The New Face-Lift: Fill'er Up!

Forget the drastic plastic surgery of old—now maintenance is the main event. Here, the ultimate pros-and-cons guide to the latest treatments and procedures.

By Jennifer Scruby
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Photograph: John Teate

On a recent chilly afternoon in Los Angeles, during a baby shower at the Chateau Marmont hotel, makeup artist Amy Holiber picked up a glass of Champagne and gazed around the penthouse suite. “There were about three dozen women there, all of them forty-something mothers, from different backgrounds and income levels,” recalls Holiber, 43. “I was just thinking how young everyone looked when a friend of mine—a physician’s assistant who works in a dermatologist’s office—walked up. ‘There are only two people in this room who haven’t touched their faces,’ she whispered.

“Once she pointed out those women, I noticed the difference in their faces,” Holiber says. “The weird thing was that I couldn’t detect that the others had had work done. They just looked really good.”

Want your face to look younger without the world taking insta-note? Your odds of success have never been better. Right now the world of facial reshaping (the preferred term of industry professionals) is undergoing a revolution, says Manhattan plastic surgeon Scott Wells.

For starters, many current treatments result not just in cosmetic changes to your face but also in long-term improvements in your skin, with the result that it ages more slowly. Here’s how it works: Fillers like Restylane, Juvéderm, Radiesse and Perlane soften lines, restore lost volume and put pressure on fibroblasts in the skin to stimulate collagen production. Lasers and noninvasive treatments like Ulthera (which heats the deeper layers of the skin using focused ultrasound) and Thermage (which uses radio--frequency waves but doesn’t go as far down) also spur new collagen. Botox injections, which freeze wrinkles, can stop strong lines from ever forming. The result? Many women aren’t signing up for face-lifts at 50 anymore; instead, they’re focusing on maintenance through less invasive treatments, starting in their thirties and forties. “Now you do surgery when everything else doesn’t work,” says Fredric Brandt, MD, a dermatologist with practices in Manhattan and Miami.

One reason maintenance is now the main event is that doctors have learned a lot about what time actually does to the skin. For example, they know that certain parts of the face lose volume fasterthan others. Consider the area around the nose and mouth, where deflation leads to deeper nasolabial folds (from the nose to the corners of the mouth) and marionette lines (from the corners of the mouth to the chin). In the past, doctors compensated by plumping up the lips, which sometimes left the patient with an overly full “trout pout,” or by filling in the wrinkles, creating a Planet of the Apes effect that made the lower face heavier rather than more youthful. Today the most influential dermatologists soften the nasolabial folds and lift jowls by placing injections at the temples and the edges of the cheeks, which pulls up the skin on the lower half of the face, unfolding the creases around the nose and mouth.

 “That’s the new trend,” explains L.A. dermatologist Karyn Grossman. “Doctors have gotten carried away with plumping up the apples of the cheeks; that look screams injection, because it makes your eyes seem hollow. But filling in the edges of the face gives you fullness without making you look ‘done.’ ”

The goal of the “natural” trend is a face with movement and a few age-appropriate lines. But the treatment options can be dizzying, and then there are the risks. Why do some women come out looking like well-rested, airbrushed versions of themselves, while others—many of them smart, rich, resourceful women—appear windswept, overfilled or otherwise unartfully rearranged? If your idea of “natural” is the face you were born with, helped by good products and all the sleep you can get, then you don’t need answers to these questions. But if you think you might go down this path, now or someday, find out here how to end up looking like yourself, only better.

No. 1

Add this to the life-isn’t-fair list: The younger your skin looks, the better any kind of rejuvenating treatment will work. “The effects of long-term photoaging—large pores, laxity, irregular pigmentation, dilated blood vessels—make it hard to get a great end result,” admits Manhattan dermatologist Patricia Wexler. (That said, if your skin were flawless, you wouldn’t be seeking any treatment.) Women with darker complexions tend to have an edge—they often look more youthful because the higher levels of melanin (pigment) in their skin offer some built-in sun protection. Note to repentant sunbathers: It’s never too late to start with sunscreen and retinoids. The latter stimulate collagen production, which is the most crucial factor in preventing aging.

