Beauty: Pursuit of the Fountain of Youth

With new minimally invasive cosmetic procedures coming on the market every year, the options for a younger look are increasingly more attainable and affordable.

by Daniel Pye

Anyone who’s ever picked up a newspaper or watched a half hour of E! network in the past 10 years has heard of Botox. With more than 3.8 million Botox injections performed in 2005, the drug is the most popular minimally invasive cosmetic procedure on the market. Other products, like Restylane, Radiesse and Sculptra, actually fill in the gaps when skin has begun to sag. All of these injectables have revolutionized the way doctors look at facelifts.

“If you look at where we are today versus three years ago, it’s been a dramatic change,” says Keith Davis, M.D., of the Plastic Surgery Pavilion of the South. “We’re now able to do pseudo-facelifts just with injectables. Procedures that at one time required implants, bone grafts or surgical procedures to implant foreign material can now be done solely with injectables.” Doctors are doing more injectable procedures than ever as less expensive and less time-consuming alternatives to traditional facelifts. But which ones, if any, are right for you?

Starting with the most popular, Botox works by weakening muscles in the face that pull skin together and cause the wrinkles that occur when you make facial expressions. While there are companies working on longer-lasting versions of the drug, Botox hasn’t changed, Dr. Davis says. Botox costs between $300 and $400 and lasts four to six months, but patients who are treated repeatedly may see more time in between treatments and the reappearance of wrinkles. “People I see on a regular basis will say, ‘My Botox is lasting eight to 10 months.’ My answer to that is no,” Dr. Davis says. “The muscles are just becoming weaker over time and taking longer to regain strength.”

Botox can be used to reduce the crow’s feet around eyes or to make the brow higher or lower by weakening the muscles that pull up or down on it. The drug is also approved for treatment of hyperhydrosis, or excessive sweating, and has a longer lasting effect than for relief of wrinkles. When injecting Botox, it’s important for doctors to thoroughly understand the musculature of the face so they weaken the right muscles. “When you’re lowering the browline, it’s important to lower the middle without lowering the sides,” says Achih Chen, M.D., director of the Georgia Center for Facial Plastic Surgery & Laser Aesthetics. “Lowering the sides produces a hooding effect over the eye and makes it difficult for the patient to see.”

As insurance reimbursements decrease for things like checkups, Dr. Davis says other specialties are trying to branch into injectable cosmetics, which is not billable to insurance and thus requires cash up front. “The basic message here is that people who are not properly trained are doing these procedures,” Dr. Davis says.

In the natural course of aging Dr. Chen says people’s faces get longer and thinner. The reason for this is the slow breakdown and loss of fat that makes the face look full. “As we age, it’s not just that skin gets looser. We also lose some of the volume in our face, so when you’ve lost volume you can’t just pull skin tighter and get a natural look,” Dr. Chen says.

Aging isn’t the only thing that can leave cheeks looking hollow and eyelids droopy. Dieting to lose weight in problem areas has the same effect on the face, even if that wasn’t the intention. “People are eating healthier on their own weight reduction programs and in the process are losing some of the subcutaneous fat that keeps your face looking full,” Dr. Davis says.

“Skin is like a sheet of paper,” Dr. Chen says. “You can flatten it after you fold it, but you can still tell it’s been folded.” For these deep folds, you need fillers, which come in a variety of forms with different applications and results. Dr. Chen does a lot of fat injection, which involves pulling fat from a donor site, often the inner thigh or buttocks, and placing it in areas like the eyebrow to replace fat that has broken down over time. Dr. Davis steers away from fat injection because the area being injected must be overfilled by 30 to 50 percent, costing the patient more down time than other injectables. But even though it takes two weeks for the overfilled fat to be absorbed, Dr. Chen likes fat injection because the results are permanent, unlike other injectables.

At the top of the non-permanent injectable list is Restylane, which costs $400 to $500. Restylane was the first generation of injectables that didn’t have the risk of allergic reaction and is used extensively to increase the fullness of lips and get rid of fine lines around the nose and mouth. “It’s a naturally occurring body substance and it allowed us to do immediate volume replacement,” Dr. Davis says. “Not everyone could do collagen and it took a month of testing just to see if you could or not. With Restylane you can come in and leave ready for your party or wedding without the waiting.”

Since Restylane lasts four to six months, Dr. Davis uses it if the patient isn’t sure what they want or to what degree they want it. “The risk with the more permanent fillers is the same as the benefit: It lasts a long time,” he says. “That’s great for someone who is sure what they want, but what if you’re not and you don’t like it when it’s done? That’s where Restylane comes in handy.”

Somewhere in between the permanent and temporary lies Radiesse, a filler that lasts from 18 to 24 months. In addition to lasting longer, Radiesse can be used to fill deeper folds that would be cost-prohibitive using Restylane. Dr. Davis says patients might initially balk at the approximate $1200 price tag, but once they understand that they’d pay the same amount or more for Restylane over the same period of time with one treatment instead of four, they tend to feel better about the investment. Radiesse is also an instant gratification type of treatment, with what you see when you’re done being what you get for the duration of the product’s life.

For even longer lasting results there is Sculptra, which Dr. Davis says can last for three to four years. It works by tricking the skin into thickening and tightening, working on the face from the inside out. Sculptra costs $1400 to $1500, requiring two treatments spaced a month apart and six months of waiting to achieve the desired results. “This is a good option for people who don’t want to telegraph that they’re having work done,” Dr. Davis says. “If you want it tomorrow, then Sculptra is not for you. If you can take a little time with it for longer lasting effects, it might be right.” The filler was originally approved for HIV patients who lost the fat in their face, but has since been applied to more common fat loss due to aging.

A permanent filler named Artefill gained FDA approval in late October 2006, but Dr. Chen is still waiting for verification of its effectiveness before he starts offering it to patients. “We will be offering this product as soon as we can demo it for ourselves,” Dr. Chen says. “I’ve seen the Canadian facial plastic surgeons use it and they really like it, but I’d like to try it out for myself on a few study patients before we start using it routinely.”

While the chemical makeup of Botox hasn’t been updated since its creation, the use of Botox has changed to accommodate and assist other treatments. Strong muscles that create frown lines and wrinkles can be weakened with Botox to allow a treatment like Sculptra to work without being interfered with for a time.
In addition to being used as stand-alone treatments, this new generation of fillers can also be used to augment more traditional surgical facelift procedures for better, more natural-looking results. “The facelift with added injectables is called a volumetric facelift, and that achieves a fuller look than a traditional facelift,” Dr. Chen says.

One problem patients had with the notion of using fillers in conjunction with a facelift in the days of collagen was the lack of permanence. With better fillers, Dr. Davis has found patients much more receptive to using them along with the facelift procedure. “People coming in for a surgical facelift don’t want to have to come back every three months,” Dr. Davis says. “They want a permanent solution. Now we can use these new fillers in addition to the facelift and give a longer-lasting result.”