Evolution and Trends of Facial Plastic Surgery and Facial Aesthetic Procedures in India: From Awakening to Revival

Abstract

 

Facial aesthetic surgery is an emerging branch worldwide. India, a torchbearer country in facial plastic surgery, has seen tremendous growth in medical technology, resources, and clientele over the past century. This study aims to study past practices and current trends in facial plastic surgery and aesthetic procedures in India by individually addressing commonly performed nonsurgical procedures (Botox, Kybella [Allergan, Irvine, CA], fillers, threads, micro-focused ultrasound, and nonsurgical hair restoration), and surgical procedures (rhinoplasty, blepharoplasty, hair transplant, and facelift). It also aims to further elaborate on the scope of facial aesthetics and make recommendations on prospects in the field. A structured scoping review and a subsequent evidence-based synthesis were done following an extensive literature search on various databases such as PubMed (National Institutes of Health, Bethesda, MD), LILACS (Latin American and Caribbean Center on Health Sciences Information, São Paulo, Brazil), MEDLINE (National Library of Medicine, Bethesda, MD), EMBASE (Elsevier, Amsterdam, the Netherlands), and Cochrane (Wiley, Hoboken, NJ). The initial search yielded 703 articles, out of which 20 were found to be relevant to the present study and discussed. It was found that there is an upward trend in the growth of facial plastic surgery in India, and a gradual shift in patient attitude toward nonsurgical aesthetic procedures was seen. This article affirms the growth of facial aesthetic surgery in India by highlighting the recent development and trends in the practices of surgeons. It also addresses the shortcomings in the current administration and makes recommendations to fill the existing loopholes in plastic surgery.

Level of Evidence: 5

The current trends in the field of medical sciences obtain suggestions from the previous descriptions, interpretations, and practices of physicians and give a perspective on the prospects and scope of medicine in the future.¹ The medical sciences have grown by a far and large margin since their inception and have taken a “specialty creep” over the course of time.² Of these specialties, the field of plastic surgery has seen immense development. This development has never been outlandish to India, a forefront country in contribution to medical sciences and a torchbearer of facial plastic surgery since the ancient times of Vedas. The earliest available literature on facial plastic surgery dates to 800 BC. Sushruta, an Indian surgeon who is also considered the father and founder of plastic surgery, performed a nasal reconstruction procedure³ that he documented in his infamous book Sushruta Samhita. Over the succeeding millennium, numerous Indian surgeons made a significant contribution to this field, especially in the correction of skin defects by various flap designs that would later become popular as the Indian Flap.⁴

With the advent of colonization of the Indian subcontinent, an amalgamation of ancient Indian practices with modern European practices is believed to have occurred. The perilous times of war during the 18th and 19th centuries necessitated the treatment of its traumatized and disfigured survivors. This served as a spark that lit the flame of innovation in surgeons serving the British East India Company who allegedly popularized their work throughout the world.⁵ Since then, facial aesthetic surgery has witnessed not only extensive development that was no longer restricted to corrective procedures but also extended to cosmetics.

The beginning of the 20th century is considered the beginning of The Modern Era, the period of time that continues into the present moment without interruption. This period is rightly called the golden age for aesthetic surgery⁶ as it saw a marked change in the attitude of people toward this field. It gradually began to be viewed as a valid scientific means of improving appearance. This, in turn, resulted in an increase in the clientele of facial plastic surgeons and an overall rise in the advancement of facial plastic surgery.^7,8Figure 1 depicts the year-wise evolution of plastic surgery in India.⁹

Figure 1.

Year-wise evolution of facial plastic surgery in India.

