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At one point or another, we've all been influenced to buy something we saw online. Whether it was a post by a celebrity, sponsored content from an influencer, or an advertisement, chances are great visuals and/or some well-executed targeting were enough to persuade you to part with your hard-earned money. For some, this extends beyond wellness tinctures and cute clothes to cosmetic treatments and procedures. 

We use [social media](https://aedit.com/aedition/march-2020-study-shows-relationship-between-social-media-cosmetic-surgery) for so many aspects of our lives, and aesthetic medicine is no exception. On one hand, with conversations around plastic surgery normalizing, patients are more comfortable sharing their experiences (hi, [Marc Jacobs](https://aedit.com/aedition/marc-jacobs-facelift)). On the other hand, providers are finding their social media presence to be an increasingly important element of connecting with prospective patients — and this goes beyond sharing before and after photos. 

Today, dermatologists, plastic surgeons, and the like use their social media platforms as a place to spotlight who they are and how they work, all while cultivating an heir of both credibility and approachability that encourages followers to trust them and maybe even book a consultation. But, with so much misinformation online, it can be hard to know who to trust or what to look for. 

To better understand how to successfully use social media during the research phase of finding a provider, we spoke to physicians and patients alike. Below, AEDIT providers share how they showcase their work in the digital age, as a patient shares her experience finding a surgeon for her rhinoplasty surgery online.

## **What Providers Use Social Media For**
Individual social media feeds and strategies are as unique as fingerprints at this point, and the content aesthetic providers post is no exception. Ultimately, the look and feel of their account(s) depends on their specialty and who they are trying to reach. Some dermatologists and plastic surgeons exclusively post before and after images of their most popular procedures. Others share footage from the treatment room. All the while, there are those who take a more personal approach by keeping medical content to a minimum in favor of focusing on themselves and their families or even creating a lifestyle of sorts. And then there are the providers who do a little bit of everything.

[Melissa Doft, MD](https://doftplasticsurgery.com/), a double board certified plastic and reconstructive surgeon in New York City falls into the latter category. Her Instagram feed ([@doftnewyork](https://www.instagram.com/doftnewyork/)) features a beautifully curated collection of editorial imagery among pics from her travels, media clippings, patient testimonials, and, yes, the occasional B&A. “I like to share some photos of my family and vacations sometimes,” she says. “It helps to keep things human.” Even so, the primary goal of her feed is to give her patients (current and future) something aesthetically pleasing — and maybe even a bit aspirational — to look at. 

## **Instagram vs. TikTok**
If you are researching potential providers and wondering what social media platform you should be on, the answer is not as cut and dry as it used to be. While Instagram had long been the undisputed go-to, frequent tweaks to its content guidelines and algorithm have made it difficult for providers to showcase certain parts of their practice (think: potentially graphic procedure footage). As a result, TikTok now plays host to a growing number of doctor accounts. “We post more videos to Stories and Reels on [Instagram](https://www.instagram.com/jasonemermd/), and [TikTok](https://www.tiktok.com/@jasonemermd?lang=en) is popular, too,” says [Jason Emer, MD](https://aedit.com/provider/jason-emer-md-722), a board certified dermatologist in West Hollywood, who can be found at @jasonemermd on both platforms.

While Dr. Emer still uses static before and after photos for some posts on Instagram, his use of video gives patients who want to know what's going to happen during treatment the opportunity to learn about the procedure(s) they’re considering prior to coming in for a consultation. [Jason Roostaeian, MD](https://aedit.com/provider/jason-roostaeian-md-449), a board certified plastic and reconstructive surgeon in Los Angeles, has begun to adopt a similarly video-driven approach. On his [@drjasonplasticsurgery](https://www.instagram.com/drjasonplasticsurgery/) Instagram account, you’ll see Reels of patients holding their ‘before’ photos while being filmed to show the results of their procedures mixed in amongst more traditional before and afters.

The most significant difference when it comes to determining whether Instagram is still the standard-bearer in the search for a cosmetic dermatologist or surgeon comes down to whether it's the place you spend the most time scrolling. At the moment, [gen Z and younger millennials](https://aedit.com/aedition/aedit-survey-reveals-how-2020-altered-aesthetic-landscape) are generally more active on TikTok than Instagram, while IG still reigns supreme for older millennials and gen X.

## **How to Find a Provider on Social Media** 
Cautionary tales were echoed by Dr. Doft, Dr. Emer, and Dr. Jason: Not everything you see online is to be believed, nor does a massive following on social media mean a provider is the right person to perform your procedure. “Before and after photos are valuable, but photos taken shortly after surgery don't take things like [swelling](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery) and [long-term healing](https://aedit.com/aedition/how-long-does-it-takes-to-recover-from-cosmetic-surgery-procedures) into account,” Dr. Jason warns. 

While there is no universal governing body dictating how before and after photos must be presented, best practices indicate that, depending on the procedure, they sometimes need to be taken weeks, months, or even years apart. As such, be wary of the provider who is showing ‘after’ photos of surgeries like rhinoplasty from the operating room, doesn’t use consistent lighting, or isn't showing multiple angles of a result. Dr. Doft says cases of photoshop run rampant on social media, so be sure to read plenty of reviews in addition to pursuing images. Still have questions? Check out our [complete guide to viewing before and after photos](https://aedit.com/aedition/importance-of-before-and-after-photos-in-plastic-surgery).

While the rise in the quality and quantity of the information available about plastic surgery and cosmetic procedures has generally increased for the better, it’s important to keep in mind that your honorary MD from Google does not replace the advice of a trained professional. Dr. Emer says one of the issues with social media is that patients often come in with inspiration images that are not realistic for their anatomy or arrive dead set on a specific procedure regardless of whether or not it makes sense for them. It’s important that you find a provider who is willing and able to give it to you straight, so that you receive the best treatment for your needs and aesthetic goals.

Last but not least, don’t forget about the human element. We all likely know someone in our own lives who comes across one way on social media and another way in person. Since rapport and bedside manner are such important components of the provider-patient relationship, take the time to find someone you trust both online and IRL. At the end of the day, all of the scrolling in the world cannot replace a [virtual](https://aedit.com/aedition/virtual-consultations-telemedicine-plastic-surgery-dermatology-cosmetic-dentistry) or in-person [consultation](https://aedit.com/aedition/questions-to-ask-your-doctor-during-plastic-surgery-consultation) with a provider.

## **Patient Perspective**
Finding a provider, particularly if you've never had a cosmetic procedure before, can feel super overwhelming. Jenni*, a patient who had [rhinoplasty](https://aedit.com/procedure/nose-shaping-solutions) when she was 22, used social media to narrow down her search for a surgeon, and here she opens up about what she learned from the process.

<Dialogue>
  <Question party={The AEDITION}>
    When you were looking for a surgeon, what did the research phase entail?
  </Question>
  <Response party={Jenni}>
    First, I asked my closest friends if they had anyone to recommend, which gave me the ‘master list’ that I worked from. I took each of those doctors' names and searched for them online. I looked at patient reviews, before and after photos, and read through comments from their followers.
  </Response>
  <Question party={The AEDITION}>
    How did the information you gathered online influence your decision?
  </Question>
  <Response party={Jenni}>
    I was looking for a surgeon who created natural-looking results and who was someone I felt comfortable with. Before and after photos were very influential for me, but I also think I got a feel for surgeons from their social media presence. I wanted to be able to trust the person who was operating on me entirely. Hence, surgeons who over-shared online, particularly with images during surgery, went to the bottom of my list.
  </Response>
  <Question party={The AEDITION}>
    What was it like meeting the providers in person for a consultation?
  </Question>
  <Response party={Jenni}>
    One of them in particular didn't give off the same vibe in real life as online. I guess it's a bit like online dating. We've all been there, right? The other two I consulted fell in line with what I expected from their online presence. They were very approachable and offered the kind of look I was hoping to achieve. The surgeon I ended up going with didn't have so many before and after photos on his socials, but I went to the consultation based on the fantastic reviews I read. He ended up showing me tons of past patient photos in person and talked me through what to look for in them, which was so helpful.
  </Response>
  <Question party={The AEDITION}>
    Do you have any advice for people in the process of researching providers?
  </Question>
  <Response party={Jenni}>
    I'm so pleased I asked friends. I think that's something I'd recommend to everyone, where possible. I wouldn't be as obsessive about looking through before and after photos if I started my search again. It isn't easy to gather what a surgeon could do for you from their work on other people. The best information to form an educated decision came from the consultations I had. I recommend going to a few different surgeons and figuring out who you feel will be your best option.
  </Response>
</Dialogue>

## **The Takeaway**
When it comes to researching aesthetic providers and learning more about cosmetic procedures, social media can play a very helpful and important role in the discovery process. Scrolling through before and after photos and treatment videos on Instagram and TikTok can help narrow down the search, but be careful not to be swayed by large followings or deceived by duplicitous editing. At the end of the day, choosing a provider is a deeply personal decision and nothing can replace a face-to-face consultation. 

*The patient's name has been changed

Aesthetics

The short answer: maybe. To better understand how to successfully use social media during the research phase of finding a provider, we spoke to physicians and patients alike.

How To Find A Plastic Surgeon On Social Media

Should You Use Social Media To Find Your Plastic Surgeon?

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To be honest, I never really thought much about my breasts — until I started to lose them. They were always on the smaller side of average, yet, due to my height (I’m 5’9”), I believed they looked even smaller and flatter than they actually were. I felt like my shoulders and the flatness of my torso made my upper half just look… long. But, once I started to run marathons, the volume loss and deflation became a serious insecurity for me.

## **The Decision-Making Process**
As much as I told myself that there was something impossibly chic about having tiny breasts (I mean, it’s good enough for Kate Moss!), I couldn’t stop myself from obsessing over my chest after every single run. I even bought a seamstress-style tape measure. And then a second one. I was certain the first was wrong — there's just *no way* that my A-cup bra could be baggy. It must be the tape.

It was a rude lesson to learn that losing weight is the same as gaining it. We can’t choose the body area where it comes and goes, and that deflation from volume loss is *real* (I still don’t know why I thought they would stay perky if they were flat as a pancake). But it wasn't until one Saturday, about six miles into a long run, that I realized I wasn't wearing a sports bra (or any bra for that matter) and I hadn't even noticed. At that moment, I began to seriously consider medical intervention in the form of [breast augmentation with implants](https://aedit.com/procedure/breast-augmentation-with-implants).

Then the [COVID-19 pandemic](https://aedit.com/aedition/plastic-surgery-dermatology-cosmetic-dentistry-practices-reopening-during-covid-19) happened. I certainly couldn’t stop running now — it was my only activity! But, as it did for many, the pandemic certainly put things in perspective. I always expected to get a ‘[mommy makeover](https://aedit.com/concern/mommy-makeover)’ after I had children, with a breast procedure or two on the list. But, over the last year, my perspective evolved into: What the heck am I waiting for?

## **The Consultation**
“How much volume did you lose?” my plastic surgeon, [Adam Kolker, MD](https://www.drkolker.com/), immediately asked when I began our [breast augmentation](https://aedit.com/procedure/breast-augmentation-solutions) consultation by blaming marathons for my newfound insecurity. *“How did he know?”* I thought, as we sat socially distanced with me in a chair on one side of the office, Dr. Kolker on the opposite side, and his right-hand RN, Ashley, standing against the wall between us. All of us were masked, temperature-checked upon arrival, and sanitizing our hands like crazy. Although we were all vaccinated, both rising cases and the chaotic Delta variant were increasingly worrisome. 

During the examination portion of our consult, Dr. Kolker and Ashley measured my breasts in a few different ways (think: the collarbone to nipple, nipple to base, and width, among others). We discussed my goals — “natural but juicy,” I told him — but my main concern was balancing out my tall silhouette with implants that look like they belonged on my body’s shape. Then they took the ‘before’ photos and opened a briefcase of implants to try on and take for a test drive. Dr. Kolker recommended I ignore the [measurements on the implants](https://aedit.com/aedition/how-to-get-the-most-natural-looking-breast-implants) and decide what I liked based on the look and feel, not the number of CCs. 

Left alone, I tried on every single one, starting with the largest. I placed each set of implants in my bra and modeled from every angle. I felt like Goldilocks, and giving the different sizes a test run was immensely helpful for me to determine just how large I wanted to go. When Dr. Kolker returned to wrap up our conversation about size goals, I told him that I thought 250-ish CCs looked the most proportional to my body. He noted my preference and explained that the final decision on CC amount is decided in the OR, based on several factors that are revealed only once the incision is made. We also went over his instructions for pre-surgery care. As I was heading out, Ashley asked me to send a photo of my COVID-19 vaccination card before the big day. 

