I think these are probably listed as, uh, primary, uh, procedures. Um, [00:16:00] I think that, um, you know, the, the trend in, uh, cosmetic plastic surgery, uh, in North America is that most or many plastic surgeons who come out are pretty comfortable with doing body procedures and maybe not as comfortable or have this much experience doing facial procedures.

Uh, I certainly found that to be the case, uh, when I came out in practice and then, you know, as you get more experience, you get more and more comfortable, but I think that's, um, that's reflected in why the, um, the procedures, the cosmetic procedures are, are more skewed towards, uh, body procedures, but I think that, you know, liposuction is probably the most common procedures, uh, that we do, even if somebody does a good portion of the procedure.

of the practice with facial cosmetic procedures.

Dr. Sam Rhee: I think the other thing is, is I know that there's a lot of encroachment both on the reconstructive side [00:17:00] and cosmetic side in terms of other specialties out there. But excellence, I believe, always wins. If you are a really good surgeon, you know, I'll be agnostic here, I'm not gonna say that plastic surgeons are all really good surgeons, or all non plastic surgeons are sucky surgeons.

Like, if you're a really good surgeon, and you demonstrate that, It shows like when I see Larry Tong and what he does with his, um, facial stuff that he's, you know, we've seen his talks about, or Sal, when you, you know, show your reconstructive, your eye work, like that stuff blows me away. You can't just take anybody, even a, a relatively well trained plastic surgeon and take them to that level without a lot of experience, a lot of talent and a lot of skill.

And so when I look at these procedures and I look at like. You know, am I worried about our specialty? Am I worried about, um, you know, encroachment or, you know, people [00:18:00] taking away our piece of the pie? If you go to a program and you're incredibly well trained, if you go out there and you're smart and you learn and you become more experienced, you're going to do incredibly well.

Unfortunately, it looks like it's going to be more on the cosmetic side for most of the young plastic surgeons out there. Like, that's just the reality. Um. I don't know if you're going to talk about the minimally invasive stuff, Sal, but I think that that's even more telling in terms of where the future of plastic surgery is.

Dr. Sam Jejurikar: In fact, that's where I was going to go. Um, because Sal's question was, do we think these are primary breast augmentation or primary liposuction versus sort of adjuncts? Well, if you look around, there are so many of these, um. You know, chains, if you, you know, whether that that have that operated in multiple cities that are doing awake liposuction and that just sort of shows the general trend towards minimally invasive or lesser invasive procedures like, you know, that you're looking at [00:19:00] 325, 000 liposuction cases versus over 8, 000, 000 neuromodulators versus over four and a half million, um, Um, in general, people are looking to do minimally or lower invasive procedures at a rate that they've never, we've never seen before.

I think it was almost 75 percent of an increase from 2019 to 2024 in terms of the number of neuromodulators or Botox, uh, cases. And I think that's a trend that we really need to be paying attention to. Um, because that's, I think where society is going as technology is getting better. Botox and fillers are lasting longer, uh, and the treatments are getting better.

We're just going to see more and more of that and possibly less, you know, less surgery in the future.

Dr. Salvatore Pacella: And that's, uh, that's such a huge

Dr. Lawrence Tong: yeah, that's definitely true.

Dr. Salvatore Pacella: go ahead, Larry. Sorry.

Dr. Lawrence Tong: Oh, uh, thanks. I was just going to say that, uh, you know, part of the reason for that increase in numbers is also because these, [00:20:00] uh, minimally invasive procedures are generally much more accessible in terms of cost. And recovery, but I think that it also should be noted that, uh, minimally invasive procedures do not replace, uh, surgical procedures.

So there's definitely things, um, like on the face, if you're, you know, you probably, you guys probably do some, uh, something called liquid rhinoplasty, which is using fillers to, uh, create a certain look to the nose and I'll have patients come in and they'll, they'll want a liquid rhinoplasty, but oftentimes.

