SKIN DEEP Botox Plus: New Mixes For Plumping And Padding By NATASHA SINGER 14 July 2005 The New York Times BABAK AZIZZADEH, a facial plastic surgeon in Beverly Hills, recently concocted a menu of ''Cosmetic Cocktails.'' Although the frothy title might suggest intoxicating mixed drinks for patients who have just gone under the knife, the doctor's elixirs are not alcoholic. They are toxins and wrinkle fillers that he injects into patients' faces to smooth their age lines and puff up their cheeks. Dr. Azizzadeh employs the bartending analogy to suggest the advantages of mixing his remedies. His typical cocktail might include Botox, a toxin that relaxes frown lines in the forehead; Sculptra, a synthetic filler, to bulk the cheeks; and Radiesse, a gel containing microscopic calcium particles, to fill wrinkles. Billed as ''filler face-lifts'' or ''tissue tailoring,'' multi-injection procedures are not merely the latest gimmick for cosmetic-treatment aficionados who have already tried every kind of laser and acid peel. They represent a kinder, gentler alternative to face-lifts, a way of plumping up rather than cutting away and hoisting sagging tissue. Their growing popularity is part of a trend toward injections and away from surgery. In 2004 the number of face-lifts dropped by 3 percent from 2002 to about 114,000, according to the American Society of Plastic Surgeons, while the number of Botox injections soared by 166 percent to nearly 3 million. Collagen injections were also up, to more than 500,000, an 18 percent increase, the society said. Filler face-lifts offer only temporary results -- lasting six months to two years, depending on which materials are used -- but at $2,500 to $3,500 they are cheaper and less invasive than surgical face- lifts, which can run from $10,000 to $20,000. They also require less recovery time. And though their results are not as dramatic as a face-lift, injection cocktails, say doctors who offer them, are sufficient for patients in their 30's, 40's and 50's who do not have a lot of loose skin to cut away. ''Why go under the knife unnecessarily when you can have these treatments that make you look natural and youthful?'' said Barbara Kaminsky, a Manhattan fashion stylist who for two years has been having her face injected with three different substances: Botox in her forehead and neck; Restylane in her cheeks and chin; and collagen in her lips. ''I'm a single woman over 50, but now I'm getting hit on by men who think I'm in my 30's or 40's,'' she said. ''The only drawback is that, just like going to the dentist or the gym, with injectables you have to keep up a maintenance routine.'' Some doctors say it is pointless to use so many different substances. ''A wrinkle is a wrinkle, and you just fill it; you don't have to add whipped cream and chocolate sprinkles on top,'' said Marvin Rapaport, a clinical professor of dermatology at the University of California, Los Angeles, and a practicing dermatologist in Beverly Hills. Others question the safety of cosmetic cocktails. Although the substances have been found to be generally safe when used individually, little research has been done to ascertain whether they might somehow mix together under the skin, potentially diminishing one another's effects or causing unforeseen problems. Still, hundreds of early-adopter physicians and their patients are forging ahead. ''Combining Botox with one or two injectable agents is becoming widespread,'' said Dr. Richard G. Glogau, a clinical professor of dermatology at the University of California, San Francisco. He is a consultant for Allergan, the maker of Botox. This new approach to cosmetic enhancement is a recent development. Just four years ago only two substances were approved for injections: fat, to add volume, and collagen, to fill in wrinkles and acne scars. Then in 2002 the arsenal began to expand when the Food and Drug Administration approved the cosmetic use of Botox. In 2003 the agency sanctioned Restylane, a gel that is used to fill wrinkles and folds around the nose and mouth and, off label, to plump cheeks and lips. Last year the F.D.A. approved three new hyaluronic acids to treat wrinkles and folds: Hylaform, Hylaform Plus and Captique, which doctors also inject to fatten lips and structure cheeks. Doctors are also now using Sculptra (F.D.A. approved to rebuild the hollowed faces of AIDS patients) and Radiesse (approved to strengthen vocal cords) for facial enhancement even though they have not been sanctioned for cosmetic