As opposed to General Plastic surgery, the elite branch of Facial Plastic surgery usually deals with the structures above the neck. Plastic surgery is also alternatively referred to as aesthetic or cosmetic surgery.¹⁰ The effects of aging like loose skin, diminished tissue volume around the face and neck, crow's feet, hyperkinetic lines on the forehead, loss of jaw-line contour, drooping jowls, and double chin are often corrected with Facial Plastic surgery. Botox, fillers, thread lifts, nonsurgical/surgical rhinoplasty, blepharoplasty, browlift, genioplasty, rhytidectomy, and fat transfer are among the popular procedures done in facial plastic surgery.¹¹

However, a certain gap prevails in the literature regarding the current trends and advances in the field of facial aesthetics in India. Therefore, this article aims to discuss the past, present, and future of facial aesthetic surgery in India. By doing so, it analyses the growth of this field over time in terms of newer technology and procedures, studies the shift in the attitude of people toward aesthetic surgery, and attempts to gain a perspective into the prospects of this field. It individually addresses each procedure that is commonly performed in aesthetic surgery, not only evaluating their past practices but also recent advances.

METHODS

To provide a comprehensive review of the knowledge about previous practices and current trends in the field of facial aesthetic surgery in India, an electronic search was performed in October 2022, using the following databases: PubMed (National Institutes of Health, Bethesda, MD), LILACS (Latin American and Caribbean Center on Health Sciences Information, São Paulo, Brazil), MEDLINE (National Library of Medicine, Bethesda, MD), EMBASE (Elsevier, Amsterdam, the Netherlands), and Cochrane (Wiley, Hoboken, NJ). The keywords used in the search were “facial aesthetic surgery,” “nonsurgical aesthetic procedures,” “trends in plastic surgery,” and “rhinoplasty.” A partial gray literature search was performed using Google Scholar (Google, Mountain View, CA).

Appropriate keywords and Medical Subject Heading terms were selected and combined with the use of Boolean operators such as AND and OR. The keywords used were as follows: Facial aesthetic surgery, nonsurgical aesthetic procedures, trends in plastic surgery, rhinoplasty, Botox, kybella, fillers, India. The search was limited to publications in the English language, open-access articles available as full text and no restrictions were placed on the date and year of publication. Eligible articles included cross-sectional studies, surveys, case reports, quantitative and qualitative analyses, and reviews of the literature.

The initial PubMed search yielded 703 articles and abstracts. Three hundred eighty-one articles were excluded as they were not available as open-access full-text articles. Out of the remaining 322 articles, 198 articles were irrelevant to the objectives of the present study. One hundred twenty-four articles and references were screened by 2 reviewers, and 20 articles were included for an evidence-based synthesis of a structured scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guideline,¹² as designated in Figure 2. Key findings and descriptive characteristics of the included 20 studies were tabulated after data extraction, as depicted in Table.

Figure 2.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram describing the method of inclusion for selected studies.

Table.

