Overview

Today women can reduce, prevent or even erase the signs of aging without resorting to surgery. Nonsurgical aesthetic treatments, also known as cosmetic skin procedures, can reduce the appearance of wrinkles, facial lines, unwanted hair, broken blood vessels, large pores and acne scars.

Women—and men—are embracing these procedures, which range from injections and microdermabrasion to laser and hair removal treatments. Plastic surgeons perform an estimated 8.5 million minimally invasive aesthetic treatments annually, while dermatologists, otolaryngologists, ophthalmologists and other medical specialists perform millions more.

The increased acceptance of aesthetic cosmetic procedures—both surgical and nonsurgical—is partially due to the decreased stigma attached to them. According to the American Society for Aesthetic Plastic Surgery, nonsurgical procedures make up nearly two-thirds of aesthetic treatments performed by plastic surgeons today.

Despite the growing popularity of these procedures, it is important for consumers to do their homework. Even something as simple as a chemical peel carries potential risks, particularly when performed by someone who is not properly trained in the procedure.

The most important things to remember about nonsurgical aesthetic treatments are:

• You will likely have to bear the entire cost; insurance rarely covers cosmetic treatments.
• Few treatments are permanent. Most will need to be repeated within a few months or a few years.
• Just because a health care provider offers a treatment doesn’t mean that person is qualified to perform the treatment. Ask for references, talk to patients and confirm certifications.
• Plastic surgeons and dermatologists are the most qualified professionals available to provide most nonsurgical aesthetic treatments.

Diagnosis

Treatment

The first step is determining the right treatment for your aesthetic concern. You have numerous options. The most commonly performed treatments follow.

OnabotulinumtoxinA (Botox Cosmetic)

OnabotulinumtoxinA, often referred to by the brand name, Botox, is a purified protein derived from the bacterium Clostridium botulinum. It reduces muscle activity by blocking the nerve impulses that cause the squinting or frowning muscles to contract. OnabotulinumtoxinA is approved for the temporary treatment of frown lines and brow furrows.

Only licensed health care professionals can purchase onabotulinumtoxinA. Plastic surgeons or dermatologists routinely administer onabotulinumtoxinA , although any physician with special training in facial anatomy may perform the injections. Some states also allow nonphysicians such as registered nurses or physician assistants to administer the drug if they are directly supervised by a physician. Regardless of who administers your injection, always ask to see the vial and look for the manufacturer’s safety hologram to ensure you are treated with authentic product.

It only takes a few minutes to be treated with onabotulinumtoxinA, and the effects last up to four months. Botox in winnipeg costs an average of $350 to $500 per area of treatment, and costs vary across the country based on a number of factors. Some aesthetic specialty physicians charge by the unit of product. This allows them to charge more or less depending upon the specific patient’s need. Be sure to ask your physician the estimated total cost of your treatment.

Potential risks include allergic reaction, headache, bruising (if injections occur while taking aspirin or anti-inflammatory medications or if you’ve had alcohol within the previous week), redness and numbness at the injection site. There is a slight risk of paralysis of nerves adjacent to the injection site. If you are pregnant, nursing or have a medical condition, make sure you discuss the possible risks with your physician. OnabotulinumtoxinA is not recommended for pregnant or nursing women.

Dermal Fillers

These injectable products fill fine lines and plump up wrinkles to provide a natural and smooth look. They are among the most popular nonsurgical cosmetic treatments. According to the American Society for Plastic Surgery, hyaluronic acid dermal filler procedures—one category of soft tissue fillers—are the second most popular aesthetic injectable treatment behind onabotulinumtoxinA.

Dermal fillers work differently than onabotulinumtoxinA. Fillers are injected directly into wrinkles and lines, instantly adding volume. There are many dermal fillers to choose from, so make sure to ask your aesthetic specialty physician which type of filler will help you achieve your desired results. Certain dermal fillers may work better in different people and for different areas, so you may need to try more than one before finding the best product for you. Physicians may use multiple products, depending on your needs, to obtain your desired result. You pay by the syringe, and several syringes may be required, so ask your physician for an estimated total cost before beginning your treatment. Costs vary based on geographic region and type of filler, but the average cost for treatment with injectable fillers is $1,000.

