The most popular of injectables is a refined protein produced by bacteria. Although there are competitors, Botox is considered “the gold standard,” according to Beachwood plastic surgeon Dr. Mark Foglietti, who serves as chief of plastic surgery at both Marymount Hospital in Garfield Heights and Richmond Heights Hospital in Richmond Heights.
Originally approved by the Food and Drug Administration for use on the vertical furrows between the brows — “You very commonly see them become more evident toward middle age, because there’s a little bit of a squint going as your vision changes,” Foglietti says — Botox is now routinely used to treat forehead lines, crow’s feet, smokers lines around the lips, and neck bands, often in tandem with “fillers” such as Restylane, Juvederm Ultra and collagen. Westlake plastic surgeon Dr. Edward Levy notes that the relaxation of muscles caused by injecting wrinkles at the corners of the eyes often lifts the outer brows, resulting in a more wide-awake appearance.
Side effects are limited mainly to minor bruising and a slight drooping of the eyebrows, a temporary problem that usually occurs when too much Botox is used or it is injected at the wrong site. According to Levy, the problem usually occurs when forehead lines are treated. “It’s not the product — it’s the expertise of the physician,” Foglietti stresses. Prices begin at a couple hundred dollars to temporarily fix lines between the brows. Results start to appear after two to four days and last two to four months.
Dr. Levy explains that Botox softens or eradicates a line caused by muscle action by blocking transmissions from the nerve ending to that muscle. Use of Botox for cosmetic purposes is FDA-approved for patients 18 to 65 years old; however, Levy notes that those past retirement age can still benefit from it.
“It’s just that older patients may have more well-established wrinkles that don’t respond as well,” he says.
This lab-made version of hyaluronic acid, a gel-like substance found in connective tissue, has replaced collagen as the most common choice for enhancing lips and filling the nasolabial folds, which develop from the corners of the nose to the corners of the mouth.
“It absorbs your own body’s water for a natural plumping of the areas that are injected,” Foglietti says.
Levy also uses it to fill depressions under the eyes. The results are softer, more natural and longer lasting than collagen. Levy says patients go usually six to nine months before the body has absorbed enough of the Restylane to merit a touch-up.
“You’ll start to see the lines gradually getting a little deeper as time goes by,” he says.
The cost starts at $475 for treating nasolabial folds. Levy advises those with a history of severe allergic reactions to other drugs (trouble breathing, for example) to forego Restylane entirely. Foglietti says he has also seen an occasional post-injection swelling of the lips that disappears after three days.
“Rarely, it has not worked,” he adds. “Out of several hundred patients, I’ve had two.”
This Restylane competitor recently made its debut with a claim that it lasts longer because of its higher hyaluronic acid concentration, which absorbs more body water. “It’s unclear if there’s any advantage of one over the other, at least at this point in time,” Levy says. Foglietti agrees that Juvederm Ultra is so new it is not clear how much longer it may last than Restylane. The cost is comparable, though Juvederm Ultra Plus is slightly more expensive because of its higher hyaluronic acid content.
According to Foglietti, this standby is still a viable alternative for the few patients who do not respond to Restylane or Juvederm Ultra. “There are still a lot of patients who are loyal to it,” he adds. The thin, puttylike protein is less expensive — Foglietti estimates a patient can fill the laugh lines and plump the lips for roughly the same price as using Restylane for the nose procedure alone. However, the effects only last two to four months. Patients with a known allergy to collagen products or with connective tissue disorders are also advised to avoid it.
There are two kinds of collagen available: that derived from bovine cartilage such as Zyplast, which requires a skin test before use, and lab-created counterparts such as Cosmoderm. Foglietti notes that Cosmoderm is actually better for filling very fine lines than either Restylane or Juvederm Ultra. “It actually obliterates them,” he says.
This newcomer to the injectable lineup was recently approved by the FDA for treatment of deep nasolabial grooves. Foglietti explains that the synthetic bony substance is formulated in “microspheres” that are small enough not to cause a reaction but large enough to remain in the treated site for 12 months before the body gradually begins to absorb them. Because of its staying power, Foglietti has injected Radiesse to build up cheekbones and chins; some physicians are also using it to enhance the lips. Prices range from $800 to $1,200 to fill the nasolabial folds.
There are, however, a couple of drawbacks to Radiesse. Its longevity can actually be a problem if the patient is less than satisfied with the result.
“If Radiesse is injected too close to the skin surface, you can get a cyst that can take months to go away,” Foglietti adds. “If it doesn’t go away, it must be cut out.” Therefore, he advises people who are thin-skinned to avoid it.
To restore the youthful fullness of the mid-face, doctors turn to what Foglietti describes as a suspension of pulverized dissolvable suture material in saline solution, originally approved by the FDA for use on HIV/AIDS patients. “Due to the medicine they take, those patients will lose fat in the face and develop a hollowing of the cheeks,” Levy says. But unlike other injectables, which provide quick results, the improvements afforded by Sculptra occur gradually as the body develops fibrous tissue around the injected material, Levy says.
According to Foglietti, patients require at least three $2,000 sessions of injections scheduled a month apart, each of which takes 35 to 45 minutes and can cause considerable bruising. The results can last one to two years.