Aesthetic medicine is evolving at an unprecedented pace, driven by new technologies, innovative treatments, and the pervasive influence of social media. As patient expectations shift and digital tools—from AI-generated images to social media trends—reshape perceptions of beauty, practitioners face complex ethical and technical challenges. To explore these dynamics, Dr. John Arlette, a dermatologist and cosmetic surgeon based at the University of Calgary, and Dr. Alexander Rivkin, a facial sculpting specialist in Los Angeles, discuss the controversies, opportunities, and future directions of the field during IMCAS World Congress 2025.

Introducing the Experts

Dr. John Arlette: I’m a dermatologist, and my position is in the Department of Surgery and Division of Plastic Surgery at the Cummings School of Medicine in the University of Calgary, Alberta, and my background as a dermatologist is primarily as a surgical oncologist and as a cosmetic surgeon. I have then developed into primarily an injector of filler and my one specialty is in ultrasound.

Dr. Alexander Rivkin: I’m Alexander Rivkin and I’m based in Los Angeles. My background is head and neck surgery, otolaryngology. But for the past 22 years now, I've been doing exclusively non-surgical procedures where I specialize in basically facial sculpting, non-surgical facial sculpting, and specifically in the nose. And so, these days, a lot of my practice consists in revision, non-surgical rhinoplasty.

Major Controversies in Aesthetic Treatments

IMCAS Team: What are some of the major controversies that you are observing in aesthetic treatments today?

Dr. JA: Well, depends on the controversy. It’s always, ‘how do we manage patients' expectations with our abilities and skills?’ I think in the end, the real part of what we do is we have a toolbox that we can offer to patients who come in with expectations of what they want to achieve. And it's trying to marry those two things together as to what we can deliver to them in order to meet what they see themselves as. In doing that in a non-judgmental and open way, respectful of what people have as their request and their desires.

Dr. AR: I find that a lot of the controversies in our field these days come from one place, and that's social media.

Dr. JA: The information on social media is based on the perception of the person presenting it. It may be misrepresented, it may be misleading, and it may be misinformation for the basis of really promoting whatever one person wants to set as the agenda on social media. And then in addition to that, which has just started to really appear in social media, is the effect of computer-generated images as well as Artificial Intelligence in terms of producing results that neither of us are able to produce in a realistic fashion.

Dr. AR: It really generates a lot of issues for us in terms of debunking myths and in terms of people saying things that are maybe beneficial for them, as opposed to beneficial for the patients, and then us having to really deal with information that's not as accurate as it could be.

Social Media, AI, and Patient Expectations

IMCAS Team: How has social media skewed the way patients perceive and approach aesthetic treatments?

Dr. JA: Skewing ideas, that's a really good way to put it. How do you reverse what we're presented with? There's a certain level that we can achieve, and then, for me, the challenge is meeting the expectation of the people that you're working with. Leaving no scars, no marks, no evidence that they've had any treatment, and no downtime, and the results are immediate. And maybe you've invented a way to have no bruising, but I haven't achieved that yet.

Dr. AR: Sometimes patients come in not with somebody else's face, but with their own face morphed into the idea of what they would like, and that's not necessarily achievable. Sometimes these expectations can be met, and sometimes they can't. But there is a positive side, which is that they come in much more informed than they used to be. Our field is much less of a black box to patients, thanks to social media.

Research and Innovation

IMCAS Team: Do you think cosmetic trends affect research and innovation in medical therapies?

Dr. JA: The effect of research in cosmetic therapies is a boon to research into medical therapies. Right now we're in this sort of blossoming stage where we now have so many ways of treating that we're now able to be more selective, specific, and focused in the treatments that we're going to be able to provide patients, because treatments that are designed for specific diseases will be cross-linked into other areas.

Dr. AR: There's so much attention these days, and so much money that goes towards research on the cosmetic side, I think that we are seeing and we will see, especially as you're saying about these kinds of biostimulatory things that we do, that that may go over to the therapeutic side and say, ‘Oh, look, they see these kinds of changes in aesthetics with these kind of agents. Maybe we can use them off-label in therapeutics.’

The Filler Debate: Fads, Risks, and Responsibility

IMCAS Team: With fillers being such a widely discussed topic, how do you both view the current trends and concerns around their use?

Dr. AR: Right now the fashion is, ‘Oh, fillers are terrible, they do all these kinds of things, and what you really need is a facelift.’ There are stories in the popular media about people getting facelifts in their 20s, which is obscene. That's ridiculous.

Dr. JA: The overfilled face is a real consequence of inappropriate treatments. When we talk about fads, we go to meetings and someone says, ‘I put 20 syringes in this face.’ Really, what did that patient need? Or what was it that made you to think that that person would benefit from 20 syringes of filler?

Dr. AR: Perception drift is a real concern among the patient as they're exposed to social media. But that doesn't stop there because it goes to the provider as well. We have to be, as injectors, on guard for perception drift, and we have to be careful not only educating our patients about it but being careful within ourselves.

Dr. JA: How do we then protect ourselves from not being swept up by either the patient's demand or knowing what we could do? Once that question comes, you already have a dilemma. Is there a dilemma when financial return drives patient care?

Dr. AR: The incentives drive behavior, no matter if you're aware of it or not. Physicians and nurses think of ourselves as beyond this kind of influence, but we're really not.