Saving Face – Injectable Cosmetic Drugs Can Help Turn Back the Clock

Many people would like to change the way they look, and over the past five years, women have spent more than $9.6 million on cosmetic procedures to do just that. Male cosmetic surgery increased by 43{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} during the same time period, and an increasing number of Americans are turning to plastic surgeons to subtract years from their appearance.

But new products have been created that reduce the need for surgery and offer people the opportunity to restore a youthful look without pain or lost time from work.

“Historically, cosmetic surgery was reserved for movie stars and the rich, and if they had procedures done, it wasn’t information they shared,” said Dr. Helen Perakis of Northampton Plastic Surgery. “But society has changed, and these topics are no longer taboo. People want to get things done that make them look and feel younger, and thanks to Botox and other injectable fillers, it’s possible today to rejuvenate someone’s looks without surgery.”

Dr. Glen Brooks agrees.

“Twenty years ago, the only cosmetic filler was collagen. But Botox was a game changer because it allowed us to relax muscles and reduce forehead wrinkles and crow’s feet around the eyes,” said the certified plastic surgeon at Aesthetic and Plastic Reconstructive Surgery, P.C. in Longmeadow. “It is not used around the eyelids, but it can also soften wrinkles beneath the eyes and around the mouth.”

He added that people call the cosmetic filler Juvederm Voluma “a liquid facelift. You don’t have to go under the knife, and it can be injected in one visit with no downtime. There may be a little bruising, but in experienced hands, it can result in a very natural look.”

Leah Kennedy told HCN that cosmetic injections have moved past the point of merely filling in lines.

“We’re in an era where you can really bring back the look of a youthful face and rejuvenate a person’s appearance with them; people can achieve very good results in a single office visit,” said the physician’s assistant who works with Brooks. With 17 years experience, she travels across New England as a trainer in injection techniques for a major company that makes well-known cosmetic injectable drugs.

Although most people seeking injections tend to be older, physicians report people in their 20s are turning to them to prevent wrinkles.

“Most young people are happy with their appearance and want to maintain it,” said Dr. Melissa Johnson, a certified plastic surgeon at Pioneer Valley Plastic Surgery in Springfield. “They want to slow down the aging process and feel good about themselves, and wrinkling and bagging around the eyes can make someone look tired.

“By age 50 or 60, people have static wrinkles that won’t go away, but you can only see wrinkles in 30-year-olds when they animate,” she went on, “and younger patients want to prevent them from getting worse.”

The injections are almost painless, and a person can schedule a visit in the middle of the workday and return to their job immediately after receiving them. “It’s quite comfortable. Ice or a topical numbing medicine is used before the injections, and there is lidocaine in many products, which causes temporary numbness as soon as you begin to inject them,” Johnson said.

Perakis agreed. “The use of topical lidocaine takes a little of the sting away. People can still feel the injections, but the pain is not much worse than plucking your eyebrows,” she said.

Scientific Advances

Collagen plays a key role in providing support to the skin and giving the face its shape. But at about age 30, the body begins producing less of it, and the aging process can start to become visible.

Years ago, bovine collagen, which came from cows, was the only product available to fill fine lines or plump up the face, and people had to be tested for allergies before it could be injected.

But the first product to gain immediate popularity was Botox. It is made from botulinum toxin and temporarily improves the appearance of moderate to severe lines between the eyebrows in people aged 18 to 65, as well as diminishing wrinkles around the eyes by paralyzing the muscles that move when people squint or frown.

Dr. John Papale of Papale Eye Center was the first physician in the area to inject Botox for medical problems. However, when he began using it 30 years ago, the drug had not been approved for cosmetic improvements.

“It was used to treat hemifacial spasms and blepharospasms. People would come in with one side of their face or their eyes in spasm, but Botox was a miracle cure for these conditions,” Papale said, adding that the drug relaxes the muscles for about three months.

At that time, no one knew it could reduce or eliminate wrinkles. But reports soon began surfacing that the injections caused wrinkles to disappear, and in 2002, Botox was approved by the U.S. Food and Drug Administration to treat fine lines on the face. Since that time, it has also been used for severe underarm sweating; spasms of the bladder, neck, and shoulder; cerebral palsy in children; and migraine headaches, although Papale said it is not a first-line therapy for that problem.

However, cosmetic use of the product is its most well-known application, and it quickly became so popular that, at one point, demand exceeded supply. Other products that contain botulinum toxin have been created since that time, but many people ask for Botox by name, and many doctors choose to use it.

Over the past decade, other facial fillers have been created that typically last about nine months. Most contain hyaluronic acid, and trade names include Juvederm, Restylane, Perlane, and Bellatero. But there is another family of fillers that use calcium hydroxapetite; these include the trade name Radisse.

“What the injector uses depends on the location they are injecting,” Perakis explained. “Hyaluronic acid is more likely to be used to fill nasal labial folds or marionette lines, while calcium fillers are injected in deeper spaces, such as the cheeks.”

Juvederm Voluma, an injectable hyaluronic acid that lasts two years and was designed to recontour the face and restore lost volume in the cheeks, cheekbones, and chin, has become very popular.

