News & Politics

No Knives, Please

A facelift without surgery? New treatments—from wrinkle fillers to Thermage to lasers—promise a more youthful, vibrant face with little pain and no downtime.

Looking to get rid of wrinkles? There are nonsurgical ways to combat aging.

The popularity of what professionals call “minimally invasive procedures” is growing. According to the American Society of Plastic Surgeons, 1.8 million Americans had cosmetic surgery in 2005 while 8.4 million chose Botox, chemical peels, and injections of collagen and other wrinkle fillers.

Aging baby boomers created the demand for cheaper, more convenient, less painful ways to look young, and companies responded. While older lasers blasted away wrinkles, for example, a new generation is gentler. Chemicals in chemical peels are less harsh but still effective.

These procedures are popular with people in their midthirties to midfifties who can’t yet face a surgical facelift, says Rockville plastic surgeon Barry Cohen.

Physicians do not expect injectables, peels, and lasers to replace facelifts. For older patients with sagging skin, surgery still may be the best alternative.

“Minimally invasive procedures appeal to people who are willing to accept a less perfect result because there is no general anesthetic, no downtime, no scars,” DC cosmetic surgeon Steven Hopping says.

Which treatment you choose depends on how dramatic a change you want, how many treatments you’re willing to undergo, and what’s best for your skin—which means relying on a doctor’s advice. Unfortunately, those recommendations might be affected by what equipment the office has.

“If you only have a hammer, everything looks like a nail,” says Dr. Tina Alster, whose Washington Institute of Dermatologic Laser Surgery offers more than 20 types of laser treatments.

You might also consider who you want performing the procedure. Some doctor’s offices allow technicians, physician’s assistants, or nurse practitioners to do the work, but some are best performed by an experienced physician.

One way to get the results you want: Bring a photo of your younger self to show what you would like to achieve.


What it is: Botox and other botulinium type-A neurotoxins make it impossible to contract muscles that cause frown lines and crow’s feet. Reloxin, used in Europe, is close to approval by the Food and Drug Administration.

Best for: Botox is FDA-approved for the eye area and brow, but many doctors use it off-label in the lower part of the face. Dr. Alster says Botox can bring up the corners of lips and relax muscles in the neck that cause horizontal creases. Dr. Cohen uses Botox to reduce vertical “smoker’s lines” on the upper lip.

Risks: “Using Botox anywhere below the eyes takes a lot more practice,” Alster says. All of the physicians interviewed say that nurses or technicians would not be able to handle complications that can arise, such as swallowing problems.

How long it lasts: Three to four months.

Cost: $400 to $600 per syringe. Treatments can require more than one.

Wrinkle Fillers

In the past decade, cosmetic surgeons recognized that gravity is not the only factor in facial aging. A facelift—tightening muscles in the neck and face and removing excess skin—eliminates sagging and some wrinkles. But a lift alone doesn’t re-create the contours of youth.

Plumpers like collagen can be injected to bring back the volume lost as we age, typically in cheeks and lips and under eyes. Plumpers can fill in furrows like nasolabial or “marionette” grooves between the edges of the nose and mouth.

The longer a filler is designed to last, the higher the cost. Doctors charge by the syringe or vial, and most facial treatments require one to two syringes. There may be a discount for multiple syringes or multiple treatments.


What it is: Fat is suctioned out of the abdomen, buttocks, or thighs, then processed and injected into the face or lips. “Fat is still the gold standard,” says Hopping. “It has the potential of lasting for a couple of years.” Since the fat is your own, there is no chance of an allergic reaction. “Fat has an additional benefit—it can improve the complexion and reduce acne,” Hopping says.

How long it lasts: Results are unpredictable, lasting six months to indefinitely. Some fat is absorbed quickly back into the body; multiple treatments may be needed.

Risks: Swelling and bruising.

Cost: Fat is often harvested during other cosmetic surgery. As a stand-alone procedure, fat removal and injection costs $2,000 or more.


What it is: Fillers derived from human collagen (CosmoDerm and CosmoPlast) or bovine collagen (Zyderm and Zyplast). Bovine collagen requires an allergy test with a one-month waiting period, says Virginia plastic surgeon George Bitar. If a patient is not allergic, the bovine variety is less expensive, says Alster. Collagen causes less swelling and bruising than other fillers.

How long it lasts: Two to three months, less than other fillers.

