A Journey Through Time

Aristotle famously argued that time is the measure of change.1 To test this thesis, I recently pulled out a photograph of myself from 20 years ago and asked a few of the folks around the office what they thought. All of them assured me that I had not changed a bit. My wife was not quite as generous. But it's wonderful how photographs can serve to chronicle the passage of time, to remind us of the steps by which we've arrived at where we are today. Likewise, upon this 20th Anniversary year of Aesthetic Surgery Journal (ASJ), I am reminded how this journal serves to chronicle the changes in aesthetic surgery that have occurred over time. In fact, looking back over the last 20 years of ASJ, one has an amazingly panoramic view of how our field has evolved. Perhaps for some of us, the practice of aesthetic surgery in 2016 is not quite what we imagined it would be 20 years ago, with patients today often opting for minimally invasive treatments over more traditional surgical methods despite the generally less satisfying results.2 We have learned, however, to adapt our practices accordingly and even to appreciate the ever-expanding palette of choices available to us. Nevertheless, the challenge of narrowing that palette to things that really work, or with which we feel personally comfortable, is not easy. Over the past 20 years, ASJ has done the bulk of heavy lifting as far as presenting current data both supporting and challenging the virtually nonstop claims of "new and better." Looking back on the mid-to-late 1990s, some of the most covered "hot topics" were lasers, endoscopic surgery, ultrasound-assisted lipoplasty (UAL), tumescent and large-volume liposuction, evolving styles of breast implants (including the short-lived soybean oil-filled implants, later abandoned amidst safety concerns), "off-the-shelf" tissue glues, and fillers (primarily collagen, fat, and Gore-tex).3-14 An article appearing in 1998 heralded the use of botulinum toxin type A as an adjunctive treatment in facial aesthetic surgery15 (for the record, an earlier mention appeared in 1995 in Aesthetic Surgery Quarterly, which pre-dated the Journal16). The first mention of Restylane to appear in ASJ was in 1999.17 Most of these articles were more practical than scientific and most often in the form of panel discussions or advice from the experts on their preferred techniques. In 1996, Dr Bruce Achauer wrote: "Laser resurfacing is a rapidly evolving technology. Interest in the technique is outstripping the usual time frame for publication in medical journals. The rush to clinical application is such that normal medical channels are being overwhelmed."18 By the following year, thanks to ASJ's uniquely rapid submission-to-publication timeframe, this journal already had published a substantial number of articles on laser technology and techniques and had encouraged active debate on the pros and cons of lasers versus peels.19,20 On another developing front, a 1998 article published in ASJ by Dr Moris Topaz raised serious questions about the long-term safety of the new UAL technology, engendering a firestorm of controversy.21,22 Both lasers and UAL were the focus of special task forces convened by the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS, formerly American Society of Plastic and Reconstructive Surgeons/ASPRS). Their findings were extensively reviewed in ASJ.18,23 One of my favorite ASJ article titles from the 1990s was this one: "Are You Ready for the Internet?"24 Looking back, it is clear that most of us had no idea what was coming! In some ways, I believe that the Internet has had more to do with many of the significant changes in aesthetic surgery over the past 20 years than has any other single factor. Not only has it made it possible for practitioners (both those who are qualified and those who are not) to learn about new techniques faster and with greater ease, but it has helped to alert consumers to these new developments, often before they have been proven safe and effective. It is this relentless consumer demand that has driven many physicians to adopt, sometimes prematurely, new modes of treatment in which they might otherwise have had little or no interest at the time. The rapid ascension of nonsurgical aesthetic procedures was like a runaway train. In the years between 1997 (when ASAPS first began collecting procedural statistics) and 2010, the number of nonsurgical aesthetic procedures performed in the United States increased by a whopping 225%. By 2010, 83% of all aesthetic procedures performed were nonsurgical treatments such as fillers, botulinum toxin, lasers and chemical peels.25 The pages of ASJ naturally reflected these trends. Yet the "bread and butter" of most plastic surgeons remained the surgical component of their practices. In 2010, even though the volume of nonsurgical treatments was astronomically high, it represented only 38% of expenditures on aesthetic procedures.25 Plastic surgeons still made most of their income by performing surgery. Furthermore, a plastic surgeon's reputation was, and still is, based primarily on his or her surgical results. Therefore, while the Journal strove to extensively cover developments and techniques in nonsurgical treatments, it was imperative that we not lose our focus on the core surgical techniques employed by the average aesthetic plastic surgeon who was reading the journal. Patient safety became a major focus of many articles published in ASJ during the decade beginning in 2000. That was the year in which, responding to reports of fatalities in office-based procedures, the Florida Board of Medicine declared a 90-day moratorium on office surgery using level III anesthesia (defined by the Board as general anesthesia, major conduction anesthesia, and preoperative sedation, including intravenous sedation beyond that defined for level II office surgery).26,27 Some plastic surgeons quite vocally questioned the continuing viability of office-based aesthetic surgery while others went about the business of developing more effective safety and quality-control measures that could be widely adopted and