## **The Surgery**
On the day of the surgery, I arrived alone — no companions allowed — and went over what to expect before and after the surgery with Kat, the recovery room nurse. Dr. Kolker then came in to review our surgery goals once again, take a few more photos, and finally — the dramatic moment I was waiting for — [draw on my body with a Sharpie](https://aedit.com/aedition/purpose-of-a-plastic-surgeons-markup-pen-during-cosmetic-surgery) just like they do in movies. At that moment, it all felt very real. I thought to myself, *“I have Sharpie on my body, it’s REALLY happening!”*

In the last, and less dramatic, step before walking to the OR, I had a tête-à-tête with the [anesthesiologist](https://aedit.com/aedition/everything-you-need-to-know-about-anesthesia) to align on our sedation plan. I asked him what the likelihood of accidentally waking up mid-surgery (a new-found fear), and he said he was zero for 60,000-plus, meaning that he’s managed more than 60,000 surgeries and zero patients have woken up before they were meant to. I felt very safe and that weird new fear became a memory as we walked to the [operating room](https://aedit.com/aedition/unexpected-things-to-know-about-the-plastic-surgery-operating-room) to meet Ashley and Dr. Kolker.

I was very impressed with the OR — all of my information was splashed up on a wall-mounted TV across from Dr. Kolker, music was playing, the temperature was chilly (my favorite), and Ashley put a pillow under my knees for extra circulation. It felt kind of like a spa, until the anesthesiologist attached the needle. 

Next thing I know, I woke up in the recovery room with Kat, who told me that my friend was on her way to the office to pick me up. Three juice boxes later, I was cleared to go home and hopped in an Uber.

It was all very efficient and speedy: neither Dr. Kolker nor his nurses overstayed or lingered. They came in, got down to business, answered my questions with care and compassion, and left because, after all, we were still indoors, in small treatment rooms, during a pandemic.

## **Post-Op**
Happily, the [breast implant recovery process](https://aedit.com/aedition/breast-augmentation-recovery-healing-process) wasn’t as intense as I predicted. Pain was manageable, and I only took prescription pain killers for the first two days and then just Tylenol after that. The first few days post-op were mostly just uncomfortable. My chest felt pressure but rarely pain unless I forgot I just had surgery and tried to open our heavy fridge door. [Sleeping](https://aedit.com/aedition/sleeping-better-after-cosmetic-surgery-aesthetic-procedures), however, was nearly impossible for the first week. Imagine trying to sleep sitting up straight — and I mean stiff-as-a-board-straight — with a [pillow fort](https://aedit.com/aedition/best-pillows-for-plastic-sugery-recovery-healing) all around so you are immobile. 

Dr. Kolker called me the day after surgery to check in, and I went back into the office on day seven for my first post-op appointment. On my post-care sheet, Dr. Kolker recommended a few [specific options for sports bras](https://aedit.com/aedition/benefits-of-compression-garments-after-cosmetic-surgery) to wear at one-week post-op, and I brought them along. I was temperature checked, masked, and ushered into a treatment room, where Dr. Kolker inspected [swelling](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery), the incisions, and the implants, followed by taking a set of photos. I was instructed to wear a heavy-duty sports bra 24/7, along with a white strap that sat right above the implant to help with settling.

Two days later, I had a mini freakout that my sports bra was compressing my implant too much and called the office. Rather than have me come by (which I suspect they would have had me done in ‘Normal Times’), Dr. Kolker hopped on FaceTime to visually inspect my compression concerns and reassure me.

On day 14, I began a set of three implant displacement ‘massages,’ which are very much not massages but rather awkward-feeling push and pull movements to encourage the implant to move, reducing the risk of capsular contracture. I was cleared by Dr. Kolker to take long walks and even a quick dip in the pool, but I still had to wear the sports bra and strap for most of the day. 

At my week four in-office post-op appointment, Dr. Kolker evaluated my healing progress and took another round of ‘after’ photos. I couldn’t stop gushing about how happy I was with the size and the totally manageable recovery. Somewhere around week three, I stopped feeling discomfort when lying down and sleeping became fun again. At the one-month mark, I was allowed to start wearing regular bras during the day, and I raced home to online shop — adding only the sexiest and laciest push-up bras to my cart.

## **My Takeaway** 
This past year, I’ve lost any sense of being able to evaluate what is weird. I may be in the minority, but I don’t think that my experience of getting breast implants during a pandemic deviated *that* much from what the surgery would have looked like in pre-COVID times. Aside from the masking, sanitizing, and temperature checking, it seemed business as usual. All of my post-op visits, just like my [consult](https://aedit.com/aedition/questions-to-ask-your-doctor-during-plastic-surgery-consultation), were very efficiently managed but never rushed, just the good sense to discourage anyone to linger in tight spaces unnecessarily. 

I couldn’t be more thrilled with my results. My body finally looks proportional and natural, which I always kind of thought was just a thing you say to be nice — but they *actually* look natural! Hands down, I’m happy that I didn’t wait. Pandemic or not, I’d do the surgery again.

Patient Perspective

It was weird, but definitely not as weird as I was expecting.

What It's Like To Get Breast Implants During The COVID-19 Pandemic

What It’s Really Like To Get Breast Implants During A Pandemic

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There’s no question that Botox® and its fellow [neurotoxins](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin) (hi, Dysport®, Jeuveau®, and Xeomin®) are among the most efficacious and popular non-surgical wrinkle reducers in aesthetic medicine. Botulinum toxin type-A (BoNT-A) has come a long way since its accidental cosmetic discovery by ophthalmologist Jean Carruthers, MD, and her dermatologist husband Alastair Carruthers, MD, in 1987. The couple noticed a smoothing and anti-wrinkle effect on the forehead of patients who were being injected with Botox® to treat uncontrollable blinking and eye spasms known as blepharospasm. 

Fast forward to today, and the toxin has drastically advanced in terms of both its approved and off-label uses. The uses of [Botox®](https://aedit.com/procedure/botox) and its competitors are seemingly endless. They have been used to address everything from [minimizing crow’s feet](https://aedit.com/procedure/periorbital-botox) and migraines to [slimming the jawline](https://aedit.com/procedure/jawline-slimming-with-botox) and [reducing the amount of sweat](https://aedit.com/procedure/botox-for-hyperhidrosis) your body produces with little to no downtime and minimal pain (the injection feels like a pinprick). 

When it comes to lines and wrinkles, neurotoxins work by temporarily paralyzing muscles for cosmetic effect. By injecting BoNT-A into areas where repeated muscle contractions occur (think: in-between the middle of the eyebrows, the outer corners of the eyes, and the forehead), the lines, folds, and furrows that would normally etch themselves into the skin are softened. The results are not immediate — initial benefits start to be visible at the five-day mark, with full results at two weeks — and they don’t last forever. For most patients, Botox® and the like naturally degrades over the course of three to four months, which is why [upkeep is essential](https://aedit.com/aedition/how-frequently-to-get-non-surgical-cosmetic-procedures-like-dermal-filler-botox-chemical-peel).

But what if the effects of the wrinkle-reducer start to fade after only a few weeks? Or what if, after years of success, you are hardly seeing a result anymore? You may be resistant to Botox®, and we’re talking to experts to understand why. 

## **What Is Botox Resistance?** 
Known as ‘Botox resistance,’ some patients may develop an immune response to Botox® that reduces the effectiveness of the treatment, says [Steve Fallek, MD](https://www.fallekplasticsurgery.com/), a board certified plastic and reconstructive surgeon and medical director of [BeautyFix MedSpa](https://www.beautyfixmedspa.com/). “The protein complex in the product may stimulate neutralizing antibodies,” he explains.

While BoNT-A is the primary active ingredient in cosmetic neurotoxins, the exact formulation of each brand is unique. Botox® (a.k.a. [onabotulinumtoxinA](https://media.allergan.com/actavis/actavis/media/allergan-pdf-documents/product-prescribing/20190626-BOTOX-Cosmetic-Insert-72715US10-Med-Guide-v2-0MG1145.pdf)), for example, features a proprietary blend of protective proteins alongside inactive ingredients like human albumin (i.e. plasma proteins) and sodium chloride. As such, it’s not just Botox® that can stop working — the effect can occur with any injectable neurotoxin. “Therapeutic proteins, including the core neurotoxin found in all neuromodulators on the market today, can induce immunogenicity, or an unwanted immune response,” says [Brian Biesman, MD](https://drbiesman.com/), a board certified oculofacial plastic surgeon in Nashville, TN. “Yet, the critical factors for neutralizing antibody formation are not well characterized.”

Neurotoxin resistance is nothing new. There are [scholarly publications](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872090/) dating back to 2013 referencing Botox® immunity and the potential for antibody formation in certain individuals, says [John Layke, DO](https://aedit.com/provider/john-layke-645), a board certified plastic and reconstructive surgeon and co-founder of [Beverly Hills MD](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fbeverlyhillsmd.com%2F). The first incidents came from medical uses of Botox®, which employs higher doses of the neuromodulator. “Usually, immunity is a very dose-dependent thing,” notes [Paul Jarrod Frank, MD](https://pfrankmd.com/), a New York City-based board certified dermatologist. “For cosmetic uses, Botox® doses tend to be rather small, which is why it is not very common to develop a true immunity to the product.” 

As Dr. Frank explains, there is a difference between actual resistance and patient satisfaction. “The development of antibodies causes true Botox® immunity,” he says. “However, many people claim to experience Botox® immunity because they symptomatically feel that Botox® — or another neuromodulator — does not do what it used to do.” This is especially common among those who have been going under the needle for years. “As we get older, some of the simpler cosmetic treatments become a law of decreasing return,” Dr. Frank shares. “Some people will assume that if things don't give the same effect at age 40 as they did for them at age 30, they are now immune to the product.” While the treatment may not be as effective, such patients are not immune. “That is a psychological thing and not so much of a true immunological antibody immunity,” he notes.

If the body does in fact develop antibodies, the patient will not see as dramatic of a result — or any result at all. “Actual immunity, when people get less sensitive to Botox®, is that the body responds with antibodies to the product,” Dr. Frank says. “Once those circulating antibodies are in the bloodstream, they will attach to the Botox® molecule.” So, as the immune system produces the antibodies, repeat injections of Botox® or other neurotoxins begin to become less active in the treated areas. 
 
Unfortunately, the only way to tell if you are producing antibodies is with visible evidence (i.e. lack of results). [Clinical trials](https://media.allergan.com/actavis/actavis/media/allergan-pdf-documents/product-prescribing/20190626-BOTOX-Cosmetic-Insert-72715US10-Med-Guide-v2-0MG1145.pdf) released by Allergan (the manufacturer of Botox®) show that no more than 1.5 percent of patients develop any “neutralizing antibodies.” In short, only about one in 10,000 people have a natural resistance to the drug. “It’s an extremely rare phenomenon,” Dr. Biesman says. “I have been injecting for over 30 years and have seen very few true cases. Most often, the patients who feel they are non-responders require treatment of a different dose or distribution."

## **Why Botox May No Longer Be Working For You**
Many patients use neuromodulators for decades with good results, and it is unclear what precisely about Botox® makes patients believe they are more immune to it than other toxins, Dr. Layke says. “Botox® is made of the active ingredient botulinum toxin A and other nontoxic complexing or binding proteins,” he explains. “Any one of these may induce an immune or ‘foreign’ response leading to antibody formation.”

Perhaps it’s less about the product and more about the patient. According to Dr. Frank, it’s not that the neuromodulator itself becomes less effective. Instead, we age and our anatomy changes, which limits our ability to get the effect that we want. “Neuromodulators are never going to be as effective on a patient who’s been using them for 20 years,” he shares. “That has less to do with the immunological aspect and more to do with the fact that we are fighting time and the muscles change, so the relaxation of the muscle doesn’t always give the same clinical effect.” In some patients, neurotoxins may begin to produce less desirable results. “As we get older, neuromodulators can cause an over-relaxation of the muscles and lead to adverse reactions, like flattening the eyebrows, weakening of the smile, and motion limitations,” he adds. 
 
Every doctor we spoke to for this story agrees that there is no connection between injector technique and product storage and a lack of visible results. “Injections at more frequent intervals and higher doses may have an effect on immunogenicity, but this is such a rare phenomenon and impossible to study,” Dr. Biesman notes. 

Besides developing toxin-inhibiting antibodies, it is also possible for the body to naturally metabolize the toxin at a faster-than-normal rate. “The normal amount of time it takes the body to metabolize Botox® ranges from two to four months,” Dr. Layke says. While no clinical data supports the claim, there are anecdotal reports that Botox® is shorter-lived in avid exercisers. If you’re someone who spins relentlessly on the Peloton bike and follows it up later in the day with a Pure Barre class, all that working out may be doing wonders for your body but little to no good for your wrinkles. 

## **What to Do If Botox Is No Longer Working For You** 
Botox® isn’t the end-all, be-all when it comes to neuromodulators. Other toxins that are just as, if not more so effective are available. “If you feel that Botox® no longer gives you the results you want, I recommend trying an alternative neuromodulator,” Dr. Layke suggests. “Many times, patients that are unresponsive to Botox® see effective wrinkle reduction with Xeomin® or Jeuveau®.” Both of those and Dysport® work towards the same end goal of smoothing out lines and wrinkles. However, each contains a different molecular structure, so people may be sensitive to one and less to another. 