purposes. ''It's nice to have different products for different situations because each injectable works differently on each person,'' said Jeffrey S. Dover, a Boston dermatologist who himself prefers to use only two, Botox and Restylane. ''It's like being a painter. You'd like a variety of colors at your disposal.'' Fredric Brandt, Ms. Kaminsky's dermatologist, who practices in Manhattan and Miami, said he regularly injects two, three or four agents in one sitting. (He is a consultant for Allergan and for Medicis, Restylane's distributor.) In extreme cases, like ''thin women in their 50's whose faces are caving in,'' Dr. Brandt said, he might use five. Patricia Wexler, another Manhattan dermatologist, uses up to four substances, often on patients who have recently lost a lot of weight. Each agent serves a purpose, she said. ''First you use volumizers to restore the youthful contours of the face, then you use fillers that give definition and structure to wrinkles,'' she said. Doctors do not know whether these agents mix together once they are in the skin, or what would happen if they do. ''There is no hard clinical data right now,'' said Nick Teti, the chief executive of Inamed, the manufacturer of the collagen fillers Zyderm, Zyplast, CosmoDerm and CosmoPlast. ''We know physicians like to use collagen and Captique at the same time for different purposes, but we do not promote combination therapy.'' In Vancouver, British Columbia, Alastair Carruthers, a dermatologist who is a consultant for Allergan, has begun to experiment with the simultaneous use of Botox and Restylane. In 2003 he published a study of 38 patients who were given this treatment. He found that their results lasted 32 weeks, almost twice as long as those who had been given Restylane alone. But not all patients do as well. Dr. Carruthers said he is treating a patient whose previous doctor injected her face over a period of years with collagen, Restylane and Artecoll (a filler that is not approved in the United States) with unpleasant results. ''For the last six years I've had raised, very prominent blue lines that run from the folds of my nose down to my mouth,'' said the patient, 60, who would not disclose her name because she did not want to impugn the doctor who injected her. ''But because I had so many injectables put in the same location, we can't tell what the cause is.'' Side effects like bruising and skin irritation can occur even when only one filler is used. ''If something goes wrong and you have injected four or five different foreign agents, how is the doctor going to be able to determine the cause of the problem and how to treat it?'' asked Audrey Kunin, a dermatologist in Kansas City, Mo. Cosmetic treatments sometimes have aesthetic side effects, which is why potential patients are often advised to take care that the doctor they choose shares their sense of how much work is too much. ''I think of an aging face as a sagging sofa which has to be restuffed so the pillows fluff up to their beautiful original shape,'' Dr. Brandt said. ''But a sofa can be overstuffed by someone overzealous.'' He has a nickname for those unfortunate patients who end up on a cosmetic cocktail bender. ''I call them the 'big giant heads.''' Six Injections And What They Do DOCTORS started filling in facial wrinkles with collagen almost 25 years ago. Since then, they have started using a variety of other injectable substances that can flatten or fill lines and furrows. All of the following have been approved as safe by the Food and Drug Administration, though not necessarily for treating wrinkles. 1. Botox smoothes frown lines (those vertical furrows between the eyebrows) by paralyzing the muscles that cause them. The F.D.A. has approved its cosmetic use for this part of the face only, but some doctors also use it on horizontal forehead wrinkles, crows'-feet, neck bands (vertical cords than run below the chin) and the area under the nose to stretch out lines above the lip. If injected incorrectly, Botox can temporarily make the eyelids or lips droop. Treatments last up to four months. Cost: $376 to $850 per area treated. 2. Fat, harvested via liposuction, can be purified and safely injected into cheeks, lips or temples because patients are never allergic to their own fat. Treatments last from six months to several years. Cost: $500 to $1,300 for one treatment (not including the liposuction fee). Several treatments may be needed. 