FDA-approved dermal fillers include:

• Hyaluronic acid fillers (Elevess, Hylaform, Juvéderm, Voluma, Perlane, Restylane and others). Hyaluronic acid is a natural substance found throughout all living animals. It absorbs more than 1,000 times its weight in water, thus adding volume to the skin’s surface. With age, however, hyaluronic acid concentrations drop, causing wrinkles and folds. These fillers are used to temporarily replace lost hyaluronic acid and restore skin volume.Hyaluronic acid dermal filler injections typically take less than 30 minutes to perform. Hyaluronic acid injections last between three and five months, depending on your body chemistry, lifestyle and the rate at which you are aging. Most people receive new injections two to three times a year.
• Collagen fillers (CosmoPlast, CosmoDerm, Zyderm, Zyplast and others). Collagen is a protein substance found in all human and animal tissue. It makes your skin, bones and ligaments tough while providing structure. Collagen is often used for filling wrinkles and lines and scars on your face, neck and back. Zyderm and Zyplast cosmetic injections use collagen from cattle, called “bovine collagen.” CosmoPlast and CosmoDerm injections use highly purified human collagen, a natural protein that supports the skin and helps replenish collagen lost with time, exposure to sunlight and other factors. Other collagens used in cosmetic procedures include collagen from human cadaver skin that has been sterilized, purified and processed into a liquid form. Brand names of this form include Cymetra, Dermalogen and Fascian. These fillers are rarely used anymore.Collagen injections typically take less than an hour, and for best results, should be repeated every one to two months. Plastic surgeons and dermatologists are best suited for providing collagen injections. Rare side effects include the formation of small, temporary bumps beneath the skin, infection and scarring.
• Fat fillers. Your aesthetic specialty physician may suggest afat filler, in which fat is removed from another part of your body and injected into the wrinkle/line. Since the fat is of your own body, the risk of complications is very low.
• Synthetic fillers (polymethyl methacrylate, hydoxylapatite and polylactic acid).Synthetic fillers are used for filling facial wrinkles and folds. It takes less than an hour for synthetic filler injections, and the results can last anywhere from six months to five or more years, depending on the filler product. Synthetic fillers should be administered by plastic surgeons or dermatologists. Synthetic fillers differ depending on the brand:
  • Polymethyl methacrylate (PMMA) contains 20 percent PMMA beads suspended in 80 percent collagen. A few months after injection, the collagen breaks down, sparking your body to produce its own natural collagen to fill in the space. Unlike other fillers, it is not absorbed by the body. Brand names include Articol, Artefill and Metacrill.
  • Hydroxylapatite is an injectable gel. Calcium hydroxylapatite is a substance found in teeth and bones and is used for numerous medical applications including cheek, jaw, skull and chin implants. Brand names of the injectable form include Radiesse and Radiance.
  • Polylactic acid is a compound used in numerous medical products, such as stitches and screws used to repair broken bones. Although Polylactic acid has only been approved to restore shape and contour to the faces of those with AIDS, it is often used “off label” for cosmetic treatments. Polylactic acid treatments do not produce immediate results because they stimulate college production, so it may take up to a few months the full effect. Although polylactic acid is considered semipermanent, you may need an occasional touch-up treatment. Brand names include Sculptra and New-Fill.

Skin Resurfacing

These techniques are designed to smooth fine lines and wrinkles, get rid of brown spots, reduce sun damage and shrink pores. The level of intensity varies from mild chemical peels to laser resurfacing and laser pulses, and after-effects range from mild redness to peeling and scabbing. Skin may also be very sensitive to sunlight and unable to tan.