Other factors that work to your advantage: high cheekbones, a strong jawline, a chubby face, a healthy, stable body weight (not too thin or too heavy) and—surprise—a habit of sleeping on your back. “Most dermatologists can tell which side you sleep on just by looking at your face,” says San Francisco dermatologist Katie Rodan. “The lines become deeper on the side that’s carrying the weight; your face can even become flatter on that side.”

Another important issue: Are you sinking or sagging as you age? Some faces sag more than they hollow out, and vice versa. If you’re a dramatic hollower, you may never feel the need for a face-lift. If you’re a significant sagger, you may consider surgery early on. “Going to a doctor who knows the difference is key,” says Grossman. “If the MD tries to fix very loose, droopy skin using only filler, you could wind up looking like a stuffed sausage. And if he tries to fix a hollow face with just surgery, you get a tight, wind-tunnel effect or even more hollowing.”

What a face-lift can really deliver is an improved neck and jawline. Decide how much help you need in those areas. Most women, for example, never develop a turkey-wattle neck. So if you can tackle the jawline and other problem areas as they begin to deteriorate, you may be able to forgo a face-lift indefinitely.

On the other hand, if you do have sagging skin and muscles that can’t be fixed by less invasive methods, then it’s best to take action sooner rather than later. “The perfect time for surgery is when your skin is still healthy, and the collagen and elastin are good,” says New York plastic surgeon David Rosenberg. Concurs Wexler: “If you’re open to the idea of a scalpel procedure, early intervention is better. The golden window can be anywhere from 45 to 60, though some people can stretch that a bit if they’ve taken care of their skin. There’s a saying: If you do it in your forties, you’re thrilled; in your fifties, you say, Why did I wait?; and in your sixties, Why did I bother?”

In terms of what treatments to try and when, you might consider looking to Hollywood for guidance. Don’t. Women who have access to everything sometimes blow it, says Ramtin Kassir, MD, a New York City plastic surgeon. “There’s a tendency for celebrities to try trendy procedures and overdo it,” he observes. Rodan offers an interesting insight: “I think what happens in the case of some stars—the ones who look like they’ve gone into the witness-protection program—is that they do things that look good on camera and in magazines. But in real life, their eyebrows are in the middle of their foreheads.”

In the end, what will save you from a disastrous, exaggerated look is keeping your adult perspective—meaning, don’t let your doctor push you into a procedure and don’t try to push your doctor. “Patients constantly tell me, ‘I like how you did my lips last time, but now I really want them larger,’ ” says New York City dermatologist Doris Day, author of Forget the Facelift. “The same thing with Botox—they only want a tiny bit at first, and then they come back and want more. I always say, ‘No, you look beautiful; it is time to stop.’ But it’s easy for doctors to lose track of what normal looks like, and trying to please a patient can override their good judgment.”

No. 2

What’s new:
Temples have become the hottest new area to treat. “If you work out and are thin, your temples start to get really sunken,” says Brandt. “It’s incredible what a difference it makes to fill them in a bit—it balances everything out.” At the same time, doctors are injecting volumizers much deeper, closer to the bone, to make the complexion extra smooth. “In the eye and cheek area, the skin is pretty thin,” Rodan explains. “Fillers have a tendency to migrate or create a bump there if they’re placed too close to the surface.”

And most women are asking for subtler lip injections, if any. (That’s good: The experts agree that lips are where things can start to go off the rails.) There’s also buzz about stem-cell face-lifts—injecting your face with fat from your own body. Why would this help? Fat is rich in active cells that can promote tissue repair, cell growth and new collagen. Little research has been conducted so far to back the regeneration theory, “but that’s where we’re headed,” says Wells. “The potential for engineering tissue with stem cells is huge.”

What goes right: Opting for subtle maintenance with volumizers rather than a total overhaul with fillers. “The whole key is doing subtle, incremental things that keep up with the aging process rather than going out for a home run,” says Manhattan plastic surgeon Alan Matarasso. In other words, people who demand a drastic change don’t end up looking the best.

What can go wrong: Beyond overinflating, the real minefield is assuming that all problems can be fixed with a filler. “The amount of volume you had in your face when you were 20 will look weird on you when you’re 55,” says Haideh Hirmand, MD, another New York plastic surgeon. “We have all these people now who look overly filled, and it’s almost worse than when people looked overly lifted. Patients think that if they do fillers instead of surgery, they’ll by definition look more natural. But you have to combine things in the right proportions to get the best results and make the work look invisible.”