implemented.28-30 Authors were encouraged to thoroughly address patient safety issues associated with techniques advocated or discussed in their manuscripts. Peer reviewers were alerted to consider such information as an important criterion for publication. With the number of bariatric procedures escalating dramatically, the particular patient safety challenges involved in dealing with the massive weight loss population became a major theme.31,32 During this period, among the products and procedures vying for their "15 minutes of fame" were barbed sutures. The concept of barbed sutures for facial rejuvenation received early but generally cautious coverage in the Journal, as it did at many plastic surgery national and international meetings.33 Some physicians were aggressive in promoting these procedures directly to the public as the ultimate "quick fix." As reports of complications were subsequently reported and published in this journal and elsewhere, enthusiasm waned.34 By 2006, a report published in ASJ showed only 40% of surveyed plastic surgeons responded that barbed sutures were a useful adjunct to their practice.35 The popularity of these sutures, however, later rebounded as proponents claimed useful applications in body contouring surgery.36 It was also during this decade that awareness of the need to further "legitimize" aesthetic surgery rose precipitously. Again, I believe the Internet had much to do with cosmetic surgery's "delegitimization," if you can call it that, mostly because of the wide and rapid spread of misinformation as well as the often misleading or tasteless, self-promoting marketing techniques employed by some practitioners. But even from a more "academic" perspective, our specialty needed a bit of a facelift. A common criticism of scholarly presentations in aesthetic surgery—whether delivered at meetings or in the pages of specialty journals—was the generally poor quality of pre- and postoperative photographs. In 2000-2001, ASJ presented its popular 3-part Digital Darkroom series, which offered detailed guidelines for ensuring the quality and integrity of patient photographs used for educational purposes.37-39 Over time, the Journal further bolstered its own stringent standards for manuscript and photo publication. Partly as a result of these efforts, in 2008 ASJ was accepted for indexing by the National Library of Medicine. It was not until the next decade, however, that ASJ would launch perhaps its most ambitious effort to further the scientific credibility of aesthetic surgery among medical professionals and the public. In 2011, ASJ embarked upon a new initiative to further the goals of Evidence-Based Medicine (EBM) in aesthetic surgery. In that year, the Journal, in conjunction with Plastic and Reconstructive Surgery, published a summary of the first EBM Summit.40 In addition, ASJ instituted a new EBM rating system for articles involving human subjects.41 These efforts have had a significant impact on the way authors, peer reviewers, and readers evaluate manuscripts. Our latest addition, the EBM Hub Challenge, is an ongoing program to help aesthetic surgeons become more proficient at analyzing the strengths and weaknesses of scientific evidence presented in journal articles and other educational forums.42 The emphasis on EBM has truly changed the way we approach clinical decision-making as we have taken education a step beyond rating levels to the dissection of principles such as randomization, allocation concealment, meta-analysis, and blinding with accompanying videos and analysis of published articles.43-48 I believe that already it has had, and will continue to have, a real and measurable impact on aesthetic outcomes and on the further evolution of aesthetic surgery as a scientifically-based endeavor. Just as aesthetic surgery itself has changed, the Aesthetic Surgery Journal of today is a different "animal" than it was in the past—certainly a more formidable one. Our evolution from a "how-I-do-it" newsletter to a scholarly journal has not been without challenges. The decision to include more basic science research in a "translational" context (meaning that even the hard core clinician should be able to appreciate the relevance to everyday practice) occasionally meets with resistance.49 Our editors have always understood that the "practical stuff" is what drives our readers. We continue, therefore, to maintain a focus on the "meat and potatoes" of aesthetic surgery, including regular features such as "My Way" and "Featured Operative Technique." And we have not lost our willingness and ability to tackle the controversial and the "new" which takes on a different meaning and expression as the decades pass. A number of years ago, who would have thought ASJ would have an entire section devoted to cosmetic medicine or a "virtual issue" on genital rejuvenation? Our widening Internet and social media impact has attracted worldwide attention to the important work of aesthetic surgeons. For several years now we have been aware of Altmetrics which is the social response to published work in real-time via retweets, Facebook posts, blog mentions and news media coverage and this is a technology we will continue to champion because it provides important metrics to our authors.50 Recent feedback indicates a level of engagement with the Journal that is unprecedented in our 20-year history. I am sure that every plastic surgeon wishes that he or she could travel into the future and see what will become of aesthetic surgery in one hundred or even five hundred years. There are those much smarter than I who have suggested that past, present, and future may exist simultaneously, but as far as I know none of us has yet passed through that portal. At least, however, we have the pleasure of being able to look back over 20 years of Aesthetic Surgery Journal and the enduring contributions of so many to the art and science of aesthetic surgery. Thank you to all who have made that journey possible. The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The author received no financial support for the research, authorship, and publication of this article.