• Chemical peels. A chemical solution is “painted” onto your face to literally “peel away” damaged top layers of skin. Solutions range from mild alpha hydroxy acids to stronger acids like trichloroacetic acid (TCA) and phenol. It takes from 15 minutes to two hours for a chemical peel, depending on the strength of the peel.Chemical peels cost an average of $764; specific cost depends on the strength. Aestheticians may perform mild peels. Plastic surgeons or dermatologists are your best bet for stronger peels.
• Microdermabrasion. A more superficial form of dermabrasion (described below), microdermabrasion uses crystals or a diamond tip to lightly smooth the top layer of your skin. It is used for fine lines, crow’s feet, age spots and superficial acne scars. Microdermabrasion takes about 30 minutes and requires no anesthesia. For best results, many people start with a microdermabrasion treatment every two weeks and then move to one per month as maintenance. Each session costs about $154.Microdermabrasion may be performed by aestheticians, licensed cosmetologists, plastic surgeons or dermatologists. Complications are rare.
• Laser skin resurfacing. In laser resurfacing, or laser peel, the doctor uses a laser beam of light to remove areas of damaged or wrinkled skin. New cells form as the skin heals, creating a smoother, tighter, younger-looking appearance. Laser resurfacing is used for minimizing the appearance of fine lines, uneven pigmentation and facial scars. It works best for light-skinned women. The treatment takes between 30 minutes to two hours and is typically performed under local or general anesthesia. Each treatment costs an average of $1,113 to $2,222 and the results last a year or more. Laser skin resurfacing is best performed by a qualified laser specialist, usually a plastic surgeon or dermatologist. Possible complications include burns, scarring, obvious lightening or darkening of the skin. It may also activate herpes virus or other infections.
• Plasma skin rejuvenation (Portrait). This nonablative procedure improves skin texture and reduces wrinkles and irregular skin coloring by delivering millisecond pulses of nitrogen plasma energy to the skin. The procedure takes about 15 to 40 minutes, depending on the extent of the work. Discomfort may be managed with pretreatment application of topical anesthesia. The skin is red for about six days on average. The optimal results may require one to three procedures, depending on the energy and settings used. There is usually marked improvement in wrinkles without creating a wound. Improvements are noted after a month and continue to improve with subsequent treatments. The average cost is about $1,800.
• Fractional photothermolysis or fractional resurfacing. This technology removes a small fraction of the surface of the skin during each treatment to resurface the skin. This procedure is similar to a resurfacing laser, but with much less down time. The micro-injury causes the collagen to remodel. This procedure is used for large pores, pigment abnormalities and acne scars. The procedure usually takes about 30 minutes, and you may require three to five treatments for the best results. The cost is between $750 and $2,500 per treatment.
• Noninvasive skin tightening. Noninvasive skin tightening uses radiofrequency technology or pulsed light to treat wrinkles and sagging skin. Unlike laser treatments, this technology can be used on all skin types, on patients of nearly any age and on almost any body part where skin tightness is a concern. Brand names include Thermage, Accent (both radiofrequency) and Titan (pulsed light). Prices vary and range between $400 and $800 per visit.

Hair Removal

Treatments such as electrolysis or laser hair removal can keep you smooth longer than razors, tweezers or waxing. The two most common treatments are electrolysis, in which an electric current is used to permanently destroy the hair follicle, and laser treatments, which use a laser to destroy the follicle. Both are eventually permanent after years of repeated treatments. Laser hair removal only works on dark brown or black hair. White or blond hair will not respond to the laser. Red hair may have limited response to the laser treatment.

Electrolysis may be performed by an electrologist. Each session takes between 15 minutes and an hour, and the cost varies widely depending on the area from which the hair is to be removed. Risks include permanent holes where the needle penetrates the skin.

Laser hair removal takes from 10 to 30 minutes, depending on the size of the areas to be treated, and multiple sessions—usually four to six—are required. Then the patient will most likely need a maintenance treatment two to three times a year. Cost varies depending on the area being treated. Laser hair removal is best performed by a dermatologist or plastic surgeon.

Possible complications of both include pain, scarring and pigmentation changes.

Prevention

Aging, sunlight, smoking and dryness all contribute to the wrinkles, brown spots, large pores, redness and other imperfections women try to correct with nonsurgical cosmetic treatments. For instance, as you age, the top layer of skin doesn’t turn over as often, leaving dead skin cells on the surface longer and giving your features a dull appearance and texture. This is also when the sun damage of your youth comes back to haunt you. That sun created free radicals that broke down the collagen in your skin, as well as the elastin fibers that keep skin flexible. If you’ve spent a lot of time in the sun, your skin may even have a leathery appearance.