Key Findings and Descriptive Characteristics of the 20 Included Studies

Sr no.	Author and year	Title	Study design	Sample size	Intervention	Key findings
1	Andrade et al (2011)13	Use of botulinum toxin (Botox) in the management of masseter muscle hypertrophy: a simplified technique		5	Injection of botulinum toxin type A (Botox) clinically, and to formulate a simple technique for administration of the drug to achieve optimal results	Satisfactory regression of the hypertrophied muscle with intramuscular injection of botulinum toxin
2	Ramesh et al (2019)14	Esthetic lip repositioning: a cosmetic approach for correction of gummy smile—a case series	Case series	3	Lip-repositioning technique and laser-assisted crown lengthening in vertical maxillary excess cases	Aesthetically enhanced smile
3	Shome et al (2018)15	An algorithm using Botox injections for facial scar improvement in Fitzpatrick type IV-VI skin	Prospective clinical study	100	Intramuscular Botulinum toxin was injected around the scar, to prevent movement of the facial muscles. 2 weeks postsurgery, Cicatrex (Kshipra Health Solutions, Mumbai, India) was used routinely TDS for 6 months along with fractional CO2 laser treatment performed every 4 weeks.	All patients had satisfactory results, as measured by a patient satisfaction survey and objectively by the physician assessment.
4	Shamban et al (2016)16	Noninvasive submental fat compartment treatment	A literature review	N/A		Kybella (Allergan, Irvine, CA) seemed to be extremely effective as a solitary noninvasive injectable treatment for reducing submental fat.
5	Kandhari et al (2020)17	Mesococktails and mesoproducts in aesthetic dermatology	A literature review	N/A		There is scarcity of RCTs and controlled trials to standardize the techniques of mesotherapy.
6	Vadera et al (2021)18	Innovative approach for tear trough deformity correction using higher G prime fillers for safe, efficacious, and long-lasting results: a prospective interventional study	A prospective, double-blind, study	30	Group A (n = 15)—conventional technique with low G Prime filler and Group B (n = 15)—lateral injection technique with a high G Prime filler was used.	Amount of filler required was lower in the group with lateral injection technique.
7	Kumar et al (2021)19	Nonsurgical rhinoplasty using hyaluronic acid dermal fillers: A systematic review.	A systematic review	N/A		>90% patients reported high satisfaction with nonsurgical rhinoplasty
8	Kalra et al (2008)20	Use of barbed threads in facial rejuvenation	Review	N/A		Shorter downtime and ease of use have made the barbed threads a popular modality for facelifts.
9	Goel et al (2022)21	Nonsurgical facelift-by PDO threads and dermal filler: a case report	A case report		4 pair mint PDO cog threads were used followed by injection of 5 mL of hyaluronic acid dermal filler for 2 sessions	Combined use of PDO threads and dermal fillers is an effective technique for face lift and to correct sagging.
10	Shome et al (2019)22	Use of micro-focused ultrasound for skin tightening of mid and lower face	A prospective clinical study	50	Subjects were treated using Ulthera 3.0 mm probes (Merz Pharma GmbH, Frankfurt, Germany) which targets deep dermis and 4.5 mm, which targets the superficial muscular aponeurotic system	Improvements in mid face and lower face were reported in 93% patients
11	Kumar et al (2022)23	The iceberg phenomenon of alopecia associated public health ramifications on the quality of life among adults in India	A descriptive cross-sectional study	800	Dermatology life quality index (DLQI) scale and the hair-specific Skindex-29 (HSS-29) scale was used as assessment parameters	The psychosocial impact of alopecia was greater in women than men.
12	Gupta et al (2019)24	Platelet-rich plasma as a treatment for androgenetic alopecia	Meta-analysis	N/A		PRP is beneficial in the treatment of alopecia when used for 3 moths including 3 sessions each month.
13	Shome et al (2021)25	Comparison of QR 678 and QR678 Neo as monotherapy and as combination therapy with 5% Minoxidil solution and oral Finasteride in the treatment of male androgenetic alopecia	Prospective clinical study	50	Group A (n = 25) was administered QR678 Neo solution whereas Group B (n = 25) was administered QR678 Neo along with topical 5% Minoxidil solution and oral finasteride.	QR678 is promising modality in nonsurgical hair restoration. It gives better results when combined with monoxidil and finasteride.
14	Kapoor et al (2020)26	QR 678 & QR678 Neo Vs PRP-A randomized, comparative, prospective study	Prospective clinical study	50	Group A (n = 25) was administered QR678 Neo solution whereas Group B (n = 25) was administered PRP.	The Group with QR678 administration gave better results when compared with PRP
15	Kapoor et al (2020)27	Evaluation of efficacy of QR678 and QR678 Neo hair growth factor formulation in the treatment of persistent chemotherapy-induced alopecia caused due to cytotoxic chemotherapy—A prospective pilot study	Prospective clinical study	20	Patients in postchemotherapy stage were administered 1.5 mL solution of QR678 Neo intradermally	QR678 showed significant safety and efficacy in the treatment of chemotherapy-induced alopecia.
16	Bhat et al (2008)28	Primary rhinoplasty: An Indian perspective	Prospective clinical study	316	patients were operated for primary rhinoplasty	Most excellent and good results were seen in cases of ill-defined nose, augmentation and deviated nose. Cartilage grafts, when used as a fill, produce soft, natural results.
17	Baser et al (2021)29	Nonsurgical rhinoplasty and use of hyaluronic acid based dermal filler-user experience in few subjects	Prospective clinical study	20	Rhinoplasty Outcomes Evaluation (ROE) was used to assess the results of rhinoplasty	The mean postprocedural ROE score was significantly higher than the pre-procedural score.
18	Naik et al (2009)30	Blepharoplasty: an overview	Case studies	2		Blepharoplasty requires a combination of therapies including fat excision, repositioning or transfer, simultaneous brow, or mid-face lift
19	Handa et al (2021)31	Asian blepharoplasty: the Indian perspective	Case studies	3		Indian eyelids may require a different technique/approach for blepharoplasty.
20	Chouhan et al (2021)32	Hair transplantation in androgenetic alopecia	Review	N/A		Acquirement of necessary expertise for hair transplantation in the near future in India may be a challenging task.

