AAFPRS President Dr. Corey Maas Talks Top Plastic Surgery Trends

Alison Werner:
Hello, my name is Alison Werner and I am joined today by my co-host Keri Stephens. We are the co-chief editors of Plastic Surgery Practice. Thank you for joining us for today’s podcast. Today, we are joined by Dr. Corey Maas, a board certified facial plastic surgeon in San Francisco and the current president of the American Academy of Facial Plastic and Reconstructive Surgery. He is here to talk to us about the Academy’s annual member survey released in February. Dr. Maas, thank you for joining us today.

Dr. Corey Maas:
Thank you for having me.

Keri Stephens:
Thank you. Well, let’s just start with a simple question. What surprised you most about the findings in this year survey?

Dr. Corey Maas:
Well, I think it was the dramatic increase. I think we were all surprised, frankly, on the dramatic increase of 2020 over 2021. We saw a slow rise because of the sort of paralysis that happened in the spring of 2020, but then over the summer there was a gradual increase, but it really exploded through the fall and winter with cases rising. I mean, we’re talking 60% or more increase and some practices even more. That’s not a normal year over year increase in procedures performed, [inaudible 00:01:37] dramatic.

Alison Werner:
Yeah. Well, talking about those procedures, the survey has the most common surgical procedures performed by academy members in 2021 as rhinoplasty, facelifts, and blepharoplasty. Is this consistent with previous years or was there a shift here?

Dr. Corey Maas:
I think a little bit of both. If you just think about the overall number went up so dramatically of all procedures, those stood out as being procedures that were performed with greater frequency for, I think, a number of reasons which we can get into. But the biggest one being, probably the top two or three, is number one, people we’re seeing themselves every day on Zoom, Microsoft Teams, whatever your video conferencing thing is, seeing themselves in ways they may not have ever seen themselves before because it’s a different image then looking in your well lighted mirror.

Dr. Corey Maas:
Number two, people had nowhere to go. They had nothing to spend money on. You couldn’t go to restaurants, you couldn’t travel, you couldn’t even go to retail, frankly. So they started investing in themselves and then doctors offices are safe. I mean, we all had policies in place and I think our patients trusted us to follow the CDC guidelines and maintain those, and certainly we did during that time period. So, there was no exclusion to doing these things based on need or desire or whatever. It was really something that was the perfect storm, if you will, for those of us that do things.

Dr. Corey Maas:
It’s a long answer, but the short one is, the fourth part was that you’re wearing masks during this time, and it’s a great opportunity if you’re wearing masks. People didn’t even find it unusual to be on a conference call, like a podcast here, with a mask on. You could do that. So you could function normally with a mask that disguises, certainly all of the facelift and rhinoplasty stuff is disguised. The one that’s not is blepharoplasty, but that’s a fairly quick recovery type of procedure. You get a little bruising on the upper eyelids, but it almost looks like purple eyeshadows. So people aren’t out for that. Then, of course, the other big part of the explosion was in minimally invasive or not invasive procedures too. It was a big part.

Alison Werner:
Well, talking about the minimally invasive procedures, in the report it was neurotoxins to Botox fillers and skin treatments were the most common. Were those procedures in previous years at the top or has there been any shift in which procedures are kind of gaining traction there for the minimally invasive?

Dr. Corey Maas:
Historically as the science and understanding and comfort level with the public has increased every year, year over year, better consumer awareness and good messaging from both physicians and industry. There was a much greater comfort level with the cosmetic injections, whether the Botoxins in this country, Dysport, Xeomin, and Jeuveau, and Botox, of course, the well branded one. But also the fillers which were used quite extensively and became really, there was a shift from Botox being the entry treatment to a younger group of people coming in and doing fillers, in particular for lip enhancement.

Dr. Corey Maas:
That was a shift, but it was a pretty big number. Again, what DMO group they’re in, I would guess Gen Z or whatever, the groups that are in their twenties now, and they were doing it, and if done appropriately, it’s a very nice procedure. Of course, we’ve all seen the overdone people too, and there’s been some pushback since that time where people were kind of overcooking it, but in general done correctly, they look really nice and that was a big change. Is that there’s a younger group in the twenties where Botox people generally start in their thirties. So a little bit younger group of people started coming in too.

