Call it the Millennial makeover — and many believe it's becoming scary. The past two to three years have seen an explosion in the popularity of noninvasive cosmetic procedures — with the Millennial and Baby Boomer generations now flocking to clinics in almost equal measure.
It's a major shift in the space, which was once almost exclusively focused on Baby Boomers and even their parents looking to reverse the effects of Mother Nature (not that they can be totally reversed). Now patients from their early 30s to even their 20s and, yes, teens (at least when it comes to lip injections — think the plump-lipped Kylie Jenner) are rushing to doctors to get ahead of the effects of gravitational pull before they become too noticeable. And for the more mature crowd where gravity has started to take its toll, Ultherapy (micro-focused ultrasound that lifts and tightens skin), light-based therapies (IPL, or intense pulse light) and laser treatments claim to have gotten so advanced that, in conjunction with dermal fillers, they reportedly can stave off facelifts for up to a decade, if not altogether.
The reason for all this upsurge? Pop culture and social media. It is the selfie generation, after all.
Dr. Simon Ourian, the Los Angeles-based doctor who shot to fame because of his association with the Kardashians (Kim Kardashian Snapchats from his office), called the Kardashian-Jenner clan both individually and as a unit the "biggest influencing power force behind any concept that happens on social media" today.
"Imagine if all of them post something one evening or in the morning — pretty much the largest proportion of people who have access to a smartphone will see what they're saying. No media, I don't care [what anyone says], no CNN, none of these have that kind of power," Ourian said. "I can't think of any other celebrity who has more impact on social media or on culture as a whole than they do. That's not debatable. They have more than half-a-billion social media followers between all [of them].…That's more than twice the size of the U.S."
In the view of Ourian — a social media celebrity in his own right with 1.5 million followers — it's the Kardashians' world, and they are dictating the trends.
But not every doctor thinks the movement is a good thing.
"I watched a show last night, and I was like, 'Is this Clutch Cargo?'" Dr. David Colbert said in an interview at New York Dermatology Group, the practice he cofounded with JP Van Laere in 1996. He was referring to a Sixties cartoon he watched as a kid where the characters' faces never moved, only their mouths did.
"I saw this woman — and I know her — and I was like, 'Oh my god,' because all I saw was lips moving. All the other characters in the scene were Millennials, and their faces weren't moving, either," Colbert said of rampant Botox use of individuals starring in movies, reality TV and by extension, online via social media. "Before I used to be able to differentiate between [people] 40 or 50 and 27 or 30. Now, all I saw were mouths moving and tongues coming out."
The American Society for Aesthetic Plastic Surgery released data on March 15 that crowned Botulinum Toxin, the formal name for the family of neurotoxin injectables Botox, Dysport and Xeomin, as the number-one nonsurgical procedure for the eighth year in a row. More than 4.5 million procedures were done in 2016 and more than 4.2 million in 2015.
Botulinum Toxin use among Millennials ages 19 to 34 jumped 87 percent between 2011 and 2016, with last year seeing a 31 percent increase from 2015. Of the $15 billion that Americans spent on surgical and non-surgical procedures, 44 percent went to non-surgical procedures like Botox and light-based therapies. Millennials accounted for 18 percent of total treatments performed.
The data mirror what Colbert has observed in his own practice. For starters, he cited a sharp increase — 50 percent — in the amount of Millennial patients flocking to his practice for Botox in the last few years. But that is simply indicative of a larger shift toward cosmetic procedures in general: when NYDG opened 21 years ago, the breakdown of services performed was 70 percent medical dermatology and 30 percent aesthetics. Today, it's 70 percent aesthetics and 30 percent medical dermatology — due in large part to pop culture and the explosion of all things digital, Colbert believes.
While on the one hand, the advent of social media has been immensely positive — it breaks down regional barriers, globalizes trends and connects people who might have otherwise never been able to engage — there are serious drawbacks. Physicians interviewed for this story expressed grave concerns that social media does more harm than good when it comes to Millennials and Gen Zers, or what's largely been dubbed the "selfie generation."
