by Megan McIntyre
view article on Refinery29.com
We’re not big fans of the term “anti-aging” — it connotes that aging is bad, and you need to be young in order to be beautiful. Which is a fat load of crap. Beauty comes in all forms and all ages — it’s about being confident in who you are. That said, confidence doesn’t always mean acceptance. For many women, feeling good from within can sometimes mean opting for cosmetic procedures — like lasers, plastic surgery, or injectables — on the outside. And we’re here to say there is absolutely nothing wrong with that, either. Every woman has the right to alter, or not alter, her appearance in the way she sees fit without being ostracized for her personal choices. Period.
Okay, now that that’s out of the way, let’s talk about one of those procedures in particular: injectables. These are formulas that are injected — hence the name — into the skin to alter the appearance and, sometimes, the structure of the skin. They are divided into four main categories: neuromodulators (freezers), fillers, biostimulators (collagen-building), and fat modulators (dissolvers). According to The American Society of Plastic Surgeons (ASPS), 15.6 million cosmetic procedures, including both minimally invasive and surgical, were performed in the United States in 2014. Of those 15.6 million, injectable treatments made up 9 million. Which is a 4% increase from 2013. Meaning, injectables are not only becoming more commonplace, they are being also administered more frequently.
Part of this reason is because they are much safer and more minimally invasive than traditional plastic surgery. “Prior to the last decade or so, you only had surgery,” says Paul Jarrod Frank, MD, a cosmetic dermatologist and founder of The 5th Avenue Dermatology Surgery and Laser Center. “The use of injectables has become the number-one form of cosmetic enhancement in the world because of its ease, safety, and immediacy.”
With the variety of options out there, it can be confusing to know what each one is and what it does — which is where we come in to help break it all down. We spoke to a large sampling of derms and plastic surgeons to get all of the injectables intel. One thing all the doctors we spoke to said was important to note? All injectables are created equal. “There is no one injectable that is the best,” says Dr. Frank. “It’s what is the best treatment [for the patient]. I try not to sell my patients on a syringe of X — I try to sell them on a result.”
Another common point brought up by our experts? Where you go and who you go to is the difference between a natural look and a “done” look. “Do your due diligence in making sure you are treated by a credentialed and expert injector, such as a dermatologist or plastic surgeon,” says Vivian Bucay, MD, a dermatologist in San Antonio. “Having an MD is not enough. After all, would you want your gynecologist taking care of your heart or your cardiologist performing neurosurgery?”
Yannis Alexandrides, MD, a plastic surgeon and founder of 111Skin, adds, “It’s important to remember that just because these injectables can be administered quickly with low risk, this is still a medical procedure. Always choose a board-registered professional with extensive expertise before undergoing any treatment.”
Whether you’re interested in injectables or not, we think it’s important to educate yourself on what’s out there in order to make informed choices about if and how you want to alter your features. You do you.
Ahead, you’ll find a detailed overview of each category, as well as information on each product that falls under it, and what it is best for — because the world of injectables is so much bigger than Botox alone.
Neuromodulators or neurotoxins are most well-known for “freezing” wrinkles and lines. “[They] are best used for temporary treatment to smooth wrinkles that form as a result of facial movements like frowning, squinting, and smiling,” says dermatologist Whitney Bowe, MD. Freezers work by blocking the release of acetylcholine, a chemical that signals muscles to move, says Dr. Bucay. This category of injectables contains three main players: Botox, Xeomin, and Dysport.
Says plastic surgeon Z. Paul Lorenc, MD, “They all originate from the same strain of bacteria, therefore they work essentially in the same way.” Explains dermatologist David Bank, MD, “Think of it as Pepsi and Coke — none is inherently superior, but some patients respond slightly better to one over the others.”
For dermatologist Joshua Zeichner, MD, the advantage of the different formulas lies in their diffusion properties: “The greater the diffusion, the more spreading a single injection will give. This is advantageous around the eyes for crow’s feet. In the forehead, however, sometimes we don’t want as much diffusion because knocking out the upward pulling forehead muscle can result in the flattening of your eyebrows.” Nope.