Alison Werner:
Do you mind, I’m going to kind of circle to a different question we were going to ask later. It was about this, the report members did report that there’s a greater emphasis on earlier maintenance and age prevention starting with the twenties and thirties, that population you were just talking about, so that they could put off bigger procedures and surgeries later on. In addition to the lip procedures, what other types of procedures is this age demographic doing to put off these procedures later on?

Dr. Corey Maas:
Well, this group is a very highly informed group who are very comfortable with search and sort of dissecting out the hype from the reality, and will come in generally to the office with sort of self propagated education, and it makes it a lot easier in many ways, for us. It can make it a little more challenging so that you can’t confuse Dr. Google with Dr. Maas, because sometimes they get a misunderstanding.

Dr. Corey Maas:
There’s got to be some filters there, but at the same time, that group is also very much aware that, some of these early interventions can prevent some of the sun… There’s intrinsic and extrinsic aging. Intrinsic is very hard to manage because it’s really your genes. I mean, your skin type, [inaudible 00:07:32] you can’t really get to pick those things, but the extrinsic aging things like smoking and sun damage, which are the two probably biggest things that affect skin, they’re very conscious of skincare products and sunscreen, and we’ve certainly gotten away from that sixties and seventies trend that was really a very brief moment in human history because historically lighter skin has always been associated with more prosperity and not working in fields, if you will. [inaudible 00:08:04] Only a couple decades where we saw this big bump in the tan sort of James Bond thing where you tan, and that means you have more free time, and that’s how you spend it.

Dr. Corey Maas:
Unfortunately, because skin cancer rates have gone through the ceiling. Sun damage is a cumulative type of thing and we can do certain treatments to help reverse that, and there are certainly topicals that can help including the retinoids and [inaudible 00:08:32] acid and whatnot, but the treatments themselves go from sort of non-ablative laser resurfacing to particularly fractional laser, because there’s very little downtime if any, to microneedling, or radio frequency microneedling in particular. The microneedling where you’re just putting a roller on your skin probably doesn’t do that much, but when you [inaudible 00:08:59] some energy where there’s a little bit of thermal injury, those particular went up quite dramatically.

Alison Werner:
Okay.

Dr. Corey Maas:
Yeah.

Keri Stephens:
One of the things I want to talk about is a shift in the number of revision procedures and what procedures are being revised, can you talk about that a little bit?

Dr. Corey Maas:
Well, revision surgery is part of what we do and it doesn’t necessarily mean anybody did anything wrong. Sometimes revision surgeries, just to get a little bit more of what you already got. It might be altering a little bit of what you’ve already done. There are more people entering the field now, and I think there’s this experiential component to it which has several layers. The first layer is proper patient selection, matching up the right patient for the right procedure based on their desired outcomes. That’s generally where you have the happiest patients, if they have a concern and we’re addressing it with the right procedure. That’s part of the cerebral portion that has nothing to do with how good your hands are, it really has to do with really figuring out what the patient’s looking for and trying to match up the procedure or procedures that would best address those concerns.

Dr. Corey Maas:
Once you get past that step, if you can match them up, you’re going to have a very low rate of revision if you execute well. Some of the things that I’ve seen at least, it gets to sort of stratified by most challenging procedures are probably rhinoplasty, in general, is at the top because you’re blending form with function and it’s so individual. That’s why I always use computer imaging with our patients. We come up with some mutually agreed upon image that they’re hoping to achieve. If you get pretty close to that, then people are generally happy, but even with that said, the published rates of revision rhinoplasty, primary for doing it for the first time are in the mid-upper single digit numbers. Not that many but enough to be significant given the number that’s done overall.

Dr. Corey Maas:
If we’re talking about revising a revision, so somebody’s already had a surgery and they’re coming in for a secondary or tertiary rhinoplasty, it gets a lot more complex, and it really does. I mean, this is where trusting your face to a facial plastic surgeon is the real deal because this group in particular has a lot of expertise in working in and on and on the nose. So there’s a comfort level with that. There are a lot of different techniques described. It’s really about executing them. So I would say there was a big rise in revision rhinoplasty for the same reasons we’ve discussed is that people can get that procedure in revision rhinoplasty in particular, the swelling last a little longer than a primary rhinoplasty. It’s not dramatic, but the best results you’ll see after six months to a year, literally. So that means longer recovery. So, people wearing masks was a good opportunity for something that’s bothered than for a very long time, if they had it when they were much younger with some of the [inaudible 00:12:34] things they did in the sixties and seventies in particular.

