Non-surgical cosmetic treatments


Is knifeless surgery too good to be true?

Lunch-time lifts


A visit to the plastic surgeon isn't the only way to improve your looks or turn back the years. The "lunch-time facelift" promises a younger, better-looking you with no surgery, no general anaesthetic and no down-time. Although "lunch-time" and "facelift" may be a bit of a stretch, these days it's increasingly possible to take a few years off your face in a day clinic without the expense, pain and temporary disappearance from public life associated with surgery.

CHOICE dives into the fountain of (non-surgical) youth to see what's on offer.

In this article:
  • Need to know
  • Injectables
    • Dermal fillers – collagen, hyaluronic acid, Restylanem, Juvederm, Radiesse, fat transfers
    • Muscle relaxers – Botox, Dysport
    • Liquid facelifts
    • 'Fat melting' – Belkyra, Kybella
  • Skin treatments
    • Chemical peels
    • Dermal rolling and microneedling
    • Microdermabrasion
  • Laser and similar procedures
    • The difference between continuous, fractional, ablative and non-ablative lasers
    • IPL and other heat-based treatments such as Thermage (radio frequency), Ulthera (ultrasound) and Cutera Titan (infrared)
    • Personal LED anti-ageing devices
  • Doing your research and finding the right doctor

The ageing process

Ageing takes its toll in a number of ways, including expression lines, loss of fat volume, loss of bone structure, gravity, and the big one – sun damage. Dermatologist Dr Phillip Artemi says, "Seventy-five per cent of what you see in the mirror at 50 or 60 is due to sun damage."

There's no one treatment that deals with all skin issues and works for all people, and a cosmetic physician may suggest you have more than one: for example muscle relaxers for forehead lines, dermal fillers for nasolabial folds (running from the corner of the nose to the corner of the mouth) and volume replacement, and IPL or a peel for fine lines and skin texture.

Need to know

  • There's no such thing as a "non-surgical facelift". There's skin smoothing and tightening, volume replacement and wrinkle reduction, but no non-surgical treatment is going to give you the same lifting results as surgery. You may look "fresher", but don't expect gravity-defying miracles!
  • These procedures are designed for people in their 30s to 50s with reasonably good skin, who are prepared to protect it from the sun.
  • Some procedures involve a lot of pain and some will still leave you temporarily looking like you've been burned/beaten/stung by a bee, so you may need a recovery period hiding out at home. The greater the (initial) damage, the better the long-term effect.
  • The results won't last as long as a surgical facelift, and the costs of repeating the procedure several times over 10 years (which is how long a facelift "lasts") may end up exceeding those of surgery.
  • You get what you pay for – mostly. Although salons and spas may offer radio frequency or ultrasound skin firming or facial peels for a tenth of the price of a cosmetic physician, it's likely the treatments aren't as strong. In addition, the staff may not have had the training and experience necessary for evaluating client suitability or delivering the procedure safely. That said, there are no guarantees with cosmetic physicians either – but the odds of a safe and effective procedure are better.
  • All procedures carry risks of temporary or even permanent damage, and could leave you wishing you had your old skin back.
So, if you're still willing to go ahead, what are your options?

Injectables

Dermal fillers

The injection of filler materials under the skin can fill in deep folds, such as nasolabial folds (also known as "smile lines" or "laugh lines"), create fuller lips and pad out hollow cheeks and eyes. Rather than just smoothing or tightening skin, they can change the facial profile to a more youthful one.

Although collagen used to be the standard filler, hyaluronic acid, with brand names like Restylane and Juvederm, is now more popular. Hyaluronic acid lasts somewhere between six months to a year – although treating areas of the face that move less will last longer than those that move more, such as the lips – and you tend to get better results with each treatment. There's evidence that hyaluronic acid injections can also have a more permanent anti-ageing effect by stimulating collagen growth.