Other types of ‘allergies’ to Botox® and the like can occur. A lot of times, this happens not due to the botulinum toxin type A but to the additive proteins or preservatives in the saline used. It’s all a matter of trial and error. 

If the toxin route isn’t the right fit for you, filler may be an alternative. While neurotoxins and fillers are both injectables, it’s important to note that they do not act in the same way. [Dermal fillers](https://aedit.com/aedition/everything-you-need-to-know-about-dermal-fillers) will not soften wrinkles where there is a loss of collagen in the skin. “They will not have the same effect as Botox®, but they can lift and create a rejuvenated look and feel,” Dr. Fallek explains. 

Another possibility is a [thread lift](https://aedit.com/procedure/thread-lift), which Dr. Fallek says “will not have the same effect as an anti-wrinkle injection, but they will lift and tighten loose, sagging skin tissues.” Other alternatives? Any treatment or procedure that improves wrinkles on the upper part of the face. “That could be getting your [eyes done](https://aedit.com/procedure/eye-rejuvenation-solutions), a [laparoscopic brow lift](https://aedit.com/procedure/endoscopic-brow-lift), or using [fillers for fine lines](https://aedit.com/procedure/under-eye-filler) in areas,” Dr. Frank shares. “It’s certainly best to always offer a patient several options if they see less efficacy from neuromodulators as they get older.”

## **Is It Time to Take a Botox Break?** 
Believe it or not, if there isn’t a viable solution that works for you, it might be time to take a bit of a Botox break. A pause doesn’t mean you can’t ever get Botox® (or another neurotoxin) again; it’s just that your body may need a hiatus from it. In some cases, a respite allows any remaining product to leave the body so that you can start from a clean baseline.

There are also rumors of a connection between zinc supplements and an increase in effectiveness in Botox®. While the jury is still out, an April [2012 clinical study](https://jddonline.com/articles/dermatology/S1545961612P0507X) in the *Journal of Drugs in Dermatology* found that 92 percent of subjects supplemented with zinc 50 milligrams and phytase experienced an average increase in toxin effect duration of nearly 30 percent. Only time will tell if popping a few milligrams of the cold suppressant prolongs the life and betters the results of neurotoxin injections. 

Until then, stick with what works for you, be it Botox®, a different neurotoxin, or another rejuvenation technique — as long as the results are evident enough for you, that’s what matters most.

*All products featured are independently selected by our editors, however, AEDIT may receive a commission on items purchased through our links.*

Even if you’re diligent about staying on top of your appointments, is it possible to become less responsive to neurotoxins and see fewer results over time? All signs point to yes — but it’s complicated.

Botox Immunity And Neurotoxin Resistance: Causes, Symptoms, Alternatives

Can You Become Immune To Botox?

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One trend that doctors are seeing — and it’s not a positive one — is so-called [doctor hopping](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3552465/). The practice involves patients constantly bouncing amongst different cosmetic providers in hopes of achieving their aesthetic goals for as little money as possible and with little to no regard for the skill-level or certification of the doctor. “I wish I had a concrete answer as to why so many patients jump from doctor to doctor to doctor, but there are various reasons why it happens,” says [Michele Green, MD](https://aedit.com/provider/michele-green-md-34642), a board certified dermatologist and clinical instructor at Mount Sinai Hospital in New York City.
 
As more people get work done and talk about it, conversations around aesthetic medicine have, in many ways, normalized. “The number of people seeking aesthetic treatments continues to increase,” says [Farhad Ardesh MD](https://aedit.com/provider/farhad-ardesh-md-19202), a double board certified facial plastic and reconstructive surgeon in Beverly Hills. “Patients see celebrities, friends, and even family members receiving treatments, and they want to look their best, too.” But what these prospective patients often underestimate is the time, cost, and safety precautions involved. Here, top dermatologists, plastic surgeons, and psychologists reflect on the dangerous trend.

## **The Reasons for Doctor Hopping**
As [Julius Few, MD](https://aedit.com/provider/julius-few-md-15580), a board certified plastic and reconstructive surgeon in Chicago, explains “most patients jump around between doctors to get the outcome they want independent of the advice they may have received from a trusted authority.” This can quickly spell T-R-O-U-B-L-E. “There are countless ads out there for the impossible, often posted by individuals who are not adequately trained,” he says. 

It’s not just advertising that lures consumers to partake in doctor shopping. [Social media](https://aedit.com/aedition/march-2020-study-shows-relationship-between-social-media-cosmetic-surgery) is a culprit, too. “Instagram, TikTok, and other forms of social media contribute to the desire for everyone to want to look their best,” Dr. Ardesh notes. “Some want to look like their favorite influencers or celebrity and are willing to go to any extreme to achieve that goal.” The problem with social media is that what you see is rarely what you get. “Remember, social media is full of tricks, like great lighting, body positioning and editing with filters and photo editing apps,” he cautions. “These factors create [unrealistic expectations](https://aedit.com/aedition/how-plastic-surgeons-balance-patients-cosmetic-surgery-desires-and-safety) that followers try to achieve.” 
 
Another motive for doctor hopping? [Being told no](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679752/). Dr. Few says that if a patient does not like the advice or recommendation given (even if that suggestion is *not* to do a procedure), they’ll go ahead with it anyways. “I have had hundreds of cases over the past 20 years where a patient will ask for surgery or a cosmetic procedure, and I give them a clear, scientific reason as to why I am not willing to do the procedure; yet, they will go to someone much less experienced who believes they can deliver magic,” he shares. More often than not, he sees those patients again. “In the end, the patient comes back to me wanting to undo or fix what the other surgeon did,” he says. 

Similarly, Dr. Green performs a lot of revisions. “Half of the time, I end up fixing the work of another doctor or injector who screws up the patient because the patient — for whatever reason — came to me, then went to see someone else who they’re unhappy with, and then ends up back in my office,” she explains. “It can be a vicious cycle.”
 
Then, of course, there are the bargain shoppers. “Many of these treatments can be expensive and patients want to find the best deal,” says [Roseann Capanna-Hodge, EdD](https://drroseann.com/), a psychologist and integrative medical health expert in Ridgewood, CT. “Unfortunately, most of the discounted prices and deals are offered by less experienced providers, and they come at a cost (think: a lack of skills to properly evaluate, plan, and perform the treatment).” The psychological power of a sale runs deep. “Plenty of people hear of a deal or see a promo and, even if they aren’t due for a treatment or really need it, get it done anyway because they can’t pass up the savings,” Dr. Green adds. 

## **The Risky Business of Doctor Hopping**
“Those who are desperate to fix their physical appearance often make poor decisions,” says Dr. Capanna-Hodge. “There is a false belief that you can bargain shop for everything — including low-cost medical procedures from unqualified or inexperienced providers.” That desire for a discount often outweighs safety concerns. “Many would rather cut corners instead of investing in a provider that is not only experienced but provides safe quality care,” she notes.
 
Doctor shopping is more common with noninvasive procedures simply because patients believe it is easier to dupe their provider. But that doesn’t mean it doesn’t apply to surgery as well. And, as Dr. Few explains, the onus is on the doctor to do their due diligence. “Doctors need to play the role of investigative reporter before agreeing to treat these types of patients,” he says. “Often, I insist the patient give me their records from other places of treatment.” Over the years, he’s also learned some telltale signs of prior work. “Even if the patient does not share that they doctor shop, a trick to figure it out is to ask them to lift their brows and squint for signs of Botox®,” Dr. Few explains. “If they have signs of Botox® or previous surgery, I ask why they are not seeing the person who did their original work.” 

It's not just the lack of patient-provider honesty that makes doctor hopping problematic. It’s a slippery slope because of the large number of unqualified providers out there. While It’s difficult for patients to categorize an unqualified provider as the real deal, it’s also tricky to distinguish between authentic products, knockoffs and watered-down versions of the original. Any time anything is injected into your face or body, ask to see the bottle and verify that the product is in fact what it is supposed to be. “Usually, someone willing to do this type of thing is cutting corners,” Dr. Few warns. “It’s common for the person claiming to perform Botox® or Xeomin® for $5 a unit (less than the cost of the product) is likely getting it from an illicit place or watering it down so that it does not work as well or for as long as it should.”

Even if a patient is not well-versed in what to look for in a provider, dermatologists and surgeons know what red flags to look for in patients. “I question the ones that see a half-dozen different doctors and say, ‘no one is good,’” Dr. Green says. “Why has one patient been to so many doctors in a short time? What is the underlying reason why they can’t stick to a single doctor?” 

Dr. Few also keeps an eye on patients who talk about all the various places and doctors who have treated them. “This is a red flag,” he cautions. For some, doctor hopping is a way of life, but it’s like playing Russian roulette. “When doctors and services are treated as commodities such as purchasing groceries or gas, you may not receive the best outcome,” Dr. Ardesh says. “Aesthetics is still a part of medicine and it should be treated as such.”

## **The Dangers of Doctor Hopping** 
There are serious consequences — some even life-threatening — that can result from doctor shopping. “One little mistake and your life can be in danger and the damage will be permanent,” Dr. Capanna-Hodge says. “When it comes to cosmetic procedures, it’s best to think about why you’re getting the procedure, what it will do for you in terms of happiness, confidence, etc., and research the most qualified provider.” While finances will obviously play a role in the decision making process, don’t let [budget](https://aedit.com/aedition/how-much-cosmetic-surgery-costs) be *the* deciding factor. “If money is an issue, then reconsider your options and revisit when you have the funds to do so,” she suggests.

Here is just a sampling of the things that can go wrong when patients choose to crowdsource their care or see unqualified providers:

### **1. An overfilled face that appears distorted**
The entire face is fair game for overfilling, though the lips and cheeks usually take center stage. Some patients chase an overly plump aesthetic and seek out multiple doctors and rounds of treatments to obtain their ideal look. Poor technique is also often apparent. “Recently, I saw a patient who had her temples injected by another provider,” Dr. Green shares. “One side of her face looked injected, the other looked hollow. Needless to say, she wasn’t happy, and I had to correct it.” 

### **2. A blue-ish tint to the under-eye skin** 
Injecting [filler under the eyes](https://aedit.com/procedure/under-eye-filler) can erase hollowness and give an instant refresh, but, if the product is placed too superficially or the wrong filler is used, the skin can appear blue. Known as the Tyndall effect, the only way to reverse the pigment is by dissolving the hyaluronic acid-based filler with an enzyme called hyaluronidase. 

### **3. Excessive scarring**
Scars are an expected part of any surgery, but abnormal [scarring](https://aedit.com/aedition/minimizing-scars-after-surgery) (think: those that are painful, extremely thick, and easily infected) are not the norm and require patience, time, and TLC to correct.

### **4. Hard-to-fix lumps and nodules**
Here’s another reason why you shouldn’t let just anyone inject you, and why you should only do what is necessary, when it’s necessary: lumps and nodules. An overabundance of product (or the wrong product) can cause asymmetries, lumps, bumps, and nodules. If hyaluronic acid is used, it can usually be reversed. But with [biostimulatory injectables](https://aedit.com/aedition/everything-you-need-to-know-about-dermal-fillers) or products like silicone that are not approved by the United States Food and Drug Administration (FDA), there’s little to nothing that can be done to correct the issue. 

### **5. Painful hematomas & seromas**
Although hematomas only occur in about 1 percent of [breast augmentation](https://aedit.com/procedure/breast-augmentation-solutions) surgeries, they can develop from any type of cosmetic surgery. [Hematomas](https://academic.oup.com/asj/article/37/10/1175/3112265), which are pockets of blood that collect outside of the blood vessels, resemble a large, dark bruise, are painful and require additional procedures to remedy. Seromas, which are a pooling of fluid under the skin, can also form when surgery is performed by an unqualified surgeon. 

### **6. Skin that displays signs of hyperpigmentation**
It’s not just injectables and fillers that can cause problems — [lasers](https://aedit.com/aedition/guide-to-ablative-laser-skin-resurfacing), in the wrong hands and without proper understanding of the patient’s skin tone, can be dicey, too. If the wrong setting is used on [darker skin tones](https://aedit.com/aedition/best-laser-skin-hair-removal-treatments-for-darker-skin-tones) or those that have certain undertones, hard-to-fix hyperpigmentation and melasma can easily ensue. “A patient may be of Asian or Mediterranean descent, but they may not look it, or they have darker undertones in their skin,” Dr. Green explains. “If a patient’s true skin type isn’t considered when it should be, the wrong device is used or the setting is placed too high for their skin, they will pigment.” When that happens, there is no easy remedy. “Some patients end up with [melasma](https://aedit.com/concern/melasma), which isn’t an easy fix,” she says. “Correcting pigment takes a very long time and a series of peels, lots of topicals, and other treatments to rectify the discoloration.” 