PDO, polydioxanone; PRP, protein-rich plasma; RCT, randomized controlled clinical trials; TDS, ter die sumendus (to be taken three times a day).

RESULTS

Nonsurgical Aesthetic Procedures

Modern facial plastic surgery has gone beyond the concept of a surgical approach for harmonizing the face to make it look more appealing. The recent past has seen a bloom in the use of aesthetic medicine for enhancing facial features. In today’s time and era, a physician must be well-versed in the chemical details of these agents, safe therapeutic options, hazards, and safety profiles attributed to these therapies, in addition to achieving optimal results, since there are more injecting agents available. There is also a sharp rise in the number of patients seeking less invasive procedures.³³ Botox, Kybella (Allergan, Irvine, CA), fillers, threads, micro-focused ultrasound (MFU), and nonsurgical hair restoration are some of the commonly performed procedures on an outpatient basis that are discussed further. Figure 3 depicts nonsurgical procedures performed in plastic surgery in 2020 in India.³⁴

Figure 3.

Percentage of various facial plastic nonsurgical procedures performed in India in the year 2020.

Botox

Botox, the synthetic form of Botulinum toxin, is used in small doses to relieve the contraction of facial muscles and hence, results in a wrinkle-free face with minimally invasive techniques. It is also used in the treatment of several other conditions, such as facial lines, rhytids, migraine, cervical dystonia, blepharospasm, and hyperhidrosis. In 2011, Andrade et al at Nair Hospital and Dental College, Mumbai, explained a simplified technique in which Botox can be used successfully for the treatment of masseter muscle hypertrophy.¹³ In recent times, Botox seems to have made a breakthrough in the field of aesthetic dentistry. Botox injections used in the correction of the gingival or “gummy” smile have a plethora of advantages such as noninvasiveness, immediate results, and lesser cost when compared with surgical procedures.¹⁴ It can also be used in the treatment of “black triangles,” a challenging aesthetic concern following the placement of dental prostheses. In 2018, Shome et al proposed an algorithm using Botox injections for the improvement of facial scars in Asian Indian patients, with Fitzpatrick's type IV-VI skin, in whom wound healing, and scar formation are of dramatic variation.¹⁵ Numerous complications such as erythema, edema, pain, ptosis of eyelid and brow, and ecchymosis due to the use of Botox were reported and reviewed by Sethi et al in 2021.³⁵ According to a global survey conducted by the International Society of Aesthetic Plastic Surgery in the year 2020, 44,800 Botox procedures were performed in India, which was still statistically lower than the preceding year,³⁴ as shown in Figure 4. However, this shift may be attributed to the COVID-19 pandemic and inconsistency in data assimilation.

Figure 4.

Year-wise number of Botox procedures performed in India.

Kybella

Kybella or deoxycholic acid is an adipocytolytic medication that is FDA approved for nonsurgical lipolysis. The subcutaneous injections of deoxycholic acid result in necrosis of the tissue due to its cytotoxic and detergent effects on the cellular layer.³⁶ In a study conducted by Ava T. Sambhan, over 70% of the participants found enhancement of the submental region after injection of 2 mg/mL of deoxycholic acid/cm². The common side effects were reported to be bruising, loss of hair and numbness.¹⁶ While surgical or laser-assisted liposuction remains the gold standard for the reduction of subcutaneous fat, injection lipolysis provides the advantage of minimal downtime, less pain, and minimal invasiveness of the procedure. However, injection lipolysis requires proper patient selection, good technique, and multiple sessions for appreciable results.¹⁷