Botox and similar injections
What’s new: Botox recently won FDA approval as a treatment for chronic migraines. But it can help you feel better in other ways, too. “A lot of people hold tension between their eyebrows without realizing it. There’s actually a mood-elevation effect that can happen with Botox—possibly because frowning sends feedback to your brain that you’re feeling bad,” says Adam Scheiner, MD, a plastic surgeon in Tampa, Florida. Block the frown, the thinking goes, and you’ll bring on the Zen. Meanwhile, Dysport, a relatively new neurotoxin, is gaining popularity. “It’s almost identical to Botox but diffuses more easily, so it gives a slightly softer, smoother effect,” Wells notes.

What goes right: Erring on the light side. Botox is intended to smooth mild to deep-set frown lines, crow’s-feet and furrows while leaving your face capable of moving. Injected correctly (and conservatively), it does just that. Another clever trick: Injecting the platysmal bands in the neck—the ones that stand out when you grimace—can lift the corners of the mouth and diminish jowling, no surgery required.

What can go wrong: “A doctor has to be really careful injecting Botox into the forehead,” says New York dermatologist
Brad Katchen. “If you relax that area too much, you can get a waxen look, and your brows drop.” Nerves connect in the face even when they’re far apart—which means that if Botox is injected too deeply between your eyebrows, it can give you a saggy eyelid; if your crow’s-feet are overtreated, you may end up with a droopy lip.

Lately there’s been some blowback regarding Botox. Much of the controversy stems from an Italian study of rats, published in the Journal of Neuroscience in 2008, which showed that Botox particles could travel into the brain. The experts More consulted aren’t concerned. “Botox is one of the safest procedures out there,” says Brandt. “There’s been so much FDA research on Botox, and all the studies I’ve reviewed show that it binds to the muscle where it’s injected, and that’s where it stays.” Scheiner agrees: “If you inject Botox in high doses, it can move. But the amounts we use are minuscule.”

What’s new: Moderation. Gone are the days when doctors aimed to make faces as tight as possible. Plastic surgeons are dipping into the dermatologist’s tool kit, often lifting and filling at the same time for a more natural look. Surgery was once your only recourse; now, with all the gentler therapies, it’s typically a last resort.

What goes right: Some doctors believe that skin-only lifts can work well, especially in younger patients. But for natural, longer-lasting results, most pros recommend the SMAS (subcutaneous musculo-aponeurotic system) face-lift, which involves repositioning the face’s underlying muscle and fat layer along with the skin. Done properly, “it will give you a relaxed, refreshed look with good cheek volume, a nice jawline and minimal scarring,” says Kassir. Some of the younger generation of surgeons, including Rosenberg, go even farther into the face below the SMAS layer to do what’s called a deep-plane face-lift.

Note: A face-lift doesn’t affect your whole face. It tightens everything from the cheekbone to the collarbone; it doesn’t affect your eyes. If you want to give those a lift, you need to undergo treatment entirely separate from the face-lift. Expect to pay $6,800 to $30,000 for a face-lift, depending on the reputation of the surgeon and his or her location. Results should last eight to 12 years.

What can go wrong: “Face-lifts are operations. And as with other operations, unless the patient is vetted properly, there can be bleeding, infection, delayed healing or poor scars,” says New York City plastic surgeon Elliot Jacobs. Any procedure that requires general anesthesia involves risks, including, rarely, heart attacks and strokes. Make sure you check in with your regular doctor before you have the surgery to be certain you’re in good enough shape for it. Other risks are aesthetic. If the doctor removes too much fat or pulls your skin too much, you could end up with a warped look. Other telltale signs of a face-lift gone awry: disappearing sideburns, “pixie ears” (lobes stitched so tightly that they meld into your jawline) and high-set, Mommie Dearest eyebrows.

No. 3

Use: Botox and fillers.

Jowls and a sagging neck
Use: Fillers and Botox if you’re looking at mild jowling or early-stage laxity in your thirties and forties. Laser treatments such as Ulthera and Thermage can tone and tighten. But if you have a lot of loose skin and it bothers you, consider playing the face-lift card.