Plastic surgeon David Shafer, MD, notes that patients can see the effects of the neuromodulators within three to five days, and that the average duration of the treatment is from three to five months. He also notes that in addition to treating existing lines, there has been some evidence that neuromodulators work as a preventative treatment, as well, “by relaxing the face and preventing the dynamic wrinkles (those that are only visible when you move your facial muscles) from turning into permanent deep lines with injections in the glabella (skin between the eyebrows and nose), forehead, and crow’s feet every four months.”
Side effects from these types of injections range anywhere from bruising and tenderness to drooping and the perma-startled expression, a telltale sign of freezers that are not applied properly.
There are more neuromodulators on the horizon, including one called Evosyal, a Korean import that Dr. Frank says could provide more longevity than the current options on the market. Dermatologist Deanne Mraz Robinson, MD, points to the company Revance, which is currently testing a new injectable toxin, RT002 “that has a very targeted delivery, which they believe may lead to a longer duration.” Even more exciting is the testing on a topical toxin called RT001 that will not require needles and will be applied on the skin in the targeted areas.
The OG of neurotoxins, Botox made its debut as a wrinkle softener way back in 1989, and it has been going strong ever since. The drug has been cleared to be used in treatments for all types of maladies, from migraine to muscle spasms. Like Xeomin and Dysport, Botox Cosmetic is FDA approved to treat frown lines between the brows and — just recently — crow’s feet. “Current off-label (not FDA approved, but generally accepted as safe) uses include the neck (to treat the ‘turkey gobbler’), to diminish wrinkles on the forehead, to produce a brow lift, to prevent dimpling of the chin, and raise the corners of the mouth and nasal tip, just to name a few,” says plastic surgeon Norman M. Rowe, MD.
One of the main benefits of Botox is that it’s a household name, but that is also its greatest downfall. Because people have heard of Botox but aren’t necessarily familiar with what it does, they end up asking for it by name for things that it actually can’t be used (well) for. “People will come in and say, ‘I want Botox — can you put it here?’ pointing to their nasolabial creases,” says Sachin M. Shridharani, MD, plastic surgeon and founder of the Luxurgery Medical Center in Manhattan. “But what they really need is filler — because if I Botox your mouth you’re not going to be able to move it.”
As for pricing, that’s where things get confusing. “Botox is measured in units,” says Dr. Shafer. Each unit is anywhere between $15 and $20. So, he says, if you were looking to treat the glabella, it could require anywhere from 15 to 30 units, meaning you’re looking at $300-$600 for one area of the face. “Some offices charge per area and charge a flat rate of $500 for the glabella, for example,” he notes. “For a patient that would normally require 30 units, they are getting a good deal. For patients that would normally require 15 units, they end up paying more per unit under this type of pricing.”
Dr. Shafer says that crow’s feet are typically five to 15 units, forehead can be 10 to 30 units, bunny lines are five to 10 units, smile lifts are three to six units (per side), and lip wrinkles are three to six units. Thinking about getting your underarms Botoxed to treat extreme sweating? That’s going to be 50 to 100 units.
And, like almost all of the fillers listed here, Botox requires maintenance visits, as it only lasts three to five months. Dr. Shafer recommends getting a Botox top off every four months. This means you’re looking at a hefty chunk of change to keep those brow furrows away.
Newer to the neuromodulator market is Xeomin, which received FDA approval in 2011, but has been used in Europe since 2008. It is almost identical to Botox — its main ingredient is botulinum toxin type A, and it works by temporarily weakening the underlying muscle to prevent dynamic wrinkles.
The difference between the two is that Xeomin is a “naked” toxin, meaning it has no associated proteins. In theory, this is said to cause fewer allergic reactions or resistance to the drug. There are also some instances where Xeomin works where Botox won’t. “I have had a couple of patients who have been immune to Botox and Dysport but who have an excellent response to Xeomin,” notes Dr. Bucay. She adds, “Another nice thing about Xeomin is that patients tell me that they cannot ‘feel’ it working, meaning that there is no tightness or heaviness.”
Pricing for Xeomin is around the same as Botox and the life span of the treatment is similar.
Again, same ingredient – botulinum toxin type A — but this one has a wider “spread,” says Dr. Mraz Robinson. “I find that in my clinical practice, Dysport does have a slightly larger area of spread, which can result in a very soft and natural look for broader areas such as the forehead. However, in areas where I want very contained and precise action, I am more apt to use Botox or Xeomin.”