Fillers

The present trend actively promotes less invasive volumetric rejuvenation treatments by subtly improving facial aesthetics with an emphasis on a more natural look. Gravity and aging cause volumetric changes in men and women, causing the skin to sag and look older than usual. Even though there are a plethora of permanent and semi-permanent fillers available in the market like poly l-lactic acid, hyaluronic acid, calcium hydroxyapatite, and polymethylmethacrylate. Hyaluronic acid is India's most commonly used filler, with an estimated 45,120 procedures carried out in 2020.³⁴ It is also the safest, with minimal allergic potential.³³ Hyaluronic acid fillers can be used in conjugation with botulinum toxin, lasers, and radiofrequency for more efficacious results.³⁷ In 2021, Vadera et al demonstrated an innovative approach to tear trough deformity using higher G prime fillers for safe and long-lasting results.¹⁸ Nonsurgical rhinoplasty, a cosmetic procedure that is rapidly gaining popularity in the Indian subcontinent for the correction of nasal deformities, is also done using hyaluronic acid dermal fillers.¹⁹ Complications in periocular aesthetic treatments such as allergy, hypersensitivity, infection, and vascular occlusion have been reported with the use of dermal fillers.³⁸

Threads

Due to gravitational effects, soft tissue ptosis develops in all areas of the face as facial aging progresses. The downward migration of the fibrofatty tissue in the cheek results in a tired and saggy appearance of the face. Threads can tighten and raise drooping or loose skin in various areas of the face and body to help mitigate the effects of gravity and aging, or they can be used to revitalize the face. There are three main types of threads currently available; polydioxanone (PDO), polylactic acid (PLA), and polycaprolactone (PCA). PDO threads are absorbed into the body over 6 months by hydrolysis and work by triggering fibroblasts to produce more collagen in a targeted area.³⁹ The conventional monothreads cause collagen formation which helps in skin rejuvenation with practically no side effects except for bruising and swelling at the site of insertion, which lasts for 1-2 weeks.⁴⁰ The barbs alongside the thread open like an umbrella and engages the underlying tissue, thus decreasing the skin sag.²⁰ The combined use of PDO threads along with dermal fillers is also being advocated to correct facial sagging.²¹ In the field of rejuvenation surgery, there is currently a trend toward noninvasiveness, as evidenced by the rising popularity of high-intensity targeted ultrasonic lifting and thread lifting.

Radiofrequency Microneedling

Radiofrequency microneedling (RFM) is a new technique used in the management of scars without causing damage to the epidermis and resulting in neocollagenogenesis.⁴¹ Alternatively, it can be implicated in periorbital wrinkles. RFM with insulated tips has been developed for the management of wrinkles, acne scars and melasma, along with total face rejuvenation.⁴²

Micro-Focused Ultrasound

A surgical facelift has been the most popular method for the treatment of facial sagging and wrinkling for decades. However, it is associated with a plethora of unavoidable complications such as anesthesia-related injury, excessive scarring, bleeding, and numbness or disruption of the motor activity of the underlying muscles. The increasing patient demand for noninvasive procedures brought about the advent of MFU. This procedure derives its name from the practice of using high-frequency ultrasound waves, which are literally micro-focused at a point in the skin. It is also commonly referred to as HIFU, short for high-intensity focused ultrasound. The ultrasound waves emitted from the probe cause a well-defined thermal injury, resulting in collagen shrinkage and breakdown, which in turn induces neocollagenesis. MFU is indicated in eyebrow lift, chin and neck lift, and for the improvement of lines and wrinkles.⁴³ Shome et al, in the year 2019, documented the use of MFU for the first time in India. The study showed a positive outcome for the Indian population in terms of overall aesthetic improvement as well as patient satisfaction.²²

