AN ALL-STAR CAST OF INDUSTRY LEADERS IN ONE COLLABORATIVE TEXT!
Produced and edited by Dr. Robert L. Bard, (NYC based cancer diagnostic imaging specialist) this collective project showcases the most highly sought-after cosmetic treatments in each priceless chapter- through detailed breakdowns, experiential insights and a generous graphic tour of before and after progress visuals. Thanks to the additional safety benefits of clinical imaging, our treatment professionals express added confidence in the pre-operative and post-op areas. In addition, many aesthetics procedures noted also brings significant advantages (of accuracy and efficiency) to the actual treatment process from real-time image guidance.
AUTHOR LIST (alphabetical)
• Arun K. Garg, DMD
• John Catanzaro, MD
• Noelle Cutter, PhD
CHAPTER 1: INDUSTRY REVIEW OF THE AESTHETIC INDUSTRY
By: January Howard & Lennard M. Gettz, Ed.D
The history of cosmetics is reviewed with technologies unfolding less invasive options and more functional solutions involving neutraceutical supplementation with natural resources. Minimally invasive options are documented as is the adaptation of therapy to the Covid-19 pandemic. This chapter dives into the positive and negative implications of aesthetic procedures and how minimally invasive tactics could help advance all procedures focusing on the sake of performance, safety, and longevity
Conducting an industry review on the current state of the aesthetic industry would be incomplete without shedding a spotlight on social outlook and how it drives consumer activity trends. All aesthetic procedures are promoted to enhance one's overall look and public appeal and are often theorized to elevate one’s self-appreciation. The public desire to achieve this is what supports this multi-million dollar industry to self-generate constant energy to acquire new market support each year. Fig 1.
Historically, the study of human nature has shown consistent evidence of aesthetic personalization throughout every social class as part of natural human desire and need for visually expressing personal pride and individualism. To date, there is an ever-growing list of solutions to enhance and improve a person's image, from PRP injections, microneedling,
chemical peels, Botox, and fillers. These procedures have widely grown in popularity throughout the global community because of their affordable cost to the client/patient, their easy access and their immediate performance and effectiveness.
The future of minimally invasive modalities has projected a major market growth without any signs of slow-down. Introducing aesthetic procedures to just about ANY practitioner, let it be a dentist, an OB/GYN, a plastic surgeon or a urologist offers a natural add-on, exponentially widening the access of these treatments to the community at large. Where dentists and plastic surgeons clearly have their specialized work intact, aesthetic procedures offer a supplemental income and a lucrative addition to their existing service set. For the practitioner, these procedures are a sensible upgrade by adding fairly recognizable protocols and equipment from prior training.
Practitioners find the integration and learning curve of adapting aesthetic modalities into their existing practice to be quite comfortable and cost-effective. For example, one can be trained to produce their own dermal filler or bio filler by extracting PRP (which is the client's own biologic) by "cooking" the platelet poor plasma. This is instead of purchasing bio filler from any of the existing manufacturers, offering a savings of anywhere from $300 to $800 per box.
As the industry concepts of beautification evolved and expanded toward clinical procedures, a sensible upgrade is the implementation of IMAGE GUIDANCE- a valuable tool forged by medical diagnostics. For over 30 years, ultrasound imaging has offered great value in clinical applications and is now adding great directive support to injection situations whereby knowing where the veins and bones truly are could be very helpful as a matter of safety. Whether someone is new to conducting injectable treatments or is a seasoned professional, having the reassurance of visual confirmation lowers the likelihood of hitting a vein or creating an occlusion. Reducing or eliminating risk to the client from pain or the stress of a “land mine” event is a major selling point for imaging devices in pre and post procedures.
The Modern Age of Clinical Aesthetics
Throughout the 20th century, economic and medical industry reports have traced major activity in cosmetic procedures as part of a global consumer trend of personal enhancement investments. Where elective surgical procedures like breast augmentation, liposuction and rhinoplasty once dominated the aesthetic media, the early 1980's brought forth a new wave of Minimally Invasive procedures which forged an entire industry of cosmetic self-rejuvenation. In 1981, bovine collagen was the first agent approved by the FDA for cosmetic injection. It was developed to induce a youthful appearance (as well as address facial deformities) to target smile lines and improve the presence of facial acne scars. The first regulatory approval gave way for dozens of injectable cosmetic filling agents as well as technologies in pursuit of "anti-aging" or facial enhancement. This minimally invasive treatment trend includes chemical peel, dermal fillers, laser skin resurfacing, hair removal techniques, microdermabrasion and others.  Fig2.