Preventing skin damage boils down to:

• Protecting yourself against the damaging effects of the sun by wearing sunscreen that protects against UVA and UVB rays. Put it on just like you put on moisturizer every morning (many moisturizers contain sunscreen), even if it’s cloudy outside. Just sitting near a window or riding in a car exposes your skin to the sun’s rays.
• Quitting smoking and staying away from second-hand smoke.
• Taking care of your skin. That means washing it with gentle cleaners and using moisturizer in the morning and at night.

Mirror, Mirror on the Wall

Stopping the aging process and living eternally has been an enduring human desire, sought by Egyptian pharaohs, Chinese emperors, and Ponce de Leon’s search for the Fountain of Youth. Cosmetic medicine has developed a number of nonsurgical procedures that can camouflage the effects of sun exposure and the passing years. These procedures seem to be gaining in popularity versus surgical procedures.

Botox Basics

Three different forms of botulinum toxin are available (Botox Cosmetic, Dysport, and Xeomin) for the injection of facial muscles. This bacterial protein temporarily paralyzes the muscle that received the injection. Certain types of wrinkles, such as those on the forehead and at the corners of the eyes, diminish if the muscles producing them cannot contract normally. A thin needle and a small volume of toxin minimize the pain of the injection .

Botox: Before and After

After toxin injection, there is a gradual loss of muscular control, which usually takes up to a week to reach maximum effect; the areas of the affected face appear calm and unexpressive. The paralysis lasts about four months so patients must receive injections at regular intervals for maintenance.

Chemical Peel Basics

Chemical peels use a variety of substances to damage the skin in order to exfoliate the outer layers. The depth of the peel depends on the type of chemical, its concentration, and the length of time it remains on the skin. Glycolic acid, lactic acid, salicylic acid, trichloroacetic acid (TCA), and phenol are some of the chemicals used in cosmetic peels. There is an improvement over the skin’s pre-peel state after the skin heals.

Chemical Peel: Before and After

Mild peels may be repeated every few weeks for the desired effect. Deeper peels may cause some initial discomfort as well as swelling and crusting of the face. Moderate or deep facial peels can be repeated at six- to 12-month intervals. It is important for patients to choose a physician who has plenty of experience with the chosen procedure, since the results of chemical peels are technique dependent. The doctor will be able to choose the best approach for the particular cosmetic issue.

Microdermabrasion Basics

Microdermabrasion is a procedure whereby silicon crystals (grains of sand) are propelled by air onto the skin surface, producing a small amount of inflammation. The minimal swelling produced by this technique can improve the appearance of superficial wrinkles. The results are modest, temporary, and must be repeated at frequent intervals. On the other hand, there are few side effects.

Microdermabrasion: After

The irritation produced by microdermabrasion initially looks like a sunburn and feels tight, but this effect goes away within one day. Multiple treatments may be necessary.

Thermage Basics

Radio waves can improve the appearance of sun-damaged skin. It is believed that either changes produced by directly heating skin collagen produces tightening of loosened skin, or new collagen synthesized after heating is responsible for the improvement, or both. Devices (for example, Thermage) used to generate the radio energy can produce enough heat in the skin to be painful, but a single treatment is all that is generally needed.

Thermage: Before and After – Eyelids

Droopiness of the eyelids is one condition often treated by Thermage. Results are not visible until four to six months after the procedure.

Nonablative Laser (Fraxel) Basics

The idea of nonablative lasers like Fraxel is to protect the outer layers of the skin (the epidermis) while damaging only the deeper dermis. Topical anesthetic reduces the pain associated with the procedure.. Since the surface layers are preserved while the deeper layers of the skin sustain the damage, scarring is unlikely to occur and new collagen is generated.

Nonablative Laser: Before and After

One of the advantages of nonablative laser therapy is that it does not require significant time away from work or daily activities. The skin may be mildly reddened after the treatment, but this quickly improves. Most people undergo four to six treatments over a period of several months.

Nonablative Laser for Melasma

The use of lasers is just one of many approaches to the treatment of brown spots or patches, including “pregnancy mask” (melasma). The doctor will determine the best treatment depending on the patient’s skin color, the extent of discoloration, and their experience.

