Cosmetic Connection

From Botox and brow lifts to breast augmentation — everything you wanted to know about plastic surgery.
by Julie Short

Rather than beginning this article with tales of botched boob jobs, nose tips falling off and liposuction gone awry, we offer up an up-lifting story: A young woman visits a prominent plastic surgeon in the Back Bay. She’s tall, thin and pretty but feels insecure about her less-than-straight nose. The doctor agrees to perform corrective surgery. After her last post-operative checkup, she leaves his office and strolls down Newbury Street. There, a local modeling scout stops her, hands over his card and asks her to call him.

Three months later, that woman is about to debut on the local modeling scene. It’s a true story, says Dr. Ramsey Alsarraf, the cosmetic surgeon who practices at the Newbury Center and who performed the surgery. Now… who’s ready to book an appointment?

OK, so we all know that not everyone who opts for cosmetic surgery ends up a supermodel, and the media has covered plenty of stories about cosmetic surgery gone bad. Hollywood film director Martin Scorcese made the news with a tirade against Botox last month. Apparently Botox injections, which paralyze the muscles in the forehead to smooth out wrinkles, also hinder actors from expressing their emotions on screen. That’s true, says Alsarraf: “Actors may be the one group of people who shouldn’t try Botox.”

But for the rest of us, says Alsarraf, Botox can be a relatively painless and affordable introduction to the world of cosmetic surgery. “No other non-invasive procedure works as well to smooth out forehead and frown lines,” he says.

Botox, of course, is just one way to reduce the signs of aging, much of which is sun-related. According to the American Academy of Dermatology, 80 percent of total lifetime sun damage occurs before the age of 18. In other words, by the time most of us understood the importance of slathering ourselves with sunscreen instead of baby oil, is was too late.

Genes play a role in the aging process, too. A good way to figure out what you’ll look like in 20 years is too take a look at your parents. The wrinkles on the forehead, the bags under the eyes, the drooping eyelids, the sagging jowls — that’s your future. “You can’t escape heredity,” says Alsarraf.

But you can look younger with a variety of non-surgical and surgical cosmetic procedures. “You should do what’s age-appropriate,” Alsarraf says. “You don’t get a face-lift in your 30s — it’s just not beneficial.” For those in their 20s, the plastic surgeons we talked with recommended the non-surgical route — chemical peels, laser surgery, micro-dermabrasion, Botox and collagen injections. A brow lift would be appropriate in the mid-30s and lower lid surgery in the early 40s. Hold off on the face-lift until you’re in your mid-40s. But don’t wait too long, says Alsarraf. “You still want to be young enough to enjoy it.”

Curious about what the latest cosmetic procedures might do for you? Here’s a quick guide to some of the most popular procedures for men and women ages 25 to 50.


As mentioned earlier, an injection of Botulinum toxin (Botox) into the forehead smoothes out facial wrinkles by blocking nerve impulses and temporarily paralyzing the muscles under the surface of the skin. It’s a quick prcedure — “People can even come in on their lunch break,” says Alsarraf — and the results last three to six months. “Botox is good for those people who aren’t yet in the age group for a face-lift,” he says.

Common side effects: temporary redness

Risks: allergic reaction, bruising, numbness, swelling, headaches
Recovery: immediate
Average cost: $350-$750


Using more moisturizer may not be the best remedy for dry, chapped skin, especially in the winter, says Alsarraf: “It’s better to get rid of the layers of the dead skin instead of trapping them under moisturizer. Winter is the time to exfoliate — you’ll look younger as a result.” Micro-dermabrasion is a popular exfoliating procedure practiced in dermatologists’ offices and in beauty spas around the country. An instrument blasts aluminum oxide crystals onto the skin to remove the top layer and smooth lines, scars and wrinkles, plus stimulate the production of new cells. “it leaves your skin glowing and fresh,” says Claire McArdle, owner of Beauty Therapies in Brookline. The results, she claims, are immediate. “If you want to look good on a Friday night, you can book an appointment that afternoon,” she says. The procedure — which McArdle compares to the feeling of a cat licking your face — should be repeated once every couple of weeks for three months.

Common side effects: temporary redness, swelling and sensitivity

Risks: slight burning (looks like a sunburn)
Recovery: immediate
Average cost: $125-$200

Laser Skin Resurfacing and Chemical Peels

“Children’s skin is beautiful because it’s one color — not blotchy with hyper-pigmentation — and it’s free of wrinkles,” says Dr. Daniel Del Vecchio, a plastic surgeon with offices on Newbury Street. One way to turn back the clock is through laser surgery, which exfoliates the top layer of skin using intense heat and tightens the collagen fibres in the under-layer. The end result is smooth, healthy-looking skin, says Del Vecchio. Laser surgery is best for those in their mid-30s who have fine lines around their eyes and lips. The procedure requires anesthesia (general is the norm), and the redness lasts four to six weeks.

