An Article By Beth Janes

Smooth Skin Solutions
An article By Beth Janes
For most grown-ups, needle pricks and pokes are the necessary evil of flu vaccines and blood tests. But more and more women are getting shots to stave off the signs of aging. In fact, recent statistics from the American Society of Plastic Surgeons (ASPS) show that Botox injections and other noninvasive cosmetic treatments are still on the rise, despite the crummy economy and a dip in cosmetic surgery procedures. The reason: They deliver almost instant gratification. They're also cheaper and involve less downtime than plastic surgery. Here's the crib sheet on what's available now, what's on tap, and how to get the best outcome.
The Shot: Botulinum Toxin Type A
Botulinum toxin type A (a.k.a. Botox and its new competitor, Dysport, which the FDA just approved in April).
How it works. The toxin temporarily paralyzes muscles so they can't contract, helping to smooth wrinkles that are created — and reinforced — whenever you make facial expressions (like furrowing your brow). "Dysport, which has been used in Europe for years, is very similar to Botox," says Anne Chapas, M.D., assistant professor of dermatology at New York University School of Medicine, who performed trials on the drug. The differences between the two are subtle and mainly in formulation, not performance, she says.
Best uses. Botox and Dysport are both approved for smoothing wrinkles between the brows. But doctors also inject the toxin to relax forehead lines, crow's feet, and sinewy-looking neck muscles resulting from fat and collagen loss, as well as to soften muscles pulling down the corners of the mouth. These uses, while generally safe in experienced doctors' hands, are considered off-label. (Once the FDA approves a shot for one area, doctors often inject it in other spots, too.)
Potential pitfalls. In untrained hands or if overused, injecting this toxin could lead to a face-freezing or drooping effect (imagine a lopsided smile). And Dysport spreads out more than Botox during injecting, Dr. Chapas says. This diffusion can be a good thing — if you have a large forehead, for example, you'll probably need fewer shots — but your dermatologist or plastic surgeon must take it into account to avoid freezing unintended muscles.
How long it lasts. Dysport lasts about six to nine months, says Dr. Chapas, compared with Botox's three or four. The reason: Dysport contains fewer proteins than Botox, so your body breaks it down more slowly. Dysport also seems to take effect more quickly: within one to two days, versus Botox's three to five.
Cost. Starting at about $400 per treated area; Dysport could be about 15 percent cheaper. "The makers may try to win over Botox patients with lower pricing," Dr. Chapas says.
The Shot: Hyaluronic Acid
The most widely used forms of the sugar-derived gel, hyaluronic acid (HA), currently include Restylane, Juvéderm, and Perlane. But even more options are poised to flood the market by next year, including — attention, pain-phobes — Restylane and Juvéderm paired with lidocaine (the same mild anesthetic your dentist uses).
How it works. Doctors inject HA to add contour, plump up sagging skin, and smooth wrinkles.
Best uses. HA fillers are approved for the treatment of medium to deep facial creases, like the nasolabial folds that run from the nose to the corners of the mouth. But its various viscosities enable doctors to use HA off-label for filling superficial lip and forehead lines, as well as for contouring the jaw. Some doctors may also fill hollowed undereye areas to compensate for fat loss, but Dr. Chapas warns that this delicate, thin-skinned area is especially prone to complications (she suggests having this procedure performed by a cosmetic eye surgeon).
Potential pitfalls. Swelling and bruising are common side effects, usually lasting less than a week. Injecting HA unevenly or too superficially can cause bumps; using too much may leave you looking inflated or puffed up. If you really don't like the results, ask your doctor about an injectable enzyme to dissolve the material.
How long it lasts. HA fillers are all fairly similar — except in terms of longevity, says Fredric Brandt, M.D., a New York City and Miami-based dermatologist and founder of the Dermatologic Research Institute in Coral Gables, FL, where he conducts trials on cosmetic treatments. One shot of Juvéderm lasts up to a year, while the FDA recently OK'd a claim by Restylane makers that it persists for up to 18 months. You do need a second injection after six months or so, because the filler will dissipate slightly, but it's typically half the amount of your first shot.
Cost. Anywhere from $600 to $1,000 per treated area.
The Shot: Collagen
Once the only filler in town, collagen injections steadily declined in popularity over the past decade as better alternatives hit the market. With Evolence, a new FDA-approved version that lasts twice as long, collagen could make a comeback, says John Canady, M.D., president of the ASPS. Unlike its predecessors, which are made of cow and bioengineered human collagen, Evolence comes from pigs. It's more similar to human collagen than the bovine version, so it doesn't require allergy testing.
How it works. Collagen makes up about 80 percent of skin's deeper layer, the dermis. As these fibers break down over time, wrinkles develop and skin becomes looser. Collagen injections replace the lost volume by integrating with your tissue to bolster skin structure and smooth out lines.