Keri Stephens:
Okay. I want to talk about men now. So in the study, you talked about how there was a smaller chunk of the patient population undergoing both surgical and nonsurgical procedures, but members report that they believe there will be an uptick. What procedures do you think men will be looking for specifically?

Dr. Corey Maas:
Well, the obvious one is hair. I mean hair restoration is unique to men, and that’s not unique because I do a lot of hair restoration on women too, but that I really start both with men and women on medical hair restoration. We do have some very good pharmaceuticals that are very helpful and particular retaining hair but also growing new hair. Then probably a close second if you include the younger population in particular, because rhinoplasty is done in men and women, typically around high school or college age range, there was a bunch of questions yesterday about how early you can do rhinoplasty. Generally that’s going to be middle school age kids that are 13 or 14, they’re pretty much fully grown by that age. And it doesn’t have any impact on their growth of their face or facial symmetry or anything beyond that.

Dr. Corey Maas:
Eyelid surgery for men has always been really at near the top of the list, because hooded skin makes you look tired [inaudible 00:14:10] That’s sort of boardroom thing. And that’s why they talk about Botox and boardrooms. Part of that is softening the features around the eyes. And even as our papers, we published in the early 2000s showed you can do substantial brow lifting and people just doing Botox. But those are areas where men feel the most comfortable, I think, coming in but once they cross the threshold, they just like women start talking about everything. They lay out what their concerns are, but those are the threshold crossing type of procedures.

Alison Werner:
Well, when it comes to the future of nonsurgical procedures, members are reported that they expect there to be more choices going forward, especially when it comes to body contouring for fat reduction and skin tightening, what procedures or technologies do you think are going to be at the forefront here?

Dr. Corey Maas:
Well clearly right now, I think the fat [inaudible 00:15:12] the cool sculpting, and non-invasive body contouring procedures are leading the way as alternatives too even though technically liposuction can be minimally invasive depending on the patient. Those procedures work very well and they’re reliable. And now we even have body toning with some of the electromagnetic energy devices that can work on literally doing gluteal tightening, butt muscle tightening, sculpt and cool tone out there that are both working, basically the same type, there’s subtle differences, but same technology. And those are being used for abs and so you get the fat removed with freezing the fat and preserving the skin, of course. And there is some skin tightening that happens with those procedures that we don’t see in liposuction.

Dr. Corey Maas:
I don’t do body lipsuction myself other than to harvest fat for facial grafting, but I have done it in the past, but there’s a quite a remarkable sort of inflammatory response that gets a little skin tightening for patients. And then you add those to the toning of the muscles. And then some of these skin quality improvement treatments can be applied to the skin like radio frequency and doing things like VelaShape or microneedling. What I said VelaShape is a bipolar radio frequency or Thermage, which is monopolar radio frequency are things that can tighten skin anywhere. So you really got all three levels. You’ve got the fat, you’ve got the body toning and muscle tightening, and then you’ve got the treatment of the skin quality, which historically was never done off body. We couldn’t do deep chemical peels and things like that, or even certainly not a blade of laser on the body. Now with fractional laser, I’ve got lectures on whole body fractional laser resurfacing. You don’t do it all at once by the way, but you can do it [inaudible 00:17:15]

Keri Stephens:
That’s good. [crosstalk 00:17:18] This is interesting. And while the report also knows the increase in bookings and treatments for both surgical and nonsurgical treatments in 2021, what’s the outlook for 2022, what can we expect this year?

Dr. Corey Maas:
Well, where I’m not seeing any decrease. I think there’s a lot of inertia that we have going now. And there’s still some of the headwinds for people in terms of travel. And there’s a certain fear factor out there. The pandemic for all practical purposes is over at this point. I’m not saying you don’t take it seriously. I mean, Omicron, you should get a booster. And that’s the best way, but it’s really for most people who are boosted or have already had the virus, it’s not much more than a cold.

