Dr Linda Fiumara on the changing face of plastic surgery

Beauty is in the eye of the beholder, so the saying goes. It is subjective. But it’s also not. From symmetry to the golden ratio, there are rules of proportion that can be applied to the face to make it more attractive. But where do you start? We wanted to find out and who better to ask than someone who spends their life contemplating the faces of strangers, determining what combination of small tweaks will make the biggest difference. 

“I am convinced that beauty is the result of a harmonious combination of hundreds of details and features,” says Dr Fiumara, a Consultant Plastic and Reconstructive Surgeon with a specific interest in Cosmetic Surgery and Aesthetic Medicine. “My personal philosophy is that of ‘facial micro-optimization,’ which is obtaining tiny and subtle improvements in multiple areas of the face. As surgeons, we should never aim to drastically change the human face.”

Dr Fiumara started her career in reconstructive surgery, with a focus on mastectomies and reconstructing breasts after cancer. And while the majority of her work is still with breasts, she has also branched out into cosmetic procedures, including non-surgical treatments such as Botox and fillers. On the front line of surgery, Dr Fiumara has witnessed first hand the changes the industry is currently undergoing: the soaring popularity of non-invasive procedures, the falling age of patients and the changing standards of beauty that have come about as a result of social media. We caught up with the surgeon to find out more.

If beauty is truly subjective, how do you look at someone’s face and say what kind of treatment they might need? What are you using to measure their appearance?

Dr Fiumara: First of all, nobody needs what I can give. Indications are all given by the patients, whether it’s breast implants, fillers or whatever. There are generic rules that you apply. One is signs of youth, which is defined by skin that is poreless and without wrinkles. So the first thing that we look at is lines and we tackle them with botox and fillers. Another is signs of symmetry. There are psychological studies where they ask men and women to choose between different faces and they all go for the more symmetrical face. It’s instinctive. 

So we tackle symmetry, looking at areas that have lost volume. Then skin texture and pigmentations.

According to numerous studies, more and more people are having things done. Why do you think this is?

Dr Fiumara: Make-up is no longer sufficient, hair has to be dyed and everything has to be announced. Social media has significantly raised our standards when assessing the beauty of the face and body. Even though the images portrayed are almost invariably enhanced by professional make-up, strategic lightening, filters, Photoshop, airbrushing, people want to look like these versions of their friends or celebrities.  

Also, the widespread habit of taking selfies has increased the level of awareness related to facial features. Interestingly, patients are now more aware of minor facial imperfections because of taking selfies so often. All of this is exposing young generations to high levels of social and peer pressure because everyone is comparing themselves to everyone else.

And corporations are capitalising on it.

Dr Fiumara: The thing about the beauty industry is that billions are being spent on creams, where there’s no medical background to say the creams will do anything. According to literature, the only molecule that will do anything for fine line is retinoic acid, which is a derivative of Vitamin A. I’ve used retinol occasionally, I do it only at night time, and only once a week. It’s drying for the skin, it’s quite irritating – drying in a weird sense that it could trigger blemishes because it’s so irritating for the skin. Vitamin C is also good, it’s a high strength antioxidant. Other than that, creams just sit on the skin, they can’t permeate the skin so they can’t moisturise it, but they will reduce the appearance of lines. And yet, we’re all obsessed and we will buy the brands that are really expensive. Have you heard of collagen drinks? I don’t believe in those I’m afraid.

“With breasts, people are becoming a little more conservative and do understand that bigger is not necessarily better”

For someone that doesn’t know any different, how do you navigate all the noise of the skincare industry?

Dr Fiumara: With skincare and products, keep it really simple. I would say a good moisturiser, a good eye treatment. Something that contains Vitamin C and antioxidants. Any brand as long as it contains this, it would be okay but I would say SPF is more important than moisturiser. Treatments are what work best - lasers, peels. 

You started in reconstructive surgery, didn’t you?

Dr Fiumara: Yes, my background is mainly breast reconstruction. So whenever women have breast cancer, they have to undergo a mastectomy. The breast bone has to be reconstructed and the nipple recreated. Plastic surgeons train in reconstructive surgery and then they tend to branch out into a more specific field for example cosmetics. Today 90% of my work is breast related, followed by labias, conjugal procedures, I do a bit of rhinoplasties as well and a small part of my business is surgicals on gender roles.

Have you noticed a difference in trends in these areas?

Dr Fiumara: With breasts, people are becoming a little more conservative and do understand that bigger is not necessarily better. There are patients that want mini boob jobs like more subtle changes, so a breast lift without an implant.

Do you think the original face lift has gone down in popularity? 

Dr Fiumara: It definitely has. 