Nonsurgical Hair Restoration

Hair thinning or baldness alters the appearance of a person impacting their psychological and social behavior. This psychosocial impact is greater in women when compared with males who are suffering from the same.²³ Scientists, doctors, and researchers have been in a race to find a remedy for the increasing situation of hair thinning among the population. Angiogenesis, androgen antagonism, vasodilation, potassium channel opening, and 5-alpha reductase inhibition are the major nonsurgical therapeutic strategies for hair growth promotion.⁴⁴ Protein-rich plasma (PRP) has been widely used for hair restoration with no known side effects, where growth factors like VEGF, FGF, IGF, EGF, TGF-B, and PDGF help in the stimulation of the dormant follicle when administered at an interval of 1 month, for 3 sessions.²⁴ QR-678 preparation is a plant-derived polypeptide solution that contains a variety of growth factors, which when injected intradermally, boosts the follicles, thus accelerating new hair growth. This preparation when injected intradermally is proved to boost hair growth in patients with androgenetic alopecia, and chemotherapy-induced hair loss, and is known to give better results than PRP.^25–27 Other adjuvant therapies like growth factor concentrate, dermaroller, and low-level laser light therapy, along with medical management like topical application of Minoxidil and oral supplements of finasteride are known to enhance hair growth in an individual.²⁵

Surgical Procedures

India is one of the top 5 countries in the world in terms of the number of people who undergo cosmetic surgery.³⁴ Facial aesthetic surgery is an area of expertise that primarily works on correcting and improving facial imperfection, further enhancing the face. They are used routinely to enhance the appearance of an individual or to correct deformities in the anatomical area limited to the head and neck. Facial plastic surgery by itself includes a wide variety of surgeries, including rhinoplasty, blepharoplasty, hair transplant, and facelift procedures, as depicted in Figure 5.⁴⁵ Even though facial plastic surgery procedures are comparatively safer, the advent of newer technologies in the surgical field has substantially deducted the rate of morbidity in facial plastic surgery.⁴⁶

Figure 5.

Percentage of various facial plastic surgical procedures performed in India in the year 2020.

Rhinoplasty

In the Indian subcontinent, an ill-defined nose with a lack of projection and a broad osseocartilaginous framework is commonly encountered, requiring augmentation more often than reduction.⁴⁷ The advent of open rhinoplasty has revolutionized the treatment of complex nasal deformities such as cleft-lip rhinoplasty and severely deviated noses. Initially, a closed or intranasal approach for lateral osteotomy was employed, but it has since changed to the external percutaneous technique because it offers better control and is simpler to execute. Furthermore, it is preferable to conduct a transverse osteotomy at the level of the medial canthi rather than a greenstick out-fracture because the latter is simpler.²⁸ Though a relatively simple surgery, Heilbroom C 2020, concluded that rhinoplasty is associated with risks of scarring, keloid formation, paresthesia, discoloration, need for revision surgery, and saddle nose deformity.⁴⁸ Rhinoplasty surgeons in India have noticed a shift in patients’ desire to achieve a perfect nose without the need to go under the knife in recent years, as depicted in Figure 6.³⁴ It has been concluded that nonsurgical augmentation rhinoplasty is welcomed by patients and doctors alike due to the remarkably low incidences of complications.²⁹

Figure 6.

Year-wise number of surgical rhinoplasty procedures in India.

Blepharoplasty

The periocular soft tissues typically experience the normal physiological senile changes that cause dermatochalasis. In a surgical treatment called a blepharoplasty, the patient's eyelid skin, orbicularis oculi muscle, and orbital fat are removed, re-draped, or molded in order to improve their aesthetic appearance and address any functional abnormalities.³⁰ Blepharoplasty has been labeled as the fourth most commonly done facial aesthetic surgical procedure, with around 13,000 procedures performed in 2020 in India. With the advent of the double blepharoplasty technique of Mikamo at the end of the 19th century, there have been significant developments in the idealized periorbital appearance of the Asian patient.³¹ In a review of complications of blepharoplasty, Lui proposed that the most dreaded complications are hematoma formation, infection, dry eyes, Blepharoptosis, retrobulbar hemorrhage, rarely vision loss, and aesthetic complications.⁴⁹