### **7. Loss of mobility**
Although it is rare, permanent loss of mobility, both to the face and body, can occur after surgery. “I have seen patients who are not candidates for blepharoplasty have surgery and, in the end, are unable to close their eyes because the surgeon did not have enough experience to know better,” Dr. Few recalls. “It is critical to always ask what the risks and the benefits are.” The way he sees it, the onus is on board certified surgeons to properly assess prospective patients. “If someone the doctor hops, it’s the doctor’s responsibility to slam on the brakes and make sure you know what is going on,” he says.

### **8. Permanent disfigurement**
Perhaps the most severe and debilitating side effect is permanent disfigurement, which can be a complication of both surgical *and* non-surgical procedures. Nerve damage, permanent numbness, and tingling that doesn’t subside can be serious long-term effects, and there’s also the rare complication of blindness if filler is injected into an artery.

## **The Takeaway**
We get one body, and aesthetic treatments to enhance it are not a place to cut corners. While there is always a chance that complications can arise from any procedure — invasive or non-invasive — even in the most qualified hands, [finding a board certified doctor or surgeon](https://aedit.com/aedition/finding-the-right-plastic-surgeon-dermatologist-or-cosmetic-dentist) who specializes in the treatment(s) you are interested in and understands your aesthetic goals is the best way to minimize risk. At the end of the day, there is little to gain but a whole lot to lose from rolling the dice with your care.

For those that think visiting numerous doctors for fillers and injectables in a short period of time is the way to go, we are here to tell you it does more harm than good. Four experts explain why it's never a good idea.

The Dangers Of Doctor Hopping For Cosmetic Procedures

Why Doctor Hopping Is A Major No-No

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Imagine it going down like this: You fork over a pretty penny and the better part of your Saturday afternoon in hopes that you’ll walk out from behind the salon chair with gorgeous, natural-looking [hair color](https://aedit.com/aedition/best-hair-care-products-by-texture-color) that will have women chasing you down the street wanting your colorist’s name and number. Instead, you succumb to an allergic reaction on your scalp (or worse, your face, too) that rivals the itch and burn of chickenpox. While your color looks fabulous, the discomfort and pain leave you questioning if the J.Lo-inspired shade of honey brown locks was really worth it. 

If this sounds familiar, you likely have a sensitivity to hair dye. Here’s how to recognize a reaction and what to do if you’re not ready to go au naturel.

## **The Dicey Ingredient in Your Hair Color**
There are numerous chemicals in hair color, but the one that is most commonly associated with allergies is paraphenylenediamine (a.k.a. PPD). “PPD is an amine that is mainly used as an ingredient in hair dyes and henna tattoos,” says [Naana Boakye, MD](https://bergenderm.com/), a board certified dermatologist in Englewood Cliffs, NJ. The ingredient, which is used in almost every dark hair color formulation, allows the dye to deposit into the hair shaft and for the color molecules to penetrate the cuticle and stick.

PPD (it can also appear in the ingredient deck as PPDA or 1,4-benzenediamine) is a well-known skin irritant and allergen — so much so that, according to Dr. Boakye, it was declared the [Contact Allergen of the Year in 2006](https://www.researchgate.net/publication/340921466_American_Contact_Dermatitis_Society_Allergens_of_the_Year_2000_to_2020) by the American Contact Dermatitis Society (ACDS). Sure, plenty of women and men safely color their hair with no side effects. But, for those that are sensitive to color, it’s an uncomfortable allergy. “A reaction of some sort to the ingredient is more common than people might realize, but it more often causes a mild dermatitis irritation,” says [Ava Shamban, MD](https://aedit.com/provider/ava-shamban-md-2325), a board certified dermatologist in Santa Monica, CA. As she explains, [research estimates](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3927172/) that 1 to 2 percent of users experience an allergic reaction and less than 1 percent a severe allergic reaction.

Other ingredients frequently used in hair color include paratoluenediamine (PTD), which is said to be better tolerated but can still cause reactions, as can cobalt, glyceryl thioglycolate, ammonia, peroxide, and resorcinol. “Hair dye, in general, can cause issues — even those that claim to be organic,” says [Kavita Mariwalla, MD](https://mariwalladermatology.com/), a board certified dermatologist in West Islip, NY. And reactions and irritations aren’t limited just to darkening hair. “Anytime you lighten the hair, you are exposed to chemicals that are some form of ammonia or bleaching agent,” she explains. “Over time, the skin can become sensitized and develop a rash.” In case you’re wondering, the same goes for henna, too.

## **What a Hair Dye Allergy Looks Like**
If an allergic reaction ensues as a result of hair coloring, it’s common for a series of dermatitis-like reactions to appear on the skin. “It classically appears on the hands, head, and neck where the chemical is in contact with the skin,” Dr. Boakye says. “These allergies appear as [eczema](https://aedit.com/aedition/best-skincare-products-to-treat-eczema-flare-ups-in-the-winter), spongiotic like a rash, or, at times, it can appear very non-specific and present with hives or lichen simplex chronicus, which is thickened skin.” Other symptoms include an itching, stinging, burning sensation on the scalp and blisters, welts, and swelling at the hairline and on the scalp, forehead, neck, ears, eyes, lips, upper back, or feet. 

Here’s the tricky part with hair color allergies: the reactive response is not always instant. “Symptoms may occur immediately or take up to 48 hours to manifest and become more severe over time,” Dr. Shamban notes. This classifies the allergy as a [type IV hypersensitivity reaction](https://aedit.com/aedition/moderna-covid-19-vaccine-dermal-filler-swelling) (meaning it doesn’t show immediately). 

But that’s not to say that one session in your colorist’s chair (or if you’re doing your hair yourself at home) can’t lead to an immediate reaction — it can. Dr. Mariwalla says that if there is an aggressive exposure that occurs over several episodes (like ignoring the itching at first and then getting your hair done again with the same product), the reaction will worsen. “So, what may begin as itch can progress to severe redness and even swelling and blisters,” she shares.

Because an allergy can occur the first time color is used or years afterward, it’s important to patch test hair dye on the inner crease of the elbow and the nape of the neck. “Patch testing is crucial because, otherwise, you are just guessing,” advises Dr. Mariwalla. “The right way to do it is to see a board certified dermatologist or an allergist for proper patch testing” However, as Dr. Shamban points out, any single-use or contact point can solicit an allergic response. “Therefore, even a patch test one day, on one area or repeating use of a product used multiple times previously can still result in an unexpected allergic reaction,” she adds. Dr. Boakye agrees and says she has a few patients that have developed allergies to hair color after years of use, which “was a surprise to them because they have been dying their hair for years and subsequently developed the allergy.”

Age can also be a driving force — especially since the body’s ability to fight off allergens declines as we get older — but plenty of younger people are sensitive to hair color, too. It is important to note that once the body is exposed to an allergen, the body will continue to recognize the known allergen and, “while it does not accumulate or remain in the body, usage is like pulling the wild card out of the deck; one never knows when it will occur,” Dr. Shamban explains.

Hair color shifts the pH of the scalp, which won’t necessarily cause an allergic reaction, but it can lead to an irritated or inflamed scalp. “Color is meant to be placed on the hair, which is already-formed keratin strands,” Dr. Mariwalla says. Even so, the scalp is impacted. “The process of hair dying can irritate the scalp, but, once the hair is dyed, there is usually not an issue,” she explains. “During the process, the scalp takes an insult due to the chemicals, heat, and processing experience.”

New York colorist Lauren Paglionico of [LRN Beauty](https://lrnbeauty.com/) has watched minor color reactions ensue right before her eyes. “I have seen clients experience sensitivities to hair color with PPD, which shows up as itchiness or redness at the nape of the neck,” she shares. “Luckily, it went away after an hour.” But that’s not always the case for everyone. 

In extreme cases, the face can become so swollen, puffy, and tight that the eyes and nose appear distorted and the face doubles in size and width. The lips can react, too, and blow up. In the most extreme cases, anaphylaxis (a severe, potentially life-threatening allergic reaction) can occur, which can land you in the emergency room. “Symptoms to look out for with anaphylaxis may include the same stinging, burning, swelling, or rash, but it will extend to the tongue and throat, followed by trouble breathing with feelings of faint, nausea, or vomiting,” Dr. Shamban says. “It is very, very rare, but a hair dye allergy can even be fatal if not attended to properly with immediate medical attention.”

### **How to Treat a Hair Dye Allergy**
To remedy dermatitis and allergic reactions, first rinse off the dye as much as possible with warm water and a gentle, [fragrance-free](https://aedit.com/aedition/fragrance-free-beauty-skincare-for-sensitive-skin) shampoo (like baby shampoo). “A shampoo with a topical corticosteroid, such as Clobex, an antifungal shampoo, like Ketoconazole, or a coal-tar shampoo for dandruff may work as well,” Dr. Shamban says. 

Next, apply a layer of topical cortisone or a corticosteroid cream or lotion to the affected areas and take Benadryl to reduce the inflammation. “I also suggest using hydrogen peroxide to oxidize the PPD, steroids to help cool the scalp, and antihistamines to quell the itch,” says Dr. Boakye, who also recommends allergy testing to determine the exact causative agent. As far as any scabs that form, treat them with a layer of [emollient-rich, fragrance-free cream](https://aedit.com/aedition/dermatologist-approved-body-creams-moisturizers) applied to damp skin. 

## **Gentler Color Options**
So, what’s a girl ([or guy](https://aedit.com/aedition/guide-to-mens-hair-color)) to do if the act of hair coloring is too risky and virtually out of the question? For starters, avoid any type of hair color that contains PPD (PPD-free color is available in [Wella Koleston Perfect Me+](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fwww.walmart.com%2Fip%2FWella-Koleston-Perfect-Me-Permanent-Creme-Hair-Color-Deep-Browns-2-Oz%2F683520515) dyes) or an allergen. “Highlights and balayage are safer options because bleach does not contain PPD,” Paglionico says. But bleach can be irritating, too, so proceed with caution. Gloss and toner, which are used after highlights to add shine and soften freshly highlighted hair, typically don’t contain PPD and are applied to the hair, not the scalp. 

A few hacks to keep in mind include adding a few packets of Sweet N’ Lo (yes, you read that correctly) to the color, which Dr. Mariwalla says changes the pH of the solution to prevent an itchy scalp. Or try an anti-irritation solution, like [Antidot Pro Scalp](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fantidotpro.com%2Fcollections%2Fconsumer), which is mixed into hair color to prevent reactions. “Also, if you can avoid it, don’t color your hair on your own at home,” she cautions. “You don’t know what is in the box and you can get exposure without realizing it.”

“Hair color has come a long way and many of today’s lines are safer than they used to be,” says Paglionico, adding that her favorite is the ammonia-, silicone- and PPD-free L’Oréal INOA. Now that clean beauty is the norm, it’s fitting that options like these are available in the hair color arena:

- [CHI’s Iconic Shine Shades Permanent Hair Color](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fwww.sallybeauty.com%2Fhair-color%2Fshop-by-type%2Fpermanent-hair-color%2Fionic-shine-shades-permanent-hair-color%2FCHI02.html) is an ammonia- and PPD-free formula that can be used as permanent, demi-permanent, or semi-permanent color depending on how much of the color is mixed with the brand’s [Color Generator](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fwww.sallybeauty.com%2Fhair-color%2Fother-products-and-applications%2Fdeveloper%2Fcolor-generator-20-volume-developer%2FCHI05.html) (a developer).
- Although [Maria Nila’s Colour Refresh](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fmarianila.com%2Fus%2Fcolour) isn’t traditional hair color, the 17 different shades (they’re available in both DIY and professional versions) deposit non-permanent color pigments in minutes, while adding moisture to hair — sans parabens, PPD, sulfates, and animal byproducts. 
- [Madison Reed’s Radiant Hair Color Kit](https://go.skimresources.com?id=170670X1638612&xs=1&url=https%3A%2F%2Fwww.madison-reed.com%2Fhome-hair-color-kit) (it’s also available as a color service at a Madison Reed Color Bar) is a permanent color option that’s in the clear of ammonia, resorcinol, and PPD. Instead, it uses PTD- Toluene 2,5-Diamine Sulfate (TDS) as an effective replacement for PPD. According to the brand, studies show that more than half of users who are allergic to PPD did not experience any adverse effects to products using a PTD substitute. Because the ingredients are chemically similar, it is possible for users who are allergic to PPD to experience some irritation when using color with PTD. So, always patch-test first.
- [Miranda Shaffer](https://www.instagram.com/mirandashafferhair/?hl=en), a hair color specialist and balayage expert at Adel Atelier in New York City, recommends a powder-based color line called [Water Works](https://www.amazon.com/stores/Water+Works/page/B0D0819A-B039-444B-BA01-8085DD1FE059?ref_=ast_bln), which she says works similarly to henna (it can’t lighten hair) to cover greys or deepen your natural color. “Instead of using a developer, the color is mixed with water,” she shares. “But, for some, natural products can also cause reactions, so always proceed with caution.”
- Ammonia-free color is another avenue to explore. Celebrity colorist [Ryan Pearl](https://www.instagram.com/ryanpearl23/?hl=en) of IGK Salon in Miami says color that is formulated without ammonia “helps to decrease the tingling and burning sensation that can come with regular color” because ammonia “opens up the follicles on the scalp and gives the allergen easy access to penetrate the skin.” He likes the Redken Chromatics color line (available through professionals) because “it is a lot less harsh than traditional color” and “it does a great job of lifting and depositing color.” To keep the follicles closed and less permeable, Pearl suggests not washing your hair for a day or two before getting color.