I'll have to explain to them what the, uh, limitations are, uh, with, uh, that type of procedure because, uh, the, uh, the public, um, sometimes has a view that, uh, you can substitute these minimally invasive procedures for, um, uh, for actual surgery. And that also goes with things like liposuction. Um, you know, you guys probably do, uh, some [00:21:00] CoolSculpting, but I can tell you that that Definitely not a substitute for liposuction in certain patients.

Maybe it comes pretty close, but I think it's, um, it's important to know that minimally invasive procedures are probably more popular because they're easier to access. There's less, uh, financial commitment to it. You can recover from them much easier. Um, and, and that's why They've been very popular. I'm sure the pandemic has, uh, contributed or did contribute to that.

Uh, so minimally invasive procedures are great, but we just have to be aware that they're, um, they do have their limitations as well. Haha.

Dr. Sam Rhee: you guys? Like, I know minimally invasive stuff like Botox, like fillers, all this stuff is growing. And I can see it, and I see it reflected around me, and I see it reflected in my Uh, I don't know if I mean, I've been very I find [00:22:00] the minimally invasive stuff to be sort of, I don't want to say boring, but it's, it's not what I feel like.

My bread and butter is my bread and butter is surgery. I want to do really, I want to do minimally invasive procedures. Well, I need to know how to be on the cutting edge of this stuff and do it in a, in a really great fashion, but it's because I want to be able to offer everything to my patients. Not necessarily because I love doing fillers more than anything else, or I loved injecting Botox more than anything else, like, but I feel like.

It's, I don't know how these trends are going to play in the future. Um, you know, it worries me a little bit as a surgeon, I, I, I suppose.

Dr. Salvatore Pacella: Well, they, you know, this brings me

Dr. Sam Jejurikar: like doing bigger procedures.

Dr. Salvatore Pacella: so, so this brings

Dr. Sam Jejurikar: Okay, what I was going to say is we're surgeons.

Dr. Salvatore Pacella: we got a little bit of a delay here, so it's like, it's hard to [00:23:00] chill.

Dr. Sam Jejurikar: who's delayed? Me or, uh, um. Well, here's what I was going to say. So I think

Dr. Salvatore Pacella: this on? Is this on?

Dr. Sam Jejurikar: like doing big, big, we like doing big operations. That's why we went into surgery. But as a patient, if I had my choice between something that had less of a downtime and uh, you know, I, I would definitely in less expense, I would choose that.

I can only say that, you know, in my practice, because we do have a really large med spa and we're about to undergo a huge expansion of it. The revenue growth in the med spa over the last five years has been about 300 percent. Like it has exploded and it's, and it's Botox and fillers. I mean we have five full time injectors there, it's radio frequency treatments, it's laser treatments, it's I mean, there's, there's a huge, huge, huge demand for this.

And most of these procedures are not being done by board certified plastic surgeons. [00:24:00] In fact, most of them aren't even being done by physicians in the U. S. They're being done by nurse injectors, estheticians, you name it. So what we may like doing as surgeons doesn't necessarily jive with what people want.

Dr. Sam Rhee: I think the prediction for me, just for my last thing to say is, is that if you are an aesthetic plastic surgeon, or a plastic surgeon who does a lot of aesthetics, You had better set up a med spa. You had better set up ancillary services to do minimally invasive stuff because it's, it's only going to grow.

And I think your trend, Sam, of what you just mentioned in your, um, in your practice and in your business is what most. young plastic surgeons should be following as their strategy or blueprint for success. If you don't, if you don't have some toe or foot or big part of your practice in growing your participation in minimally invasive procedures, you're going to, you're going to be missing out.[00:25:00]

Dr. Salvatore Pacella: well, gents, we're right at about 20.

Dr. Sam Jejurikar: right, now he's ready.

Dr. Salvatore Pacella: right at about 25 minutes. So, um, we're about hit our timing here. So, well, we want to thank all of our surgeons here today. And it was great chatting about the latest trends. So, otherwise we'll be signing off. ​