With Niche Plastic Surgery On The Rise, Where Do Doctors Draw The Line?

Just a few years ago, the idea of having your inner mouth sliced open to push out pads of tissue was considered on the more extreme end of the cosmetic surgery spectrum. Now, it’s more than just casual dinner conversation — it’s a full-on parlor game, with breathless speculation over photos of snatched-looking celebrities and fictional lists of work one might get done in the event of a random windfall. It’s no secret that plastic surgery is more popular and more niche-focused than ever before, but the demand is surprising even industry experts.

Not only are procedures getting increasingly specific, but the patients requesting them seem to be getting younger. In a recent survey compiled by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), 75% of facial plastic surgeons report year-over-year upticks in patients under 30 years old seeking cosmetic surgery or injectables, which many participants attribute to both celebrity influence and the ubiquity of front-facing camera use.

While the cosmetic procedures of yesteryear largely focused on youthful feature restoration for the 35 to 50 year old demographic or correcting notably disproportioned body or facial imbalances, the door has now flung open to a much greater group of candidates. Group chats discuss scar visibility, wraps, and recovery time like last week’s podcast, with proper procedure names and internet-gathered information adding new gravity to surgery talks. Nose jobs are rhinoplasties, and they have to take your “ideal philtrum length” into account. Eyelid surgeries are blepharoplasties, and it could be just the thing to balance out a “negative cantal tilt.” But with virtually unprecedented demand and aesthetic trends constantly in flux, how do doctors decide who actually gets what procedure?

What’s Driving The Niche Surgery Boom?

Over on Instagram Live and TikTok, it’s not uncommon to hear users preface their videos with things like, “Ew, ignore my face.” Between Zoom meetings, selfies, and feature-augmenting filters — not to mention the disposable income saved during the 2020 pandemic, cited by AAFPRS as a major factor in demand — staring at your own face all day from virtually every angle is a breeding ground for insecurity and even dysmorphia. This gives doctors an additional element to watch out for as they screen their prospective patients for surgery suitability.

“Social media and their filters have unfortunately given so many younger people false hopes of reality,” says Dr. Adrienne O’Connell, President and Medical Director of Laguna Beach Aesthetics. “Some of these filters can completely alter and distort a person's face to where they are almost unrecognizable. These are not true results, however, so many people buy into it.”

At O’Connell’s own practice, unrealistic expectations are the most common reason why she turns down patients for procedures. If a patient’s perspective doesn’t align with reality, O’Connell says, virtually no surgical outcome would make them happy. That patient expectation-hedging starts in initial consultations, beginning with reference photos. O’Connell is frank about the results and makes sure they’re understood. “For example, if they undergo buccal fat removal, their cheeks will slim down, but they will not look like Bella Hadid,” she says. “If we add filler to their cheek bones, they will have more angular cheeks, but will not look like Kim Kardashian.”

Enter The Age Of ‘Tweakments’

Generationally, there seems to be a divide within cosmetic surgery. According to Dr. Forrest S. Roth, a top Houston-based surgeon with more than 20 years of experience, most procedures are designed to “rejuvenate” — which is, essentially, a refreshed and more youthful look. This stands in contrast to the rise of 20- and young 30-somethings seeking procedures of their own, many of which are set on fine-tuning actual or perceived feature imperfections (think evergreen procedures like nose jobs) rather than seeking a more youthful look with something such as a face lift.

“The social media revolution has patients taking selfies more than ever,” Roth explains. “They are seeing themselves more often and in different poses than in the past, instead of the traditional ‘smile for the camera.’”

Just as cosmetic surgery is up across the board — especially for procedures like upper eyelid blepharoplasties, brow lifts, and rhinoplasties — so are minimally invasive “tweakments” that aim to deliver similar results with high-tech equipment and little downtime. Innovations like the skin-tightening EmFace treatments and radiofrequency microneedling, for example, can help bridge the gap and cut costs. “These are technological advancements which have occurred in the realm of medical equipment and deliver cosmetic results, which were not available without surgery only a decade ago,” Roth says, which is why his office, along with many others across the country, are incorporating them as in-practice treatments.

Where Doctors Draw The Line

At this point, it’s unlikely the American way of life will ever be extricated from front-facing cameras, but doctors and their duty of care are helping stem the tide. Doctors abide by standard industry screening processes that evaluate prospective patients ahead of approval for surgery to ensure both physical safety and a positive mental outcome once the procedure is complete and healed. According to Dr. Christopher Zoumalan, board-certified oculoplastic surgeon and founder of Skinuva, the best patient candidates are those in good general health with an overall positive view of their life, no active issues with the operation area, and a firm grasp on realistic surgery expectations. The time dedicated to parsing out who might be negatively effected by a procedure — either physically, or post-op due to factors like an unhealthy body image or outside pressure — can quite literally be life or death for some patients.

“I always ask my patients why they are interested in the certain procedure or treatment and why at this particular time in their life,” O’Connell says. “I want to assure that my patient is seeking the procedure or treatment for the right reason.” She says there are studies concluding that those motivated by intrinsic factors — for example, getting surgery to feel better about themselves versus to please a partner — are much more likely to be satisfied by the results of their procedures.

But beyond psychological profile, sharp-eyed surgeons are also tasked with looking out for potential aesthetic pitfalls of trendy, of-the-moment procedures. The AAFPRS 2023 report details a rise in buccal fat removal surgery thanks to a general resurgence of the ‘90s waif look, but also highlights how skeptical many doctors are to perform it on young women. I am constantly asked by my patients, ‘What should I do to look younger/better/prettier’, etcetera,” O’Connell says. “It is my job as an aesthetic professional to know what types of procedures the patient would be a good candidate for.” For that very reason, she cautions against any permanent volume or fat loss in the face as it naturally decreases with age — which categorically rules out buccal fat removal.

Roth also shares that he most often turns requests down due to either an unrealistic expectation or an inappropriate request altogether. For instance, he says, a mother with a very low body fat percentage seeking liposuction. “Another classical example is a young male in his 20s looking for rhinoplasty,” Roth explains. “However, upon physical exam there is nothing cosmetically or functionally wrong with his nose and the deformity he describes is not visible or appreciable.”

By all accounts, it doesn’t look like this emphasis on specific, “refining” surgeries to stop any time soon. According to the most recent AAFPRS trends report, the majority of participating surgeons report at least a 10% increase in patient demand just up from 2021 alone. Easier access to procedures through more practicing offices, medical credit cards with low rates, and surgery-approximating tweakments all spell out record numbers just on the horizon. While there is a lot of money to be made in the aesthetics space, the surgeons who are realistic with their chronically online, procedure-happy patients are key to maintaining healthy expectations for those considering going under the knife in the future.