Diode Laser Basics

Diode laser is a technique that can achieve improvements by destroying oil-producing glands for those with severe acne. Similar to Fraxel laser therapy, diode lasers penetrate below the surface layer of skin without damaging the outermost layer. Side effects are temporary and include redness and inflammation.

Diode Laser: Before and After

Diode laser therapy for acne may require several treatments. This image shows skin that has improved after a series of five diode laser treatments.

Intense Pulse Light (IPL)

Intense pulsed light (IPL) technology exposes human tissues to broad spectrum (non-laser) light sources that produce sufficient heat to destroy colored molecules that can absorb the light. In the case of human tissue, this involves melanin (skin pigment) and hemoglobin (blood pigment). When used appropriately on aged or pigmented skin, IPL can improve the skin’s appearance.

IPL: Before and After

Since IPL relies upon the absorption by hemoglobin and melanin, it can work on skin discolorations that are red or brown. It may be effective in patients with dark spots (melasma), redness (rosacea), dilated blood vessels (telangiectasia), and aged skin. IPL also stimulates the production of collagen.

Cosmetic Filler Basics

Cosmetic fillers add substance to skin in order to lift up areas that are sinking. Certain wrinkles, depressed scars, and hollows can be camouflaged using this technique. The substances that have been used are varied and include one’s own fat or fibroblasts, poly-L-lactic acid, hyaluronic acid, calcium hydroxyapatite, polymethylmethacrylate beads, and even silicone. Some of these substances produce improvement by enhancing collagen in the area injected, which adds volume to the tissue beneath the skin, and helps smooth the appearance of lines or wrinkles.

Cosmetic Filler: Before and After

Many, but not all, fillers disappear over a period of months, so it is necessary to reinject them to retain the desired appearance. The benefit of this is if too much of the filler is injected, producing an undesirable puffiness to the tissue, this swelling will diminish over a period of months. On the other hand, repeated treatments are needed to maintain the desired look. Injection with fat cells often yields permanent results. Polymethylmethacrylate is another filler that produces permanent results.

Cosmetic Filler: Beyond Wrinkles

The anatomy of the aging face is now better understood than in the past. Aside from increased wrinkling, there is a loss of fat in the cheeks and temples, and an increase in fat in the neck. As shown in this photograph, a filler has been used to plump a woman’s sunken cheek area.

Cosmetic Filler for Dark Circles: Before and After

Physicians may use fillers in the hollow area around the eye socket to minimize dark circles and bags under the eyes.

Cosmetic Filler for Lips: Before and After

Health-care professionals may use the same fillers that plump wrinkles and minimize dark circles to plump the lips. Fat-cell injections may have permanent results, but collagen and hyaluronic acid fillers produce a temporary effect.

Making the Decision

The perception that nonsurgical cosmetic procedures are less risky than conventional scalpel surgery is not entirely accurate. The choice of the best procedure to fix a particular problem requires careful consideration by both the patient and physician. It is important for the patient to have realistic expectations regarding the outcome.

1. Today, plastic surgeons perform an estimated 8.5 million minimally invasive cosmetic treatments annually, while dermatologists, otolaryngologists, ophthalmologists and other medical specialists perform millions more.
2. Nonsurgical procedures make up nearly two-thirds of aesthetic treatments performed by plastic surgeons today, according to the American Society for Aesthetic Plastic Surgery.
3. According to the American Society of Aesthetic Plastic Surgery, in 2012, Americans spent $2 billion on injectable procedures; $1.8 billion on skin rejuvenation procedures; and over $483 million on other nonsurgical procedures, including laser hair removal.
4. Even something as simple as a chemical peel carries potential risks, particularly when performed by someone not properly trained in the treatment.
5. Insurance rarely, if ever, covers the cost of cosmetic treatments.
6. Few treatments are permanent. Most will need to be repeated within a few months or a few years.
7. Just because a health care provider offers a treatment doesn’t mean that person is qualified to perform the treatment. Ask for references, talk to patients and confirm certifications. Plastic surgeons and dermatologists are the most qualified professionals available to provide most nonsurgical aesthetic treatments.
8. It is very important that you have realistic expectations about the treatment you choose. Ask your doctor to show you before and after photos of patients he or she has treated. Also ask how long the effects will last and how many treatments you may require and how many vials or syringes may be required for some procedures.
9. Dermal fillers are injectable products that fill fine lines and plump up wrinkles to provide a smoother, younger look. They are among the most popular nonsurgical cosmetic treatments. The fillers are injected directly into wrinkles and lines. You pay by the syringe, and several syringes may be required, so ask your doctor for an estimated total cost before beginning your treatment.
10. Skin resurfacing techniques are designed to smooth fine lines and wrinkles, get rid of brown spots, reduce sun damage and shrink pores. The level of intensity varies from mild chemical peels to laser resurfacing and laser pulses, and after-effects range from mild redness to peeling and scabbing.

