In this month’s “Meet the Aesthetic Expert” column, Will Kirby, DO, FAOCD, talks with Ryan Greene, MD, PhD, FACS, about how this board-certified facial plastic surgeon applies his expertise to non-surgical aesthetics and what that means for improving outcomes with injectables and other minimally invasive techniques.
Welcome to “Meet the Aesthetic Expert,” where, each month, dermatologist Will Kirby, DO, FAOCD, of LaserAway, will connect with select industry leaders to get their expert opinion on the aesthetic specialty. With an emphasis on straightforward, candid questions, Kirby will focus on the best in aesthetics and get the experts’ frank thoughts on where the field is headed.
Ryan Greene, MD, PhD, FACS is a double board-certified facial plastic surgeon who considers himself a ‘super specialist’ in non-surgical and minimally invasive facial aesthetic treatments. He is considered somewhat of a maverick by his peers, having made the decision to transition his thriving surgical practice into one of the highest regarded injectable centers in the country. He is a frequently invited international speaker, researcher, and serves as an advisory panel member and consultant to a number of prominent industry leaders in the injectable space.
K: Would you start off by telling us a little about your backstory?
G: I took a very circuitous route to facial plastic surgery and aesthetics. After college, I obtained a PhD. in immunochemistry and parasitic diseases, completing all of my research at the Centers for Disease Control and Prevention (CDC) in Atlanta, my hometown. This chapter of my life led me to a trip to Peru with the CDC and ultimately the discovery of novel Taenia solium diagnostic antigens. These antigens were eventually patented and are currently being utilized in diagnostic tests for neurocysticercosis. While I enjoyed basic science research and working in public health, I ultimately realized that clinical medicine was my calling.
K: What initially led you to an aesthetic career path?
G: I began medical school with an interest in otolaryngology–head and neck surgery, due to a fascination with the intricacies and anatomy of the head and neck. I gained early experience in the operating room, from which I was drawn to the art of rhinoplasty and facial reconstruction. A mentor in medical school helped solidify my decision that aesthetic surgery was my passion. My residency training in otolaryngology was at the University of Illinois at Chicago, considered to be a powerhouse of facial plastic surgery at the time. It was there where I learned injectable treatments from some of the pioneers in the field, which set my trajectory along its current path. My fellowship in facial plastic surgery at the University of Miami, Florida further enhanced my education, from facial reconstruction to valuable experience with facial injectables.
K: What is the best piece of (aesthetic) career advice you have received?
G: Your career will be built on the patients you choose not to operate on (or treat), not those who you decide to treat.
K: What is something interesting about you that you have never before publicly revealed or is not widely known?
G: My wife and I have a very popular blog that concentrates on French wine, its region, and people. Before we had children, we would travel to Bordeaux and other areas of France multiple times each year to visit friends and their wine estates. It’s been a fantastic journey for both of us, and we love sharing our experiences with others who are looking to learn more about French wines and the regions where they are produced.
K: What adversity did you have to overcome on your journey?
G: After finally completing my studies and training at age 37, I was eager to work as a facial plastic surgeon. Unfortunately, this was in 2009, which was one of the worst economic periods in our country’s history. Despite this obstacle, I decided to start a private practice on my own. With so much economic uncertainty, I honestly didn’t know if it was going to be successful. I made a number of financial sacrifices, taking a meager salary for several years, living with my in-laws, and operating my business on a strict budget. This turned out to be one of the best decisions of my life, and I have enjoyed the successes far more than I would have otherwise.
K: Telehealth exploded during the pandemic. Is it here to stay?
G: When it comes to aesthetics, I think that telehealth will always play a limited role. Aesthetic surgery is a specialty that relies on face-to -ace interaction. There are a number of limitations posed by a remote consultation. A 3-dimensional assessment and examination is critical when you are talking about a specialty that is rooted in art and aesthetics.
K: What steps should the aesthetic industry take to increase overall market penetration?
G: The initial focus should be on marketing to all demographic groups, rather than just one select group. I’ve already seen this change happening within the industry. I also believe that improving the training process for those who use fillers and energy-based devices will improve outcomes, minimize complications, and lead to more natural results. Individuals who previously hesitated to undergo treatment are more likely to seek treatment if the treatments are safe and the results are natural.