We can track the history of cosmetic enhancement and aesthetic rejuvenation through the timeline of cosmetic body art as the earliest tribal rituals, to the old testament (840 BC) from the book of Esther to ancient Egypt (1,320 BC). Since ancient times, the concept of cosmetics, and facial enhancement have been part of personal essence- especially for the elite. Often they were used in religious ceremonies - as seen in ancient Egypt - or as cultural identification.  Cosmetic products such as creams, lotions, and talcum powders became more globally accessible to the human zeitgeist, supporting pursuits of cultural acceptance, personal enhancement and beauty. Tracking the aesthetic market in the west, skin care products including skin lotions, powders, creams, bleaches, ointments, and cleansers have historically accounted for a large percentage of the American cosmetics and hygiene industry. The claims and perceived notion of smoother, whiter skin is aligned with better health and beauty has become the impression of beauty since the 1800s. Concealing and removing imperfections like freckles, rashes and pimples are also part of the aesthetic objectives. 
The Demand for Aesthetic Surgeries
The history of plastic surgery goes back as far as between 1000 and 800 BC with Sushruta - considered the "Father of Plastic Surgery" from ancient India. He was responsible for the advancement of medicine and his early teachings of anatomy, pathophysiology, and therapeutic strategies were achievements linked to nasal reconstruction. Sushruta's surgical studies led to his development of the cheek flap for nasal reconstruction. His surgical concepts and his creative approaches still apply today. 
The term PLASTIC surgery is traditionally a clinical term often used for reconstructive treatment of parts of the body affected by disease, injury, infection, birth defects or trauma. COSMETIC or aesthetic surgery is an elective procedure that enhances or reshapes parts of the body to support the patient’s pursuit for self- esteem. Analysts identified the many influences of opting for cosmetic surgery- covering perceived advantages of the likelihood of a more fulfilled life. Where one’s self-confidence is linked by societal behavior with an attractive appearance through surgical enhancement, studies emphasized exposure to the media may have significant influence in pursuing cosmetic surgery.
One of the oldest cosmetic procedures has been Rhinoplasty (nose job) dating back to the 6th century. Within the recent decade, surgeons have perfected this process such that in 2014, Rhinoplasty has been recognized as the second most popular procedure in the US with over 215,000 cases within a total estimate of 15M cosmetic procedures. This procedure is second in popularity only to breast enhancement. Other aesthetic procedures that fill this public demand is for gluteal implants, liposuction and eyelid uplift. 
The demand for enhancement procedures directly aligns with the worldwide human ambition to fight the many foibles of natural affliction of the aging process. To pursue the ability to improve one's personal health and appearance is heavily driven by the desire to look and feel young again- such that "the battle to reverse time" has expanded this multi-million dollar market. This trend includes the increase in demand for facial aesthetics products such as anti-aging, anti-wrinkle, oxygenation, rejuvenation neurotoxin free botulinum as well as the growing industry of minimally invasive procedures.
Additionally, dental implants have been added to the list of cosmetic procedures, addressing the treatment of dental imperfections and congenital defects. More recent dermal solutions cover technology-driven laser treatments of lesions, skin toning and the removal of tattoos, hair and scars. 
Risks and Complications
By now, we all understand the set of risks that exist within any surgical procedure. Not only are all patients prone to different healing rates and capacities, but there may be a wide array of possible complications associated with cosmetic / plastic surgeries- including: Infection, post-op internal bleeding, reactions to foreign materials or anesthesia and complex issues during the healing process such as nerve damage, fluid buildup and blood clotting. 
2020 news headlines published a major health alert with women who invested in textured breast implants to potentially cause Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) - an uncommon and treatable type of large cell lymphoma that can develop around breast implants. BIA-ALCL is not a cancer of the breast tissue itself. In a 2020 FDA study, there have now been 733 unique confirmed cases worldwide which included 36 known deaths. 