Best uses. Whereas the old collagen was used mainly on fine lines, Evolence is effective at restoring lost volume to just about any medium-depth wrinkle, Dr. Chapas says (think folds around the nose and mouth or deeper furrow lines). And if Evolence Breeze is approved this year as anticipated, this less-viscous version will provide a viable option for superficial wrinkles like crow's feet. Collagen's potential advantage over other fillers: "It has a really soft, natural look because it's more like your own skin," Dr. Chapas says. There's often less swelling and bruising with collagen than with HA.
Potential pitfalls. Lumps and bumps are a risk, but malleable collagen can be massaged down at the doctor's office if the bumps are immediately apparent, or your doctor may be able to dissolve them within two weeks by injecting the enzyme collagenase. Collagen is one of the shortest-lasting filler options, so look elsewhere for longevity. It's a great choice, though, if you want to smooth your skin temporarily for, say, an upcoming wedding or other special occasion.
How long it lasts. Six months or longer for Evolence; three months for older collagen products like CosmoDerm and Zyderm.
Cost. $500 and up per treated area.
The Shots: Synthetic Fillers
These collagen boosters include Sculptra and Radiesse.
How they work. Both prompt your body to make its own collagen over time. Radiesse, made of calcium-based microspheres suspended in gel, provides instant plumping; Sculptra (poly-L-lactic acid) takes a few months to produce results because it depends solely on your body's producing more collagen. "We do a treatment once a month for several months until you get the volume you want," Dr. Chapas says.
Best uses. They're both most effective for filling in deep creases around the mouth or for bolstering severely hollowed cheeks.
Potential pitfalls. Because you don't see results right away with Sculptra, the less-is-more rule definitely applies to each doctor visit. There is also a tiny risk of hardened nodules, particularly if Radiesse is injected too superficially; for this reason, avoid both fillers around thin-skinned areas like the eyes.
How long they last. A year or more for Radiesse; up to two for Sculptra.
Cost. About $800 for Radiesse, $1,000 for Sculptra, per treated area.
Safety Check
Not all is smooth sailing in the world of injectable wrinkle fillers: An FDA panel reviewing the shots' safety recently called for warning labels and more testing of all cosmetic fillers after nearly 1,000 adverse reactions were reported between 2003 and 2008 (ranging from severe swelling to permanent scarring). Most of the problems were the result of off-label use (injections in areas not specifically FDA-approved). "But if you look at these cases in the context of the millions of safe injections given, the complication rate is small, about one in 11,000," says Renato Saltz, M.D., president of the American Society for Aesthetic Plastic Surgery (ASAPS).
Doctors say patients should be aware of these risks, but not scared away. "The first thing to consider is who's doing the injecting," says Dr. Saltz, who maintains that poorly trained doctors and non-physicians are usually behind the problems. Choose an M.D. who's board-certified in plastic surgery or dermatology, which means he or she has met training standards set forth by organizations such as the ASPS, the ASAPS, or the American Academy of Dermatology. Also, ask how long your doctor has been using the material — especially if you're considering an off-label shot. The more practice and experience your doctor has with the injectable, the better.
No-Needle Alternatives
Dozens of new non-prescription creams are claiming to mimic Botox, while others, housed in syringe-like dispensers, are billed as facial "fillers." While the benefits of these dermal doppelgängers don't come close to their injectable counterparts, they may do something, says Dr. Brandt. Here's what's out there — and what works:
Wrinkle "relaxers." Ingredients like GABA (gamma-aminobutyric acid) and the peptide Argireline (acetyl hexapeptide-3) have wrinkle-softening abilities. It's a cumulative, temporary effect, says Dr. Brandt. They'll never rival Botox in strength. What might: topical Botox. The biotech company Revance Therapeutics has developed a peptide that attaches to a Botox-like toxin and drags it down to where the muscles contract, says Richard Glogau, M.D., a clinical professor of dermatology at the University of California, San Francisco. "You would likely get an application at the doctor's office for results that last one to three months," he says. Until it's available (about two years), look for modest softening of wrinkles from products such as Fusion Beauty LiftFusion Triple Threat Intense Target Magic Wand ($39, Sephora).
Wrinkle "fillers." Instant fillers can smooth skin, but most are little more than glorified moisturizers, Dr. Glogau says. Those with hyaluronic acid don't penetrate to where an injection does, but they do bind water to skin so it looks smoother and plumper for the day. Try Roc Retinol Correxion Deep Wrinkle Filler ($22, drugstores) or Dr. Brandt Lines No More ($55, Sephora). Products with dimethicone, a form of silicone that sits on the surface of skin, literally fill in creases. Like makeup primers, they'll help skin look and feel smoother and more youthful — temporarily. Try Soap & Glory Fill Monty Dab-On Instant Wrinkle Filler ($13, Target).