Every artist has their medium. Caravaggio found light in oil on canvas. Dürer celebrated details in watercolors. Bourgeois brought humanity to marble and bronze.
Alexiades, Idriss, and Subbio sculpt with botulinum toxins and illuminate with hyaluronic acids. They probably won't make it into Janson’s History of Art, but they’re three of the many dermatologists and plastic surgeons who are reimagining the planes of the face (and areas south) with their syringes. When injectables first arrived on the scene, they were viewed as a means to a "liquid face-lift." Today, they’re a way to control light and shadows, to chisel angles, to round curves. And some of the doctors using them to the best effect have credentials beyond medical school. Exhibits A through C: Macrene Alexiades, a New York City dermatologist, is a trained sculptor; Shereene Idriss, also a New York City dermatologist, has a living room adorned with her own abstract paintings; and Christian Subbio, a Philadelphia plastic surgeon, almost headed to art school.
Inside the artist-injector’s toolkit, you’ll find skin-shaping fillers (hyaluronic acid and others), muscle-relaxing neurotoxins (like Botox and Xeomin), fat-sapping deoxycholic acid (aka Kybella), and needles and cannulas of many dimensions — finer points for discreet detailing and blunt tips for broader strokes. With a syringe or two of hyaluronic acid filler, injectors can carve a new jawline, alter the shape of a nose, and build lips to new proportions. By harnessing the collagen-growing potential of Sculptra (poly-L-lactic acid), they can subtly restore lost volume. Tapping into the reductive nature of neurotoxins and deoxycholic acid, they create negative space, tapering the lower face and streamlining the silhouette. And if faces appear overstuffed, they can clear the canvas of too much hyaluronic acid with an enzyme called hyaluronidase. We asked doctors famous for merging imagination with medicine to explain how they’re elevating injectables to an art form — and turning patients into masterpieces.
The "liquid nose job" is perhaps the most impressive example of shape-shifting with hyaluronic acid fillers. "Nonsurgical rhinoplasty is the ultimate optical illusion," says Lara Devgan, a plastic surgeon in New York City. In reality, of course, augmenting the nose with filler renders it bigger, not smaller. "But by creating a highlight down the center of the nose, and a delicate point of light at the tip, we can make the nose appear more diminutive and proportionate." (The nose is a vascularly complex area for filler, so it’s best to choose an experienced rhinoplasty specialist to do this.)
The artist-injector also shines when tasked with redefining the lips. Anyone can blow them up like a balloon, but Devgan stresses that an elegant lip augmentation "is not just a volume game — it’s a structure and shape change that you want." Her approach: Use a medium- to high-viscosity hyaluronic acid filler (like Restylane Refyne, Restylane Defyne, or Versa) to build the height of the top and bottom lip to showcase more of their pinkness. "By injecting tiny strands of filler vertically into the lips, I can make them turn out slightly," she says.
Neurotoxins can be quietly transformative too. A strategically placed shot can downplay a gummy smile, perk up a Cupid’s bow, adjust the symmetry of the brows, or lift the tip of the nose. On their own, each of these changes can be measured in mere millimeters, but step back to take in the whole picture and you’ll see that "such detail work can be dramatic," says Idriss.
Aesthetic doctors view certain fillers as a sort of armature, or framework, for the face. "As we age, fat starts to diminish and even our bones shrink," says Kay Durairaj, a facial plastic surgeon in Pasadena, California. "To help replace what’s been lost in terms of contours, we place filler more deeply under the skin — often right against the bone. This technique restores that foundation without leaving the skin looking stretched or puffy." With respect to the sculptural variation of the face — its natural peaks and valleys — injectors judiciously place robust hyaluronic acid gels (like Restylane Lyft and Juvéderm Ultra Plus), or brawnier, longer-lasting Radiesse (made from particles of calcium hydroxylapatite), at key points to give back defining angles and contours. "If skin didn’t sag, if ligaments didn’t stretch, if fat didn’t deflate, the face would always stay nicely anchored at the cheekbones and jawline," says Durairaj, who sometimes uses Radiesse as a mooring to accentuate cheekbones and tug back the angle of the jaw for crisp lines and a more defined chin. By fine-tuning the topography of the face, Devgan finds she can also "cast a more flattering light pattern over the face." Unlike Durairaj, Devgan prefers to build better bone structure with hyaluronic acid fillers: "They allow the highest degree of flexibility — and reversibility." (More on that later.)