Minimally Invasive/ Injectable Treatments
According to international studies, the market of non-invasive aesthetic treatment has been a steady boom at an estimated USD 53B since the early 2020’s with a projected growth of
15%+ for the next 10 years. This continued consumer demand for improving physical appearance in adults gained an uptick in the induction of the more affordable and more accessible non-invasive and minimally invasive aesthetic procedures within this period.
INJECTABLE procedures also gained significant popularity especially in the 50+ year old age group. A high population of women are recorded to request aesthetic fillers including Botox. In 2018, an est. $2.8 Billion minimally invasive cosmetic procedures were conducted domestically, (according to the Grand View Research) showing a consistent rise each year of 9%- identifying its major growth in demand and popularity. These procedures rose sharply by an est 228% within 2000–2018 in the US, and they now account for 95% of all cosmetic treatments undertaken were for NSFA treatments with a 5% decrease in surgical procedures. Minimal invasiveness results in faster recovery, lesser scarring, limited stress, and better patient satisfaction.  Fig 3Figure 3: Variations on injections include microneedling procedures are useful in scar and keloid treatments
Within the last two decades, the widening term “Medical Aesthetics” has become a trend representing physical corrections and restoration beyond cosmetic applications. Injectable techniques have expanded to clinically support the aesthetic dermatologist to repair facial texture structurally through contouring, lifting, volumizing, improving muscle and tissue tone or implement focal fat reduction. The professional may apply a host of materials into the skin including inert fillers, platelet-rich plasma (PRP), stem cells and lipolytic agents. As the expansion of agents and injecting materials continue to grow with its demand, the inducing clinician must undergo comprehensive safety and procedural training alongside a solid understanding of the elements used in these injectable treatments in order to achieve proper outcomes. 
The Covid-19 Pandemic & Self-Enhancement
Global analytics of the aesthetics community during the coronavirus outbreak (COVID-19) in 2019 resulted in the freeze of all non-emergency/elective hospital procedures. It is this suspension alongside the societal distress caused by the lockdown that created a backlog
of procedures and an increased demand for self enhancement. Also, other influential factors driving the rise in cosmetic surgery during the pandemic were attributed to the vast exposure to video conferencing, where more individuals are forced to view themselves (and grow critical of their appearance) during video meetings. Fig 4.Figure 4: Real time imaging may better demonstrate blood flow and thin facial nerves and provides a preop map of danger sites
Global studies have been implemented on adults observing behaviors and concerns while undergoing multiple video conferencing usage, including the use of video-enhancement tools to improve picture quality and focus of visual attention while on video calls. A significant percentage of participants identified appearance concerns while on video- associated with self-focused attention and increasing appearance concerns due to their time on video calls. The report concluded a large number of interest in acquiring future beauty treatments and nonsurgical aesthetic procedures such as anti wrinkle injections. A recent colloquialism for this is the “Zoom Face Phenomenon” driven by the covid-driven boom of video conferencing (tying this issue with the Zoom video brand). 
Phasing out the “Anti-Aging” Terminology
More than a definition, applying the term "REJUVENATION" is truly the goal vs. ANTI-AGING. For decades, the term “anti-aging” has been a phrase that represented the entire marketing lexicon describing products, services and procedures to promote aesthetic enhancement. Further review of this Ageism is seen as more about stereotyping and/or discrimination against individuals or groups on the basis of their age.
The science is not about recapturing the fountain of youth, alluding to a criticism of one’s natural aging process - but about firming, tightening, polishing or skin conditioning. A commentary on social appeal dictates that beauty and attraction is defined not necessarily on looking younger but having a radiant appearance. The recent trending term identifies today’s aesthetic procedures as REGENERATIVE or AESTHETIC ENHANCEMENT; implying a more objective-based category. Where wrinkles, shadows and loose skin render a fatigued and worn
impression, it is the million dollar industry of ENHANCEMENT that has taken on what tolls of time has done to the physical self- both the face and body. 