Fine lines, brown spots and uneven skin tone
Use: Mild chemical peels. LED and resurfacing lasers like Fraxel abolish fine lines and improve skin texture on a deeper level. And Botox can freeze wrinkles in their tracks.

Tired, puffy eyes
Use: Botox, fillers or lasers. Properly placed injections can raise your brows a few millimeters, which can go a long way toward making you look more rested and relaxed. Lasers can smooth and strengthen skin. If you have heavy, sagging lids and lasers don’t yield the results you want, consider an eye-lift.

Use: A vascular laser, like Vbeam or Iriderm, to obliterate broken capillaries and dilated blood vessels, at least temporarily. For ideal results, you’ll need three sessions and an occasional touch-up.

No. 4

Get referrals from friends, family members and physicians. Word of mouth is best. Beware of the Internet: Docs can pay search engines to have their names pop up on “best plastic surgeon” lists.

Ask to see before and after photos to get a sense of what your doctor thinks is beautiful. Keep in mind that doctors usually put up their best pictures, and these can be altered with Photoshop. What you want to check out is your doctor’s overall aesthetic judgment. “Every doctor has his own brand of rejuvenation. They’re kind of like fashion designers whose clothes have a certain look,” says Wells.

Heed warning signs. Lynne McPhail, an occupational therapist in Colorado, realized she was in the wrong place for an eye-lift when she noticed that the surgeon had pictures of a very famous, very altered country-western singer all over his office. “I just wanted to look a little more rested,” McPhail says. “It’s not like I’m performing at the MGM Grand.” Try to find someone who’s conservative, cautions Rodan: “It’s hard to get back to your old face if it’s been overdone.”

Inspect other patients in person. “It’s very fair to ask the doctor if you can meet people who’ve recently had the procedure you’re considering,” says Rosenberg. Look around the office, too: Almost every doctor has done work on his staff.

Make sure your doctor specializes in more than one treatment. You need someone who can do what’s best for you, not what’s best for him. “A good dermatology practice should own at least two or three lasers,” says David Goldberg, MD, who practices in New York and three other states. “Find out which machine the doctor plans to use on you, and then Google it.”

Think worst-case scenario. Find out what side effects and risks are involved. (Beware the doctor who offers only good news.) What about complications? Will the doctor be available if anything goes wrong? Also important to know: How much will the procedure cost? Are there any additional expenses—such as for a surgical facility or hospital—that you should factor in?

Don’t trust imaging machines that are supposed to predict results. “They’re a joke,” says Rosenberg. “Every one of them has a disclaimer: ‘This drawing may have nothing to do with your ultimate results.’ ” The problem is that the images can overpromise what procedures can deliver. “If you want a preview of face or neck surgery, the easiest thing is to sit on the edge of your bed with a hand mirror, lean forward and jiggle your face to loosen things up, and then lie flat on your back and hold a mirror up over your face,” Matarasso says. Considering an eye-lift? Take a Q-tip and push in on the upper lid to see what a smooth crease would look like, or iron out your lower lids with your fingertips.

Earn bonus points by bringing your doctor a photograph of yourself from 10 years ago. “That can help us determine which treatment plan would be the most appropriate for making you look like a better, younger version of yourself, not someone else,” Katchen says.

No. 5

There’s always a patient who exercises or hops a flight too soon after surgery (causing her stitches to pop) or, worse, goes swimming (cue rusty staples and an infection). But by and large, complications are incurred at the time of treatment. Use common sense and listen to directions. With certain fillers, like Sculptra, you’re required to massage your face five times a day for five days to prevent lumps and bumps. Tanning before or after any laser treatment spells disaster. And don’t schedule a massage right after getting fillers: If you lie facedown on a massage table for an hour, you move the material injected and mess up its placement.

No. 6

As long as injections are done correctly, there shouldn’t be a problem. In fact, to get the best results, it’s wise to cluster your treatments—that is, to get frequent injections the first year (three or four Botox treatments or two or three filler applications) and then scale back to one or two sessions a year. “Once you get Botox multiple times, your muscle starts to forget how to contract in that way, so you need injections much less frequently,” Rodan says. “That often happens in the area between the brows; I have patients who hardly need Botox there anymore. And the same goes for fillers: If you build up a foundation, the effects can really persist.”