Dr. Jean-Louis Sebagh, who splits his time between offices in Paris and London and worked with Cindy Crawford to develop her Meaningful Beauty skin-care line, maintained that Botox has been his most popular procedure for nearly 25 years. But what's changed within his practice, he said, is less the actual procedures he performs and more the psychological mind-set of patients.
Sebagh said droves of Millennials have entered into a "narcissistic era," which he believes is a direct result of social media. He pointed to popular photo-editing app Facetune and reality stars (and in some cases even the doctors who treat them) as catalysts for patients younger than ever-demanding cosmetic procedures.
Also to blame, according to Sebagh: formerly very private celebrities are becoming increasingly open about their cosmetic procedures — normalizing a longtime taboo — and their millions of social media followers want to emulate them. Sebagh contended 19-year-old Kylie Jenner is the reason throngs of teenagers (some as young as 16 and accompanied by their moms) and early twentysomethings, especially from the Middle East, have thronged to his office over the past two years to fill their lips. He called Jenner's now-famous pout "badly done, [in] my opinion."
"It's damaging; it's absolutely mad. Because of social media and all of that, they [younger patients] have such insecurity and such image perfection [issues]. They just communicate with their smartphones — it's unstoppable. Everybody becomes a Photoshopper," Sebagh said. "And that's damaging to me because the idea of beauty has changed. We went from a period of 'Beauty is in the eye of the beholder' to 'Beauty is in the eye of my smartphone.'"
Dr. Timm Golueke, a cosmetic dermatologist based in Munich, Germany, and founder of skin-care range Royal Fern, said people still ask for what used to go by the name "Vampire Facelift" because of Kim Kardashian, who got one on an episode of "Keeping Up With the Kardashians" in 2013. In medical terms, the procedure is called platelet rich plasma, or PRP, which is the injecting of one's own platelets to rejuvenate the skin. Almost every physician interviewed for this story maintained that PRP — for the face and increasingly to combat hair loss – is one of the most requested procedures at their respective practices, from New York to London, Paris and Munich.
While social media may have fueled the boom in cosmetic surgery, doctors in some cases are using the platforms in the procedures themselves.
Ourian has found that the ability to use Instagram to showcase his work — he shoots procedures with a patient's consent on a smartphone and speeds it up to create 15 second videos — has allowed both potential patients as well as doctors on a global scale to see what he's doing and build his fame.
Among the procedures he started posting on Instagram is the non-surgical nose job, or "liquid rhinoplasty," that he said can markedly change the shape of a patient's nose in minutes — with no surgery or downtime. A syringe of filler can smooth a bump, correct a tip that may be too upturned or create symmetry, but for those looking for a dramatic change — filler can be added to tweak but it can't take anything away — surgery is still the best option to augment the nose.
It's not just social media that has made non-invasive procedures more desirable, though.
One of the best things about non-invasive treatments, he said, is that the patient is in the driver's seat. People who are "control freaks" could have a mirror in their hand watching their doctor make tweaks. They could give input, and if they wish to, even reverse a procedure (filler is dissolvable).
Perhaps that is another partial reason for the growing use of non-invasive cosmetic surgery by the "selfie generation." David Moatazedi, senior vice president of U.S. Medical Aesthetics at Allergen, said Millennials are the fastest-growing segment of injectable users, followed by men. Nearly a third — or 28 percent — of all Botox injections were administered to a Millennial last year, he said.
With respect to fillers, entrant Juvéderm Volbella XC became a starting point for a younger demographic because it's designed for use in the lips. The "soft," hyaluronic acid-based filler contains Allergan's proprietary Vycross filler technology and was approved by the Food and Drug Administration in June.
Moatazedi believes that while the social acceptability factor for injectables still has a way to go with Baby Boomers — it's become more mainstream on the coasts, he noted, but it's "not there yet for the middle of the country" — the Millennial set doesn't share the same reluctance.