K: What role do allied healthcare professionals play in aesthetics?
G: Allied healthcare professionals play a vital role in aesthetics, which is continually expanding and evolving. The truth that some physicians ignore is that the market cannot be served by physicians alone; the magnitude of patients seeking treatment is far too great. I have had a physician associate (PA) in my private practice for many years, and it has greatly enhanced the treatment of our patients. We are able to offer a wider range of treatments and reach a broader base of patients with multiple providers in the office. While ultimately, I am the leader of the practice, we see each other as collaborators with one common goal for our patients.
K: Whom or what do you fear in the aesthetic industry?
G: I fear that because of the profit driven nature of aesthetics, there will be an explosion of undertrained and unskilled injectors who could greatly increase the incidence of complications and undesirable outcomes. This could profoundly impact patient safety and the aesthetic industry as a whole.
K: What keeps you up at night?
G: I probably speak for most aesthetic practitioners when I say that complications are the number 1 thing that keeps me up at night. Fortunately, the wealth of experience I have gained over the years has taught me how to largely avoid complications and how to manage them safely and effectively. One common misconception in the aesthetic industry is that experienced injectors never encounter complications. Rather, expert injectors use strategies and techniques to avoid these untoward events and are able to manage them if encountered.
K: Why are we seeing new aesthetic products fail to launch properly?
G: The facial filler product landscape is becoming more saturated every year. That is not to say that valuable additions to the filler arsenal are not happening; it is just that there is a lot of redundancy among the currently available products. Companies often struggle to effectively verbalize what unique attribute(s) a new filler adds to the market. At this point, do injectors really need more hyaluronic acid products, or should we instead focus on improving outcomes with the current products, enhanced training, and new indications?
K: Attendance at aesthetic conferences has fallen dramatically and it cannot just be blamed on COVID-19? What went wrong? How do we fix it and/or should we even try?
G: Even before the COVID pandemic began in 2020, many were suffering from conference fatigue. It seemed that almost every month, a new conference emerged, claiming to offer a new format or significant change from the others. The reality is that these conferences were essentially no different from the existing ones. In order to fix this, I think meeting organizers need to decide if they are truly adding something worthwhile to the aesthetic space, and if so, are they delivering the most unbiased, scientifically relevant product that does not showcase the same presenters every year. There needs to be more scrutiny placed on the presenters, because many are simply marketing products, companies, or even themselves, rather than being pioneers or educational leaders in the field.
K: Does the big pharma sponsorship that enables mediocre aesthetic conferences and subpar publications to persist, undermine our industry?
G: Ultimately, all conferences require financial support to function, even those that are sponsored by academies. That said, I think that we all have to take a more critical look at conferences to make certain that there is no bias resulting from these financial relationships. It is up to meeting organizers, corporations, and even attendees to ensure that science and education are the focus, rather than profit.
K: Without using any names, tell us about an aesthetic adverse event suffered by a colleague of yours that made you rethink your own practice.
G: Routinely, colleagues will present me with difficult cases and devastating complications for me to advise and review. While I try not to rely on anecdotes to guide my own clinical decisions, it is impossible not to be at least partially influenced by some of the complications that I see. At this point, I have seen enough ischemia complications to convince me that I prefer to use fillers that can be enzymatically degraded in the face of a vascular event. All practitioners have their own opinions on this, but this is what has changed for me over the years.
K: Rather than merit-based promotion, “KOLs” propagate nepotism and cronyism. What should we do to break this vicious cycle?
G: Every medical specialty suffers from nepotism and cronyism; this is not reserved for the aesthetic space. In a perfect world, the best clinicians who set scientific precedents would be those who lead and guide our industry. We have to learn to separate the marketers from the educators and identify those who do the best work or perform the most scientifically driven research. To end this, meeting organizers and those in industry who assemble advisory panels should just make some difficult decisions and seek the voices who deserve to be heard.
K: Getting more granular, what can we do to promote integrity, rectitude, and transparency in aesthetics?
G: Every aesthetic practitioner should consider integrity to be their most valuable asset. It is the trait that engenders patient trust, and also what ensures that we deliver the best, most ethical care possible. A breakdown of integrity breeds mistrust and a lack of respect for what we do. We should all be critical of those who espouse unproven theories and techniques, all in the name of self-promotion. We should all monitor and scrutinize social media and redirect the conversation from marketers to those who represent more valuable informative sources and established experts.