Pricing gets a bit more convoluted here, says Dr. Shafer. Dysport units are one third the size of Botox units, and because of that it costs one third less. However, notes Dr. Shafer, you need three times the amount of Dysport to get the same effects as Botox, so in the end, it winds up being pretty much the same price.
There are two main types of fillers: hyaluronic acid and collagen-producing biostimulators (more on that shortly). “Hyaluronic acid (HA) is a sugar molecule that is normally found in our skin and body that we start to lose as we age,” says Dr. Mraz Robinson. Fillers can be used for everything from replacing lost volume to smoothing over dynamic lines and tightening the jawline.
They can be injected pretty much anywhere you can think of and can last from six months to two years, depending on the injectable and where it is placed. Explains Dr. Mraz Robinson, “Simply put, if filler is placed in areas of movement, like the smile lines around the mouth, it usually doesn’t last as long as when filler is placed deeply in areas that don’t have as much movement, such as the mid-cheek.”
The effect of HA fillers is instant — you’ll see the results right away. And, if you don’t happen to like those results, the good news it that they can be reversed with an enzyme called hyaluronidase, the Vitrase and Hylenex brand injectables. Some cons of HA fillers are skin infections due to improper prepping (although this is true for all injectables), asymmetries, puffiness, bumps, and something called the Tyndall effect — a bluish discoloration that can look like a vein or bruise.
Dr. Shafer notes that pricing for fillers is measured by syringe, not units, and each syringe is usually one cubic centimeter. Broken down by area, you’re looking at, per side, one half to one syringe each for undereyes, cheeks, nasolabial folds, marionette lines, eyebrows, and nose; one syringe for the chin; one half to one syringe per upper and lower lip; and one to two syringes per side for the jawline and temples. And each syringe costs anywhere from $700 to $1,500 dollars apiece.
“Some doctors charge per region or per procedure for a marketed ‘liquid lift’ or equivalent variation,” says Dr. Shafer. “If a patient signs up for something like this, I would recommend defining exactly what you will be receiving, how much product will be injected, and what happens if their promises are not accomplished.” He recommends picking target areas of the face and then discussing with your doctor what treatments are available to see if they meets their goals.
In terms of longevity, Dr. Shafer notes that the manufacturer’s claims are a bit misleading. “In general, fillers last six months to two years,” he explains. “This does not mean that you do not need more filler for one to two years — the filler does not sit dormant for two years and then instantly disappear. The clinical effect is usually about half of what the manufacturer claim is on the longevity.” For maintenance, he recommends coming in every eight months.
As a category, fillers contain the most brands and variations — and they are expanding exponentially in the very near future. Dr. Bucay expects to see filler use to increase off areas of the face, like the décolletage; thin, crepey skin on the backs of the arms; and for treating cellulite.
Dr. Frank has his eye on two new HA fillers that could be coming to market in 2016: Emervel and Teosyal. Both are currently approved and in use in Europe. Teosyal is the third-largest filler in the world right now, says Dr. Frank. It has 12 different skus, compared to Juvederm’s three. “It’s more amenable to the moving face rather than the static face,” says Dr. Frank. “When you inject filler into a static area, you inject it while the face is at rest, meaning, it looks best when your face isn’t moving. Teosyal has a greater elasticity, like a rubber band, so it moves like the face.”
Restylane, one of the very first HA fillers to be approved in the U.S., created a new option for facial fullness outside of collagen injections, which were the predominant treatment prior to its introduction.
Restylane comes in five variations: Restylane, Restylane-L, Restylane Silk, Perlane, and Restylane Lyft (formerly known as Perlane-L). Restylane-L and Restylane Lyft’s formulas contain lidocaine to help reduce the pain during and post injection.
All five Restylanes treat nasolabial folds and can be used for lip plumping. Restylane Silk, due to its smaller particle size, can also be used to treat lip lines (the only filler approved to do so) while Lyft provides fullness and lifting in the mid-face area (cheeks).
Perlane has larger particles and is injected deeper into the skin, making it a better option for those with more pronounced wrinkles. It also has a slightly longer treatment duration than Restylane.
