By MSNBC contributor
msnbc.com
updated 3/3/2004 1:28:08 PM ET 2004-03-03T18:28:08

You don't have to go under the knife to turn back the hands of time. In fact, an increasing number of Americans are opting for nonsurgical procedures that can be done over a lunch hour and simply involve a syringe full of an anti-aging concoction.

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Injections of Botox and facial fillers like the newly available Restylane are even delaying plastic surgery for some patients, doctors say.

"I'm doing fewer brow lifts now," says Dr. Robert Bernard, a plastic surgeon in White Plains, N.Y., and president of the American Society for Aesthetic Plastic Surgery (ASAPS). That's largely because of Botox, he says, the popular injectable that temporarily helps to erase wrinkles in the forehead by paralyzing underlying muscles. It's also used to minimize crow's feet around the eyes.

Fillers can also play a role in renovating a furrowed brow, though they are most commonly used to enhance the look of the lower face, such as the lips and the lines that extend from the nose to the corners of the mouth.

New ASAPS statistics show that Botox injections accounted for the majority -- almost 2.3 million -- of the nearly 8.3 million cosmetic procedures performed in the United States last year. And while surgical procedures like liposuction and face lifts increased 12 percent from 2002, nonsurgical procedures including Botox and filler injections, as well as procedures like chemical peels, jumped 22 percent.

New wrinkle fillers hit the market
The filler mainstay for more than two decades has been bovine collagen, a product derived from cow hide that requires skin testing before it can be used to make sure the patient won't have an allergic reaction to it. But about a year ago the Food and Drug Administration approved two new forms of human-derived collagen, known as CosmoDerm and CosmoPlast, that do not require such tests.

Fill 'er up

And in December, the FDA OK'd Restylane, the first drug in a new class of fillers known as hyaluronic acids. Restylane contains a naturally occurring component of skin that serves as a lubricant and shock absorber in joints. It also doesn't require skin testing and the results can last six to nine months or more, twice as long as collagen. Pending FDA approval is another hyaluronic acid known as Hylaform that is made from rooster combs.

For many doctors, Restylane is already replacing collagen. Dr. Paul Lorenc, a New York City plastic surgeon and a chief investigator of the U.S. clinical trials of Restylane, says he rarely uses human collagen because it doesn't last as long as Restylane, and he's stopped using bovine collagen altogether because of the added step of allergy testing. "I don't even have it in my refrigerator," he says.

But Dr. Tina Alster, a professor of dermatology at Georgetown University in Washington, D.C., says that while Restylane is her primary filler, she prefers collagen for enhancing the natural line of the lips.

‘One-two punch’
Though some media reports have suggested Botox will have to move over to make way for the new fillers, the reality is that doctors use both types of treatments in many of their patients -- Botox for wrinkles in the upper face and fillers for creases and crevices in the lower face.

“Most of the time they end up being quite complementary,” says Dr. Richard Glogau, a clinical professor of dermatology at the University of California, San Francisco.

Sometimes Botox and fillers are used in the same spots. For deep frown lines in the brow, Alster uses a "one-two punch": immobilizing the muscles with Botox and filling in the stubborn vertical lines between the eyebrows with Restylane.

And just because someone has cosmetic surgery doesn't mean he or she isn't also a candidate for injectables. A face lift may not completely eliminate lines around the mouth, says Dr. William Coleman, a clinical professor of dermatology at Tulane University in New Orleans and editor-in-chief of Dermatologic Surgery. And several years after a face lift, a patient may use a filler to tackle frown lines that have crept back, notes Lorenc.

But injectables don’t come cheap. Once you start treatments, it’ll cost you to keep up that youthful look. At hundreds of dollars a pop, the regular use of injectables two to three times a year could add up thousands of dollars over the years, even as much as a brow or full face lift. But unlike surgery, of course, injectables don't require time off from work or entail weeks of recovery.

Permanent not necessarily better
Consumers hoping to get more bang for their buck are seeking out longer-lasting, even permanent fillers.

While no permanent filler has been approved in the United States, some doctors are using fillers imported from other countries as well as products in this country that have been approved for other, non-cosmetic uses. And that has plenty of people in the medical beauty business concerned.

"Permanent fillers can portend permanent problems," says Dr. Rod Rohrich, chairman of plastic surgery at the University of Texas Southwestern Medical Center at Dallas and president of the American Society of Plastic Surgeons.

Liquid silicone, for instance, which is FDA-approved for treating detached retinas but not as a facial filler, has been associated with lasting inflammation and permanent nodules under the skin.

Another controversial product is Artecoll, which is available in other countries and is pending approval in the United States under the name Artefill. The product contains tiny synthetic beads suspended in bovine collagen. After the bovine collagen disintegrates, the body's own collagen fills in around the beads, which remain in the tissue permanently. Reported side effects include pockets of hard scar tissue.

As the potential problems with these products show, longer lasting may not necessarily be better. If a doctor makes a mistake or the results don't turn out as well as planned, then what?

"I don't think the ideal filler is permanent,” Alster says. “Our facial structure changes with time."

So while the currently approved treatments may not last forever, the advantage is that any mistakes also wear off with time. Side effects with the approved fillers are usually temporary and include redness and swelling.

To get the best results, experts in the field advise choosing a dermatologist or plastic surgeon who has significant experience with these products. Doctors who inject them incorrectly or in the wrong places could give patients an “over-Botoxed” look or no noticeable improvements at all.

The "frozen face" look can also be a byproduct of perfectionist patients who aren't satisfied until they've turned their faces into a blank slate, incapable of producing some of the expressions that make us human, says Alster.

"Some movement,” she emphasizes, “is natural."

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