Overview on Minimally Invasive Procedures
The value of aesthetics in our community exists throughout all social groups. The market recognizes one popular focus group in particular to include the parent community - whose exhaustive commitments to countless physical demands may oftentimes appear in their features. Investing in facial enhancements offer a sense of personal satisfaction about their renewed public appearance. In addition, such procedures have been studied to bring personal empowerment from experiencing that natural facial glow from having improved skin texture. Psychologists and counselors identify the means of having a rested appearance as looking and feeling optimized could actually support an emotional uplift by motivating the self to manifest a healthier lifestyle.
A facelift, technically known as a rhytidectomy (rooted from the word rhytis or "wrinkle", and ektome "excision"- or the surgical removal of wrinkles), is a cosmetic process dedicated to providing a more youthful facial appearance. To achieve this, there are various surgical and minimally invasive techniques available. Surgery could mean the extraction of loose, sagging skin (often from age) and the skin tightening on the patient's face, neck, cheeks or eyelids. Non-surgical enhancement strategies that address these and issues like frown lines and other facial wrinkles can also be achieved with other modern techniques such as the injection of bio fillers and the performance of laser skin resurfacing- or photodynamic therapy for the removal of wrinkles, spots, and textures.
Microneedling is a procedure using small needles to prick the skin in order to generate new collagen and healthier tissue for more toned skin. The concept of Microneedling was widely used on a commercial level since the 1900’s in Europe to address acne and skin scars. The technology continues in popularity throughout the aesthetics community and has evolved from manual applications to electric Microneedling may help with a wide set of issues such as: fine lines and wrinkles, oversized pores, acne, dark spots, hair loss and stretch marks. 
As a working arsenal to dermatologists, aestheticians and other trained clinical subscribers, microneedling is recognized to be far less costly than other skin therapeutic technologies including laser treatments, which by comparison can cost about 3-4 times. The entire process is usually around 15-20 minutes and may commonly require 4-6 treatments depending on need.
The PRP Process
In recent years, the success of Platelet-rich plasma (PRP) treatment protocols are growing in popularity, capturing an expanding share of the aesthetics market. To date, the history of the PRP therapeutic process has been recorded from Equine (Horses) Medicine since the early 1990’s. Veterinary medicine applied the use of PRP to treat ligament damage such as tears or inflammation in the tendons. This process has also been applied in horses with osteoarthritis both showing significant success for continued research both in animals and early human studies. The evolution and success of the PRP relied on the preparation of the plasma, including volume and percentages applied and the quality and consistency of the extracted matter. .
Clinical professionals find its benefits to be easily integrated within their practices to expand their services. From dentists, dermatologists and cosmetic surgeons to most non-medical cosmetic practices, training and adopting PRP systems into a practice or aesthetic related business has been found to require a low level of commitment and investment.
The vast appeal of offering a minimally invasive (non-surgical) regenerative enhancement solution provides a great alternative to the consumer while adding a much lower cost alternative to acquiring PRP is now being used to treat chronic osteoarthritis and other orthopedic injuries and is also more widely marketed in the aesthetics channels. PRP is widely applied in various areas of the medical field for its proven properties of regenerative therapy as well as in many areas of clinical aesthetics. In dermatology, there has been significant success in PRP’s expanded use from wound healing, scar reduction, skin and tissue regeneration and skin enhancement.
The science of PRP originated in hematology IN THE 1970’S as part of plasma transfusion for thrombocytopenia patients or those with low platelet count in their blood. The biological concept of plasma extraction by centrifugation of autologous blood (sourced from oneself) offers 1-to-1 cellular compatibility by accessing one’s own healing properties. 
In aesthetics, the PRP extraction and application process forges the healing properties of the plasma- extracting the usable ‘platelet rich plasma’ from the ‘platelet poor plasma’ to be used TOPICALLY in applications similar to microneedling. It is also widely applied as SUBCUTANEOUS injections such as breast lifts or to increase collagen on the facial skin’s surface. PRP also offers restorative and tissue healing value for follicles in hair restoration procedures. Fig 5Figure 5: PRP and other injectable biologics are improving blood perfusion to treated areas
Under clinical supervision, PRP treatment of facial enhancement and wrinkle removal involves drawing approximately 20-60 ml of blood. The practitioner would centrifuge this to separate plasma from blood cells, capturing the injectable YELLOW matter known to be ‘rich in platelets’. But in larger aesthetic services, like a vampire breast lift, or a P-shot (Priapus Shot), you actually need to draw an estimated minimum of 60 ml of blood to a rough minimum of six to 10 tubes. Upon the centrifuging process, once the PRP is harvested, in most cases, platelet poor plasma is discarded. 