Juvederm was introduced in 2006 and has five products: Juvederm Ultra, Juvederm Ultra XC, Juvederm Ultra Plus, Juvederm Ultra Plus XC, and Juvederm Voluma XC. The XC, in this case, denotes that the injection contains lidocaine.
Ultra and Ultra Plus are used to add volume and smooth out wrinkles. Ultra has a smaller particle size, making it ideal for smaller, thinner lines, while Ultra Plus has a larger particle size to help tackle larger wrinkles. Ultra XC was recently approved as a lip injection; Dr. Bowe notes that it can also be injected into the corners of the mouth to lift them — so basically a treatment for Resting Bitch Face.
Voluma adds both volume and lift. “Juvederm Voluma XC is tightly bound, resists swelling, and lasts longer than the other fillers — up to two years,” says Dr. Shafer. Voluma also tends to be more expensive, at $1,500 a syringe versus $1,000. Dr. Rowe and Dr. Bowe like using Voluma as a “liquid facelift” — when injected into the cheekbones, it lifts the entire mid-face (without swelling like other fillers), creating a lifted look throughout.
Dr. Shafer likes using Voluma for non-surgical rhinoplasty. “Injecting filler along the nasal bridge or tip can help shape the nose or improve symmetry. For many patients, this can save them from needing invasive surgery,” he says. Voluma can also be used to shape and lift the eyebrow, and to mask jowls. Ultra can counteract undereye bags by filling the hollowed-out area to mask the bags.
The newest HA filler on the block, Belotero, features what derms call a “smooth” injection, meaning it integrates into fine lines. Because of its thin, smooth formula, it can be injected very superficially (i.e. close the skin’s surface) without being seen through the skin and creating a bluish discoloration.
In addition to fine lines, Dr. Bowe says Belotero is also beneficial for treating frown lines. “If they don’t go away after Botox, you can use Belotero to smooth out those lines between the eyebrows.”
The second type of fillers are called biostimulators. In addition to giving a volume boost, says Dr. Mraz Robinson, they also help the body build its own collagen. There are two products that fall under this category: Sculptra and Radiesse. Each is based around a unique ingredient and has different benefits.
In general, biostimulators tend to be used for hollowed-out areas like the cheeks or temples — areas where substantial amounts of volume have been lost — as well as acne scars, hands, and prominent nasolabial folds.
One downside to this treatment is that, in addition to being long-lasting (from one to two years), it’s not reversible. Whereas an HA filler can be immediately reversed, with biostimulators, if you don’t like the look, you have to either use other fillers to craft the desired result, or wait it out until the effects wear off. For this reason, it is not recommended for filler newbies.
Radiesse, says Dr. Bucay, is calcium hydroxyapatite suspended in a gel that gives both instant and long-term volumizing and lifting benefits. “The calcium particles act as scaffolding for collagen production. As the gel is broken down, increased collagen production maintains the results.” It can last for nine to 12 months, and when injected deep — onto the bone, says Dr. Shafer — it provides “excellent lifting capacity.”
Radiesse must be injected deeper into the skin than other fillers and cannot be used for fine lines or wrinkles, and not in the lips or lower eyelids — places where the skin is thin.
Recently, the FDA approved Radiesse for use on the hands, an area where fat loss can cause a very noticeable effect. Dr. Mraz Robinson has been using it on her hands with “great success by adding volume and hiding prominent blood vessels.”
Pricing is on par with other fillers, except that Dr. Shafer says it has 50% more product in the syringe, making it a better value. It comes prepackaged, either with lidocaine or without, and treatments do not require as many injections for maintenance.
Made up of poly-L-lactic acid, Sculptra does not offer any immediate volumizing. “The poly-L-lactic acid molecules are injected into the areas of treatment, and over the next four to six weeks stimulate tissue growth,” says Dr. Shafer. “I liken the particles to grass seeds that are being planted in the skin to induce our body to grow new collagen,” says Dr. Mraz Robinson.
The benefit of Sculptra is that it’s a gradual volume increase, and therefore it tends to look more natural. Dr. Shafer notes that this filler is best for patients who need diffuse or generalized filling over their whole face or temples. It is not good for targeted application, like the lips or eyes.
Many doctors said that although it is off-label, they like using Sculptra for cheek volumization. Dr. Bowe says she also uses Sculptra as a filler for concave pimples, a.k.a. acne scars. As opposed to Radiesse, Sculptra is not a lifter but a pure volumizer.