"I'm not convinced that Millennials…view it [injectables] as taboo across the country. If you go across the country, Millennials in the middle of the country are as engaged on social media as they are on the coasts. They will be the catalysts that continue to drive the category," he said.
Kelly Huang, Ph.D. and vice president and general manager of the U.S. aesthetic and corrective business of Galderma, said it was social media — and video specifically — that led to the creation of the company's newest iterations of Restylane (a filler). Restylane Refyne and Restylane Defyne, approved by the FDA in December of 2016, were developed to fill "laugh lines" that still allow the patient to maintain a natural look while they're talking.
"A fear people have is that, 'I might look good in a photo, but if my cheeks are overfull and I smile, my face won't move naturally,'" Huang said. "Just like the selfie has been your calling card, what we see now is the way you express yourself is becoming more important. It's no longer the selfie or the static photo — it's moving toward live video [on social media]."
Dr. Debra Johnson, president of the American Society of Plastic Surgeons, stresses that plastic surgery is still "very popular" (half of her Sacramento-based practice is dedicated to breast augmentations, from reconstructive to lifts to enlargements), but she said there is no denying there has been an explosion in demand for non-invasive treatments.
Johnson compared Botox to Dysport, another neurotoxin. The former is "the big dog" that commands the majority of market share in the neurotoxin space, she said, attributing this to a first to market advantage. Botox Cosmetic was approved by the FDA for cosmetic use in the U.S. in 2002, and Dysport in 2009.
"Botox continues to be the most common thing. It's our shorthand, it's like calling a tissue a Kleenex," Johnson said of doctors' use of the term "Botox" to include Dysport, which makes up about 50 percent of her neurotoxin injections administered. "It's all in the same family, but they act a tiny bit differently. A lot of older patients do better with Dysport because it tends to last longer. You might have used Botox in your 40s and it worked great, but in your 60s it only lasts six to eight weeks."
The increase in demand for non-surgical procedures also has not gone unnoticed by the world's largest beauty companies. L'Oréal-owned clinical skin-care brand SkinCeuticals saw its biggest year ever in 2016, and Brenda Wu, general manager at SkinCeuticals, credited this to rapid growth of aesthetic procedures.
"It [our sales] directly correlates," Wu said. "When you look at data on the double-digit growth in fillers last year and the increase in neurotoxin injections, [there were] more than six million injections in this country [in 2015]."
In a "Professional Skin Care: U.S. Market Analysis and Opportunities" study released in January by Kline & Co., SkinCeuticals was ranked the top clinical skin-care brand in the U.S., followed by Allergan's SkinMedica. Last year, SkinCeuticals pulled in $103 million in wholesale sales, a 15.5 percent increase from the year prior, and SkinMedica did $89.5 million, a 3.8 percent jump from 2015 according to the study.
Part of the brand's success in the clinical skin-care space, Wu explained, is not peddling overblown claims. There still has yet to be a topical product as efficacious as a neurotoxin, and SkinCeuticals has no intention of promising the same results as an aesthetic procedure.
Instead, the brand's messaging is centered on working in tandem with physicians to achieve optimal cosmetic results. This means integrating skin care with procedures to prepare and complement any work done to "protect the investment." Upward of 80 percent of SkinCeuticals' business comes from the medical channel, inclusive of doctors' offices and medical spas.
The company is in the midst of rolling out a new medi-retail concept that transforms doctors' waiting rooms into retail stores that exclusively sell SkinCeuticals. The first SkinCeutical flagship bowed in 2014, and by year's end there will be 30 co-branded, medi-retail stores nationwide.
Even as cosmetic companies begin to promote integrating skin care with non-invasive procedures, consumers have only one thing on their minds: Botox, Botox and more Botox. The majority of physicians in the sector call the neurotoxin the number-one, most-demanded procedure.
But Golueke said while Botox remains his most requested treatment, as well as the one he performs the most, the end result consumers desire has changed in the past five years.