If none of the above are viable solutions, hair extensions are always an alternative option. Pearl says that any color can be added to extensions (pick the right shade to start with so less color work is needed). “It’s best to leave this one to a professional to get the color match just right,” he says. And rest assured that the color will never touch your strands or scalp. “The nice thing about wearing extensions as opposed to coloring your hair is that the color doesn’t come into contact with the scalp at all,” Pearl explains. “We color them off the head, using a methodical process that pretty much eliminates any sort of adverse reaction.”

And, of course, you can always go au naturel, which is — hands down — the safest bet.

*All products featured are independently selected by our editors, however, AEDIT may receive a commission on items purchased through our links.*

Wellness

While this isn’t your run-of-the-mill sensitivity, it can be severe. Here’s how to recognize a reaction and what to do if you’re not ready to go au naturel.

Hair Dye Allergies: Symptoms, Treatments, Hair Color Alternatives

Are You Allergic To Hair Dye? Here’s How To Tell

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Often, much of the discourse around cosmetic procedures comes down to risk versus reward. The [Brazilian butt lift (BBL)](https://aedit.com/procedure/brazilian-butt-lift) has risen in the zeitgeist as a [body contouring](https://aedit.com/procedure/body-contouring-solutions) option for those in search of a curvier backside. The procedure, used to enhance the posterior and shrink the waist, saw a spike of 28 percent [from 2014 to 2015](https://www.plasticsurgery.org/news/blog/recovering-from-a-brazilian-butt-lift?_gl=1*1wkvtap*_ga*MTI1OTk5Mjg2Mi4xNjIyMDMyNTQ5*_ga_2N9PTXXTDN*MTYyNDM5MTIxNS4yLjEuMTYyNDM5MTU1MC41OQ..), according to the American Society of Plastic Surgeons (ASPS), and it’s shown no signs of slowing down since. 

Celebrities like Jennifer Lopez, Beyoncé, and Kim Kardashian have all been credited with popularizing the hourglass figure in recent years, while stars like [Cardi B have admitted](https://www.gq.com/story/cardi-b-invasion-of-privacy-profile) to seeking a [butt augmentation](https://aedit.com/procedure/buttocks-enhancement-solutions) through dangerous means. No matter how mainstream it becomes, it’s impossible to ignore the headlines that call the safety of the BBL into question. With a mortality rate once reported at one in 3,000, the procedure had the dubious distinction of being the most deadly cosmetic surgery. 

So, when countless glute sessions and a strict diet can’t carve out your desired rump, a body contouring procedure can do the trick. But – and it's a big butt – are the risks of BBL worth the reward? We ask the experts for everything you need to know about the Brazilian butt lift procedure, the ideal candidate, the risks, the recovery, and more. 

## **What Is a Brazilian Butt Lift?**
In the simplest of terms, a [Brazilian butt lift](https://aedit.com/procedure/buttocks-enhancement-solutions) is a fat transfer procedure. It consists of performing liposuction on one or more areas of the body (think: thighs, abdomen, flanks) to harvest fat that is then transferred to another (i.e. the buttocks). It’s a minimally invasive, two birds, one stone procedure that offers a solution for those wanting to slim down certain areas while augmenting another. 

But, as [Nima Naghsihneh, MD](https://aedit.com/provider/nima-naghshineh-md-600), a board certified plastic and reconstructive surgeon and director of Dr. Nima Plastic Surgery in Pasadena, California, explains, the name ‘Brazilian butt lift’ is a bit of a misnomer. “In plastic surgery, ‘lift’ typically implies incisions,” he says. “In this particular case, there are no incisions. Instead, the ‘lift’ is a result of adding volume in the form of one's fat.” 

Unlike a traditional [butt lift](https://aedit.com/procedure/butt-lift), which requires the removal of excess skin (often after major weight loss), a BBL does not require surgical dissection because it solely addresses the volume of the buttocks via fat transfer. It can, however, provide a more lifted appearance for patients who are experiencing drooping as a result of volume loss. “It is essentially a [buttock augmentation](https://aedit.com/aedition/what-its-really-like-to-get-a-butt-augmentation),” Dr. Nima notes, and some prominent surgeons have even argued for [officially changing the name](https://journals.lww.com/plasreconsurg/Fulltext/2020/01000/A_Changing_Paradigm__The_Brazilian_Butt_Lift_Is.58.aspx).

## **What Happens During a Brazilain Butt Lift**
During a BBL procedure, “fat is harvested via liposuction from various body areas (a.k.a. ‘360 lipo’),” says [Ryan Stanton, MD](https://aedit.com/provider/ryan-stanton-md-644), a board certified plastic and reconstructive surgeon in Beverly Hills. Once it’s retrieved, “the fat is prepared by a wide variety of modalities – because there is no proven best one – then re-injected into the buttock cheeks and/or hips,” he adds. What lures many patients in is the minimal scarring that accompanies this procedure because “no surgical dissection required,” Dr. Stanton says. But he is quick to add that the benefit is also “why many uncertified plastic surgeons can and do perform it” (more on that below).

When it comes to anesthesia, [Kevin Tehrani, MD](https://aedit.com/provider/kevin-tehrani-md-91), a double board certified plastic and reconstructive surgeon and founder of Aristocrat Plastic Surgery and Medaesthetics in New York, says he typically uses [general anesthesia](https://aedit.com/aedition/everything-you-need-to-know-about-anesthesia) because it “is safe in young, healthy patients.” 
It also is the best way to ensure patient comfort. “The biggest problem with local anesthesia is that there is a limit of how much can be used,” he explains. “If it’s not enough, the patient will be in pain.” Local anesthesia may be an option, however, for patients undergoing what Dr. Tehrani calls a “small” or “skinny BBL.”

## **Recovering from a Brazilian Butt Lift**
To ensure a smooth recovery from a Brazilian butt lift, some thoughtful planning is in order. Dr. Nima recommends getting fitted for a [compression garment](https://aedit.com/aedition/benefits-of-compression-garments-after-cosmetic-surgery) prior to the procedure. “These garments are critical and decrease swelling and bruising but can be difficult to put on if they do not fit properly,” he cautions. Additionally, you’ll want to purchase the [right pillows](https://aedit.com/aedition/best-pillows-for-plastic-sugery-recovery-healing) to offload pressure on the buttocks while you rest, consider your pre- and post-op [meal plan](https://aedit.com/aedition/preparing-for-a-smooth-recovery-from-plastic-surgery), and proactively inquire about [lymphatic massages](https://aedit.com/aedition/benefits-of-lymphatic-drainage-massages-after-cosmetic-surgery) to help reduce swelling.  

### **Preparing for a Smooth BBL Recovery**
- Get fitted for compression garments
- Find the right pillows 
- Pre-plan your meals
- Book post-op lymphatic massages 

Once you get home from surgery, don’t expect to be sitting around much — if at all. “Sitting is prohibited for at least two weeks (six weeks for some surgeons’ protocol), except for 10 to 15 minutes sitting up for eating or using the restroom,” Dr. Stanton explains. Because this procedure involves multiple areas of the body, the first few weeks can be uncomfortable. [Swelling](https://aedit.com/aedition/how-to-treat-minimize-swelling-after-cosmetic-surgery) and bruising are to be expected, and Dr. Stanton says that “several different types of pain and anti-inflammatory medications are prescribed” to ease discomfort. Another tip? “Icing around the clock is also extremely helpful,” he adds.

As it relates to resuming normal movement and activities, Dr. Stanton says some patients are cleared to sit up for 20- to 30-minute intervals around the two-week post-op mark. They are also allowed to stand up and take short walks “for at least 30 seconds before sitting back down.” By week three, patients can move around for up to an hour, and “unlimited walking” returns at four weeks.

Patients can usually return to work after two or three weeks (as sitting and basic daily activities become easier), but you will be advised to be careful with exercise and sexual activity until the six-week mark. At that point, most restrictions are lifted. If introduced gradually, more intense [physical activity](https://aedit.com/aedition/when-to-start-exercising-again-after-cosmetic-surgery-procedures) (think: squats, lunges, and sports) can be resumed as well, Dr. Stanton says. 

### **Resuming Normal Activities After a BBL**
- **2-Weeks Post-Op**: Sit up for 20 to 30 minutes; stand up for at least 30 seconds 
- **3-Weeks Post-Op**: Stand up and move around for up to an hour; return to work
- **4-Weeks Post-Op**: Unlimited walking resumes with limits on more strenuous activity 
- **6-Weeks Post-Op**: Most restrictions lifted

Each surgeon has their own unique recovery protocol, so recovery looks different for everyone. It’s also important to note that your healing will also be influenced by where your fat was harvested from. “If we do liposuction on several areas like arms, thighs, back, the recovery may take longer,” Dr. Tehrani says.

## **The Ideal Candidate for a Brazilian Butt Lift**
As with any cosmetic procedure, not everyone will be a candidate for a Brazilian butt lift, and, as Dr. Tehrani says, “safety comes first.” As such, “patients with high BMI are generally considered to be at a higher risk of complications after any surgery, and BBL is not an exception,” he explains. After all, “liposuction is not a weight loss but a contouring procedure,” he adds.

The best candidate for a BBL is a patient who is close (within 10 pounds) to their [ideal weight](https://aedit.com/aedition/why-you-should-lose-weight-before-plastic-surgery), is active, and takes the necessary health precautions given by their surgeon of not smoking, drinking, and [monitoring their supplement intake](https://aedit.com/aedition/vitamins-supplements-to-avoid-before-cosmetic-surgery) pre- and post-op. This will help to ensure the surgeon can perform “the procedure safely” and the patient “gets the best results after the procedure,” he notes.

## **The Risks of a Brazilian Butt Lift**
While all procedures come with risk, the Brazilian butt lift has a somewhat dangerous reputation. Below are some of the potential risks, complications, and short- and long-term effects of the procedure: 

### **1. Volume Loss & Asymmetry**
Volume loss is to be expected after any [fat transfer](https://aedit.com/aedition/comparing-dermal-fillers-vs-fat-grafting-for-facial-rejuvenation-contouring) procedure, including a BBL. Dr. Nima says you can “expect to lose 20 to 40 percent of the volume that is injected” during the initial establishment period. The benefit of fat grafting is that there is no risk of the body rejecting it, but, on the flip side, the body will continue to reabsorb the tissue. “For most patients, only about 20 or maybe 30 percent of the fat survives and is permanent,” Dr. Stanton says. 

Additionally, asymmetric results can occur as a result of uneven sitting post-procedure or the surgeon’s technique. While it may be possible to correct, it will depend on the health and stability of the patient.
 
### **2. Fat Necrosis**
Fat necrosis occurs when an area does not have adequate blood supply. It manifests as “firm lumps of fat that have turned to scar,” Dr. Nima explains. “These can be tender but often improve over time.” The lumps are not cancerous.
 
### **3. Oil Cysts**
These small cysts are “composed of liquefied fat as a result of fat that did not ‘take,’” Dr. Nima says. They are typically not painful, but, if they begin to cause discomfort, it is recommended to speak with your provider. 
 
### **4. Death** 
The controversy surrounding BBL and its mortality rate mostly centers around the placement of fat. “The real killer, literally, with this surgery is where the surgeon is transferring the fat into,” Dr. Stanton says. “After extensive research over the last five years, it is now well known and globally accepted that fat injected (a.k.a. ‘transferred’) into the gluteus muscles is the fat that embolizes into the bloodstream up into the lungs, heart, or brain and causes death in approximately 3,000 to 10,000 patients.” 

Plastic surgery societies around the world do not advise placing fat into the gluteus muscles but rather the subcutaneous buttock cheek fat layer. However, he acknowledges that “fat survival is quite poor in the fat layer when compared to the muscle layer.” Herein lies the BBL conundrum: “[Surgeons are] damned if you do, and damned — but life-saving — if you don't,” Dr. Stanton says.
 
Data indicates that these new techniques have gone a long way toward increasing patient safety. While a 2017 survey from the [Aesthetic Surgery Education and Research Foundation (ASERF) determined](https://academic.oup.com/asj/article/40/8/864/5822125?login=true) the BBL mortality rate to be one in 3,448, it decreased to one in 14,952 in 2019. The 2019 figure indicates mortality has reached an acceptable level that is similar to that of [abdominoplasty](https://aedit.com/procedure/abdominoplasty) (one in 13,193).

