Many disciplines, including surgery, have not changed in nature over the decades, and simply recognizing something new does not cause change. This observation does not apply to the process of recognizing and treating the features of facial aging. Although facial aging has been treated for centuries, only recently has it been recognized that the process occurs at multiple levels, from the skeletal system of the face that provides support for the soft tissues, to the facial muscles, fat and skin. Environmental factors have been recognized for decades as having a significant impact on facial appearance, such as smoking, climate, and sun exposure, and efforts have been made to educate patients on how to minimize those environmental factors that accelerate facial aging and may lead to skin cancer. Of course, genes determine how and when facial aging occurs. Gonzalez-Ulloa and Flores1 wrote an article on facial aging in which they tried to explain the causes and consequences of facial aging. They suggest that changes occur in both bones and soft tissues. This landmark article was a wake up call to why the signs of facial aging had previously been localized to the facial skin alone and not dedicated to studying changes in all layers of the anatomy. As the thinking about how and why facial aging occurs deepened, those who had been using facelifts for decades gradually changed, recognizing that facial rejuvenation procedures were not sufficient to reestablish a youthful, harmonized appearance simply by tightening loose skin. Stent Structure and Volume: The Major Techniques The recognition of why facial aging occurs and what changes occur as a result of facial aging has spurred a significant increase in the number of medical and surgical techniques used to repair facial aging, as well as a rapid growth in related businesses. Centuries ago, people already understood what a beautiful face Cleopatra (the last queen of Egypt) was, and many others were too (the statue of the ancient Iranian queen in the ruins of Persepolis in Shiraz shows the same perfect facial contours). The universal standard of beauty has penetrated the hearts and hands of famous artists (Bill Little’s sculptures show us that Renaissance artists knew what beauty was, and his sculptures were called “perfectly proportioned” by Ralph Millard). Bill taught us that a beautiful face must include graceful curves and an understanding of framing, and whenever we look at his work, we understand that he has perfectly applied this theory to facial reconstruction. When we look back at the history of the face lift, we can’t help but wonder that this was not recognized until at least 75 years later, in 1965, when Gonzalez- Ulloa and Flores were in the literature on facial aging, and that the deficiencies based on facial volume were not recognized for a long time after that. Early surgical approaches using direct repositioning of the sagging facial soft tissues failed to recognize the volume deficit due to bone and soft tissue atrophy. The intent of these approaches was good, but the main principle of management was to free the subcutaneous and reposition it under some tension. The common rebuttal to the perception that the face is deformed and unnatural after plastic surgery is “my patients are happy”. Although Terino was not the first to use autologous or allogeneic implants, he was the first to theorize that the inadequate skeletal scaffolding of the face could be improved by transplanting allogeneic implants based on his understanding of the three-dimensional space of the face. His theory of facial subdivisions established the foundation for a proper understanding of regional volume deficiencies. Those surgeons who were able to gain a deep understanding of the role of restoring volume in facial molding clearly had better restorative skills than others. hester and his associates in the 1990s noted the role of midface vertical elevation in increasing anatomic area and toning the curvature of the lip-cheek junction. Other authors also recognized the great role of altering the sagging midface in facial rejuvenation procedures. However, more radical approaches have emerged, including subperiosteal and extensive SAMS fascial lifts, which carry the risk of prolonged edema, nerve function paralysis, eyelid dislocation, and even, in some cases, weeks to make the “new face” look “natural. In cosmetic surgery, the choice of the right technique for a particular patient is somewhat determinative of the success of the procedure. Therefore, some patients do well with this approach and not so well with others (an understanding of the vertical anatomy of the orbit allows us to understand why vertical lift techniques can have so many complications, including but not limited to eyelid dislocation). The long-term follow-up results of these procedures are encouraging, but facial rejuvenation procedures are not as exciting. The idea of a vertical facial lift as a means of improving the signs of aging is a step in the right direction, but a misconception, as the reduction of facial fat and the absorption of the supporting skeleton play a crucial role in facial aging, an idea first recognized by Lambros and Pessa and which has since had a huge impact. Therefore, rectangular facial surgery requires the repositioning of tissues to their original, youthful position and the appropriate augmentation of those soft tissues, as well as the enhancement of skeletal support to achieve the goal of harmonious rejuvenation surgery. Young people can significantly improve the early signs of aging simply by increasing soft tissue volume and/or altering skeletal support without moving the soft tissues. In short, it is not an intellectual or technical challenge that different