K: What advice do you have for people in the aesthetic space to avoid burnout?
G: Burnout occurs when the balance tips in favor of overworking and stress, and the brain does not have adequate time to rest. Aesthetic surgery places unique emotional and psychological demands on us on a daily basis. So how does one avoid burnout? First, refocus your primary goal to caring and providing for each and every patient, not trying to become the busiest or most accomplished in your field. Focus more on quality than volume. Otherwise, it becomes very hard to ever completely transition to living your life outside of work. Focus on family, relationships, and interests. Read about things that do not relate to work while at home, even if you love reading about what you do at work. Take time away, and make sure a trusted colleague can manage any emergencies or major issues. Have your manager or another staff member tackle emails and other correspondence when you are away. Meditate and learn to live in the present.
K: If you were not an aesthetic expert, what would you do for a living?
G: I would still be a physician. I love being a physician, and I greatly value the physician-patient relationship and how much it has personally enriched my life. I would definitely specialize in something procedurally based, but I am not sure what that would be. If I were not a physician, I would probably still be doing what I was doing before medicine: scientific research and public health. I think I probably would have expanded my role at the CDC or would have moved on to the National Institutes of Health (NIH).
K: What is your favorite quote (mantra, etc.) that is applicable to the aesthetic industry?
G: “Eternal vigilance is the price of safety.” (A variation on a quote often attributed to Thomas Jefferson, “Eternal vigilance is the price of liberty.”)
K: With so much confusion in the industry, where do you personally go for trusted aesthetic information?
G: I still believe that the best source of trusted aesthetic information is the medical literature. Unfortunately, even the medical literature can be flawed with bias, unsubstantiated reports, and redundant clinical research. When I was in graduate school, I formed a journal club at the CDC in an effort to better scrutinize the data in the literature. I believe scientific discourses and debates like this are absolutely necessary in aesthetics. The difference is that in aesthetics, it can be more challenging to produce solid data that relies on subjective and qualitative findings. Regardless, I believe the most responsible thing that we can all do as physicians and scientists is to question data and ensure that the most accurate scientific evidence is being published. Finally, I also rely on colleagues for trusted information. However, I realize that this is anecdotal, and I take everything with a grain of salt. This communication among colleagues is an essential adjunct to the help guide practitioners on a day-to-day basis.
K: What advice do you have for someone not in the industry who wants to enter the field of aesthetics but does not know where to start?
Number 1: Start by learning on your own to gain a foundation of anatomic knowledge. There are a number of great textbooks and reviews on this subject matter.
Number 2: Find the right mentor. This is the most difficult step, but it is also the most important. If you can find someone to shadow and who will be invested in you, this can greatly accelerate your career on the right trajectory. Finding this mentor often comes down to luck, but it is perhaps easiest to achieve if you are hired by an experienced aesthetic practitioner who also loves teaching.
K:And what advice would you give your younger self knowing what you know now?
G: Life is short, so donottry to rush it. Stay grounded and balanced. Relationships and family are what matter most.
K: What will the aesthetic industry look like 10 years from now?
G: I predict record expansion over the next 10 years and exponential growth. Surgery will not lose popularity in favor of non-surgical treatments; in fact, I believe both will continue to expand. We will continue to see increased acceptance of aesthetic treatments and plastic surgery, but patients will continue to desire a natural aesthetic.
K: What does your personal aesthetic legacy look like?
G: Ultimately, my legacy to my patients is what is most important to me. Of course, I want to be respected by my peers and viewed as an innovator and leader, but this still is secondary to the opinions of my patients. They are why I go to work every day. As long as my patients know that I put their interests first, that is the only legacy I need to leave.
K: If you could inspire a movement in our industry, what would it be?
G: I would like to inspire the scientific movement, one in which anecdotal evidence is challenged and isn’t favored over robust scientific data.
K: Thank you so much for your thoughtful insights. How can readers get more aesthetic expert information from you?
G: Please find me at www.DrRyanGreene.com or on social media at @DrRyanGreene (personal Instagram) or @GreeneMD_Weston (business Instagram).