Under Your Skin

From fat melters to nose sculptors, the latest injectables are making Botox look like child’s play.

by Joanne Chen


Cosmetic surgeons wielding needles aren’t simply, as one doctor put it, “wrinkle chasers” anymore. With highly evolved perspectives on what truly constitutes a youthful look, doctors are now injecting a host of compounds to lift, mold, and contour. Most visits last no more than an hour, and recovery times are equally swift. It’s enough to make a scalpel seem downright crude. So who’s shooting what where?

Reflation Revolution According to Beverly Hills dermatologist Ava Sham­ban, when it comes to aging, the main culprit is “deflation.” By age 50 or 60, she says, most of us have lost around 20 percent of our facial bone and fat, and as a result, our faces sag and look gaunt—not unlike a pillowcase over a shrunken cushion.

To pump up the volume, Shamban offers a procedure that was developed in Canada and is aptly called Reflation. Unlike more superficial wrinkle-erasing treatments, Reflation entails injecting a hyaluronic acid–based filler well beneath the dermal layer, where it sits on top of the bone and props the skin up, especially beneath the eyes, around the cheeks, at the nasolabial folds, and—most efficaciously, Shamban says—at the temples.

Aging temples? Indeed. They sink over time, and even the most expertly done face can look “off” if the temples are left lying close to the skull, Shamban points out. But shoot a syringe of filler into them and they look “fantastic,” she says.

A total refill takes two or three visits, at a cost of $2,000 to $3,500, and the results last for about six months. Subsequent sessions, however, require less filler—and come with a smaller price tag.

The Liquid Nose Job The nose is not immune from the aging process: Over time it can droop and appear flatter and longer. Bony irregularities that were camouflaged by the thicker skin and lipid layer we had in our 20s become more noticeable.

Now fillers—placed on top of the bone, cartilage, or tip—can give an old nose a youthful boost. “The padding softens the features,” says Coral Gables, Florida, cosmetic dermatologist Oscar Hevia—as long as the physician has a sculptor’s vision. “A millimeter can make a huge change,” cautions Stafford Broumand, an associate professor of plastic surgery at Mount Sinai Hospital in New York. The in-office procedure can be completed in as little as half an hour and starts at $700—a universe apart from the traditional two-hour rhinoplasty, which can set you back around $8,000.

Lip Service They say a genuine smile never grows old—but try telling that to a cosmetic surgeon. Jeffrey Spiegel, the chief of facial plastic and reconstructive surgery at Boston University Medical Center, points out that as we age, our lips lengthen horizontally and fine lines creep up above them, vertically. The upper lip also drifts down, hiding teeth. Darrick Antell, an assistant clinical professor of plastic surgery at Columbia University, injects filler not into the lips but into the roll of skin that surrounds them. “It gives a fuller look without appearing ducky,” Antell says.

And those vertical lip lines? Cosmetic physicians are over the moon about Belotero Balance. Like most fillers, it is FDA-approved for deep nasolabial folds, but doctors are now using it for more-superficial lines—something that’s not possible with other fillers, which have a blue tinge that shows through skin if injected close to the surface. “It’s like Photoshop,” says Miami dermatologist Leslie Baumann. “The lines immediately plump up.” The downside? Considerable bruising for 5 to 10 days. A session costs $650 to $750, with results lasting about six to nine months. »

Carbon Dating Once upon a time, carbon dioxide therapy was a little known medical practice used to improve circulation. Then, in 1998, beauty-minded scientists at the University of Siena, Italy, began injecting the gas into saggy knees, thighs, and bellies. The result: blood vessels dilated, sending a rush of oxygen into the problem areas. After six semiweekly sessions, skin density improved, and the area looked tauter. Enhanced circulation seems to flush out fluid buildup, improve fat metabolism, and promote collagen production, says Cesare Brandi, M.D., who was the lead author of the study. Subsequent research suggests that carbon therapy can be used as an adjunct to liposuction, to improve skin elasticity and smooth small lumps.

Carboxy, as the treatment is called, gained popularity in 2002 in Brazil. But, perhaps because practitioners would have to go abroad to learn the technique, it has yet to catch on with American doctors. There are, of course, outliers. Lisa Zdinak, a Manhattan ophthalmic plastic surgeon, uses a tiny needle attached to a gas tank to inject small puffs of CO into the skin around the eyes to treat dark circles. “It improves the capillary networks and reduces the bluish tinge by about 50 percent,” she says. Zdinak has also found carboxy to be “brilliant” for baggy lower lids. The best results require six 20-minute sessions, at a cost of $250 each, and last about 6 to 12 months.

Scalpel-Free Sculpting As of this writing, Voluma has yet to be FDA-approved, but the enthusiasm for this filler can be heard from across the Atlantic. “It has completely changed my practice,” says Hervé Raspaldo, a facial plastic surgeon in Cannes, France, and a consultant for Allergan, the company that manufactures Voluma. Created by the same French lab that invented Juvéderm, Voluma, which is thicker than its forerunner, can be injected under the muscle layer and massaged into the desired shape—offering a scalpel-free way to attain a stronger chin or jaw line or more defined cheekbones. “If you tried this with previous fillers, you would have gotten big lumps. But Voluma doesn’t move,” says ­Raspaldo, who performs such transformations in a rather astounding 5 to 15 minutes. The results last about 18 months.

Good Fat It almost sounds too easy: Take fat from where you don’t want it and inject it where you do. Once considered a fringe technique, fat grafting is becoming an increasingly viable option with the advent of more-precise instrumentation and a better understanding of fat-cell biology. In Boston, the plastic surgeon Daniel Del Vecchio harvests fat cells from a patient’s thighs, knees, and belly and uses them to enlarge or round out breasts. A typical procedure takes one to two hours and costs around $10,000.

In expert hands, fat—usually softer and more fluid than ­fillers—can also brighten the thin skin around the eyes. An injection not only smooths wrinkles and fills hollows but also acts as a barrier between skin and underlying facial muscles and blood vessels, hiding dark circles, says the New York plastic surgeon Sydney Coleman. What’s more, researchers suspect that the stem cells in fat can actually promote the production of collagen and elastin—and therefore eventually improve the quality of the skin. A session for the lower lids takes about 90 minutes and costs from $5,000 to $10,000.

Complications can arise, however—often due to overzealous injecting. When this occurs, little divots emerge where a dearth of oxygen has caused the fat cells to die. “You can’t do fat grafting casually,” cautions Coleman, who uses tiny increments and as many as 50 passes to complete a procedure around the eye.

Stimulus Package Despite its name, LIPO-102 isn’t liposuction at all. Instead, the promising—but not yet FDA-approved—procedure targets and stimulates tissue metabolism to reduce fat. Currently, technicians are zeroing in on the precise dose needed to melt away belly fat in average-weight individuals. “It’s a tiny needle, the medicine doesn’t sting, and there’s little bruising,” says Long Island, New York, dermatologist Marina Peredo, who has been involved in product trials. In one study, patients lost up to 1.2 inches after eight weekly sessions, each consisting of about 20 shots around the navel. It may be a couple of years before the FDA okays LIPO-102 for the belly, but once that happens, doctors are sure to be using the needle to address stubborn chin fat and saddlebags too.

In a previous published version of this piece, “Under Your Skin,” we incorrectly reported that a skin volumizing technique called Reflation was developed in the UK. It was developed in Canada, by B. Kent Remington, MD. We apologize for this error.