Hair Transplantation

Male androgenetic alopecia and female pattern baldness are the two most common modalities requiring hair transplantation. Follicular hair transplantation is a modern technique upon which modern hair transplantation is based.⁵⁰ The follicular unit excision (FUE) has gained more popularity over the follicular unit transplantation or strip harvesting method as the latter involves a risk of linear scarring at the donor area and a longer time of recovery when compared with its counterpart.³² FUE has a lesser recovery time, lesser discomfort, and affordability and leaves a virtually undetectable scar. Despite hair transplants having a long list of risks, including infection, donor-site effluvium, hemorrhage, scarring, and blood loss, it is the most preferred surgical method for treating androgenetic alopecia.⁵¹

Facelift

Surgical facelift or rhytidectomy is a procedure that eliminates wrinkles, creases, and folds caused by aging or gravitational forces. This is brought about by the manipulation of the superficial musculoaponeurotic system (SMAS) layer. Plication, elevation and imbrication, and SMASectomy are the primary methods advocated for this procedure.⁵² In addition to cosmetic surgery, the surgical facelift also plays a crucial role in corrective surgery. It is an aesthetically superior approach to parotidectomy,⁵³ thyroidectomy,⁵⁴ and orthognathic correction for facial rejuvenation.⁵⁵

DISCUSSION

Facial plastic surgery is unquestionably a growing branch in India. A large number of Indian plastic surgeons have made a significant contribution to the development of this field with their innovative techniques, procedures, and research over the course of time. India is among the top 10 countries in terms of the patient market as well as the number of cosmetic procedures carried out yearly.³⁴ These procedures are broadly classified into surgical and nonsurgical procedures. The nonsurgical procedures have shown a noteworthy rise in number when compared with their surgical counterparts, as depicted in Figure 7.

Figure 7.

Comparison between total surgical and nonsurgical procedures in India.

In his study on the prospects of noninvasive dermatological procedures,⁵⁶ Murad Alam determined that skin tightening, resurfacing, and fat-reducing energy devices combined with fillers and injectable neurotoxins have minimal downtime, associated risks and are likely to continue in the future in lieu of newer technological breakthroughs. Complex feedback devices, nanotechnology, and cell-based therapies have been predicted to gain a stronger foothold in the foreseeable future.

The use of botulinum toxin, as discussed earlier in this paper, is a novel therapeutic tool in the fields of neurology, ophthalmology, urology, and rehabilitation medicine but its application in facial aesthetics sets it a class-apart when compared with the other available treatment modalities for facial rejuvenation.⁵⁷

The findings of this study agree with those of Braccini that the more radical and external approach of large dissection in rhinoplasty is now becoming less common. The newer trends in rhinoplasty procedures are simplified with the objective of reducing surgical trauma, optimizing downtime, and progressively shifting toward nonsurgical solutions.⁵⁸

Chuang et al in 2016 conducted a similar study in China, highlighting the current developments in facial plastic surgery and concluded that the field of facial plastic surgery is evolving with innovative advances in both surgical as well as nonsurgical domains backed by adjunctive technologies and computer-based advances.¹¹

Narurkar concluded in their study that 82% of the complications due to facial aesthetic procedures occurred due to no direct supervision of the physician, and 78% occurred in nontraditional medical facilities such as free-standing medical spas and laser centers in shopping malls.⁵⁹ The study highlighted the need to ethically practice aesthetic procedures by regulating the practices of medispas in order to prevent complications and potential medicolegal liabilities.⁶⁰

A potential limitation of this study is that it fails to elaborate interesting procedures such as 3D imaging and printing, endoscopy, new biomaterials and tissue engineering, as well as surgical procedures such as facial reanimation and facial transplantation. Nevertheless, elaborate data is too sparse to comment on the trends and advances in these fields.