Patients, who are younger than ever before, are asking for a more natural approach to Botox than the frozen faces seen on New York socials and leading actresses in the early part of the Aughts. Golueke said the switch in approach contributed to a slight dip in Botox demand between 2012 and 2014 (he started working with Botox over 16 years ago and saw steady growth until 2012).
"Then we had a gap because a lot of younger people didn't want to do it because they saw older friends and moms who looked artificial," he said.
The procedure has since accelerated, with no signs of slowing down for him or other doctors in the field. Not only that, but new use cases and places Botox can be administered continue to pop up, including the chin area, lower eyelids and nose to eye brow lifts — or even to help with sweating on the face.
The neurotoxin is so hot that last year saw the opening of Botox Labb — the Drybar of Botox.
The nurse practitioner-based business model opened its first location in South Beach, Fla., last May, a Fort Lauderdale door in November and operates a recurring pop-up space in Daytona every six weeks for three days at a time. Doctors oversee the Labbs, and in each state where there's a Botox Labb, there will be medical supervisors and a medical director.
"The business model has been proven," said Joey Chancis, chief executive officer, founding and managing partner of Botox Labb, who said the business is already seeing an 85 percent repeat client rate. She cited data from Botox Labb's Allergan representative where the pharmaceutical company credited it as the highest-revenue-generating and fastest-growing new account in the country, which includes 35 territories.
Chancis and partner Danielle Smith looked to the injectables space for two reasons: it's booming and clients get instant results. They also realized that creating a focused beauty bar dedicated solely to injectables (no lasers, no peels) could result in more affordable services.
"We're taking the injectable business to the retail level and making it easily accessible and more affordable. It's not a Groupon but it's less expensive than the dermatologist," Chancis said.
Do the math: Prices run from $12 per unit of Botox and $11 per unit of Dysport to $600 per syringe of Juvederm and $800 per syringe of Voluma or Volbella. This means if someone opts to inject 20 units of Botox into their forehead area, it would cost $240 — or about half of what the procedure would typically cost in a doctor's office. A syringe of Voluma at a doctor's office in New York can cost $1,000 or even more. A "typical" procedure can mean one to two syringes.
A lease has been signed for Botox Labb's first West Coast location in Brentwood, Calif., that's set to open in early June. Another spot in Aventura, Fla., will open at the end of the year, and additional leases are under negotiation. Chancis said creating "clusters" of Labbs in Florida, California and New York are the strategy for the near term.
All of this injecting and face-filling might slow down the formation of wrinkles and stave off the need for plastic surgery for Millennials or Gen Zers. Many doctors are confident that advancements in technology could even render the traditional facelift obsolete, or at the very least push it off for a decade.
Dr. Shirley Madhere, a plastic surgeon in New York, said in just four to five years, her practice flipped from 70 percent surgical procedures and 30 percent non-invasive treatments to the complete opposite. She was clear that the amount of surgical procedures she performs has remained "relatively stable," with her practice seeing single or low double-digit increases per year. It's rising — just not as quickly and explosively as the non-invasive side, which has seen triple-digit growth in recent years, she said.
Dr. Macrene Alexiades, New York-based dermatologist, scientist and founder of 37 Actives, said a burst of new fillers — combined with any of the more than 40 lasers in her office — has resulted in a demand for non-surgical facelifts, what she deemed the "It" procedure of 2017.
"The cat's out of the bag that I'm using non-surgical facelifts. People are flooding in here right now…[for] filler and other technologies to achieve a facelift result. No scars, it doesn't show," Alexiades said, adding claiming that she is inching closer and closer to treatments that could eradicate facelifts altogether.
She maintained that Profound, a microneedling radiofrequency treatment that builds collagen, elastin and hyaluronic acid in the face, currently results in one-third the result of a facelift. And if you throw in some fillers (the addition of Kybella to Profound can yield two-thirds the result of a facelift, according to Alexiades) and strategically placed Botox, patients have what's referred to as a "liquid facelift" in the industry.
There is also Ultherapy, the micro-focused ultrasound treatment credited by many of the physicians interviewed for this story as the most significant innovation in the space in the last five years, as well as a host of lasers introduced that each possess a different delivery system.
