Is Less the New More?

Today, when it comes to cosmetic surgery, minimally invasive is the name of the game.

Cosmetic Surgery

Checking skin before botox.

Eating a good diet? Check. Exercising regularly? Check. Stopped smoking? Check. You’re feeling great, and you want to look great too, but the prospect of enduring major surgery to fix those, er, stubborn spots makes you break out in a cold sweat. Enter the minimally invasive procedure—cosmetic surgery light for the surgery-phobic among us.

“Cosmetic surgery has never been as popular as it is right now,” says Midlothian-based cosmetic facial surgeon Dr. Joe Niamtu, “It’s a perfect storm.” Changes in social attitudes toward cosmetic surgery, explains Niamtu, combined with the fact that people are living longer healthier lives and advances in technology that have introduced procedures like Botox, laser fillers and other skin treatments not available just 15 years ago, have spurred the growth of this segment of the cosmetic surgery business. Procedures, he says, are “better, safer and easier” today than they ever have been.

Since 1997 minimally invasive cosmetic surgery procedures have increased by 356 percent, according to statistics published by the American Society for Aesthetic Plastic Surgery (ASAPS). Botox leads the way as the most common procedure; in 2011 alone more than 2.5 million Botox procedures were performed in the U.S.

“There was some stigma initially with Botox and fillers,” says Dr. Kurtis E. Moyer, chief of plastic surgery at Roanoke’s Carilion Clinic and associate professor of surgery at Virginia Tech Carilion School of Medicine, “but now their use is so widespread across the country that people are more accepting of doing maintenance-type procedures.” In its most recent statistic report, the American Society of Plastic Surgeons (ASPS) notes that more than 13 million minimally invasive cosmetic surgery procedures were performed in 2012.

“One of the most common reasons people are coming in for minimally invasive procedures is to take care of fine lines,” says Moyer who was recruited last year to build Carilion’s plastic surgery program (he had served as director of Penn State University Hospital’s Hershey Cosmetic Surgery Center for five years); the new clinic for plastic and reconstructive surgery began seeing patients last fall. “We can offer complex procedures that we’ve never been able to before, it’s exciting,” says Moyer of Carilion’s ability to do things like breast reconstruction in addition to “the full gamut” of cosmetic services.

In addition to Botox, among the top minimally invasive cosmetic procedures according to the ASPS are soft tissue fillers, chemical peel and microdermabrasion—referred to by many, including Niamtu, as lunchtime procedures because they are quick and are performed in doctor’s offices.

Botox, a product that selectively paralyzes muscles in the face, has had a long run at the top of the ASPS list, but what about that oft-ridiculed Botox smile? The pop culture poke at the frozen look that Botox was known for when it first won FDA approval in 2002, is a thing of the past says Niamtu. “When it first came out, if you could move one muscle, you were unhappy. Now people can tailor their Botox and be much more specific with it.”

Moyer says he has treated patients with Botox as young as their early 20s who want to prevent fine lines and wrinkles, especially in their brows, the most common area of the face for Botox injections. When we are young, the natural elasticity of our skin prevents lines from forming as we contract and relax our facial muscles, but as we age we lose fat and thus elasticity making it harder for our skin to bounce back after every frown or furrowed brow. (Turns out your mother may have been right when she said that frown on your face could stick.)

 “I’ve seen a definite increase in men receiving Botox,” says Moyer, “I think it’s been driven by culture and society.” He says men in executive positions and sales jobs in particular who have a lot of public exposure often seek a more youthful appearance to maintain their competitiveness. (Among the results reported in 2011 by the American Society for Aesthetic Plastic Surgery from a study it commissioned found that more than half of Americans regardless of income approve of cosmetic plastic surgery.)