Laser treatments and chemical peels
“People think that you’re thinning the skin with lasers and peels,” says Tina Alster, MD, a dermatologist in Washington, D.C. “But actually you’re doing the opposite. The skin that grows in is thicker and healthier.” Still, proceed with caution. With lasers, peels and microdermabrasion, too much exfoliation can dry out your skin and make it more sensitive.

Can a second or third face-lift look as good as the first? Plastic surgeons say yes, because they’re repositioning muscle along with the skin. “I just finished a case with a 54-year-old woman—a very famous ex-model—and she’ll look better now than she did after her first surgery,” says Matarasso. Dermatologists aren’t so sure. “In theory it could be good, but in reality the odds are stacked against you,” says New York dermatologist Laurie Polis. “You could have a beautiful face-lift the second or third time, but it all depends on the quality of your skin and your healing ability. Your expectations might be a little lower when you’re 63 than when you were 52.”

Repeat face-lifts are mostly about loose skin in the neck (“Jowls rarely recur,” says Wells). “It’s hard to maintain results there,” admits Hirmand. “Your neck is a complex structure that moves and stretches all the time, in all directions. But if you’re 50 and your neck is as tight as a sausage casing, it won’t look good anyway. It’s much better to have a little softness.”


1. Neuromodulators
Diluted injections of purified botulinum toxin type A (related to the bacteria that cause botulism). The shots prevent muscles from contracting into wrinkles. Examples: Botox, Dysport.
Best for: Relaxing forehead wrinkles or frown lines and—in the right hands—softening cords in the neck and giving a subtle lift to brows and/or the corners of the mouth. Key for softening the cobblestoning (excess dimpling) of the chin, crow’s-feet and smoker’s lines around the mouth. Also used to reduce enlarged jaw muscles, which can result from years of teeth clenching.
Cost: $125 to $400 per treatment area.
Full effect: In 2 days for Dysport, 3 to 5 days for Botox.
Results last: 3 to 4 months.

2. Reversible Fillers
Injectable volumizers made from hyaluronic acid, a substance that occurs naturally in your skin. If you don’t like your results, a doctor can undo them right away by injecting an antidote. Examples: Restylane, Perlane, Hylaform, Juvéderm and Juvéderm XC.
Best for: Plumping lips and superficial fine lines around the eyes and mouth; filling out tear troughs and under-eye circles; and filling chins, nasolabial folds and marionette lines.
Cost: $350 to $800 per syringe (1 to 6 syringes, depending on the condition of the patient’s skin).
Full effect: In 3 to 5 days.
Results last: 3 to 12 months.

3. Radiesse
A long-lasting filler made up of calcium hydroxylapatite crystals, a compound found in bones and tooth enamel.
Best for: Sculpting areas like the chin and pumping up hollow cheeks and temples. (It’s not recommended for lips or the eye area.)
Cost: $500 to $1,000 per treatment (that's for one syringe; may need more, depending on the condition of the patient’s skin).
Full effect: Improvement is immediate but complete results occur within a week or so.
Results last: 1 to 2 years.

4. Sculptra
A thin, watery filler made up of poly-L-lactic acid, a substance used in implants and dissolvable sutures.
Best for: Creating overall smoothness and volume on faces that look gaunt or melted away. Wherever it’s deposited, Sculptra prompts the skin to make and repair collagen. The result: a gradual filling-out effect.
Cost: $600 to $1,200 for a one-vial treatment. Depending on your age, degree of hollowing and response to the product, you may need 2 or 3 treatments over 6 months (and in some cases, quite a few more).
Full effect: 6 months after the last treatment.
Results last: Up to two years.

5. Ulthera and Thermage

Ulthera (focused ultrasound) and Thermage (which uses radio-frequency energy) heat up tissue deep inside the skin to tone and tighten.
Best for: Firming skin on the face and neck, tightening mild jowling when you’re in your thirties or forties and creating a subtle, nonsurgical brow lift. Ulthera and Thermage go deep into skin tissue to stimulate it to produce collagen, so you get more lift and smoothness over time. Thermage can also be used to treat eyelids. Note: Results vary. Some patients see a lot of tightening; others, very little.
Cost: $1,500 to $3,000 per treatment area.
Full effect: In 2 to 3 months. Some patients see major results within 24 hours.
Results last: A year or more.