Synthetic fillers, such as Radiesse, are long-lasting (12–18 months). The main risk associated with these is lumps forming under the skin that have to be surgically removed, or changes to the skin structure that occur with age, leaving odd shapes where the filler is.

Finally, there are fat transfers, where your own body fat is extracted, processed and injected into your face. This can be expensive, and while it sometimes lasts five to 10 years, the fat may not survive long at all, and may be absorbed back into the body.

How much these procedures cost is difficult to say, because treatments are usually priced by the type and volume of filler used, and that depends on what you're having done. Prices start from a few hundred dollars and can exceed $1000, with fat transfers at the higher end.

Muscle relaxers

Botulinum toxin (brand names include Botox and Dysport) temporarily "paralyses" muscles when injected. This prevents the skin above from creasing up and causing wrinkles. It only works on so-called "expression lines", such as frown (vertical) lines and surprise (horizontal) lines on the forehead, smoothing them and preventing them from becoming more pronounced. It won't do anything for sun-damaged skin or lines caused by skin sagging, such as nasolabial folds.

Though a prescription-only drug, it's possible for non-medical professionals to obtain and inject Botox or its other variants, with potentially serious consequences if something goes wrong. It's best to leave these injections to an experienced medical professional – and definitely not to have them at a "Botox party". The products used at Botox parties have been reported to be fake imports.

The cost depends on how much is injected, and typically starts from around $100 to over $1000. The process itself is relatively painless, but you can't lie down or rub the area for several hours afterwards – this is to prevent the toxin spreading to other areas.

The effects take a few days to kick in, and initially last a few months – longer after continued treatment.

Possible side effects include a droopy upper eyelid if the drug is injected too low on the forehead, and this may last a couple of weeks. In the hands of a skilled administrator, you can avoid the notorious "frozen" look.

Liquid facelift

Combined use of muscle relaxers and dermal fillers is called a liquid facelift. It costs about $1000 to $4000, depending on how much work is done, and lasts from one to two years.

'Fat melting'

Dioxycholic acid is a chemical naturally found in the body that breaks down dietary fat in the digestive system. It can be injected into the body to reduce body fat in small areas, and is available in Australia under the brand name Belkyra (it's known as Kybella overseas). Currently it's approved for use to reduce submental fat – the fat under the chin responsible for the dreaded double chin.

Results can be quite good, with reduced fat under the chin, and some skin tightening may also occur, though it depends on the particular patient. You'll need multiple injections over a two or more sessions for it to work, and there can be significant swelling – "bullfrog neck" is the term often used! Another potential side effect is damage to the marginal mandibular nerve, which may give you a lopsided smile for a while.

The cost for two sessions is around $2200-2800.

Skin treatments

Chemical peel

Acid, such as glycolic acid, lactic acid or trichloracetic acid, is applied to the skin and exfoliates the top layer, causing dead skin cells to peel off. At stronger concentrations, new, tighter skin forms as collagen production is stimulated in response to the wounding.

It can help reduce fine lines, small scars, discolouration and sun-damaged skin. The stronger the peel, the more dramatic and longer-lasting the results – stronger peels (concentrations of more than 30%) are better left to medical professionals rather than beauticians.

The acid stings, and for a strong peel a sedative may be helpful. After-care for a strong peel may include bandaging, and it could take weeks to heal. Milder acids may result in some redness and peeling in the first week, and there may be some crusting or scabbing.

A stronger peel's benefits can last for two years, although it depends on the strength of acid used (which determines how deep the peel is). These days a course of several milder peels, rather than one strong peel, is common. Milder peels may require top-up peels every few months.

Costs range from under $100 to several hundred dollars, depending on the type.

Dermal rolling

Percutaneous collagen induction therapy, popularly known as dermarolling or microneedling, involves rolling a cylinder covered in tiny needles over your skin. The damage caused by the needles stimulates collagen production, and has been successfully used for treating scars, especially acne scarring, fine lines and wrinkles. It may sometimes be combined with radio frequency energy to create a greater effect.