Though Botox is great for smoothing fine lines and wrinkles, soft tissue fillers—the second most popular minimally invasive procedure—are meant to take care of those lines and wrinkles that go deeper. “Soft tissue fillers are designed as a stepping stone to surgical procedures,” explains Moyer. Prior to the advent of dermal fillers plastic surgeons could only treat these deep lines with a facelift. “Fillers are a way to treat people who are not surgical candidates, but want a more rested youthful appearance,” says Moyer. Of the non-permanent fillers, Moyer says the ones he uses most commonly are Restylane and Juvaderm—hyaluronic acid fillers in gel form that are made from material that is naturally occurring in skin. The gel is injected under lines and wrinkles and forms a “scaffold beneath the skin” says Moyer. More than 1 million injections of hyaluronic acid fillers were given in 2011 reports the ASPS.

Moyer advises all of his patients—even those who come in for surgical face-lift—to seek out the advice of an aesthetician and begin using a medical skin care line before undergoing any procedure. Though they are more expensive, he says medical skin care products used before a procedure like a Botox injection, chemical peel or microdermabrasion—and then after for maintenance—give patients the most bang for the buck.

Not familiar with the ins and outs of these lunchtime lifts? Here’s a quick primer for four of the top minimally invasive cosmetic procedures.


Botox, the brand name for botulinum toxin—a substance derived from bacteria—temporarily paralyzes muscles in the face allowing them to rest thereby reducing or eliminating frown lines, crows feet and forehead furrows. A thin needle is used to inject small amounts of botulinum toxin into specific muscles. (Multiple injections may be needed depending on the extent of wrinkles.) The procedure takes about 15 minutes and does not require anesthesia. The injection can take up to a week to achieve full effect, which lasts around four months. The average cost per injection is about $400.

Soft Tissue Fillers

Soft tissue fillers are injected under the skin and replace lost volume in the soft tissues of the face to reduce or eliminate deep lines and wrinkles. Non-permanent fillers may be collagen-based, made from naturally occurring protein in the human body and in that of animals including cows and pigs (they carry some risk of allergic reaction). Hyaluronic acid-based fillers are made from a substance that occurs naturally in human skin making allergic reaction very rare. Injections do not require anesthesia, and the treatment remains in effect for about a year. It can cost more than $600 per syringe.

Chemical Peel

Chemical solutions smooth the texture of skin in an exfoliating process that removes outer layers that may be damaged. Peels are used to improve the appearance of acne scars, age and liver spots, sun-damaged skin, freckles and other irregular skin color. In a light chemical peel the face is cleansed and a chemical solution is applied with a brush. It is left on the skin for about 10 minutes and then washed off (the process can be repeated monthly). Medium and deep chemical peels can reach the middle and lower dermal layers and may require some pre-treatment and local anesthetic to manage discomfort. A medium chemical peel may be repeated every six to 12 months, while a deep chemical peel can last up to 10 years. Average fees are around $800, but vary according to the type of peel performed.


In microdermabrasion the skin is lightly sanded to remove the thicker, uneven outer layer. It is used to treat light scarring, discoloration and sun damage, and more recently, stretch marks. A hand-held diamond-tipped wand is gently passed over the skin to slough off the top layer, which results in new skin growth and thicker collagen, the protein in skin that makes it appear smooth and firm. The procedure can last about 30 minutes and may feel like a light massage, but is not painful. The average cost is around $150.

*Average costs based on estimates published by the American Society of Plastic Surgeons

Not every patient is a good candidate for minimally invasive cosmetic procedures. For more complete information on these procedures visit the websites of the American Society of Plastic Surgeons ( and the American Society for Aesthetic Plastic Surgery (

—Sandra Shelley contributed to this story.

Patient Safety Tips

Before you have any procedure done be sure to ask your plastic surgeon these important questions to ensure you are in capable hands.

  • Are you certified by the American Board of Plastic Surgery?
  • Were you specifically trained in the field of plastic surgery?
  • Am I a good candidate for this procedure?
  • Where will you perform my procedure or treatment and is the facility accredited by a nationally or state-recognized agency?
  • How long will the recovery period be?
  • What are the risks and possible complications associated with my procedure?
  • Do you have before-and-after photos I can look at for this procedure?
  • What results are reasonable for me?

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