Implications of Aesthetic Surgery in Human Psychology

The face, more than any part of the body, communicates identity, and emotion. Facial appearance plays a crucial role in formulating a positive body image. Body image dissatisfaction has led to an increased prevalence of psychiatric and psychosocial comorbidity, such as depression, social phobia, and body dysmorphia.⁶¹ This implies that aesthetic surgery has not only physical components but also social and psychological. In a study conducted to assess the outcome of treatment in a group of aesthetic surgery patients, the results showed surgery to be an effective modality of addressing psychological issues related to body image.⁶² These results were synonymous with those found by Cole et al, measuring outcomes in low-priority plastic surgery patients using quality of life indices.⁶³ Due to modernization and access to western media, the beauty standards in India have evolved. More Indian women, when compared with men, tend to have anxiety and stress related to their appearance and think that cosmetic procedures can improve their looks.⁶⁴ Chowdhury et al⁶⁵ demonstrated increased self-esteem in rhinoplasty patients after comparing pre- and postoperatively in Indian patients. However, the cost is the most important variable in considering surgery among the masses and is the greatest limitation to the reach of aesthetic surgery.⁶⁶

Patient Intent for Aesthetic Surgery

The reason patients seek aesthetic surgery range from altering their facial appearance to improving their self-esteem or alleviating body image dissatisfaction. Both personal and interpersonal factors, along with an increased level of concern about personal appearance influence the decision to undergo aesthetic surgery.⁶⁷ A pilot study was conducted by Geetha and Priyadarshini in 2013 to assess the intent of Indian patients for undergoing aesthetic surgery. The study noted that body image satisfaction, the influence of closed ones, appearance investment, and perception of others, along with fierce advertisement strategies in the market, are the major factors responsible for the altered patient attitude toward aesthetic surgery.⁶⁸

Recommendations

The statistical data pertaining to aesthetic plastic surgery in India are sparse and only available to the masses through an annual global survey conducted by the International Society of Aesthetic Plastic Surgery. The result of this survey is inconsistent and variable each year as it depends upon the participation of plastic surgeons, which may be selective and partial. To overcome this limitation, adequate documentation and records of the procedures carried out should be maintained, analyzed, and published. This can be achieved through the medium of an online national database, similar to the Tracking Operations and Outcomes for Plastic Surgeons or, the TOPS system in the United States.⁶⁹ This would provide insight into the current clinical scenario and facilitate an improvement in practice.

In accordance with Section 65 of the Finance Act of 1994, plastic surgery, with an exception for the correction of anatomic deformities, is a taxable service in India.⁷⁰ Since the introduction of the Central Goods and Services Tax Act in 2017,⁷¹ a whopping 18% Goods and Services Tax is levied on aesthetic procedures as opposed to any other medical procedures which are either exempted or minimally taxed. An increased surgery cost makes it inaccessible to a large population, especially those belonging to a low socioeconomic group, further adding to their psychological burden. It is essential to independently assess the outcome of aesthetic interventions on psychological health by utilizing various health status instruments and indices.⁶² The results of these studies would help the Ministry of Finance determine the priorities in health services by expanding the scope of aesthetic surgery and subsequently, its reach.

The themes of this study are based on certain key determinants which encapsulate the major constructs of the evolution of facial plastic surgery in India. These key determinants were congregated through a thematic deduction after conducting the present study. The thematic deduction of data extracted from the screened articles of a similar domain is presented in the form of an infographic in Figure 8.

Figure 8.

Key determinants of facial plastic surgery in India.

CONCLUSIONS

Corrective and reconstructive surgery has formed the basis of plastic surgery since its dawn, and India has stepped into a revolutionary era of facial aesthetic surgery. However, in modern times there appears to be a shift in patient desire for aesthetic surgery. Patients largely seek noninvasive procedures that cater to their desired appearance. The recent spurt of such noninvasive methodology and increased awareness among the general population has resulted in the formulation of revolutionary inventions and procedures in India. Modern technology and innovative procedures have brought the Indian cosmetic market to par with other leading countries. The COVID-19 pandemic, its repercussions, such as the worldwide lockdown, the need for stricter asepsis protocols, and its effect on the global economy have adversely affected the industry of aesthetic surgery. However, certain gaps still exist in the literature that needs to be noticed, addressed and filled.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article, including payment of the article processing charge.