If the idea of plastic surgery conjures major surgical procedures with dramatic before-and-after photos, think again. Some of the most popular options in cosmetic enhancement are injectables -- precisely because they don't require an operating room and the results are subtle. According to the American Society for Aesthetic Plastic Surgery, the popularity of neuromodulators (also known as neurotoxins) and hyaluronic acid injectables has steadily been on the rise for the last 5 years, with people spending nearly half a billion dollars on each category.
"I like that using injectables does not require surgery," says Kate Zibilich Holcomb, MD, a dermatologist in New Orleans and an assistant clinical professor of dermatology at Tulane University School of Medicine. "They are largely reversible if you do not like the result, and, if done well, they make people look like a refreshed version of themselves."
The ability to target some of the most visible signs of aging without the commitment of surgery makes them an appealing option for doctors, too.
"There are three components to facial aging: skin tone and texture, wrinkles from facial expression, and volume loss," says Joshua Zeichner, MD, a dermatologist in New York City and the director of cosmetic and clinical research in dermatology at Mount Sinai Hospital.
"There are some issues that require more than just a cream to achieve noticeable improvements. Injectables like fillers and neurotoxins are non-invasive, minimally uncomfortable, have little downtime, and are cost-effective."
If the idea of injectables has piqued your interest, our experts explain the art and science of these popular treatments.
What's the difference between a neuromodulator and a filler?
In the simplest terms, fillers support and fill while neuromodulators weaken the contraction of muscles that lead to a wrinkle, Holcomb explains. More precisely, a neuromodulator interrupts the signal between the nerve and the muscle, causing it to relax. Neuromodulators, commercially known as Botox, Dysport, Jeuveau, and Xeomin, address dynamic wrinkles that are caused by the flexing of muscles, says Anthony Youn, MD, a plastic surgeon in Troy, MI. "Neuromodulators weaken these muscles, causing them to contract less and the wrinkles to smooth out." The effects last from 3 to 4 months.
On the other hand, "a filler simply adds volume," says Robert Anolik, MD, a dermatologist and a clinical assistant professor of dermatology at the New York University School of Medicine. "As we age, we lose supportive fat pads and supportive bone structure that make our face look younger. Injecting a filler allows a doctor to re-create what was there in the past and correct volume changes related to age."
Fillers can include a range of substances. "Restylane, Juvederm, and Belotero are all hyaluronic acid fillers, which are natural sugar chains that are already found in the skin," Anolik explains. "I use them the most because if there's ever a concern with the outcome, I can easily dissolve it if necessary." Other dermal fillers include Radiesse, Sculptra, and Bellafill.
What areas can you treat with neuromodulators?
"The most commonly treated dynamic wrinkles are frown lines, crow's feet, and forehead lines," Youn says.
For people who complain of prominent bands of tissue on the side of the neck called the platysmal bands, shots can relax that tissue for a softer look.
In addition, Anolik says he will often inject patients in the jaw. "Some people grind their teeth, and that thickens the muscle and squares the jaw," he says. Injecting a neuromodulator at the jawline can reduce the size of the muscle.
Doctors may inject at the top of the nose to prevent creases or "bunny lines," and at the base of the nose to help prevent the tip from turning down.
In the lip area, a small amount of neuromodulator can relax muscle fibers and make vertical lip lines less visible, Anolik says. And the injectable can also weaken the upper lip muscle to prevent the exposure of gums and create a less gummy smile.
When patients complain of orange peel or dimpled skin, Youn says he can inject small amounts into the mentalis muscle to gently relax it and smooth the area.
"Sometimes the under-eye muscle can thicken and bulge," Anolik says. "We can put a drop of neuromodulator below the eye to relax that muscle and make the under-eye bag look less prominent." That subtle change can make the eye look more open and refreshed, he says.
What areas do fillers treat?
For the most part, filler is used to lessen moderate to severe wrinkles and folds, so it's useful on many areas on the face like the nasolabial folds, or “laugh lines,” Anolik says. He says it's common to define the cheekbones, fill the temples, and define the jaw. "Figuring out which filler will give the most effective outcome for each patient is part of the challenge and fun of using them," Holcomb says.
"The lips are an important place to choose your filler wisely," she adds. "There is no specific filler for every lip -- it depends on the patient's specific needs." She also says the results can be more subtle than many social media and reality stars may have led you to believe.
Another area that fillers can have a major effect is in the tear trough. "There's a fat pad under the eyes that tends to move down with age," says Papri Sarkar, MD, a dermatologist in Brookline, MA, and president of the New England Dermatological Society. "When this happens, the area looks hollow, and we can fill that and reduce the appearance of dark circles or prominent veins in this area."
Hands also lose plumpness, causing veins, bones, and tendons to be more apparent, Sarkar says, making them another area that responds well to fillers. "The results are instantly obvious, which patients really like," she says.
"With filler, what's surprising to some is that I can address an earlobe that's losing its volume and causing earrings to pull down," Anolik says. He will inject filler around a sagging piercing, and earrings will sit higher.
Nonsurgical nose jobs have also become a popular use of fillers. In this procedure, a doctor injects fillers into the bridge to even out bumps and even lift the tip to alter the shape of the nose, Sarkar says. "This area, the tear troughs and the nasolabial folds, are the most risky areas to inject, so it is imperative that you only see someone who is an expert at these procedures. I generally recommend physicians who are board-certified in dermatology or plastic surgery in particular."
The most important thing in all these procedures is finding the right doctor. Make sure you discuss expectations and look at before-and-after pictures of their work.
"The use of fillers is an art," says Zeichner. "Everyone uses the same tools, but the outcome is directly related to the skill and taste of your injector. For example, both Monet and Van Gogh used paint, but their paintings turned out quite different."
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