3. Collagen is a fibrous protein that is used to fill wrinkles and acne scars as well as plump lips. Zyderm and Zyplast, made of bovine collagen, can cause itching, swelling and other allergic reactions, so doctors test potential patients to see if they are sensitive. CosmoDerm and CosmoPlast, made of human collagen, usually do not cause such reactions. Treatments last three to six months. Cost: $389 to $550 per syringe of Zyplast and Zyderm; $600 to $850 for CosmoDerm and CosmoPlast. One to two syringes are used for each treatment. 4. Radiesse (formerly known as Radiance) is approved by the F.D.A. to strengthen vocal cords, but a few cosmetic doctors have been using it experimentally to fill in cheeks, chins and deep wrinkles. Made of microscopic calcium particles suspended in a gel, it may cause tiny lumps or bumps, doctors say. The effects are expected to last one to three years. Cost: $900 to $2,000 per treatment. 5. Restylane, a spongy gel made of hyaluronic acid, is used to fill moderate to deep facial folds or off label, to plump lips. Restylane often causes bruising and swelling for a few days. Treatments last up to six months. Hylaform and Captique, other hyaluronic acids, cause less swelling, but doctors say they last only four to five months. Cost: $542 to $1,000 per syringe for Restylane, $600 to $850 for Hylaform and Captique. One to two syringes are used for each treatment. 6. Sculptra is a synthetic compound that has been approved by the F.D.A. to treat facial wasting in AIDS patients. Some doctors use Sculptra off label to fill hollow cheeks associated with ordinary weight loss or aging, but others, including Richard G. Glogau, a San Francisco dermatologist, question whether it might cause inflammation in people with healthy immune systems. Treatments last up to two years. Cost: $933 to $1,500 per area treated. Three treatments are usually needed. NATASHA SINGER Bottom of FormHair Today, Gone Tomorrow Tired of tweezing, waxing and shaving? A growing number of Americans are opting for a more permanent—and pricey—solution: laser hair removal. WEB EXCLUSIVE By Karen Springen Newsweek Updated: 8:34 a.m. ET July 12, 2005 July 12 - After years of tweezing facial hairs, waxing her bikini line and dealing with bumps and ingrown hairs from shaving her underarms, Vicki Winston has had enough. So last month, the 37-year-old Knoxville, Tenn., embarked on an attempt to rid the hair from those body parts for good with a laser. The $2,400 she's spending on the process is “nothing” in the big scheme of life and worth it for “convenience and just comfort,” says Winston, a massage therapist and mother of a 3-year-old. Her first treatment barely hurt and took only half an hour. She plans to go to four more sessions, every 10 weeks. “In about a year, I won’t have to shave again, and I won’t have razor bumps, and I won’t have to worry about ingrown hairs,” Winston says. Razors aren't antiques—yet. But a growing number of Americans are switching to laser hair removal. It's now the top nonsurgical cosmetic procedure for the under-35 set. Among all ages, it’s second only to Botox. Last year 1.4 million Americans got laser hair removal—up 53 percent from 2003, according to the American Society for Aesthetic Plastic Surgery. “There’s now technology that allows people to deal with a problem much like Lasik eye surgery did,” says Dean Akers, chief executive officer of Ideal Image, which plans to double the number of its laser hair-removal facilities to 50 by the end of this year. A series of sessions may range from about $900 for bikini line or underarms to about $4,400 for a man’s back and shoulders. (Insurance rarely covers laser hair removal, though occasionally it will cover treatment for African-American men who suffer from chronic infections from ingrown hairs on their beard area—called pseudo folliculitis.) But Akers says clients are not put off by the price. “It’s not a big number [compared to] the cost of shaving the rest of your life,” he explains. For many patients, the removal is permanent, though 25 to 40 percent experience some regrowth, says New York dermatologist Roy Geronemus, president of the American Society for Laser Medicine and Surgery. But the hair that grows back is usually finer and lighter. Laser removal works by targeting patients' melanin, the dark pigment that gives hair (and skin) its color. The melanin absorbs the laser’s energy, and the resulting heat kills the roots of nearby hair follicles. That’s why dark-haired people make the best candidates. “We can’t treat blonde hair or gray hair because it has no