“If you augment the checks, it can draw the eye away from the neck and toward the upper part of the face,” Perakis said. “A younger person’s face is a top-heavy face, but gravity and aging leads to a jowly appearance, so cheek augmentation has become very popular.”

However, Kennedy stressed that injectors are not meant to create apple-like cheeks.

“As people get older, they lose volume in the bony support layer of their face along with soft tissue, and Voluma can replace it,” she said. “It gives people a beautiful, natural look that reflects light, so the face looks brighter after the person receives the injections.”

Johnson told HCN that, when people think about the face, they need to think about the skin, muscles, underlying soft tissue or fat, and the bony structure, which all diminish due to aging. “The earlobes lengthen, and our nasal tip droops,” she said, adding that massive weight loss, cancer, and HIV can also cause people to lose volume in their face.

In addition, cosmetic injections can make a difference in the lips. “Hyaluronic acids can be used to outline the border of them and give them more definition,” Perakis said, adding that some people want their lips plumped up, and requests range from a pouty look to an overly full appearance.

The hands are another area that show aging, and injectable cosmetic drugs can add volume as the skin and bony structure thins and tendons and veins become more visble. Brooks said injections can be supplemented with broadband light treatments, which eliminate age spots.

Although fat is another substance that is sometimes injected, Brooks said it is typically done during other surgical procedures, such as tummy tucks or liposuction.

“It has become very popular; it’s stolen from anywhere in the body where it is not needed and added to various areas. It’s your own tissue and is a great compliment to a facelift,” he noted. “But Voluma can be used for the same amount of money or less.”

Checking Credentials

No matter what injectable cosmetic drugs are used for, physicians agree that it is critical to select someone with a full knowledge of anatomy before scheduling a treatment.

“It requires an underlying knowledge of facial anatomy, which includes the location of major nerves and blood vessels,” Perakis said. “It’s a procedure, so there are risks involved, and you want to make sure that the person you choose is qualified, trained, and does this for a living. Many people offer these injections, especially since it is a cash business, but you don’t want to end up with complications.”

Papale agreed. “Botox is a powerful drug,” he said. “In an experienced hand, it’s very safe, but if it is not administered properly, people can have problems with double vision or droopy eyelids, so it’s important to go to someone who does it all the time.”

Johnson explained that safety should always be an individual’s priority, and used the eyes as an example of a problem area. “Muscles elevate the eyelid, and it’s essential to know anatomy, because if you inject something in the wrong place it can cause the eyelids to droop,” she said. “Botox works great for what it was intended for, but you should not have anyone injecting it unless they can treat the entire spectrum of possible complications.”

Although these are rare, there are many things the injector must consider. “Different techniques are used in young patients than older ones, so it’s important to let the injector use their expertise so you end up with a natural, refreshed look rather than an overdone one,” Kennedy said.

Johnson agreed. “A little is good, but a lot is not always better. For example, high checkbones can be attractive, but if you put too much volume in them, it changes the look of the eyes.”

Choosing the right medical professional is also important because people sometimes request a cosmetic procedure that is not appropriate.

“I had one woman who wanted a chemical peel, but her main complaint was wrinkles that had formed as a result of movement, and the only way to fix that is with Botox,” Johnson said, adding that static wrinkles differ from dynamic wrinkles and are caused by factors such as genetics, lifestyle, and diet. “I examine the patient and listen to what bothers them before deciding what is best.”

Perakis concurred, adding that, in some cases, one product works better than others. “I had a patient who didn’t get the results she wanted from Botox, so I used another product that paralyzes the muscle, and it worked well.”

Brooks stressed that it’s important to find someone who is board-certified. His practice administered 1,800 injections last year, and he has seen patients with problems caused by injectors who are not highly qualified.

“Cosmetic surgery is a nebulous term. You need to ask about the person’s expertise, training, and how many injections they do,” he said, citing the forehead as an example of an area that can be problematic. “There are 28 muscles that support the eyebrows, and if an older person is injected with too much Botox, it could make their forehead tissue droop, especially if it is already sagging. The art comes in knowing how much to give each person. But no one is too old to benefit from these injections.”

Although there is no immediate fix other than time if Botox is administered incorrectly, if someone doesn’t like the way a hyaluronic-acid product looks, an enzyme can be used to dissolve it. But physicians typically start with a small amount, show the person how they look (since the results are immediately visible), then add more if needed to achieve the desired result.

Injectable fillers can also be molded right after they are injected and stay where they are put. “So it’s extremely rare for someone to want it removed,” Johnson said.

Botox injections typically cost between $150 and $600, depending on how much is used, and last three to four months, while fillers are more expensive, but last nine months to two years. For example, Voluma can cost between $800 and $1,500. However, many doctors’ offices subscribe to a loyalty program called Brilliant Distinctions, which provides points for different products that can be turned into cash.

Noticeable Improvements

Brooks says everyone ages differently, but the earlier people begin preventing lines and wrinkles, the less problematic they become.

“If you wait until you are 40, you will begin to develop permanent wrinkles,” he told HCN. “They can be softened, but you won’t be able to completely get rid of them with injections.

“But injections are effective, and we use them in people from their 20s through their 80s; other people notice that they look better, but can’t figure out what they have done,” he continued. “A lot of people don’t want surgery, but are thrilled to have alternatives that make them feel good.”