Risks: Allergic reaction with bovine collagen. In unskilled hands, too much or too little may be injected.

Cost: $350 to $600 a vial.

Restylane and Juvéderm

What they are: Hyaluronic-acid fillers help skin retain water to pump up wrinkles. The most popular is Restylane, but new Juvéderm is more malleable and easier to inject, say both Cohen and Hopping.

Best for: Bitar uses Restylane under sunken eyes and to create fuller lips—it never gets hard or lumpy. Juvéderm works well for vertical lip lines because it causes less bruising and swelling.

How long it lasts: Four to six months.

Risks: Swelling and bruising that can last a week.

Cost: $500 to $700 a syringe.


What it is: A gel with suspended microspheres of calcium. Bitar and Hopping say Radiesse creates volume in sunken cheeks, deep nasolabial folds, and prejowl areas.

How long it lasts:
One to two years.

Risks: Radiesse should not be used to enhance lips because it can form small nodules.

Cost: $750 to $900 a syringe. Radiesse can end up less expensive than hyaluronic fillers, says Bitar, because it takes less Radiesse to create fullness.


What it is: Microscopic particles of Poly-L-Lactic acid are implanted in skin and molded in place. PLA stimulates the growth of collagen to create volume.

How long it lasts:
18 to 24 months.

Risks: Swelling can last for days, and patients may be asked to massage the areas to distribute the injected material.

Cost: $1,000 to $1,200 a vial. Requires three to five treatments over several months.

Permanent Fillers

What they are: The FDA recently approved ArteFill, microscopic beads of synthetic acrylate in bovine collagen. The collagen is absorbed after a few months, but the beads remain.

Silicone, approved to treat detached retinas, is being used off-label as a cosmetic filler.

How long they last:

Risks: Permanent fillers can mean permanent problems. “Permanent, nonbiological fillers can create hard masses under the skin and can get infected,” Bitar says. “The likelihood is small, but why take the risk? There are safe fillers.”

ArteFill is not recommended for people with thin skin or in eyelids or crow’s feet—thin-skinned areas—because the implant can be visible and feel rubbery. With silicone, small bumps can form in the injection area and elsewhere; “silicone migrates,” says Cohen. Lips treated with silicone can become firm, restricting movement.

Cost: As yet, few physicians are using either filler.


Laser, or light amplification by the stimulated emission of radiation, uses high-energy light beams to treat discoloration and scars and to smooth, tighten, and lift skin. Treatment is quick—usually under an hour.

There are three main types of lasers: ablative (trade names such as Feather Touch and Ultra Pulse), which are the most effective but have more downtime and side effects; nonablative (CoolTouch, Lyra), less invasive but also less effective; and fractional (Fraxel, Affirm), an ablative/nonablative combination.

Ablative Laser

What it is: Ablative, or “wounding,” lasers use carbon dioxide (CO²) or erbium to resurface skin by vaporizing cells. Fine lines, scars, and uneven pigmentation are removed layer by layer, and skin regrowth can produce a tighter, smoother appearance. The technique is considered safer than mechanical methods as it offers more protection for healthy skin around lips and eyes.

Best for: Superficial to moderate wrinkles, scars, skin growths, acne, brown spots and other discolorations. CO² lasers can cause uneven pigmentation on darker skins, while erbium lasers are safer for a wider range of skin colors.

How long it lasts: Up to two years—longer than peels and dermabrasion.

Pain factor: Burning and stinging can be considerable during the 30-to 60-minute treatment, which requires local anesthesia and sometimes sedation. The procedure is best done in a setting approved by the Accreditation Association for Ambulatory Health Care.

Depending on the intensity of the treatment, bandages may be required for up to ten days, and oozing, swelling, and redness requiring ointments (and no makeup) can last two weeks to a few months. Most patients take at least a week off work.

Risks: Scarring, prolonged redness, infection, discoloration.

Cost: About $1,500 to $3,000 a session but can go up to $4,500. Usually only one treatment is required but may be repeated for severe or recurring problems.

Nonablative Laser

What it is: Nonablative, or “non-wounding,” lasers use short pulses of light, which bypass surface skin and damage underlying tissues to trigger regrowth of smoother, more even-toned skin. Because they are less invasive than ablative lasers, their results are not as dramatic and may require repeat sessions.

Best for: Superficial wrinkling, scarring, discoloration, spots, spider veins, and rosacea. Many lasers are also FDA-approved for treating acne.