Using Negative Space
As the masters would tell you: What’s not there can be every bit as crucial as what is. It’s called negative space, and visionary injectors know how to engineer that which is absent from the picture. To slenderize square jaws, they shoot neurotoxin into the masseter (or chewing) muscles, which tend to turn bulky after years of clenching and grinding. "If you put a substantial enough dose into the masseter, you cause the muscle to shrink just slightly, thereby narrowing the lower third of the face into a softer heart shape," explains Subbio. Administered in tiny doses under the jawline and across the platysma muscle that runs up and down the neck, a neurotoxin can also polish the neckline for a more youthful silhouette, says Durairaj: "To a certain extent, it allows the face to lift upward and any folds in the neck to lie flat."
For people with small pockets of fat and decent skin elasticity, Kybella can subtly carve out the under-chin area for a sleeker contour. "It dissolves fat beautifully in the jowls too, which can impart a heaviness that’s difficult to treat by other means," says Durairaj. She usually injects about three vials of Kybella for every pinchable inch, repeated over three to four appointments spaced at least six weeks apart.
"Just as time can produce new positive spaces, like fullness and folds, it can also create new negative spaces, like undereye depressions, sunken temples, and wrinkles," says Alexiades. Dermatologists and plastic surgeons commonly use hyaluronic acids to fill the voids and say that placing gels of the right viscosity into the appropriate planes is crucial. The skin under the eyes, in particular, is extremely delicate and treating hollows there requires a thoughtful technique. "Inject the wrong hyaluronic acids in the wrong place and you can dramatically upset the natural contours and make someone look like an avatar," says Idriss. She often starts by injecting a heavier hyaluronic acid (like Juvéderm Voluma) into the temples "to help pick up and smooth the undereye bags, so that less product will be needed directly beneath the sockets." She can then place a modest amount of a lighter hyaluronic acid (like Belotero Balance) there, "below the muscle but on top of the bone, which allows it to move with the face and blend seamlessly rather than bulging out."
Creating a Watercolor Effect
"I think of Sculptra like water-based paint," says Idriss. Its impression is diffuse and delicate, more muted than precisely detailed. Unlike hyaluronic acid gels, which are "a structure you inject into the skin," explains Subbio, "Sculptra causes the body to make its own volume." The collagen-creation process is gradual, with patients seeing maximum effect after three or four treatments performed over several months.
"The resulting collagen can last up to five years and beyond," says Durairaj. While Sculptra can cushion any sunken spot, Idriss likes it for gaunt temples and what she calls "the Bermuda Triangle of the face" — the isosceles-shaped pools that form near the corners of the mouth. "You can literally empty syringe after syringe of hyaluronic acid in that area and it does nothing — it’s like it vanishes upon injection — but Sculptra beautifully gives back an underpadding to the area."
Other doctors prefer using Sculptra off the face, to firm a crepey décolletage or level cellulite dimples. In greater quantities, Sculptra can modestly augment the butt. But again, think soft-focus filter: "Sculptra is excellent if you want to stay in the same-size jeans," Devgan says. "It’s not really powered to make you a different-size person."
Starting Fresh
Even the best artists need an eraser sometimes. Hyaluronidase is an enzyme that can make hyaluronic acid fillers dissolve. (It has no power over other types of filler, though, which generally have to degrade on their own or be surgically removed.)
While doctors liken hyaluronidase to a delete button, using "reverse" and "undo" to describe its action, the reality is not quite so simple. "Hyaluronidase is slightly misunderstood" in this regard, says Steven Levine, a plastic surgeon in New York City.
"Hyaluronidase affects only the hyaluronic acid that it touches, so it’ll typically remove some of the gel, but not all," he explains. "Even the most skilled injectors will admit that they’re not exactly sure how hyaluronic acid spreads and settles throughout the different layers of facial tissue." But doctors are increasingly relying on it to treat a growing prevalence of faces distorted by hyaluronic acid.
"People quickly lose perspective, and at some point, they’re not just filling themselves back up to where they once had volume," says Levine. "They’re adding beyond that loss, and that’s where things go awry."
For someone "grossly overfilled," Levine books four sessions, one week apart, and repeatedly floods the area with hyaluronidase in hopes of hitting the right plane. The shot can sometimes cause swelling or bruising but typically delivers about 50 percent effectiveness in the first hour and the rest over the next several days, with the goal of ultimately returning faces to (nearly) blank slates.
A version of this article originally appeared in the February 2020 issue of Allure. To get your copy, head to newsstands or subscribe now.
More on injectables:
- A Comprehensive Guide to Everything You Need to Know About Cosmetic Injections
- A Beginner's Guide to Injections
- The Dangers of Using DIY Injections
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