target color that we can isolate,” says Dr. Robert Ailes, corporate medical director for Ideal Image. Doctors classify patients on the six-point Fitzpatrick scale—with type one being a fair-skinned, blue-eyed blonde and type six being an extremely dark-skinned person of African descent. And there are specific lasers designed for different skin types. “You can’t use the same approach for every patient who walks in the office,” says Geronemus, the New York dermatologist. Lasers, which can cost $30,000 to $150,000, usually have different-sized tips, which resemble fat highlighter markers and treat an area around the size of a dime to a quarter. Operators lightly touch the skin in areas where the client wants to remove hair. It sounds painful, but most people describe the sensation as similar to a rubber band snapping against the skin. Areas directly over bone (like shins) are most sensitive, whereas body parts padded with fat or muscle are more comfortable, even without using numbing cream a half hour to an hour before a procedure. Lasers typically use a chilled tip, a cool spray or a cooling gel, which also lessens any pain. “We encourage everyone to try it initially without the numbing cream,” says Ailes, who reports that fewer than half of Ideal Image's patients need any topical anesthetic. Sometimes practitioners just use an ice pack 10 minutes before treatment; tranquilizers and general anesthesia are not used. Unlike electrolysis, which delivers a small electric current to one follicle at a time and takes several seconds per hair, lasers can zap all the hairs on a woman’s upper lip and chin in 10 minutes and the hairs on a man’s chest in 30 minutes. The laser can zap 10 or 20 hairs a second whereas electrolysis reaches only one hair every 15 or 20 seconds, says Dr. R. Rox Anderson, a professor of dermatology at Harvard Medical School. But like electrolysis, laser hair removal requires multiple treatments—usually six to 10 weeks apart. “Some of the hair follicles are capable of withstanding more than one treatment,” says Anderson. “How many times do you see a boxing match where the first time the guy gets knocked out? Usually you have to punch away.” The treatment, which is billed as “permanent hair reduction,” is most popular among women, who get 86 percent of laser hair-removal procedures. Their favorite treatment areas: the face, underarms and bikini line. But men are also flocking to laser hair-removal centers and doctors to remove the hair on their backs, chests, necks and even their legs. Miami Dolphins linebacker Junior Seau, 36, says he got tired of shaving his legs to prevent athletic tape from pulling on his hairs. Seau, who plans to go for his fourth treatment in two weeks, says his biggest problem is fitting all five treatments into his busy schedule. (Once he gets to an appointment, he says he simply sits back and reads a magazine until it’s over.) He considers the pain to be minimal—“not even close” to what he feels on the gridiron, he says. “It started out as a joke in the locker room. [But then] a lot of guys came up to me on the side and quietly mentioned if I could give them a card. They questioned me on how long it lasts,” says Seau, who spent a year as a spokesman for an Ideal Image facility in Florida. “It shouldn’t be looked at as a feminine thing to do. Hopefully we put out an awareness to men that it’s OK to get the hair off.” Ryan Goldin, 28, a 6-foot tall, 255-pound power lifter and sports trainer with a six- pack stomach, definitely felt that way. For years, he wouldn’t take off his T shirt because of his hairy back and shoulders. “I’m self-conscious about it,” he says. His wife used clippers to trim the hairs—a time-consuming process. But last week, he decided to get the hair zapped off. "It [was] like 40,000 rubber band shots to my back and shoulders,” he says. But that “mild discomfort" was an improvement over waxing, which, he says, felt like “ripping off my skin over and over again.” Though zapping large areas like the back is fine, doctors say it’s best to avoid treating too many areas at once. “If you do legs and bikini, that’s fine,” says Geronemus. “But if you begin to extend into other areas, you run the risk of toxicity from the topical anesthesia.” His staff applies lidocaine-containing cream in the office rather than asking patients to apply it themselves at home. That way they can watch carefully for allergic or toxic reactions, which are rare but possible. Last December, Shiri Berg, 22, a senior at North