INTRODUCTION
Traditionally, improving the appearance of the aging patient focused on skin laxity: surgery to remove excess skin. That meant waiting until this sign of aging was sufficient to warrant cosmetic surgery. This was effective but could result in a sudden and unnatural change in appearance that was not always natural. Deep chemical peels, dermabrasion, and even early lasers improved texture and color significantly but often with difficult recoveries and resultant permanent loss of normal pigmentation. Early injectable fillers provided short term reduction in wrinkles or enhancement of lips and did noth- ing to slow the appearance of aging. A turning point in treating the skin signs of aging was the recognition that a significant portion is due to volume depletion or ‘deflation’, not laxity or gravity.1 In fact, cadaver studies have shown the presence of distinct fat pads that are lost in a fairly consistent pattern with age.2 Skeletal changes are also foreseeable.3 At the same time, new products for soft tissue augmentation were developed to maximize rheologic properties for different areas and uses; the use of botulinum toxin became to change the position of anatomic landmarks, not just to paralyze muscle; and improved energy based devices allowed visible resurfacing or tightening without signi cant downtime.4,5 It became a realistic aesthetic goal to improve a patient’s appearance over time. And, in fact, if started early enough, these interventions have been seen to slow the aging process.6 “Benjamin Button” is a short story by F. Scott Fitzgerald and later a movie with Brad Pitt in which a man ages backward. The phrase has been used in popular culture to describe people who look as if they haven’t aged or became younger but don’t have obvious signs of intervention. In Dermatology, it describes our patients who, with a combination of cosmeceuticals and rejuvenation procedures, look more attractive and youthful after years or decades than when they rst presented. The improvement is clearly recognizable but not identi able as from a particular procedure. That is the “Benjamin Button effect”.
Achieving Recognizable Rejuvenation from Consult to Practice
There will always be patients who want or need more significant changes. A patient presenting to a plastic or facial plastic surgeon likely expects to be offered a surgical procedure that will make a significant difference quickly, like a rhitidectomy or rhinoplasty. However, even surgeons have seen an upsurge in patients wanting alternatives to surgery. According to the American Society of Plastic Surgeons 2016 National Plastic Surgery Statistics, the number of cosmetic surgical procedures decreased by 6% between 2000 and 2016 while the number of cosmetic minimally-invasive procedures increased by 180% over the same period.7 Because surgical procedures can result in extreme changes, patients often express concern about ‘not looking like me’. In contrast, after some minimally invasive cosmetic procedures, patients complain that they cannot see a significant improvement and that ‘no one noticed’ and complimented the change. By self-selection, most patients presenting to a cosmetic dermatologic surgeon do so speci cally to avoid surgery. They express concern about making extreme changes, becoming a caricature, or just ‘not looking like me’. At the same time, patients want assurance that there will be enough improvement