How long it lasts: Some results are immediate; others take months to appear. Effects can last up to two years.

Pain factor: Though relatively painless, pulses can feel like a rubber band snapping against skin. Doctors may prescribe a mild pain reliever for the procedure.

Risks: No recovery time. Redness and swelling can occur for a few days.

Cost: $150 to $500 a treatment; several may be required.

Fractional Laser

What it is: The fractional skin-resurfacing laser, marketed under such names as Fraxel and Affirm, is one of the most popular—and expensive—laser procedures. It combines the intensity of an ablative laser with the gentler impact and quicker healing time of nonablative.

Best for: Moderate improvement in fine lines around eyes, lips, and forehead and in uneven pigmentation and melasma (darkening caused by sun damage).

How long it lasts: New skin develops within 24 hours and collagen regeneration and tightening lead to smoothing over a few months. Results last at least two years.

Pain factor: Minimal discomfort during treatment, which lasts about a half hour. No downtime. Skin will have a bronzed appearance that can last up to two weeks. Flaking may occur and can be treated with moisturizer.

Risks: Burns, scarring, uneven pigmentation, persistent redness, outbreaks of cold sores around the mouth.

Cost: $750 to $1,500 a treatment; three to five sessions are usually prescribed at monthly intervals.

Plasma: For Hands?

What it is:
This latest innovation, trade-named Portrait, uses the same gas common in flat-screen TVs. A device sends plasma energy into the dermis while leaving the surface intact. Over time, new epidermis emerges as old skin sheds.

It’s quick and relatively painless but pricey. Dr. Alster, the only provider in Washington, says it is her preferred method for areas other than the face, especially hands, where lasers can scar.

Best for:
Fine lines, deep wrinkles, moderate sagging, and enlarged pores. Safe for all skin types but may produce prolonged discoloration on darker skin.

How long it lasts: Some improvement in tone within a day or two; gradual tightening can continue for a year. Some experts are not impressed with the results, and the procedure has not been in wide use long enough to produce long-term studies. The manufacturer says its clinical tests suggest results last several years.

Pain factor: The procedure takes 5 to 30 minutes under topical anesthetic. Lower levels produce mild redness and flaking for a day or two; higher levels will brown the skin and cause peeling for three to five days. Downtime and recovery are quicker than with ablative laser.

Cost: $1,200 to $3,000 a session; may require up to four.

Thermal Energy

What it is:
Radio frequencies (Thermage, ThermaCool, Thermalift, Aluma) or infrared light (Titan, Palomar Starlux) heat underlying collagen, which then contracts and tightens skin as it heals. That tightening can erase superficial lines; for more severe wrinkling, some doctors use LuxIR and Polaris, which combine thermal energy with a resurfacing laser.

The technology is said to be safer and more effective than laser—it can improve sagging as well as lines.

Proponents of infrared, which can require several sessions, say it delivers a more even, controlled tightening. Radio-frequency fans say light-based procedures have not been as time-tested as Thermage, which usually requires one session.

How long it lasts:
Because results are modest and gradual—studies show these procedures lift the skin about one-third as much as a facelift—and because many doctors report results in only one-third of patients, critics question the effectiveness. DC dermatologist Marilyn Berzin, who has been using Thermage for four years, says unhappy patients are usually those with the wrong skin type or unrealistic expectations. In successful cases, she says skin remains taut up to two years and that aging is stalled during that time. Some studies show that results last five years.

Best for:
Mild sagging and superficial lines. May not be appropriate for severely sagging skin.

Pain factor:
Some patients complain of considerable stinging and burning. Doctors usually prescribe a painkiller and mild sedation; others add numbing solution. Thermage is more painful than infrared devices such as Titan. Sessions usually last an hour and require no recovery.

Risks: A day or two of redness and minor swelling. In rare occasions, Thermage may cause divots in facial fat.

Cost: $2,000 to $5,000 a session.

Photo Rejuvenation

What it is: Photo facials are a quick, fairly cheap fix for pigment problems, but also treat enlarged pores and acne.

There are two types: intense-pulsed light (IPL) and light-emitting diode (LED). A hand-held device passes over skin with flashes of light, which are absorbed by damaged tissues. Unlike lasers, light is emitted over many wavelengths to penetrate all levels of skin. This procedure goes by the trade names GentleWaves and Starlux.