## **A Note on Finding the Right BBL Provider**
[Finding the right provider](https://aedit.com/aedition/finding-the-right-plastic-surgeon-dermatologist-or-cosmetic-dentist) is crucial for any procedure, but it is of added importance for BBL. As we mentioned above, the minimally invasive nature of the procedure paves the way for uncertified providers to offer it, yet proper training and technique are a matter of life and death. “There were several cases all over the news when unqualified practitioners performed BBL and their patients died,” Dr. Tehrani says. “As long as your board certified plastic surgeon takes all precautions, uses a blunt cannula, and stays superficial, death should never happen.” As all surgeons should, he also recommends the patient is in optimal health at the time of the procedure.   

## **Alternative BBL Treatments**
A Brazilian butt lift isn’t the only way to enhance the buttocks. For those looking to add volume, hip or [butt implants](https://aedit.com/procedure/butt-augmentation-with-implants) can provide a permanent augmentation solution. If excess fat is a concern, liposuction alone can offer some benefit, while non-surgical body contouring procedures like [SculpSure®](https://aedit.com/procedure/sculpsure), [CoolSculpting®](https://aedit.com/procedure/cool-sculpting), or [Emsculpt Neo®](https://aedit.com/aedition/why-everyone-is-talking-about-emsculpt) can be strategically employed to create the illusion of a more augmented behind. 

Filler can also be used in place of fat to add volume, though the results are often short-lived and/or not as dramatic. Dr. Nima says [Sculptra®](https://aedit.com/aedition/everything-you-need-to-know-about-dermal-fillers), a collagen-stimulating poly-L-lactic acid (PLLA) filler, can offer temporary enhancement, while newer-to-market injectables, like [Renuva®](https://aedit.com/aedition/what-to-know-about-the-new-volumizing-injectable-renuva), can work over the long-term to help you grow your own fat. The drawback is often the price. “It is an excellent product for some volume correction and cellulite treatment, but can get quite pricey for volumes typically needed for a full BBL,” he shares.

## **The Takeaway**
If days in the gym and a strict diet still can't develop those enviable curves, a Brazilian butt lift can enhance the backside — but buyer beware. When it comes to the procedure, it is important to fully vet the surgeon who will perform the BBL to ensure they have the experience and technique to carry it out as safely as possible. While the rate of fat retention is enough to maintain a rounder posterior and a slimmer waist, it is important to weigh both the risks and rewards of a BBL. 

The Brazilian butt lift (BBL) can create a rounder backside, but the procedure is not without controversy. The experts weigh in on why it’s one of the more infamous body contouring options.

Brazilian Butt Lift Procedure And Safety Overview

How Safe Is A Brazilian Butt Lift?

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In recent months, the aesthetics industry has been abuzz with confusion wondering: where did the hydroquinone go? The ‘gold standard’ treatment for [hyperpigmentation](https://aedit.com/aedition/what-its-like-to-treat-hyperpigmentation-with-skincare-cosmetic-treatments) has virtually disappeared from United States skincare shelves — an unwitting casualty of the 2020 CARES Act.

Yep, you read that right. The pandemic-inspired economic relief bill also [contained a provision](https://www.fda.gov/drugs/over-counter-otc-nonprescription-drugs/over-counter-otc-drug-review-otc-monograph-reform-cares-act) for modernizing the way the United States Food and Drug Administration (FDA) regulates over-the-counter (OTC) drugs. The law reforms the agency’s notoriously cumbersome rulemaking system ([in place since the 1970s](https://aedit.com/aedition/modern-history-of-us-food-drug-cosmetic-regulation-fda)) responsible for creating drug monographs — essentially rulebooks that OTC drug manufacturers can use to bypass the costly drug approval process. The CARES Act resolved all of the pending regulations that were stalled out by decades-old bureaucracy, declaring that “the most recently applicable proposal” would be considered final.

Problem is, the monograph for OTC skin bleaching products was still under review. Hydroquinone, which had initially been considered GRASE (read: generally recognized as safe), had been downgraded to ‘not GRASE’ in the most recent recommendation. Without a final monograph and a tentative categorization as unsafe, OTC hydroquinone was toast. Here’s everything you need to know about the compelling (and controversial!) history of hydroquinone in skincare.

## **What Is Hydroquinone?**
Naturally found in a variety of plants (including coffee), hydroquinone was first distilled in 1820 and soon became one of the primary chemicals in photographic developing solutions. An antioxidant, it’s commonly used as a stabilizer in paints and motor fuels.

The skin bleaching properties of hydroquinone were discovered by accident in 1938 when a group of Chicago leather tannery workers sued the factory owner after they developed depigmented patches (a.k.a. leukoderma) on their hands and forearms. The patches corresponded to areas covered by factory-provided rubber gloves — which had been manufactured using a chemical called monobenzyl ether of hydroquinone.

In the following decades, researchers performed a variety of *in vitro* (i.e. test tube) and *in vivo* (a.k.a. animal or human) research using various concentrations and formulations of hydroquinone. They found the organic compound to be generally effective at reducing hyperpigmentation in both white and black test subjects — though the dark patches typically returned after discontinued use.

### **What Does Hydroquinone Treat?**
Clinically, hydroquinone is used to treat dyschromia (read: skin discoloration or patches of uneven skin color). Variations include:

- **[Melasma](https://aedit.com/concern/melasma)**: A symmetrical pattern of hyperpigmentation on the face caused by UV damage or hormonal changes.
- **[Solar Lentigines](https://aedit.com/aedition/cosmetic-procedures-treatments-to-correct-sun-damage)**: Also known as sun spots or liver spots, they form when skin cells start to produce melanin as a result of repeated sun exposure.
- **[Freckles](https://aedit.com/aedition/whats-the-difference-between-freckles-and-sun-spots)**: Small dark spots, usually less than five millimeters in diameter, where skin cells have produced extra pigmentation.
- **[Post-Inflammatory Hyperpigmentation (PIH)](https://aedit.com/aedition/how-to-treat-acne-induced-post-inflammatory-hyperpigmentation)**: Skin discoloration caused by inflammatory conditions like acne, burns, eczema, and dermatitis.

Hydroquinone’s most common use is in patients with PIH and melasma, while its chemical cousin — monobenzyl ether of hydroquinone — is FDA approved to treat severe cases of [vitiligo](https://aedit.com/aedition/guide-to-vitiligo-causes-treatments).

## **Hydroquinone FAQs**
More often than not, the more you learn about hydroquinone, the more questions you have. From dispelling common myths (i.e. hydroquinone equals bleach) to clearing up confusion (so, what’s the deal with FDA approval?), we’re breaking down some of the most frequently asked questions about hydroquinone.

### **1. Does Hydroquinone Bleach Skin?**
Time for another biology lesson: When applied topically, hydroquinone has several effects on the skin cells that produce melanin. These melanocytes are found in the basal layer of the epidermis, where they produce eumelanin (brown or black pigments) and pheomelanin (yellow or red pigments). This process is facilitated by an enzyme called tyrosinase.

Hydroquinone impacts this phenomenon (known as melanogenesis) in a couple of ways:

1. It inhibits DNA and RNA synthesis, altering melanosome formation
2. It inhibits tyrosinase, which impedes melanogenesis

So, technically speaking, hydroquinone isn’t a bleach. Instead, it restricts the skin’s ability to produce melanin, which has the effect of lightening the complexion — but only while you’re using the medication.

### **2. What Are the Side Effects of Hydroquinone?**
When used as directed, hydroquinone in concentrations up to 4 percent has relatively mild side effects. Common side effects include:

- Mild irritation
- Dryness
- Redness
- Inflammation

With that said, rare but serious side effects have also been documented. These include:

- **Complete Depigmentation**: Instead of just lightening the treatment area, the skin becomes devoid of pigment
- **Leukoderma-en-Confetti**: Splotchy areas of depigmentation dotted with spots of hyperpigmentation
- **Exogenous Ochronosis**: A skin disorder characterized by blue-black, caviar-like pigment deposits

It’s worth noting that there have been just 22 documented cases of exogenous ochronosis in the U.S. Worldwide, severe side effects are most commonly associated with prolonged usage of the drug against physician or labeling recommendations or when the hydroquinone is combined with dangerous ingredients like mercury.

### **3. Does Hydroquinone Cause Cancer?**
Additionally, There have been [quite a few studies](https://pubmed.ncbi.nlm.nih.gov/18027166/) trying to conclusively determine the safety of hydroquinone. Research from the [Environmental Protection Agency (EPA)](https://www.epa.gov/sites/production/files/2016-09/documents/hydroquinone.pdf) and the [National Toxicology Program](https://ntp.niehs.nih.gov/whatwestudy/testpgm/status/ts-10022-h.html) have provoked FDA concern. Here are the takeaways:

- **Cancer**: While there is [some evidence](https://pubmed.ncbi.nlm.nih.gov/15129564/) that the drug — when taken orally — can lead to kidney cancer and leukemia in rats, no link has been found between hydroquinone use and cancer of any kind in humans.
- **Fertility**: Research examining the effects of hydroquinone on [fertility and pregnancy](https://aedit.com/aedition/skincare-ingredients-to-avoid-during-pregnancy-breastfeeding) in rats and mice have been inconclusive, but concerning enough to be noted by the FDA. 
- **Absorption**: Hydroquinone has a relatively high [absorption rate](https://ntp.niehs.nih.gov/ntp/noms/support_docs/hydroquinone_may2009.pdf) in humans, especially in certain formulations. This means that even though it is applied topically, somewhere around half of the drug enters the bloodstream.

### **4. Is Hydroquinone FDA Approved?**
A deep dive into hydroquinone regulation in the U.S. reveals a little-known fact — not all drugs (even prescriptions!) sold in America are approved by the FDA. Let’s review how drugs are marketed:

- **OTC**: Over-the-counter drugs are typically regulated via what’s called a monograph — basically, the FDA’s rulebook for a class of drugs. Any OTC medication must comply with the monograph and does not need to go through the formal approval process. If the monograph is pending, an OTC drug can still be marketed in the meantime. This is why hydroquinone was available over the counter.
- **Prescriptions**: Prescription drugs can be approved (meaning they’ve gone through clinical trials and testing) or simply regulated. In the case of hydroquinone, there is only one brand-name product that’s FDA approved: [Galderma Labs’ Tri-Luma](https://www.galderma.com/us/news/galdermas-tri-luma-cream-only-fda-approved-treatment-melasma-now-available-pharmacies). Because hydroquinone is approved for use in that medication, it’s included in the [FDA’s Orange Book](https://www.fda.gov/drugs/drug-approvals-and-databases/approved-drug-products-therapeutic-equivalence-evaluations-orange-book) — a list of drug substances and their therapeutic equivalents (a.k.a. generic substitutes). 

To bridge the gap between what’s clinically needed and what’s approved for prescribing, the [Federal Food, Drug, and Cosmetic Act (FD&C Act)](https://www.fda.gov/regulatory-information/laws-enforced-fda/federal-food-drug-and-cosmetic-act-fdc-act) allows compounding pharmacies to prepare and dispense drugs that haven’t been formally approved by the FDA. 503A compounding facilities produce drugs for individual patients on a case-by-case basis, while 503B facilities primarily supply bulk drugs for physicians to distribute in-office.

### **5. Did the CARES Act Ban Hydroquinone?**
From 2006 to 2020, hydroquinone was in regulatory limbo. With no formal FDA ruling in place, the drug was readily available in both over-the-counter and prescription forms, including at strengths that exceeded the agency’s original recommendations.

Under the CARES Act, any drugs that were awaiting a final monograph and were deemed GRASE would be allowed to remain on the market without submitting a new drug application (NDA). Meanwhile, those drugs that did not have a final or tentative final monograph and were not considered GRASE (like hydroquinone) would be considered new drugs and required to submit an NDA within 180 days or face FDA enforcement.

The net net: all OTC hydroquinone had to be removed from the market. Manufacturers have the option to file for a new drug application, but the process is no joke. It’s estimated that the median cost of the application and approval process (including fees, clinical studies, etc.) is $19 million and can take about a year.

### **6. Can You Still Get Hydroquinone in the U.S.?**
Understandably, many doctors are unclear about how the CARES Act impacts their ability to offer hydroquinone as a treatment option for patients with pigmentation concerns. “There really is no system in place or an alert that tells doctors ‘this is what you can, and cannot do,’” explains Allyson Avila, a partner at [Gordon Rees Scully Mansukhani, LLP](https://www.grsm.com/lawyers/a/allyson-a-avila), and one of the country’s leading lawyers for the medical aesthetics industry. She advises doctors to contact their state drug regulators and/or an attorney for guidance.

Here is how Avila summarizes the law as it now stands:

> “Currently, products containing hydroquinone can only be distributed if (1) they are approved by the FDA through the new drug application process or (2) the compounds are patient-specific prescriptions.
> 
> Hydroquinone remains a Category 1 substance on the [FDA 503B Bulk Drug Substances List](https://www.fda.gov/drugs/human-drug-compounding/bulk-drug-substances-used-compounding-under-section-503b-fdc-act). Items that fall under Category 1 substances are under evaluation. Therefore, compounds that come from 503B facilities are not allowed to be dispensed at this time unless they are FDA approved. If these compounds are patient-specific prescriptions, they can be dispensed from either 503A or 503B facilities. 
> 
> Additionally, each state has slightly different pharmacy regulations that go along with FDA guidelines. Physicians must comply with FDA regulations along with state and local pharmacy regulations before dispensing products and prescriptions containing hydroquinone.”