"Gravity always wins, and as we get older, it wins more," said Dr. Neal Schultz, who said being able to push plastic surgery off a decade is the most significant advancement he's seen in the past five to 10 years. He maintained that skin-tightening with laser, intense pulse light or radio frequency is just getting better.
He acknowledged there are limitations with a liquid facelift, but the introduction of fillers with varying technological properties — Boletero, Volbella and Restylane Silk are all really light, while Voluma and Restylane Lift are dense — has given him many more options. As has Kybella, an injectable released last year that has fat-dissolving properties.
For Dr. Dennis Gross, administering a cocktail of lasers and peels to firm skin and reduce lines and wrinkles has been a breakthrough in his practice. Combining two non-invasive lasers that combined work better than either one individually can yield similar results to Fraxel, an invasive laser with a "radical downtime." He also likes to use Professional Strength Alpha Beta Peels (a stronger version than the ones from his namesake line) in tandem with a Collagenesis laser, a Vbeam laser and intense pulse light. The procedure (three lasers and a peel) costs $1,300.
An even newer alternative to lifting and tightening skin is Polydioxanone, or PDO, Threads, similar to the Silhouette Soft thread lifts that are primarily available in Europe.
Dr. Leslie Gerstman, a cosmetic dermatologist in New York, said she started performing PDO in the fall. A subdermal needle is used to place suture thread in a cross-hatch pattern beneath the skin to stimulate collagen growth, she explained. It works well in the tear trough area, for fine lines in the face, the neck and abdominal or knee skin. For lifting skin, Gerstman uses a suture thread with a barb on the end to fix asymmetry or lift brows, jowels or the neck. The service starts at $1,000.
"There are no risks.…They [the threads] create a scaffold and then healing cells like fibroblasts lay down collagen. The threads dissolve and you are left with thicker, tighter skin from the new collagen. It's sort of what lasers do, but without the pain and cost and downtime," Gerstman said, adding that the thread used for PDO procedures dissolves in six to eight months.
Even with all the focus on the face, doctors aren't neglecting the body.
Laser based body sculpting is quickly replacing liposuction to reduce fat in areas resistant to diet and exercise. With Allergan's $2.5 billion acquisition of Coolsculpting parent company Zeltiq — the deal is under Federal Trade Commission review and expected to close in the second half of the year — the body sculpting space is primed to skyrocket. Less than a million body aesthetic procedures were performed last year, but it's the fastest-growing segment of aesthetics, according to research from Allergan.
Alexiades and Gross have witnessed a huge uptick in noninvasive body treatments, from Coolsculpting to Sculpture. With the ability to reduce fat permanently, it's quickly eliminating the need for liposuction.
Schultz still has reservations, however. He thinks body contouring with non-invasive fat shrinking still "isn't there yet."
"I cannot sell a procedure to somebody based on a 30 percent improvement [statistic]. All they'll see is the 70 percent I didn't give them. I have 12 lasers but no fat removal machines. I'm seriously concerned that it will not satisfy my patients, even if I try to temper their expectations," Schultz said.
Don't get these doctors wrong: they aren't against people getting "work done." It is simply that some of them think things have swung too far to complete makeovers rather than simply maintenance.
Sebagh believes strongly in taking preventative measures to slow down aging — he called Botox in the mid-20s "essential" to avoiding surgery — but abides by a strict principle of "aging maintenance." This means slowing down the aging process with assistance from "four pillars" of non-surgical cosmetic medicine: Botox; fillers; Ultherapy, and Silhouette Soft (a polymer similar to suture thread with barbed ends that's placed under the skin to give a lifting effect).
"It's a different concept than changing your face. It's slowing down your aging process because you like yourself and you want to age slower if you can — and stay the way you are. It's totally different than to change who you are," he explained. "They [patients] want the bum of Kim Kardashian, the lips of Kylie [Jenner] — it's like a puzzle. It becomes a bit crazy."