Best for:
Moderate pigment problems such as rosacea, spider veins, age spots, and freckles. Can minimize mild wrinkles, smooth skin texture, reduce pore size, and kill acne-causing bacteria. It can be used on the face, neck, chest, and hands. IPL is for Caucasians only; LED can be used on all skin types.

How long it lasts:
A few months to a year.

Pain factor: Generally painless, though minor stinging can occur. No downtime.

Risks: Burns and blisters, especially if skin is sunburned or tanned. Alster says some of the worst injuries her office sees are from poorly done photo facials.

Cost: $250 to $500 a treatment. Sessions take from a few minutes to a half hour but are usually required once or twice a week for four weeks. Some dermatologists offer photo rejuvenation for free if combined with other treatments.

Thread Lift

What it is: Barbed threads are inserted with a needle into the deep fat of the face, where they are pulled to lift the brow, cheeks, and jowls. Generally two to six threads, made of clear polypropylene suture material, are used on each side of the face.

Marketed under such names as Contour Threadlift, Featherlift, and Aptos Lift, the procedure takes about an hour and is done under local anesthetic. It’s the most surgical of “lunchtime lifts”; recovery takes a day or two.

Thread lifts originated in Asia and have become popular in the US in the past year, especially for treating minimal sagging. Critics say the risks and invasiveness may blunt the procedure’s popularity.

Best for: People in their midthirties and forties. Not for those with thin skin or hollow faces, because stitches can be visible or cause bunching of tissue. Because it was designed for Asians, concerns have been raised that it may not be appropriate for all ethnicities.

How long it lasts: Because thread lifts are new to this country, there are few predictors on how long they hold. Some doctors say the effects last at least five years. Threads can also be adjusted.

Pain factor:
Patients can return to work after a few days but are advised to not rub the face, to eat soft foods, and to sleep on their backs for up to three weeks.

The procedure requires considerable skill and should be done by an experienced physician. Risks include crookedness in the face, visible threads, infection, and lumpy scar tissue.

Cost: $1,500 to $5,000 depending on the number of threads used; the average is about $2,500.

Chemical Peels

What it is: Chemicals, such as mild alphahydroxy acids, trichloroacetic acid, or phenol (the strongest), are used to dissolve skin cells, which slough off to make way for a smoother, more evenly toned layer. This low-tech, relatively low-cost treatment is one of the most popular ways to treat skin concerns.

Best for: Fine laugh lines, crow’s feet, spots, scars, and uneven pigmentation. Older patients take longer to heal and some darker-skinned patients have suffered serious discoloration. Dr. Eliot Battle, of Cultura Cosmetic Medical Spa in Friendship Heights, which specializes in diverse skin colors, says mild peels are safe for all skin types.

How long it lasts:
Most peels are a temporary fix—as little as six months for mild solutions—though the effects of phenol can last years.

Pain factor: The intensity of the chemical and how long it’s left on determines the amount of discomfort, length of recovery, and the side effects, which can include redness, flaking, and swelling that can last days or weeks. No makeup may be required for weeks.

Risks: Scarring, discoloration, infection. Deep peels may require a medical setting and even general anesthesia. Phenol prevents the skin from tanning, which means it will always have to be protected from the sun. It may pose risks for those with heart disease because of possible irregular heartbeat and should be administered by a physician.

Cost: Light “lunchtime” peels range from $200 to $800, while deeper peels can run into the thousands.

Mechanical Abrasion

What it is: Microdermabrasion has virtually replaced dermabrasion, a sanding device. The newer tool shoots tiny abrasive crystals on the skin through one tube and vacuums up dead cells with another.

The results and side effects are similar to chemical peels, but it is used for deeper scars and wrinkles.

Best for: A quick, short-term fix for mild wrinkles, scars, and discoloration.

How long it lasts:
Weeks to months, depending on the intensity of treatments. Effects can be immediate, and rejuvenated layers grow back gradually for a smoother look.

Pain factor: Treatment can take a few minutes or as many as 90 and may need to be done in stages. Topical anesthetic is applied. Temporary redness and swelling may occur, but there is no downtime. Irritation can occur and last for weeks.

Risks: Fever blisters, pigment changes, thickened skin. It should not be done during acne breakouts because of infection risk.

Cost: Cosmetic lines have do-it-yourself kits for as low as $25; spa treatments run $80 to $100. Doctors charge $75 to $200 a session.