6. Fractional CO2 Lasers and other Resurfacing Lasers
Treatments (such as Fraxel) in which tiny beams of light are used to damage skin below the surface, thus triggering new cell growth. High-tech fractional lasers spread out the damage in microscopic treatment zones, for deeper penetration and faster healing.
Best for: Resurfacing sun-damaged skin—smoothing out fine lines and crosshatches, erasing brown spots and some redness, refining pores, evening out tone and stimulating collagen for a firmer, more radiant effect. Fractional lasers can also reduce deep acne and chicken pox scars, which until now had been hard to treat.
Cost: About $1,500 each session for a gentler treatment (a series of 3 to 5 is recommended) or $4,000 to $5,000 for a more intense, ablative procedure. (Ablative lasers vaporize the top layers of the skin. Translation: 1 to 2 weeks for healing, a full month out of the sun and more dramatic results.)
Full effect: 6 months after the last treatment.
Results last: Several years.

7. Vascular lasers
Pulsed-dye lasers that target redness in the skin, vaporizing red pigmentation or tiny broken blood vessels.
Best for: Obliterating brokencapillaries, red spots and port-wine stains.
Cost: It varies. It might cost $150 to zap one red spot, $200 to $300 to treat the area around the nostrils and about $600 to address diffuse redness all over the face. Depending on your age and degree of redness, you may need 3 sessions, spaced 4 to 6 weeks apart.
Full effect: 2 to 3 weeks after your last treatment.
Results last: At least a year (broken capillaries around the nose tend to return, as does high color in the cheeks if you have rosacea or go back in the sun)—but possibly forever: Spider veins around a scar are usually gone for good.

8. Chemical peels
Treatments that apply a chemical solution to the skin, causing the outer layer to peel away.
Best for: Minimizing brown pigmentation, unclogging pores and improving skin clarity and brightness; they’re great if you’re blotchy but not red. Chemical peels range from weak to seriously potent, and most of the deeper peels have been replaced by laser treatments, which do more to improve skin tone and texture, with a much lower risk of scarring. (“The old phenol peels that left people white and shiny have fallen by the wayside,” says New York City dermatologist Laurie Polis.)
Cost: $80 to $500, depend-ing on the depth of the peel.
Full effect: In 1 month, for a light TCA (trichloroacetic) peel.
Results last: For a mild TCA peel, 1 to 2 years.

9. Eye-lift
An eye-lift (blepharoplasty) is an operation that removes the skin of the upper lid and may also reduce fat below the eyes.
Best for: Raising droopy lids,obliterating puffiness under the eyes or repositioning the fat pad to fill in hollowness under the eyes.
Cost: About $4,000 for upper- or lower-lid surgery, $7,500 for both.
Full effect: In 4 to 6 weeks.
Results last: Fat-pad removal is permanent, but loose skin may return in several years.


These clever fixes are based on the “facial thirds concept,” the idea that attractive faces are divided into three equal sections: between the hairline and the brow, the brow and the base of the nose, and the base of the nose to the bottom of the chin. In some people—especially tooth grinders—the chewing surface of molars wears down. “Grinding can make that lower segment of the face very small and narrow and really destroy its symmetry. A dentist can put crowns in the back to increase the length and height of the molars and hence of the jaw,” says Miami cosmetic dentist Maria Marx.

Some cosmetic dentists go even further, relying on veneers to balance out your bite (making your face more symmetrical) or to make your teeth flare more on the front or sides of your mouth (to restore a hint of youthful volume). “To get an idea of what veneers can do, take a cotton roll and cut it in half. Tuck one half under the lips on each side of your back teeth, bite down, close your mouth and see how open your face is,” says Michael Apa, DDS, a cosmetic dentist in New York City. he rejuvenating dental process entails a serious wallet-stretch: Veneers cost $1,000 to $3,000 per tooth. Yet fans of the technique abound. After one of Apa’s patients got a full veneer treatment, she canceled her face-lift plans. Still, says Marx, “veneers won’t necessarily take care of wrinkles. I don’t think plastic surgery or dentistry alone can do it. After a certain age, you may want both.”

To find out more, read:

Cutting Edge Anti-Aging Treatments

Five Cosmetic Procedures for the Risk Adverse

First Published Tue, 2011-04-05 11:54

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