And it requires a commitment on your part from the outset. “Areas injected require massage for five minutes, five times per day for five days after the injections,”explains Dr. Shafer. However, the results are long-lasting and can oftentimes require less injections on subsequent treatments. Speaking of subsequent treatments, Dr. Bucay notes that treatment with Sculptra is usually divided into a series of three monthly sessions.
The technical description for this type of injection is exactly as it sounds: It dissolves fat. Also called fat modulators, right now this category is limited to one product — Kybella — and one specific concern. “It’s meant for the moderate to severe submental fullness, meaning the double chin,” says Dr. Shridharani.
Up until this point, says Dr. Shridharani, the only option for this concern was liposuction. “It seems like a long run for a short slide to undergo a surgical procedure if you just need one or two treatments with this injectable,” he says.
Some side effects of these injections are “redness and swelling that can last a week and be noticeable to other people. Some patients describe it as a ‘bullfrog’-like swelling, and the area can be temporarily larger than before the injection,” notes Dr. Mraz Robinson.
Right now, the use of fat modulator injections is restricted to a handful of plastic surgeons and dermatologists who have been trained extensively on proper administration for the best results. But Dr. Shridharani notes that you’ll be seeing more and more doctors offering it as they finish training.
All of our experts were excited by the prospects of this new category, noting that there are myriad indications, making it a viable treatment for stubborn pockets of fat in other areas of the body. “We know that it permanently kills fat in the double chin so what that means to us is that we know it can kill fat elsewhere on the body as well,” says Dr. Shridharani. “So now the exciting part is the next line of studies that we put out and that we start to do on other parts of the body — whether it’s the bra roll or the inner knee.”
Dr. Mraz Robinson points to a new injection coming down the pipeline called Lipo-202. “It’s an injectable in phase three [of] studies to reduce abdominal fat. Preliminary data shows that a series of injections can help reduce abdominal girth.”
Approved this year and recently acquired by Allergan, Kybella is made up of deoxycholic acid, a substance the body naturally secretes in the GI tract to break down fat cells and cholesterol caused by eating fatty foods. The difference between the deoxycholic acid in Kybella and that in your body, is that Kybella is plant-based and therefore less likely to cause skin allergies or irritation.
Unlike fillers and neurotoxins, which offer semi-permanent results, Dr. Shridharani says that “Kybella is meant to permanently kill the fat cells, dissolve them, and help your skin tighten up a bit and improve contour.” The actual treatment involves 25 to 30 injections at a time, which sounds like a lot — until you consider that the average treatment of Botox involves somewhere around 15 to 20 injections, depending on how many areas you treat at a time.
At Dr. Shridharani’s office, patients are given Advil or Tylenol pretreatment, and then a local anesthetic is injected into the treatment area. Once the area has been numbed, the Kybella is injected into the chin. The actual injection of Kybella is usually done in around five minutes.
Post injection, patients can expect swelling for three to seven days, possible bruising, tenderness, and a tingling and numbing sensation — which can last anywhere from a few days to a few weeks. Dr. Shridharani notes that some patients see their desired results after just one treatment, but for most it’s a range of two to four, depending on the severity of the sub-bantal fullness.
As for the cost, you’re looking at about $1,200 to $1,500 per treatment. By comparison, liposuction, which is currently the only other alternative to address this issue, can run anywhere from $5,000 to $8,000 a treatment. And, unlike all of the other injectables on the market, Kybella can claim permanence, meaning once your course of treatment is done, it’s done forever — no maintenance needed.
“Most of my patients that come in asking for Kybella are like, ‘This has been bothering me for a really long time,'” says Dr. Shridharani. “You can totally have small breasts, big breasts, small hips, big hips — everyone is beautiful in their own way. But no one says ‘A double chin gives you a tremendous amount of character —keep it!'”
So, what have we learned today? Mostly that the field of injections is a wide and varied one — that consumers have a plethora of options and therefore need to come to their doctor armed with more than just a brand name. “A high degree of skill and understanding of facial anatomy is essential for any professional administering these injectables,” says Dr. Alexandrides. “Rather than choose my favorite injectable, I rather choose my favorite result.”