As a rule, the longer the needle, the greater the damage (and bleeding and pain…) and the greater the effect.

Dermal rollers can be purchased for as little as $30 online, so are relatively cheap. However results may not be as good as those achieved by professionals, and you could do harm with poor technique, damaged needles or needles that are too long, or poor hygiene.

You can also have it done by a beautician, but make sure they're experienced and have good hygiene practices – unclean rollers can spread infection. Dermatologists and cosmetic physicians offer microneedling with or without radiofrequency.

Microdermabrasion

Not to be confused with dermabrasion (which is rarely used these days), microdermabrasion can be done at a salon or spa, and uses fine crystals to sand the face and remove dead skin cells.

It may help reduce the appearance of fine lines and wrinkles, and improve skin texture, but don't expect a major anti-ageing effect. There will probably be some redness and swelling for a few hours.

Laser and similar procedures

Many non-surgical skin-tightening procedures work using heat to create controlled injury in the epidermal and dermal layers of the skin, inducing the body to respond by producing more collagen in the treated area.

The increased collagen plumps and thickens the skin, reducing the appearance of fine lines, acne scarring and stretch marks. Some lasers act on the surface as well as deeper, and have a better track record. It's the wavelength of the laser which determines how deeply it penetrates the skin.

Lasers are used for moderate lines and wrinkles, and improve skin tone, texture, and tightness, though they don't work on very deep lines (such as nasolabial folds). There are many different laser treatments available, and they're usually classified according to injury pattern, the depth at which they act and whether they destroy or simply heat tissue.

  • Continuous laser treats the whole area of skin, while fractional lasers penetrate the skin in a pattern of microscopic columns, leaving surrounding healthy tissue unaffected.
  • Ablative lasers destroy the tissue, which is replaced by new healthy tissue, while non-ablative lasers heat the tissue to stimulate collagen production, but leave it intact.

In short, the greater the injury, the greater the effect – the trade-offs being a longer recovery time and a higher risk of adverse events. Non-ablative laser (e.g. Fraxel Re:store, Laser Genesis) has the mildest effect, followed by fractional ablative (e.g. Fraxel Re:pair, Pearl Fractional), and continuous ablative is the most effective.

  • Non-ablative treatment requires a topical anaesthetic. Your skin will be red for up to a week, and there may be mild swelling and peeling. You'll probably need several sessions a few weeks apart, costing around $250 per session. In a best case scenario, an immediate improvement can be seen, with continued improvements for the next two to three months.
  • Fractional ablative resurfacing affects surface and deeper tissue, resulting in longer down-time, with redness and swelling of up to two weeks. You may need more than one session at a cost of about $450 per session.
  • Continuous ablative laser may need a combination of topical and systemic painkillers and sedation. Recovery means a week at home out of the sun keeping the raw skin moist, and it may be red for a few weeks after that. Only one session is needed and it costs around $1500.

Possible long-term effects of ablative procedures include prolonged redness, scarring, pigmentation changes and infections, though risks are reduced with fractional systems and experienced laser surgeons. Doctors advise against laser therapy for people affected by an active herpes infection, people who have recently used systemic isotretinoin or people with darker skin.

Intense Pulsed Light (IPL)

IPL uses bursts of intense light energy to heat the epidermis and dermis, stimulating collagen production. It's best for improving skin tone and texture, as well as discolouration, and may not have much effect on wrinkles. A series of three to six treatments is usually recommended, each costing about $150–400, with maintenance treatments a few times a year. The improvement is gradual, and it may take a few rounds to notice the difference.

The different forms of energy used by these devices penetrate below the surface of the skin, inducing heat which causes collagen to contract and new collagen to form. At its best, this treatment tightens skin. Targeted at people in their 40s and 50s with mild skin looseness and wrinkling, it's promoted as the ideal compromise for taking a few years off your face without the expense and downtime of surgery.