Is that because people are getting fillers earlier?

Dr Fiumara: That’s exactly it, they are trying to avoid surgery as much as possible and they’re doing less.

“We have to be realistic with natural remedies you can only go so far”

How do things like filler age? Will people who are getting filler now, especially at the younger end of the spectrum, age weirdly?

Dr Fiumara: I think these people will have to carry on whatever they’re having done. But I don’t personally think that patients that are starting fillers and botox young, will be any worse. The key is moderation, in the sense that if you start doing it too much, at some point, you will end up looking too odd and odd will make you look worse than old. 

Wellness is huge right now. It’s what’s driving us to want to look healthy and well, but ironically and somewhat cheatingly we’re achieving this through filler, what do you make of this?

Dr Fiumara: We have to be realistic with natural remedies you can only go so far. Diet and fitness will do you good, for sure, but won’t necessarily correct those little lines. So I guess why not have a bit of botox, here and there. I think that’s a sensible approach and there’s nothing wrong with that.

With more and more celebrities tagging their doctors on social media, and the conversation about things like Botox and fillers becoming more commonplace, getting something done feels totally normal. Is this a good thing?

Dr Fiumara: Lunchtime treatments [injectables, radiofrequency, lasers, and skin resurfacing procedures] should be, again, in moderation. Because they are less invasive, lower in cost, and have low downtime they carry a lower stigma than surgery but they can’t be trivialised, it’s still a needle going into your skin that has a huge network of blood vessels. I think with social media we’ve gone a bit too far, people think there’s no risk.

There’s also plans to bring Botox and filler to high street stores like Boots and Superdrug. What are the ethics of that? 

Dr Fiumara: It’s very unregulated, especially in the UK. After a two day course, nurses are certified to carry out these treatments, but they have not studied the anatomy of the face as much as a doctor has. The complexity of the facial neurovascular anatomy is often overlooked. Mistakes can happen even in the most skillful hands and if there are any side effects, these practitioners are not trained to correct them, rectify them or prescribe the antidotes. For example, if you get an infection from dermal fillers, as a nurse you’re not really entitled to prescribe an antibiotic so you have to send the patient elsewhere. This is a bit of an emergency when the patient needs an antibiotic immediately.

What other problems do you see facing this industry right now?

Dr Fiumara: Again, there’s complications with dermal fillers where parts of the skin could basically die, it’s called skin necrosis. If these things go into a blood vessel, and clogs them so there is no blood flow through there, a small area of the skin could die. We’re talking about the face, so if someone is not comfortable with the anatomy of the face, perhaps they might feel it’s just injecting some gel into the skin. But they could cause severe harm.

“We should never forget that beauty is unique to each person”

How has becoming a plastic surgeon shaped your understanding of beauty.

Dr Fiumara: I am convinced that beauty is the result of a harmonious combination of hundreds of details and features. My personal philosophy when it comes to cosmetic procedures of the face is that of ‘facial micro-optimization,’ which is obtaining tiny and subtle improvements in multiple areas of the face. One shouldn’t really be able to tell why you look so much better. As surgeons, we should never aim to drastically change the human face. I think we should always stay true to ourselves, and never try to become another person. On the contrary, we should reinforce our strong/good sides and perhaps just ‘dilute’ or tweak our week aspects. We should never forget that beauty is unique to each person, as unique as our fingerprints, and has nothing to do with canonic measurements, breasts size, average facial dimensions, or golden ratios.

What is the most rewarding part of your job?

Dr Fiumara: Seeing a patient flourishing and thriving in their own personal and professional life after having had surgery with me. Patients often feel that their procedure has boosted their self-esteem and that they can face life with a more confident attitude. 

Is there anything that you’re excited about in terms of new tech developments in your field?

Dr Fiumara: Everything that we’ve mentioned, except for the Botox, has been perfected. With dermal fillers, there’s so many options. So, the viscosity, the longevity, the product. All these features, are getting better.

Also advances in the field of regenerative medicine and cell-based therapies will allow progress in the field of anti-ageing procedures. Technologies such as robotic surgery, artificial intelligence, three-dimensional printing and new imaging methods will contribute to change the way surgical care is delivered. Let us hope however, that the level of human artistry and love of accuracy will always remain the inspiring force of cosmetic surgery.

What is the future of beauty?

Dr Fiumara: I think we will see a further raising of the bar and increasingly more people will reach to cosmetic dentistry, cosmetic medicine and aesthetic surgery to enhance their looks. The democratization of these interventions will probably increase further, to the point where these treatments will be considered as a part of normal maintenance required – the equivalent to going to the hairdresser or having a dental hygiene session.