## **The Future of Hydroquinone in the U.S.**
With so many patients relying on hydroquinone to treat hyperpigmentation, dermatologists and plastic surgeons alike are concerned about its continued availability. This is particularly true for BIPOC patients, who are often disproportionately affected by dyschromia.

With an FDA-approved formulation and inclusion on the Bulk Substances list for compounding, many experts feel it’s unlikely that the FDA will entirely remove hydroquinone from the U.S. market anytime soon. But the controversy surrounding the drug has spurred efforts to find [safe and effective alternatives](https://aedit.com/procedure/even-skin-tone-solutions) to treat hyperpigmentation.

### **A Brief History of Hydroquinone**
- **1978**: As the first step in creating an official monograph, an FDA advisory panel [proposes recommendations](https://www.federalregister.gov/documents/2006/08/29/E6-14263/skin-bleaching-drug-products-for-over-the-counter-human-use-proposed-rule) for regulating skin bleaching products. Based on evidence presented, the panel suggests that hydroquinone be generally recognized as safe and effective (GRASE) in concentrations of 1.5 percent to 2 percent and labeled to discontinue use after two months if no improvement is made.
- **1982**: After public comments, the FDA proposes a tentative final monograph (TFM). The agency rejects an appeal from industry to allow concentrations up to 4 percent hydroquinone based on study findings showing no significant difference in efficacy between 2 percent and 4 percent. The FDA agrees with the panel’s conclusion that high concentrations of hydroquinone with exposure to the sun may cause disfiguring effects. 
- **1999**: The International Agency for Research and Cancer (IARC) determines that hydroquinone is [not classifiable](http://www.inchem.org/documents/iarc/vol71/024-hydroquinone.html) as to its carcinogenicity to humans due to inadequate evidence in humans and limited evidence in experimental animals.
- **2001**: The [European Union bans OTC hydroquinone](https://ntp.niehs.nih.gov/ntp/noms/support_docs/hydroquinone_may2009.pdf) due to concerns about leukoderma-en-confetti and exogenous ochronosis.
- **2006**: Based on additional research and data, the FDA decides to reverse its recommendation and proposes to classify hydroquinone as not GRASE, effectively withdrawing the tentative final monograph for the skin bleaching category. The agency cites “some evidence” of the drug’s potential link to cancer and fertility problems, as well as a clear link to exogenous ochronosis, even at low doses.
- **2011**: Texas [bans the sale of hydroquinone products](https://www.pharmacy.texas.gov/files_pdf/BN/May16/Tab_31.pdf) in doctors’ offices but allows prescription sales to continue.
- **2017**: FDA issues policy guidelines indicating that they do not intend to take action against facilities that compound Category 1 Bulk Substances (like hydroquinone) for prescription sale in doctors’ offices.
- **2020**: CARES Act reforms the OTC monograph process, effectively outlawing non-prescription hydroquinone.

Now Trending

In recent months, the aesthetics industry has been abuzz with confusion over the impact of the CARES Act on hydroquinone. We’re breaking down everything you need to know.

Guide To Hydroquinone: Treatment, Safety, Regulation

So, What Exactly Is Happening With Hydroquinone?

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For the last several decades, [breast augmentation with implants](https://aedit.com/procedure/breast-augmentation-with-implants) has consistently been one of the top-performed aesthetic procedures in the United States. The U.S. Food and Drug Administration (FDA) has [approved](https://www.fda.gov/consumers/consumer-updates/what-know-about-breast-implants) two types of breast implants — saline-filled and silicone gel-filled — for increasing breast size in women, for reconstruction after breast cancer or trauma, to correct developmental defects, and to improve the result of a previous surgery.

While breast augmentation surgery with a board certified plastic and reconstructive surgeon has long been considered generally safe and effective and FDA-approved implants undergo extensive testing prior to hitting the market, there are potential risks associated with breast implants once they are placed in the body. Rupture, infection, capsular contracture (scar tissue squeezing the implant), pain, and the need for replacement and revision procedures are all possibilities, as is the chance for systemic symptoms that have come to be known as breast implant illness (BII).

Over the last few years, there has been a rise in women with breast implants reporting the unexpected onset of a cocktail of symptoms ranging from fatigue and brain fog to muscle weakness and respiratory issues. Celebrities like Chrissy Tiegen, [Ashley Tisdale](https://www.instagram.com/p/CD_qbPDlajA/?utm_source=ig_embed&utm_campaign=loading), and Hayley Hubbard have recently opened up about the physical and psychological impacts their breast implants have had on them. Despite the growing chorus of anecdotal evidence, what makes BII so evasive is the lack of research surrounding it, the confusion over the root of the problem, and the difficulty in pinpointing a diagnosis. 

To learn more about breast implant illness, what may cause it, how it can affect your health, and treatment options, The AEDITION spoke with [Nima Naghshineh, MD](https://aedit.com/provider/nima-naghshineh-md-600), a board certified cosmetic surgeon and founder of Dr. Nima Plastic Surgery based in Pasadena, California. 

## **What Is Breast Implant Illness?**
“Breast implant illness or silicone implant illness, often does not refer to a specific disease or problem and has not been formally categorized or defined by the medical community,” Dr. Nima explains. Because there is no distinct set of symptoms but rather an assortment of indicators that the body is negatively impacted by the implant, it’s hard to explain what the illness is in specific terms. “BII is more like an all-encompassing category of issues/symptoms that some women with implants have described,” he continues. 

What’s more? There seems to be no rhyme or reason for when it arises. According to Dr. Nima, BII symptoms may present at any time. “There are several individual theories about what causes BII, but most hinge on the idea that there is some degree of interaction between the implant, a pro-inflammatory presence (typically bacteria or fungus), and the body’s exaggerated response to all of this,” Dr. Nima shares. It should be noted that the type of implant is not considered a specific root of the condition. “Though [textured breast implants](https://aedit.com/aedition/heres-what-you-need-to-know-about-the-allergan-breast-implant-recall) — as opposed to the more common smooth — have been implicated in breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), there is no clear association between implant type, model, or manufacturer with BII,” he adds. 

So, it is not necessarily the body rejecting the implant but rather issues during the surgery that leads to infection. “It has been shown that a large percentage of capsules (greater than 40 percent) removed at the time of implantation had bacterial colonization,” Dr. Nima explains. As such, improving implantation techniques could, theoretically, help prevent complications. “Employing sterile ‘no-touch’ techniques when placing the implants could reduce the risk of bacterial contamination and subsequent inflammation and BII as a result,” he says. 

## **Diagnosing Breast Implant Illness**
“If you believe that you may have symptoms related to BII, it is important to seek a [board certified](https://aedit.com/aedition/medical-board-certification-in-plastic-surgery-cosmetic-dermatology) plastic surgeon who specializes in breast-related issues and reconstruction,” Dr. Nima emphasizes. “Your surgeon will examine you and may suggest follow-up with your PCP and other specialists such as a rheumatologist.” Patients may undergo a blood test, MRI, and/or ultrasound to test for iron levels, autoimmune disease, liver function, blood count, and more.

One of the things that makes BII so difficult to conclusively diagnose is the fact that the symptoms often point to other conditions. “Because the symptoms associated with BII can overlap with existing known diseases, such as autoimmune diseases, it is important to rule out these known diseases at the same time as exploring the possibility of BII,” Dr. Nima says. 

Even so, medical advancements are leading to broader consensus on the illness. “Simply put, doctors are also scientists. Many make their decisions based on the evidence in the medical literature,” he explains. “As we get more data on BII, we will find less disagreement and a more unified approach to this issue,”

## **Symptoms of Breast Implant Illness** 
As we’ve established, there is no one set of symptoms for breast implant illness, and the effects aren’t always just physical. Dr. Nima says women who have experienced BII often put symptoms into the following categories:  

- **Physical**: Hair loss, dry skin, and rashes are some of the most prevalent physical indicators of BII. These are surface-level and can be seen rather than felt. 
- **Central Nervous**: This includes brain fog, memory loss, vertigo, headaches, migraines, and tinnitus (ringing in ears).
- **Cardiorespiratory**:  Dr. Nima says “shortness of breath, heart palpitations, arrhythmia, heart pain, cough, and throat clearing,” are potential issues that may arise. 
- **GI & Genitourinary**: “Frequent urination, liver and kidney problems, reduced libido, UTI, reflux, gastritis, weight loss/gain, sudden dehydration, liver dysfunction, leaky gut, IBS, metallic tastes, choking, difficulty swallowing, pancreatitis, [and] gallbladder disease” may also accompany BII, Dr. Nima explains.
- **Musculoskeletal**: Some women report muscle or joint pain, numbness or tingling in the upper and lower limbs, fibromyalgia, neuralgia/burning pain, discoloration of hands/feet, and slow muscle recovery after activity.  
- **Immune**: As we’ve mentioned, BII can present like an autoimmune disease. It may lead to “Raynaud's, Hashimoto’s, RA, scleroderma, SLE, Sjogren’s, MCTD, MS, recurrent infections, toxic shock, fevers night sweats, slow healing and easy bruising, chronic fatigue, persistent infections, sudden food intolerance, allergies, and tender lymph nodes,” Dr. Nima says. 
- **Psychological**: And it’s not just physical symptoms — BII can manifest in “anxiety, depression, panic attacks, and the feeling of impending death,” he notes. 

Breast implant illness is not life-threatening, but the symptoms can certainly be strong enough to affect a person's quality of life. Depending on the severity, it may lead to additional medical expenses and impact both physical and emotional wellbeing.  

## **Treating Breast Implant Illness**
Because women experience BII symptoms at different points in time, it may go undiagnosed, untreated, or be perceived as another ailment, which is why it’s so important for those with breast implants to be vigilant and work with a board certified provider. The reality is that treating individual symptoms may not be sufficient. The biggest source of improvement is often [breast implant removal](https://aedit.com/procedure/breast-implant-removal) — but it’s not that simple. Dr. Nima explains that “whether it’s for BII, breast implant-associated lymphoma, or severe capsular contracture with pain,” removing the implant “is not enough.” 

The explant will require the removal of the capsule surrounding the implant as well. “We know that, for many of these problems, the issue is the capsule,” Dr. Nima notes. “Therefore, when possible, an en bloc total capsulectomy is recommended.” The capsule can then be sent to a pathologist and examined. “Any fluid around the implant, as well as a piece of that capsule, should also be sent for microbiology testing which will look at whether there are any organisms, like bacteria, colonized in the capsule,” he adds.

For patients whose symptoms cannot be attributed to another condition (think: rheumatic or autoimmune), “[they] are likely to have an improvement in physical symptoms as well as psychological well-being” after breast implant removal, Dr. Nima says.

## **Patient Perspective**
*After years of weight fluctuation, Maddi, 27, decided to get tear-drop silicone breast implants in 2018 to help restore volume in her breasts. Shortly after, the Las Vegas resident started noticing symptoms of breast implant illness.* 

<Dialogue>
  <Question party={The AEDITION}>
    Why did you want to get breast implants?
  </Question>
  <Response party={Maddi}>
    My weight was often fluctuating and my breasts started to sag. I wanted a permanent solution, which is why I went with a tear-drop implant. I wanted the natural look in case my weight continued to change.
  </Response>
  <Question party={The AEDITION}>
    When did you start noticing symptoms of BII?
  </Question>
  <Response party={Maddi}>
    It started fairly early, and I had symptoms of fatigue, chronic pain, muscle aches, and overall exhaustion. I didn’t have issues like this prior to the implants and knew that it must have something to do with my augmentation. It impacted my life to the point that I had an accident at work. I dropped a tray after feeling pain in my dominant arm. After that, I had a fever and needed to go to the emergency room. Luckily, I caught it early and was able to get medical treatment to help with the symptoms, but they didn’t stop.
  </Response>
  <Question party={The AEDITION}>
    When did you get the breast implants removed?
  </Question>
  <Response party={Maddi}>
    After I visited my doctor, I knew I wanted to have them removed. Due to the high cost of the procedure and all the medical bills, I had to wait two years to finally have my operation. I decided to change my implants for a non-textured implant, which I felt would allow me to keep the shape I wanted since I had a lot of loose skin due the original implant being a bigger size than I originally asked for.
  </Response>
  <Question party={The AEDITION}>
    What did you experience after the implant replacement?
  </Question>
  <Response party={Maddi}>
    After getting my implants replaced, I had the exact same symptoms and had to go to the doctor again. The entire process has left me with a lot of scarring, but I am focusing on my health at the moment to ensure I can be healthy for when I am able to have it taken care of.
  </Response>
  <Question party={The AEDITION}>
    What would you recommend for women wanting to get breast implants?
  </Question>
  <Response party={Maddi}>
    If you want breast augmentation, go with a fat transfer instead of implants. If I could do it over, I wouldn’t get breast implants again. This has been a learning experience that has left me unhappy with the overall results, and it will take time to get it fixed.
  </Response>
</Dialogue>

## **The Takeaway** 
Not every woman who has breast implants experiences breast implant illness, but, if you are concerned it may develop, Dr. Nima says “the most effective way of reducing your risk of BII is to remove and replace [the implants] with your own fat and to have a complete removal of the capsule or scar tissue surrounding the implants.” [Breast augmentation via fat transfer](https://aedit.com/procedure/breast-augmentation-with-fat-transfer) offers a natural way to address any excess skin, volume loss, or dissatisfaction with shape that accompany the [implant removal](https://aedit.com/aedition/what-happens-when-you-have-breast-implants-removed). “When using one’s fat, you can restore a significant amount of volume in just one procedure at the time of explant,” Dr. Nima says. 