Dr. Corey Maas:
If you get it, there are very few hospitalizations and deaths, all that said there’s a layer of caution that everyone has in certain fear factors. I think people are still in… Some people very resistant to travel. And so there’s a lot of still, if you’re going to spend your money, why not invest it in myself? This is something [inaudible 00:18:32] I can feel safe about and something that I’ve always wanted to do. So I think those are driving a lot of the continued interest, the inertia that I said started during the heart of the pandemic really, and the mask wearing and the Zoom calls and all that.

Alison Werner:
Yeah. Well, I wanted to shift gears just a little bit and talk a little bit about who responded to the survey. And one of the things I saw was that the number of respondents who reported being in solo practice was slightly down from 2020, about 5% lower at 47%. How has the way a plastics surgeon practices changed in recent years? Is there a movement towards group practices or corporate, or is the solo practice still primarily where it’s at?

Dr. Corey Maas:
I think that it’s a very good question. What I think that the trends in general, there’s not a great deal of increase in academic programs. Which have certain number of faculty they have, but there are certainly a lot of economies of scale in sharing expense, overhead expenses and things like that, which takes a lot of the pressure off the whole business model. If you’re sharing expenses with others and there’s a synergy of referrals within a practice, it just makes group practice, when I say group practice, everybody has their own areas. This is a pretty broad field. If you’re talking about everything from breast lifting and breast augmentation and mommy makeover all the way to rhinoplasty and eyelid surgery. And very few people can be experts at all of those things. I mean, it’s just broad of an area now. So having practices where people got plastic surgeon and facial plastic, for example, are very common and very good partnerships and however their expense sharing works. So we’re seeing more of that type of group practice. And even some increase in multidisciplinary where you’d have a dermatologic surgeon or derm person involved.

Alison Werner:
The report notes that the majority of the facial plastic surgeons who reported as part of this survey were between their forties and their mid fifties. And the percentage of younger surgeons dropped considerably since 2018. Now the findings from the report note, that’s hard to say if this is the number of younger members are actually decreasing given the number of respondents, but are you seeing any trends in the profession about the number of new doctors entering the field?

Dr. Corey Maas:
No. I think the numbers in the field are increasing. I think that like any organizational membership type of group, what we’re seeing is, especially with the young people, is how do you spend your money? And you’re going to invest it in your practice. You have to decide, you want to buy that new machine or hire that new employee, or do you want to, I mean, obviously being a member of an organization is not going to be a bank buster or anything. There just like any business, if you’re not getting a good return on your investment, then it’s probably something that you have to work on. I think we’re having, and in general, this is happening across a lot of industries and even churches and other things like that, where they’re seeing fewer and fewer young people.

Dr. Corey Maas:
And just because how they spend their time and their free time, and then how they spend their work time and how they spend their money are all important. And there’s a real value proposition with membership in organizations in general. So it’s really one of my jobs as president of this organization is to try to make sure we’re getting our young people, our fellows and other young people that are interested in facial plastic surgery. It doesn’t matter if you came from plastic surgery or Otolaryngology fellowship train or not. If you’re doing this, we want members to see the value. And that comes down to only a few things for membership organizations. It’s are you driving interest through the branding of your specialty? Are you driving interest through, to the consumer through good consumer education, which nowadays a lot of the young people just feel like they can do this whole thing themselves.

Dr. Corey Maas:
They got social media, they’ve got all kinds of outlets to do it, and it’s not just through the organizations where they can get their name out there. In fact, they can be very effective with clever marketing platforms on their own. There still is the synergy of working together and the group meetings and sharing knowledge because the field is evolving quickly and educational programs I think are critical for all of us. Continuing medical education is how we all stay on top of our game. And at the same time, there’s more and more meetings out there and they’re good meetings. So that’s what we see. And part of our job is making sure that the member for their dollar pay for membership, they’re getting a good return. So that’s a professional side thing. That’s very little to do with the consumer, but it has to do with the younger group that’s smart about investing their money. I mean, really what it comes down to.

Alison Werner:
Yeah, exactly. Do you guys have any meetings coming up that members should know about?