areas of the face lose different amounts of fat, so directly increasing the amount of fat in one area may alter parts of the adjacent area (e.g., filling a depression in the midface with fat can soften the curvature of the cheek rim and the smoothness of its mouth-lip combination). Early investigators found that the extent to which autologous homologous fat grafting augments facial soft tissue depends on the amount of graft survival and the key points to protect the surviving fat: including appropriate donor sites, harvesting, preparation methods, and techniques for injecting small amounts of purified fat tissue into the tension-free recipient area. Economic and Aesthetic Developments Although there are many widely accepted and used methods available, patients are beginning to demand less invasive procedures with faster recovery. While offering shortcuts to facial rejuvenation treatments is not necessarily the best way to treat facial aging, when the financial meltdown affected patients’ financial expenses, it promoted the development of techniques that are less invasive, less expensive and produce significant changes in a short period of time. There are indeed damaging but effective options available to patients that are not financially feasible and not of interest to the public. Less effective, but not unavailable, are more than adequate for the patient’s level of spending. After 9/11, there was a marked process of decline in inquiries and requests for cosmetic surgery, and this process continued for several weeks. I will take a moment to review the early twentieth century and the important national and world events of the time and their impact on aesthetic medicine and cosmetic surgery. I found that after the Great Depression and events like Black Monday in October 1987, the average time from request to availability of cosmetic products and/or procedures was shorter than 6 weeks for women, and these cosmetic products or procedures made them look healthier when looking healthier was the best way to make them feel good. The current recession began in 2007 and has become more pronounced since 2008, a time when consumers have been waiting less than six weeks for cosmetic medicine and cosmetic surgery, compared to the last time a similar situation occurred in the 1990s. Anxiety about job security and retirement, declining household assets, and volatile stock markets are all factors that affect investments that “look healthy. If these anxieties don’t go away, the discretionary portion of spending will be more carefully calculated and beauty expenses will be quantified. Some people are motivated to seek the help of aesthetic plastic surgery in order to change their aging appearance and become more competitive in the job market. Some of these consumers are looking for cheaper, more modest remedies; however, they also understand that they will have to invest more to obtain more desirable, longer-lasting rejuvenation procedures, and that this expense will be deducted from their savings and checking accounts. A general overview of skin aging The products and techniques used to externally improve facial aging play an important role in the repair of facial aging. Fritz Barton proposed more avant-garde ideas in the 1990s about the need for skin care centers that protect the legal rights of patients and hold annual meetings to address the American Society of Cosmetic Surgeons. This gave skin care a trusted and legitimate platform to recognize what was happening inside and outside the aging facial organism. Facial skin aging includes internal changes due to apoptosis and genetic alterations, as well as external changes due to the external environment. Among these, the breakdown of collagen fibers in the dermis is the most important cause of skin aging, which produces significant changes in the appearance of the skin and forms an indicator of skin aging. Patients can improve these problems with chemical peels such as heat, phenol and croton oil, although there is a possibility of pigment loss due to the depth of treatment and skin type during use, and most patients are satisfied with the treatment results. Skin aging problems due to environmental causes were solved by this simple method. Decades later, Hetter and Colleagues found through their research that the concentration of croton oil was more important than the concentration of litharge in order to achieve the desired therapeutic effect, and we began to wonder how we could do better with fewer adverse reactions occurring. In 1970, collagen for filling linear or depressed scarring became available. This product, although providing only short-term correction (duration depending on the degree of cross-linking), was quickly accepted by clinicians and patients, making it very popular. Complications after proper allergy testing are rare and patients are very happy with the short-term improvement in facial lines and folds. Patients often return for additional injections, but, of course, patients and clinicians are looking for a solution that will last longer after the repair of facial wrinkles and contour deformities. Lasting solutions such as injectable medical grade silicone and other non-autologous substances are available and improvements are continually being made to reduce the risk of various products. Permanent repair is desired, but frequent, long-term sequelae have prevented such long-lasting or semi-permanent injectables, especially in the U.S. market, which is prone to prosecution (more significant rejection than fat and stem cell transplants). Retinoic acid has facial cosmetic benefits because it removes the damaged surface skin. Later, Obaji invented the method of using diluted trichloroacetic acid for facial peeling and