Carolina State University, used a $40 tube of anesthetizing cream she had bought from a laser hair-removal salon before driving there for her first appointment to get rid of the follicles on her legs, underarms and bikini area. (She had prepaid $1,000.) Too much lidocaine and tetracaine got into her bloodstream, and she apparently became disoriented and pulled off the side of the road, says Laurie Armstrong, the Kirby & Holt lawyer representing her family. Emergency responders found her slumped over in her car, bleeding from the mouth. She had cellophane wrapped around her body to help the lidocaine absorb into the skin. On Jan. 5, she was taken off life support. “You ratchet the whole risk level up once you start using these anesthetics,” says Armstrong. “Her family’s biggest hope is that the public is educated.” Patients need to take other safety precautions as well. They should avoid the sun before getting a laser treatment. Otherwise, they may wind up with burns or changes in pigmentation. And they should also wear eye protection during the procedure, like the opaque plastic eye cups in a tanning booth if they’re getting their face worked on and colored goggles if they’re getting other areas done. Consumers should also make sure they’re going to a well-trained practitioner—ideally either a physician or someone who is directly supervised by one. There is no formal certification, says Geronemus. But patients can look for local doctors on medical Web sites, like those run by the American Academy of Dermatology, the American Society for Dermatologic Surgery, the American Society of Plastic Surgeons or the American Society for Aesthetic Plastic Surgery. State laws about who can perform the procedures vary considerably, with doctors and treatment centers setting many of their own rules. Despite the additional safety precautions, and the price, many patients say it's a worthy investment of their time and money—especially those who've had a tough time with other hair removal techniques. For years, Ricquel Smith, 31, an African- American who owns an automobile-emissions testing station in Atlanta, suffered from discoloration and razor bumps in her underarm area. “Even when I'd go on vacation and go to the beach, it was just embarrassing,” she says. “I would put on a regular T shirt because I didn’t want my underarms to show.” Razors irritated her, and waxing hurt too much. She says it was worth the $600 and the return trips to the center to get rid of the hair. After four treatments (with one treatment to go), she has “almost nothing” left under her arms. "I'm thrilled," says Smith. "I tell all my friends and family [about it] … Now I see women with facial hair, and I'm almost inclined to tell them, `I know where you can go'." ABC-TV Chicago Plastic Surgery as a graduation gift Dr. Peter Geldner, nationally recognized, board certified plastic surgeon, says the reason people give and get plastic surgery as a graduation gift is that society is more accepting of changing your appearance to be more comfortable in your own skin. Many people go away to college, starting a new life in a new place with new friends. Why not take a new look, instead of the one that made them feel insecure in high school? Teens may often see plastic surgery as the answer to all their problems ie: If they can be rid of the big nose, ears or fat they have been straddled with that made them insecure in high school, it may be the answer to their dreams. He says noses, breasts and liposuction are the areas that people most often are interested in and notes that breasts are a touchy issue not only because a teenager may still be developing but also because the FDA does not allow under 18 to have breast augmentations. Another con to plastic surgery as a graduation gift is that there are risks and complications associated with any surgery. The expectation is that you can be whoever you want to be but the reality can be negative if someone isn't emotionally prepared or mature enough for a change that is often not reversible. Dr Geldner says people look at plastic surgery as allowing them to go from being the "Odd Man Out" (or woman) in high school, into being the "Big Man on Campus" in college. If a high school student feels they have been held back by a physical flaw, a plastic surgery procedure can relieve these stresses before a significant time of growth and self-expression. Braving a new college life carries plenty of worries on its own, but a poor self-image doesn't have to be one of them.