Dermal Filler Injections
A conversation with Dr. Darren Smith
Many people have that one little zone on the face that bothers them — a few deep lines indenting the forehead or little hollows under the eyes where a good night’s sleep never registers. Dermal fillers or Botox could be an easy fix, but that idea may bother them, too.
“I think they’re afraid of having an unnatural result,” says Dr. Darren Smith, a plastic surgeon who offers brief but transformative injectable treatments to clients at Mynd’s Sally Hershberger location, in New York. “Am I going to look ‘done’? Am I going to look like [name of notorious plastic-surgery addict redacted]?” But in the right hands, a small tweak can be completely natural-looking, safely administered, and even reversible if you don’t like it.
So-called medi-spas are cropping up all over, and while Mynd is, admittedly, a spa and salon, the services offered by Dr. Smith at Mynd are full-fledged (if quick) medical procedures provided by a highly respected New York plastic surgeon — not a physician’s assistant.
“There are all these little ‘skin bars’ popping up,” says Dr. Smith, “where you can go and get your fillers, go and get your Botox,” often with no doctors even present on site, let alone providing the injections. (A recent New York Times article on the trend reports the same.) “People are treating it like getting their hair done,” he adds. “And it’s really not. Yes, it’s fine to think about it as a minor procedure, [but only] if it’s done by an expert, because an expert will know how to avoid problems and deal with them if they occur.”
Board-certified in plastic surgery, Dr. Smith is indeed that. After graduating from Brown Medical School, he underwent 11 years of surgical training, including a residency in plastic surgery, a fellowship in esthetic surgery, and a second fellowship in craniofacial surgery (on the bones of the face). In his private practice on the Upper East Side of Manhattan, Dr. Smith performs a full gamut of esthetic surgeries, from facelifts to body contouring. At Mynd Spa at Sally Hershberger, he taps into the same training and fine-tuned understanding of the anatomy of the face to provide naturalistic results, as well as a low risk of complications, when he performs injectables.
After one of Dr. Smith’s sessions at Mynd — he visits the Sally Hershberger location two days a week to meet with patients for 20-minute complimentary consultations, 45-minute treatments, and follow-up sessions—we caught up with him and barraged him with questions. Below, some of the most illuminating takeaways from the conversation for anyone considering injectables.
Injectables can do more than you think — even serving as an alternative to plastic surgery.
While wrinkles are the most obvious destination for injectables, dermal fillers and Botox can also be used to create small, targeted enhancements that have a big impact on a person’s overall appearance without invasive surgery. Dr. Smith talked us through a range of options, some of which address signs of aging and some of which are simply “subtle, cool tricks” intended to help patients seeking to look more beautiful.
Note that dermal filler injectables come in different thicknesses and, depending on the density used, can simulate the type of tissue you’d ideally like more of in a certain area—soft tissue (like in the lips) or even cartilage or bone. Botox is a substance that prevents muscles from contracting.
Enhance the nose: “We can use fillers to do nonsurgical ‘nose jobs’— we call them liquid rhinoplasties, where we put them in different places on the nose to improve nasal appearance and camouflage bumps.”
Enhance the cheekbones: “We can use them in the midface — on the cheekbones to enhance the overall shape of the face, to give a more youthful, heart-shaped face” or create more pronounced cheekbones.
Pull up the corners of a downturned mouth: “Even when the face is at rest, it’s actually a very tightly calibrated mechanism, arranged with opposing sets of muscles. If you look at the mouth, it has a bunch of muscles angling up and away from it, which are lip elevators, and a bunch of muscles angling down and away from it, which are lip depressors. If you weaken a lip depressor with Botox, you can actually enhance the upward angle of the sides of the mouth.”
Reduce thickness in the cheeks or jawline: “Another neat thing we can do with Botox that isn’t that well known is we can use it to thin out the lower third of the face. If people have very bulky cheeks, we can inject the big muscle in your cheek, which you use to close your jaw, and since we’ve now weakened it, it’s kind of the opposite of going to the gym — it’s atrophying. We can use this for aesthetic purposes.” (The treatment is a “less invasive” alternative to surgical removal of the fat in the cheeks, says Dr. Smith, and while it weakens the cheek muscle, it wouldn’t affect how you talk or chew.)
Fill in “tear troughs” under the eyes: “It’s very common to use fillers in the hollows under the eyes, which can address that tired or angry look that some people think they have.”
Add plumpness to the lips or even change their shape: “Lip filler is huge now, which people might do for volumization or because they want a certain shape of lip. People come in not too infrequently and say, ‘I want so-and-so celebrity’s lips.’ You can really do a lot with lip shape, and you can also address lip asymmetry. Some people have lips that are bigger or smaller on one side.”
Create the look of a stronger chin: “We can augment the chin with filler. If someone has a more pronounced issue that we really want to take care of permanently, though, we can put in a chin implant.”
Fill out the temples: “A sign of aging is temporal hollowing, where the temporalis muscle gets thinned out. People will put fillers there for a more youthful appearance.”
Reduce the look of jowls: “Another tell-tale sign of aging is the formation of jowls, soft tissue that starts to hang down by the jaw. While the actual fix for that is something surgical, we can camouflage it pretty effectively a lot of times by putting filler in the little hollow area [between the chin and the jowl], so you’re easing that transition, making the jowl itself less visible.”
