Beyond Botox

Lisa Weissman has a problem: A cluster of wrinkles on either side of her mouth that Botox can't touch. She knows this because she has already been given Botox injections of dilute botulism toxin to smooth the furrows of her brow. And like thousands of other women who have been Botoxed and were pleased with the results, she's pursuing new and better ways of using a syringe to erase the other signs of aging on her face.

That's why the 45-year-old real estate saleswoman and mother of three is propped up on a gray surgical chair at the posh Upper East Side Manhattan office of Dr. Rhoda Narins, professor at New York University and president-elect of the American Society for Dermatologic Surgery. Narins wields a slender hypodermic needle filled with a whitish slurry. After marking the laugh lines and creases around Weissman's mouth with a rust-colored disinfectant, she steps out of her high-heeled pumps to get the angle right and sets to work. Fifteen minutes and perhaps two dozen injections later, the wrinkles have all but vanished. There's a redness around Weissman's lips, but nothing a little makeup won't cover up. The wrinkles, on the other hand, should be invisible for months.

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The slurry that was injected under Weissman's skin was human collagen, served up under the brand names CosmoDerm and CosmoPlast. But it is hardly the most exotic substance being shot into women's faces these days. More than half a dozen "dermal fillers" are already available on the U.S. market or may be soon a witches' brew of injectables that includes cow collagen, liquid silicone, plastic microbeads, synthetic bone and the ground-up skin of human cadavers.

"Botox is so wonderful for the forehead and the crow's-feet," says D. Kimberly Butterwick, a dermatologic surgeon in La Jolla, Calif., "that it has fueled the desire for fillers in the lower face." And although dosing up on wrinkle fillers may seem the height of self-indulgence in a time of war, unemployment and cutbacks in medical insurance, there has been a 33% increase in their use in the U.S. this year as compared with 2001, shortly before Botox was approved for cosmetic use by the Food and Drug Administration (FDA).

The principle is simple. While Botox works by paralyzing the facial muscles that help form wrinkles, fillers plump up wrinkles from within the dermis, or inner skin. Most of them do so by replenishing collagen. As we age, sun damage and pollution turn collagen the protein scaffolding that holds the inner skin firm into protein mush. At the same time, the dermis begins to lose much of the moisture it once retained, and it becomes parched, withered and incapable of keeping the outer skin taut. "Fillers give youth to the face because they add the volume that time has taken away," explains Dr. Fredric Brandt, a dermatologic surgeon with practices in Miami and New York City.

Cow collagen has long been used in this way to flesh out wrinkles, but because some people react badly to bovine protein, allergy tests were needed six weeks before the procedure. CosmoDerm and CosmoPlast, approved for cosmetic use by the FDA in March, don't require testing because they come from lab-grown human cells. The treatment, which costs $575 and up, depending on how much you need, may cause a little bruising or irritation but is otherwise safe and produces results that last roughly four to six months.

Dermatologists are even more enthusiastic about hyaluronic acid, a natural component of the skin. In the body, hyaluronic acid clings to water, lubricating joints and keeping the skin full and supple. The synthetic version, marketed in more than 60 countries as Restylane, rarely causes allergic reactions, and its effects last six months to a year. The FDA is expected to approve it for sale in the U.S.; treatments will probably start at $550 each.

Perhaps the creepiest substance being used to smooth wrinkles is Cymetra a gel made from the skin of human cadavers. The manufacturer claims that Cymetra harnesses the body's own skin-building machinery to fill its wrinkles. Some surgeons are also experimenting with Radiance, a synthetic version of the mineral that builds our bones, which doctors now use "off label" to fill particularly deep folds. Then there's Artefill, a mix of cow collagen and tiny acrylic beads that an FDA advisory committee in February recommended for approval. Once injected, the cow collagen breaks down, but the beads stimulate the skin to secrete its own collagen. The good news is that the fix lasts years; the bad news is that the beads sometimes show through thin skin, especially if too many are injected. Dermatologists are also worried that hard nodules known as granulomas will eventually form around the beads in some patients. Doctors stress that Artefill treat-ments should be delivered by highly skilled technicians only.

This is true of all fillers: the doctor you choose may be as important as the substance he or she uses. "Any material is only as good as the person who's injecting it," says Brandt. "Collagen put in the wrong area could actually accentuate wrinkles." On the other hand, dermatologists point out, a skilled technician may be able to transform your face over a lunch break.