Dr. Corey Maas:
Yeah. We have our meeting coming up in May 18th in Miami, and I think it’s the 18th and we’re combining our aging face and rhinoplasty courses, so they’re going to be running sequentially. And it’s really an international group. It’s a great city and we’ve got really good registration. There should be a lot of… And by the way, the first real meeting we’ve had live in almost two years. So there should be a lot of good to see colleagues and friends.

Dr. Corey Maas:
And then of course our national meeting, the annual meeting is in DC and at National Harbor, which is a new area, the DC Metro area, where there’s a great part of town and really close to the inside the [inaudible 00:25:10] thing, but still it’s a great meeting site. So I think we’ll be seeing a lot more young people. I’ve personally taken an interest in making sure our fellows and residents for sure are there because this is a good opportunity for them to get to hear from some of the real masters that are in our field, not just from the US but we have a lot of international people coming. So it’s exciting.

Alison Werner:
Excellent.

Keri Stephens:
That is really exciting. So this is kind of more of a broad question, but what is keeping up plastic surgeons at night? What are the key issues that you all are just saying, that are just really-

Dr. Corey Maas:
Well we’re like everybody else. I mean, inflation is crazy. I can tell you that the cost of medical equipment and supplies and even its ability to get to us. I mean, we’re over-ordering things as simple as sutures and certain other, drapes and things that you just wouldn’t even think, masks for a while, and they’re much better now, but I mean, you have to bulk order them because they’re back ordered, which you never think would happen, but those are in part supply chain things. And then when you do buy them, they’re probably twice as expensive as they were a couple years ago or even a year ago, so managing those costs are substantial for us. And then if you start getting into the equipment side of it really… These medical equipment is already really expensive and their costs are up too, so building things.

Dr. Corey Maas:
So it’s really about managing cost. I think that’s probably the things that we kind of gnaw our teeth on. All of us want to, if they’re like me, I want to employ as many good people as I can to help care for our patients. And I think successful businesses are making every effort to get people back in the workforce to help us all get back to productivity that we should be. And I’m in a lucky area in the bay area, there’s so much wealth here and so many people can work from home in tech, in biotech that it makes it sort of easy for me. I don’t want to knock on wood. I don’t want to jinx myself, but [inaudible 00:27:34] areas of the country, it’s not the same.

Dr. Corey Maas:
They’re super busy, the tech giants that are all out here, Google and Facebook and Apple, and Twitter, all of them are here. I mean, they’re moving too now. I mean, they’re also expanding and they’ve got offices going up in Texas and Florida and the lower tax states. But still the [inaudible 00:27:56] is all here. So we’re fortunate here that some parts of the country, I think they’re facing a little more challenges as costs go up and it’s really hard to raise prices very much on patients that are just coming out of a pandemic, that’s a tricky job.

Keri Stephens:
Yeah. That’s really interesting. That is not what I thought you were going to say. And it definitely is really a lot of good food for thought, but okay. To end this on a really positive note, what excites you most about the profession?

Dr. Corey Maas:
Well, I think it’s always been the same for me. It kind of gravitated from my professorship for 12 years at UCSF at the University of California San Francisco here, where I was probably 50, 50 doing reconstructive and trauma and facial nerve injury and some things, and then cosmetic, but all of them in the end give us an opportunity to help people feel better about themselves and improve their self image in meaningful ways. And people who get nice, and I’m not talking about the… This is when you provide somebody, a natural rejuvenation of their look, so that they can restore the look or balance to their features that they haven’t had, that really makes them feel more confident and comfortable. And that self image and the energy you see out of it is very rewarding. And they’re very thankful. I mean, it’s a very gratifying space to be in business, because people are very appreciative. So that always makes it fun if you can deliver and people are happy about it and let you know, and they generally do. We got some great people in this country, so it’s a nice feeling.

Alison Werner:
Excellent. Well, Dr. Maas, thank you so much for joining us today. We really appreciate your insight into the report and the future of the industry. So thank you.

Dr. Corey Maas:
Yeah. Well, your podcast is cool, I’m glad you invited me to come on. Thank you, be happy to join you-

Keri Stephens:
Whatever you want. We would love to have you.

Alison Werner:
Well, we look forward to talk to you again in the future and to our listeners. Thank you for joining us. We’ll be back soon for the next Plastic Surgery Practice podcast. In the meantime, visit plasticsurgerypractice.com for the latest industry news until next time, take care.