Remove vertical lines in the neck: “With age, [the muscle at the front of the neck] becomes lax and separates in the middle. The vertical lines that you see are the edges of that muscle. We can use Botox to weaken the muscle and soften those lines.”
Remove horizontal lines in the neck: “The other kind of line in the neck are horizontal lines — from moving your head all the time, you form creases. Those we can address with filler.”
Which is better for wrinkles — Dermal fillers, Botox treatments, or both?
Of course, probably the most common pain point that causes people to seek out dermal fillers and Botox is the emergence of wrinkles—classic offenders including laugh lines, “crow’s feet,” horizontal lines across the forehead, “elevens” (the vertical lines that form between the eyebrows), and “marionette lines” (the vertical lines that travel down from corner of the mouth to the jawline).
Which type of treatment is most effective depends on whether you see lines when your face is at rest or when your face is in motion—in other words, how advanced the wrinkles are.
“The analogy I like to use is the spine of a book,” Dr. Smith says. “When you look at the spine of a new book, there are no lines on it at all. The first time you open that book, you’ve created some dynamic lines that go away when you close the book. Over time, you keep opening and closing the book, and those dynamic lines become static lines that are present on the spine even when the book is closed.”
Filler usually works best for static lines, and Botox usually works best for dynamic lines, but your best option may be to use both. Botox can prolong the life of fillers, says Dr. Smith, and can be used preventatively, to stave off deeper lines from forming.
What is the downtime after receiving Botox or dermal filler?
(In other words: Can you go straight back to work?)
“There’s zero downtime,” says Dr. Smith. “With any kind of injectable, you do have a small risk of bruising, which you can almost always cover with makeup. I don’t recommend [having a treatment] right before a major work or social function, just because if you do have a bruise, you might not want to [cover up] that way, but it’s not going to prevent you from going to work.
“If you’re doing a really significant filler treatment, you might look a little puffy for a day or two, but someone might think you’re having allergies. They won’t say, ‘You had filler.’”
How long does it take to see results after a dermal filler or Botox treatment?
“With filler, it’s immediate,” says Dr. Smith, “although it takes about two weeks to see the final results, simply because some swelling needs to go away, and some fillers will actually absorb water. So we usually say in two weeks, you’ve reached your ‘steady state,’ and that’s what the final result is going to be.”
Botox, meanwhile, takes several days to kick in: “You might see results in as early as 4 to 7 days, but for the most part, it’s more of 10 to 14 days until you see the final results.”
What if you don’t like the results of your dermal filler or Botox treatment?
“Ninety nine percent of the fillers that I use are completely reversible, meaning if someone says, ‘Hey, I don’t like this’ or ‘I want it to be a little less extreme,’ we dissolve them and they go away,” says Dr. Smith. “I can’t remember the last time I had to dissolve a filler, so it’s very uncommon. It’s a safety net.”
“Botox is not reversible, but it only lasts three to six months. So, if somebody is not in love with the result, it’s not a lifetime. Which is a very rare occurrence, but it should be enough to make people say, ‘This isn’t so terrifying.’”
How long do dermal fillers last?
Fillers last anywhere from about three months to two years, depending on the type of filler used, says Dr. Smith. Usually the denser the filler, the longer it lasts.
Nearly all of the fillers Dr. Smith uses are based on hyaluronic acid — that moisture-promoting ingredient touted in many skincare products. “It’s something that’s naturally present in the body — it’s found in joint fluids and also in the fluids of the eye,” he says. “Your tissue sort of grows in and around it, and it dissolves over time.”
Are Botox treatments or dermal filler injections painful?
“We have very powerful numbing creams” for use during treatments, says Dr. Smith. “With Botox, the needle is so small, most people can’t even really feel it,” even without the cream. “We’re talking about a teeny, tiny needle, so small that it steers clear of nerve endings to a large degree—or it’s not going to disrupt that many.”
Are Botox treatments and dermal fillers safe?
“Any aesthetic procedure does have risks,” says Dr. Smith. “Cosmetic injectables on the whole are extremely safe. A possible bad outcome is bruising; [another is] infection, which is very, very unusual and would be treated by antibiotics. The really scary things are the possibility of getting filler into a blood vessel, and if that happens, you can actually interrupt the blood supply to part of the skin, which can cause a loss of some skin. Or in catastrophic cases, if you’re injecting near the eyes, you can get into the blood vessel that supplies the eyes and cause visual disturbances or blindness. But again—extremely rare, and we’re trained to avoid it and try to deal with it if it does happen. It’s why you need to go to someone who is vetted, has intimate knowledge of the anatomy of the face, and is a true expert.”
Board-certified plastic surgeon Darren Smith provides injectable treatments at Mynd Sally Hershberger (25 W 26th Street, New York). Call Dr. Smith's office directly (212.633.0627) or visit Dr. Smith’s website to book a 20-minute complimentary consultation with Dr. Smith, who can advise on the range of options specific to you. Injectable treatments are typically performed in less than 45 minutes; prices range from $399 to $1000 depending on your treatment.