Key Q&A

1. What are the most important things I should know about nonsurgical aesthetic treatments?Nonsurgical aesthetic treatments are medical procedures, and with any medical procedure there are potential risks. If you have realistic expectations of the results, understand that most treatments are not permanent and may need to be repeated in a few months or a year to maintain results, and carefully research your options and the aesthetic specialty physician who will provide the treatment, you can achieve a natural, refreshed look that enhances your appearance.
2. Are aesthetic injectable products such as Botox Cosmetic and dermal fillers safe?Yes. The U.S. Food and Drug Administration (FDA) reviews significant clinical data on the safety and effectiveness of all drugs and medical devices before approving them for marketing in the United States. Some products have years of clinical history for other conditions before being approved for cosmetic procedures. Botox, for instance, has been approved in the United States for more nearly 25 years to treat a variety of medical conditions.
3. Is it really true that I can get a “lunchtime facelift?”That depends on what treatment you’re having. Some treatments, like dermal fillers and microdermabrasion, can provide smoother, younger-looking skin in just a few minutes. Others, such as laser resurfacing, may take days or weeks to heal.
4. What is the best way to find a aesthetic specialty physician who provides nonsurgical aesthetic treatments?Go to the websites of the major plastic surgery and dermatologic societies listed in the Resources section. They have searchable databases allowing you to find physicians in your area who provide cosmetic treatments. Also talk to friends who have had treatments and to your primary health care provider for recommendations. Just make sure you check physician credentials carefully, ensuring they are qualified to perform the specific treatment.
5. Even though many of these nonsurgical treatments are less expensive than surgery, they’re still too expensive for me. Is there any chance my insurance company will pay for part of it?It’s highly unlikely. Most insurance companies don’t cover elective treatments. However, if you are having a filler for a medical reason, like restoring your appearance after an accident, or if you have loss of fatty tissue related to AIDS, it might be covered. Also you can talk with your physician about financing options.
6. The idea of getting shots into my face gives me the willies. But I really need to do something to bring back some freshness. Any suggestions?Not all treatments require needles. Facial resurfacing with microdermabrasion or dermabrasion, for instance, are needle-free. To reduce pain associated with aesthetic treatments, your doctor will use either a local anesthetic-to numb the area being worked on-or a general anesthetic, to put you totally out. If you opt for injections, most doctors use topical anesthetics to numb the area first.
7. How do I know if my doctor is qualified for the aesthetic treatment I want?Ask a potential doctor about his or her credentials. Where was he/she trained? In what specialty did he/she do her residency? Did he/she complete a specialty fellowship? What are his/her board certifications? Also ask where your doctor trained on the treatment you’re having. If at any time you don’t feel comfortable with the answers or the doctor, find someone else.
8. My doctor says she has a “cheaper” alternative to the dermal filler I asked about. How can I find out about it?The FDA must approve all medications and medical devices before they can be marketed in the United States. The FDA also approves all devices used in treatments like dermabrasion and laser therapies. Most dermal fillers are considered medical devices.
9. My doctor is recommending Sculptra dermal filler, but I see it was only FDA-approved for people with AIDS. How can it be used for cosmetic reasons?Once the FDA approves a medical device or drug and it is on the market, physicians can use it for any reason. This is called “off-label” use, and it is legal. Sculptra is often used off label for cosmetic reasons, as are other nonsurgical aesthetic procedures.

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