adding different substances to change the percentage concentration of TCA, which became a landmark in the development of dermatological aesthetics. Specialists from different disciplines began to adopt the method for chemical peeling, and his method and formula were popularized. obagi continued to add new products along his lines to provide treatment for skin changes caused by environmental factors, including but not limited to hyperpigmentation due to different causes. obagi’s creation raised the level of awareness of what to do to improve the signs of skin aging to a new Many clinicians began to offer a wide variety of TCA peel concentrations and began to peel with tretinoin and salicylic hydroxyacetic acid. vitamin C medicinal cosmetics are another in a long line of ways to address skin aging. There are endless new topical medications for improving skin texture, reducing wrinkles and correcting areas of hyperpigmentation or photodamage. Some are licensed for use by physicians only, yet many more may be sold in pharmacies, kiosks, stores or online. The public is undeniably unaware of when, how, and where to use them, and even some physicians are unaware of this. Strange Discoveries in Modern Medicine and Surgical Methods Just like other medical and surgical disciplines, a new drug or method may be discovered and used in unanticipated circumstances. Sometimes, certain agents and methods are used far beyond their original expectations. In cosmetic surgery, one of the best examples is the use of endoscopy for frontal and midface lifts, a plastic technique derived from general surgery (laparoscopic cholecystectomy) and gynecology (laparoscopy.) Tessier founded craniofacial surgery, and he established the theoretical and practical work on planes and midface incisions under the frontal bone periosteum, and based on his work, thanks to the development of endoscopic techniques , endoscopic surgical operations for facial and mid-1/3 facial rejuvenation can be performed, thus making the previously long incisions into the current small ones. Also, the cosmetic use of botulinum toxin (e.g., for the treatment of frown lines between the eyebrows) discovered by Carruthers and Carruthers was a coincidence, when botulinum toxin was far from being used for cosmetic purposes and was only used to treat a medical condition (benign blepharospasm). As stated, they were treating a patient with benign blepharospasm who requested a higher dose. (Not to mention the further increase in the safety of this drug as more experience is gained in its administration). There is no better temporary way to improve motility wrinkles than this. As expected, the indications for this drug are gradually increasing (the recent FDA approval of Botox for migraine headaches is a well-known example). The earlier mentioned recession still motivates the use of temporary solutions because it is relatively inexpensive. The advent of hyaluronic acid provides a good solution for facial fillers, contour deformities and volume deficiencies. Early on it was extracted from the crown of the cockerel and was not well received when it first entered the filler market. Then came bovine and human collagen products, and non-animal-derived hyaluronic acid quickly took over the market and became the gold standard for facial fillers. Laser Technology and Aesthetics It was not until the late 1990s that the perception that lasers were suitable for treating a wide range of aesthetic conditions gained substantial acceptance. Initially, the CO2 laser was only used to treat wrinkles around the mouth and eyes, but it soon evolved to be used on the entire face. Undesirable sequelae and complications were reported, but improved with the advent of new technologies (erbium and graded lasers). Lasers are widely used for facial restorative treatments because complications are rare, with only occasional prolonged erythema or loss of pigmentation. Lasers are also indicated for the following conditions: hair removal, removal of vascular damage, tattoo removal, and more recently for laser lipo removal. Due to the economic recession, patients need cheaper and faster recovery methods, stimulating the contouring market towards less invasive or non-invasive procedures. Most of the soft abdominal contouring in cosmetic surgery is performed at the request of the patient. In many countries, the increasing obesity among men, women and children, who are trying to be healthy and maintain their appearance, has stimulated the development of related medicine and surgery. The end result of non-invasive techniques gives a new meaning to “no pain, no gain”, but some non-invasive techniques do offer some improvement in contouring. Newer techniques such as microwave high frequency technology offer new techniques for non-invasive body contouring and facial tightening. The Future of Aesthetic Medicine As you can see by following this article, aesthetic techniques for medical and surgical options for various aesthetic purposes continue to expand, including tattoo treatments, neurotoxins, cosmeceuticals, sclerotherapy, dermabrasion, facial fillers, lasers, and new devices for treating congenital and acquired facial aging and body contouring with minimal damage to the patient. Driven by the economic downturn to respond to consumer demand and provide solutions. Driven by the economic downturn, companies and clinicians have teamed up to offer alternatives to expensive solutions. However, even though these technologies have improved significantly, they are far from adequate in the long run. Thus, what was initially very expensive may later become very inexpensive (depending on the type of treatment, who performs it and where), or when the method is valued again for cosmetic purposes.