But don't get your hopes up just yet – according to Dr Phillip Artemi, "The technology is still in its infancy, the results are very variable and, while it has potential, really good responses are rare."

Even in the best outcomes, this type of treatment doesn't lift muscle, as a surgical facelift would; it doesn't correct sun damage; and it doesn't reduce hollows caused by age-related fat loss. For these reasons it may be used in combination with other treatments such as dermal fillers and laser resurfacing or a chemical peel.

The process is uncomfortable and you may need topical anaesthetic. There may be some redness afterwards, which can be disguised by make-up, but it's rare that you'll experience swelling, bruising or pain. There may be an immediate skin-tightening effect as collagen fibres contract, but the full results take a few months to kick in, showing a gradual improvement as collagen production increases.

Other heat-based treatments

  • Radio frequency (Thermage is the most well-known brand of treatment.) Only one session is necessary and it lasts a few years. It costs $2500-5000, depending on the clinic and the amount of coverage (full face, half face etc).
  • Ultrasound (e.g. Ulthera) costs around $1000-3500 and one session will probably be enough, though you may need two.
  • Infrared (e.g. Cutera Titan) costs around $700 and will likely need two to three sessions.

Personal LED anti-ageing devices

There are several handheld LED-based devices designed for in-home use. Dr Adrian Lim, from the Australasian College of Dermatologists, says that they could have some effect, though it won't be as good as professionally available services.

While convenient and relatively cheap (around $200-$300) compared to clinical treatments, it can be quite time consuming, especially because you have to repeat the treatment regularly (daily in many cases) to get any benefit. "Most people just give up!" says Dr Lim.

Do your research on cosmetic procedures

There are plenty of online reviews of these anti-ageing procedures. Among them, RealSelf is worth a look because it's moderated and has input from doctors. But take the reviews with a pinch of salt because results can be subjective, and some side effects or negative results may in fact be due to patient idiosyncrasies or level of expectation rather than the procedure itself, or may have been due to operator error or older technology.

Keep in mind also that some procedures take some time to have optimum effect; for example, the collagen-generating technologies that peak at about six months or so – reviews or pictures taken before then might not do the procedure justice. If you notice people reporting similar problems about a procedure, raise your concerns with your doctor.

You can easily find before and after photos of the different treatments if you search online. With some it's difficult to tell any difference, while with others the results are nothing short of miraculous – and may perhaps have had a little help from photo-editing software. Lighting, hair, makeup, clothing and facial expression can make a big difference too. Advertisers may choose to show some of the better outcomes, rather than typical outcomes.

Choosing your doctor

When choosing a doctor for cosmetic procedures, you could ask for recommendations from your GP or from friends or relatives who have had similar work done. Consider:

  • Qualifications: Ideally look for someone who's a member of the Australian Society of Plastic Surgeons, a fellow of the Australasian College of Cosmetic Surgeons or of the Australasian College of Dermatologists. However, many other doctors (GPs, for example) and some nurses are trained and experienced in administering cosmetic procedures.
  • Experience: Find out how often and for how long they've been doing the procedures.
  • Fees: What are the initial consultation fees?
  • Manner: It's important to feel comfortable with the doctor, and that other staff in the practice are pleasant and knowledgeable.

Some questions to ask your doctor about the procedure

  • What does it involve and how long will it take?
  • What will I look like immediately after the procedure? Will I need time off work?
  • Are there any complications associated with the procedure? Are there other side-effects?
  • How much are the procedure fees, including after-care and the cost of take-home skin care products or medication, if applicable?
  • How many sessions are required and over how long?
  • If more than one session is recommended, is there a package available? If I choose not to go ahead with all sessions in the package do I get a refund?
  • If complications do occur or the procedure is not successful, how will you deal with this? How long do the effects last, and how often should they be repeated to maintain the effect?


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