Historical Context of Natural Aesthetics
Four thousand years ago the Egyptians used plants especially rose petal extracts for aesthetic enhancement. The treatment of the flower of Rosa Gallica, organically grown in France, pesticide free and chemically balanced with antioxidants, is currently used in clinical practice as an extract of whole fresh or cut and dried rose petals; rose petal tinctures: organically distilled.
Traditional usage has been as:
- Cellular Regeneration
- Collagen Accelerator
- Internal Detoxification
- Dermal Rehydration
Rose petal essential oils were used as a dermal rehydrator to beautify the skin by the ancient Egyptians. In Roman times people treated breast diseases, skin conditions and even wound infections with orally ingested preparations. Research has shown that an extract from Rosa Gallica strikingly increases the effectiveness of several antibiotics against methicillin-resistant Staphylococcus aureus. Two active compounds from the extract have been identified as tellimagrandin I and rugosin B. Other studies have demonstrated strong activity of Rosa Gallica extract against strains of Candida albicans isolated from overtreatment with antibiotics. Additionally, the effect of an anthocyanin preparation isolated from the flower petals of Rosa Gallica demonstrated strong effects of Rosa extracts against abnormal cells. A three year research study by the Biofoundation for Angiogenesis Research preceded the development of the chemical constituents of the ProRose+ formulation. Scientific evaluation has shown the antioxidant effect to be 10x (ten times) more powerful than green tea preparations and resveratrol formulations. Collagen regeneration has been observed clinically and documented with high resolution sonograms. Improved blood flow to hair follicles has been demonstrated with vascular imaging technologies. The 2011 World Anti Aging Conference showed poor dermal penetration of creams and good tissue regeneration with internal antioxidants. A 20 year study by the AngioFoundation revealed that the curative effects appeared in other glandular sites, such as the breast, prostate and thyroid which was presented at the international 2021 Inflammatory Skin Disease Symposium as it showed improvement in cutaneous inflammatory processes such as psoriasis, rosacea, lupus, hidradenitis and related collagen type diseases.
Rose Petals contain: Anthocyanins and proanthocyanidins; tellimagrandin I and rugosin B; carotenoids; plant acids including gallic acid and essential oils. The liquid portion of oil of rose contains as its chief constituent the alcohol geraniol. Geraniol, with a rose-like odor, is a primary alcohol, and yields, upon oxidation, the aldehyde citral, also present in rose petals. Rose oil furthermore contains about 20 percent of l-citronellol. A proprietary blend of balancing antioxidants has been added to the extract. Rose petals as concentrated extract/elixir with the recommended dosage of ten to twenty drops twice per day. Drug Interactions: None known Contraindications: None known except alcohol dependence.
Side Effects: Allergic reactions are possible in susceptible persons.
Synergism: when combined with Coenzyme Q10 and resveratrol the treatment benefit is enhanced. [29-39]
The modern age of aesthetic procedures has much to thank the medical scientific community when it comes to their approach and strategies behind clinical treatments. Recent visionary concepts such as injectable bio-fillers are clearly rooted from the same delivery of
therapeutic material, showing similar logic, tools and applications. Also, medical innovations such as laser, ultrasound, radiotherapies and other non-invasive electronic devices have also added a major foothold to the aesthetics movement.
The evolution in clinical aesthetics continues to advance all procedures especially for the sake of performance, safety and longevity. Over time, this level of evolution also reflects on the economics and access of these procedures- where the major BOOM in aesthetic modalities have clearly engaged the global market. And as the global market maintains a major uptick in demand for aesthetic procedures, so continues the introduction of new protocols, strategies and improvements in treatment options and opportunities.
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28) Healthline: "What to Expect from a Vampire Breast Lift (VBL)" -