If you have breast implants and are experiencing any of the symptoms outlined above, it is important to consult with your plastic surgeon to determine the best course of treatment. 

Breast implants are one of the most popular cosmetic surgeries in the U.S., but some patients experience post-op complications that seriously impact quality of life. Here’s what you need to know about BII.

Breast Implant Illness: Causes, Symptoms, Treatment, Recovery

Understanding Breast Implant Illness

shutterstock 795630103

You found out that you need to have a medically necessary procedure. You and your provider have submitted all of your necessary documentation and insurance has approved your case. While you’re not necessarily thrilled about going under the knife, there just so happen to be a few cosmetic tweaks that you’re interested in making to that same part of the body you already scheduled to have surgery on. So, can you blend functional and aesthetic surgeries? We asked the experts.

## **Functional vs. Aesthetic Procedures**
First things first, you may be wondering what the difference is between functional and aesthetic procedures? The best way to understand it is to look at these two definitions from the [American Medical Association (AMA)](https://www.ama-assn.org/): 

- **Cosmetic Surgery**: Performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.
- **Reconstructive Surgery**: Performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.

Another way to put it? A functional procedure is one that you probably *need* to have, whereas an aesthetic procedure is one that you *want* to have. As you may have guessed, functional procedures are more likely to be [covered by insurance](https://aedit.com/aedition/insurance-coverage-for-plastic-surgery-cosmetic-procedures) than cosmetic ones. 

While it may sound straightforward enough, there is actually quite a bit of gray area. Many procedures have dual purposes and can treat both functional *and* aesthetic concerns. For example, patients who have [trouble breathing](https://aedit.com/concern/breathing-issues) due to a deviated septum (medically necessary) and are also unhappy with the appearance (aesthetic) of their [asymmetrical or crooked nose](https://aedit.com/concern/nose-angle) could address both concerns with the [same rhinoplasty surgery](https://aedit.com/aedition/difference-between-cosmetic-rhinoplasty-vs-functional-rhinoplasty).

## **Blending Functional & Aesthetic Procedures**
Rhinoplasty isn’t the only procedure that has functional and aesthetic benefits though. And, if you are curious as to what other plastic surgery fits the bill, we’re breaking down six of the most common: 

### **1. Rhinoplasty (a.k.a. nose job)** 
While we often think of rhinoplasty as a way to improve the appearance and [shape of the nose](https://aedit.com/concern/nose-shape), it also can help with breathing problems. “It is a very well understood scientific fact that the nose is the primary organ for delivery of oxygen to the body,” explains [Oren Friedman, MD](https://aedit.com/provider/oren-friedman-md-1609), a double board certified facial plastic and reconstructive surgeon and director of facial plastic surgery at the University of Pennsylvania. “The nose humidifies, filters, and warms the air we breathe, so that, when the air reaches the lungs, it is primed for gas exchange, allowing for oxygen to reach important functional regions of our bodies and brains.” Needless to say, the proper function of the nose is medically necessary. “It is essential that people be able to breathe through their noses, and, as such, insurance companies should cover surgery to correct a patient's nasal breathing surgery,” he adds.

How does this relate to aesthetic concerns a patient may have? If a patient has a major nasal shape deformity that is directly contributing to their inability to breathe through the nose, the surgeon will correct it as part of the functional rhinoplasty procedure. According to Dr. Friedman, nasal deformities that need to be corrected in order to improve the breathing function include cleft lip nasal deformities, nasal defects following cancer removal, and traumatic defects as with a dog bite.  

### **2. Abdominoplasty (a.k.a. tummy tuck)** 
For patients with a [body mass index (BMI)](https://www.dukehealth.org/treatments/weight-loss-surgery-candidate) of 35 or higher, [weight loss procedures](https://aedit.com/aedition/what-its-like-to-get-plastic-surgery-after-bariatric-surgery-weight-loss) (e.g. gastric sleeves, lap gastric bands, gastric bypass, etc.) are often covered by insurance. This is especially true if it is coupled with medical complications, like diabetes, heart disease, or pulmonary hypertension. Procedures like an [abdominoplasty](https://aedit.com/procedure/abdominoplasty) (to remove [excess fat](https://aedit.com/concern/excess-fat) and skin) and panniculectomy (to address extra skin) may also qualify as medically necessary in certain patients, though it is not as common as the weight loss treatments. 

But complementing a significant weight loss isn’t the only functional benefit of abdominal surgery. “[Body contouring](https://aedit.com/procedure/body-contouring-solutions) procedures such as a tummy tuck often provide much more than aesthetic outcomes and may actually improve function,” explains [Gregory Buford, MD](https://aedit.com/provider/gregory-buford-md-1015), a board certified plastic and reconstructive surgeon in Englewood, CO. “When we tighten the abdominal muscles, the overall core is made more functionally competent.” 

As a result, he says patients “will often report improvement in chronic back pain” and has also seen patients comment that “bladder function has improved.” While these benefits will probably not qualify the procedure for insurance coverage, Dr. Buford notes that a good number of his tummy tuck patients experience health improvements in addition to the cosmetic benefits. 

### **3. Blepharoplasty (a.k.a. eyelid surgery)** 
Eyelid surgery is another procedure that can be performed for cosmetic or functional reasons — and, in some cases, both. [Lower](https://aedit.com/procedure/lower-eyelid-blepharoplasty-transconjunctival-approach) and [upper eyelid blepharoplasty](https://aedit.com/procedure/upper-eyelid-blepharoplasty) surgeries can treat loose or sagging skin, under eye bags or puffiness, and eyelid droopiness.

Functionally, a blepharoplasty may be medically necessary when excess skin impedes vision. Dr. Friedman says that when the degree of eyelid droop is so extensive that it obstructs a patient's ability to see, insurance usually covers the eyelid surgery. “Failure to see well is a hazard to the patient and to those around the patient, and, as a result, functional surgery should be performed for health reasons,” he explains. 

If vision is not impaired, don’t expect the procedure to be classified as functional. “At times, patients do not like the heavy appearance of their eyelids and may want to have skin removed from the upper eyelids,” Dr. Friedman notes. “In such cases of cosmetic dissatisfaction, insurance should not cover the procedure.” Depending on the patient’s goals, a blepharoplasty can help with [rejuvenation](https://aedit.com/procedure/eye-rejuvenation-solutions) or [reshaping](https://aedit.com/procedure/eyelid-correction-solutions) the eyes.

### **4. Breast Surgery**
No, your standard [breast augmentation](https://aedit.com/procedure/breast-augmentation-solutions) — be it with [implants](https://aedit.com/procedure/breast-augmentation-with-implants), [fat transfer](https://aedit.com/procedure/breast-augmentation-with-fat-transfer), or some [hybrid](https://aedit.com/aedition/hybrid-breast-augmentation-with-implants-fat-transfer) of the two — is not functional. But breast surgery encompasses a wide range of procedures, some of which are considered medically necessary. Mastectomy, breast reconstruction, and breast reduction are three such treatments. 

As per the [1998 Women’s Health and Cancer Rights Act (WHCRA)](https://www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-health-insurance/health-insurance-laws/womens-health-and-cancer-rights-act.html), health insurance plans that cover [mastectomy](https://aedit.com/aedition/what-to-expect-before-during-after-mastectomy-breast-cancer) (whether it’s for breast cancer prevention or treatment) must also cover [breast reconstruction](https://aedit.com/aedition/comprehensive-guide-to-breast-reconstruction-nipple-reconstruction-after-breast-cancer) — in the form of prostheses (like breast implants) — for both breasts. In these cases, providers do not need to document health problems or trials of alternative treatment as is usually custom in insurance cases. 

In the case of [breast reduction](https://aedit.com/procedure/breast-reduction-and-revision-solutions), addressing the size of the breasts can have a true impact on the patient’s quality of life. “When we reduce a woman's breasts, our goal is not only to achieve functional improvement (e.g. less weight and, so, less pressure on the lower back and neck) but to also create an aesthetic outcome that is attractive,” Dr. Buford says. “In this sense, breast reduction is likely one of the best examples in plastic surgery where form meets function to achieve an endpoint that creates benefit for our patients on multiple levels.”

### **5. Otoplasty (a.k.a. ear surgery)**
In order to understand the functional benefits of [otoplasty](https://aedit.com/procedure/otoplasty), it’s important to understand the functional benefits of the outer ear. “The external ear serves the primary function of funneling sound to the middle and inner ear in order to aid in hearing,” Dr. Friedman explains. “Repair of deformities that cause poor hearing should generally be covered by insurance.” 

[Cosmetic ear surgeries](https://aedit.com/aedition/otoplasty-ear-pinning-benefits-for-large-prominent-ears), as you may have guessed, are usually paid for out of pocket. “Aesthetic ear deformities often present as children and adults expressing that their ears protrude from their heads too far, making their ears stand out,” he says. “Patients sometimes come in stating ‘I get bullied for my funny looking ears’ or ‘my ears look like dumbo ears.’” Despite the mental health component to such concerns, Dr. Friedman shares that “otoplasty to correct these types of cosmetic deformities are generally not covered by insurance.”

There are, however, certain exceptions. “At times, children are born with excessively small ears [or] with no identifiable ears at all,” he notes. “These ear deformities require reconstruction of the missing ear and should be covered by insurance.” 

### **6. Botox®**
While it’s not a surgery, we’d be remiss not to mention the therapeutic benefits of a certain cosmetic injectable. As you likely know, [Botox®](https://aedit.com/aedition/comparing-neurotoxin-botulinum-type-a-injections-botox-dysport-jeuveau-xeomin) is a form of botulinum toxin type A (BoNT-A) that is used in aesthetic medicine to reduce the appearance of fine lines and wrinkles caused by facial expressions (think: forehead lines and [crow’s feet](https://aedit.com/procedure/periorbital-botox)). But the neurotoxin is approved by the United States Food and Drug Administration (FDA) to treat medical conditions as well. 

Therapeutic uses for Botox® include the treatment of [migraines](https://americanmigrainefoundation.org/resource-library/botox-for-migraine/), [hyperhidrosis](https://aedit.com/procedure/botox-for-hyperhidrosis) (read: excessive sweating), and eye spasms (to name a few). “I treat a good number of patients with Botox® who report additional benefits such as reduced local sweating and an overall reduction in migraines,” Dr. Buford shares. “For these patients, the additional benefits often vastly outweigh the cosmetic improvements and are literally life changing.” In such cases, insurance may cover the cost of routine Botox® treatments.

## **How to Find the Right Provider**
The most important part of any procedure — functional or aesthetic? [Finding the right provider](https://aedit.com/aedition/finding-the-right-plastic-surgeon-dermatologist-or-cosmetic-dentist) to ensure you receive the best and safest treatment for your needs. “Choosing the right surgeon is always the most important predictor of success for a surgical procedure,” Dr. Friedman says. During the research and [consultation](https://aedit.com/aedition/questions-to-ask-your-doctor-during-plastic-surgery-consultation) process, be sure to inquire about how often they perform the procedure(s) you are interested in and ask to see [before and after photos](https://aedit.com/aedition/importance-of-before-and-after-photos-in-plastic-surgery). 

No matter what area you are looking to treat, it is important that the surgeon has extensive knowledge of anatomy and how the body works. “A surgeon who understands the functions of the facial sense organs — the nose, the eyes, the ears — is well suited to safely and comprehensively achieve the best possible surgical outcomes,” Dr. Friedman says. “Knowing the nose, eyes, and ears inside and out allows us to insure success in both form and function.”

In choosing a [board certified](https://aedit.com/aedition/medical-board-certification-in-plastic-surgery-cosmetic-dermatology) plastic surgeon, you are often, well, blending the best of both worlds. “The beauty of plastic surgery is that it is essentially an art,” Dr. Buford concludes. “And, when form meets function, art is ultimately achieved.”

When you think ‘plastic surgery,’ you probably don’t think ‘medically necessary.’ But there are certain procedures that can provide dual functional and aesthetic benefits. Here’s what you need to know.