Another option is a chemical peel, which Alsarraf prefers to laser treatment because the recovery time is shorter to laser can cause a noticeable white line along the jaw. The procedure, he says, isn’t as painful as the name suggests: A chemical solution is applied to remove the damaged, wrinkled top layers, revealing healthier skin underneath. Essentially, the treatment provides the same results as a laser, evening out pigmentation and smoothing fine lines and acne scars.

Common side effects: temporary swelling, redness, sensitivity to sun

Risks: infection, scarring, flare-up of skin allergies, fever blisters, cold sores, permanent discoloration
Recovery: two weeks (laser surgery); one to three weeks (chemical peel)
Average cost: $5,000-$7,000 (full-face laser); $400-$900 (chemical peel)

Collagen and Lip Enhancement Procedures

Take a close look at a smoker, and you’ll see telltale evidence of years of nicotine abuse: fine lines around the lips. But Alsarraf tells us that runners also suffer from the same problem. “You see it in anyone who breathes heavily,” he says. Collagen treatments — using either bovine or human collagen, the fibrous protein constituent of bone, cartilage, tendon and other connective tissues — fills in the fine lines. The results of both are immediate and natural looking, though human collagen lasts longer (six months as opposed to a few weeks), says Alsarraf.

De Vecchio, on the other hand, prefers to perform the procedure using fat suctioned from the patient’s own abdomen or thigh and injecting it with a small, blunt needle into the corners of the lip to smooth out wrinkles and add fullness. The downside is that fat particles tend to dissolve over time, but Del Vecchio uses the Coleman Technique, which distributes small bits of fat throughout that lip (thereby increasing the likelihood of permanent results).

Another technique used by Del Vecchio to add volume to the lips is the dermis graft. He takes a piece of skin two inches long from the area right above the patient’s buttocks and tucks it into an incision in the upper lip. “There’s a saying in plastic surgery: ‘Replace like tissue with like,’” says Del Vecchio. “I always prefer using natural substance.” Neither doctor recommends Gortex implants (yes, the same flexible material used in your ski jacket). “It’s soft and malleable, but it’s more noticeable. If you kiss your boyfriend, he will feel that ridge,” says Alsarraf.

Common side effects: bovine/human collagen and Gortex implants: swelling; fat injections: temporary swelling in lips, slight bruising; dermis graft: temporary pain in buttocks and lip

Risk: bovine collagen: allergic reaction; fat injection: low risk; dermis graft: infection and bleeding; Gortex implant: infection or extrusion of implant
Recovery: bovine and human collagen: one day; fat injection: one-three days; dermis graft: five to seven days
Average cost: bovine collagen: $250-$500; human collagen: $500; fat injections: $1000; dermis graft: $1,500-$3,000; Gortex implant: $1,500-$3,000

Brow Lift, Face-lift

What surgeons call the aging face or restorative procedures are mainly for those in their mid- to late-30s and early 40s. “It’s about turning back the clock,” says Alsarraf. “You want to look like exactly the same person — just 10 years younger.”

Clients on the east coast are looking for more conservative, natural-looking results, says Alsarraf. “That ‘Mary Tyler Moore and Joan Rivers can’t-move-your-mouth look’ doesn’t work in Boston,” he says, asserting that just as many procedures are performed on the East Coast as the West.

Because the brow is the first area of the face to change with age, that’s where most plastic surgeons are likely to start. Alsarraf removes a segment of the muscle on the forehead and pulls the skin up from behind the hairline, so “there’s no chance of scarring on the face.” The procedure elevates the eyebrows (making you look less tired), smooths out the horizontal lines in the middle of the forehead and eliminates crow’s feet around the eye. At the same time, eyelid surgery, or blepharoplasty, can correct drooping upper eyelids and puffy bags below the eyes by removing excess fat.

Face-lifts work to correct sagging skin on the face and neck that are common in people in their mid-40s. Instead of pulling only on the skin, which can result in a stretched look that only lasts a few years, Alsarraf performs a deep-plain face lift, a procedure that lifts skin and muscle for a longer lasting result (up to 10 to 15 years).

Common side effects: temporary swelling, bruising and dryness
Risks: slight loss of control of facial muscles, excessive scarring, change in hairline
Recovery: seven to 10 days (eye surgery), 10 to 14 days (face-lift)
Avergage cost: $3,000-$7,000 (brow lift); $3,000-$5,000 (blepharoplasty); $6,000-$12,000 (face-lift)

Breast Augmentation

Safety tops the list of concerns for most people considering breast augmentation. Due to the silicon scare of the late ‘80s and early ‘90s — when leaky or ruptured implants were reported to be linked with serious health problems for thousands of women — many are hesitant. They shouldn’t be, says Del Vecchio: Implants are much safer now. Surgeons who use the new and improved silicon implants must participate in a national study tracking their use and safety. But most doctors chose saline implants, which are only slightly firmer than the silicon and cause very few complications, says Dr. Bill Adams, who has offices on Newbury Street and in Salem, Mass. “I’ve never had to take one out,” he says.

The empty implants are rolled up into inch-wide cylinders and inserted into the area in one of four ways: though an incision in the nipples, under the breast, though the belly button or though the armpit (used mostly for gender reassignment patients). After positioning the implant, a surgeon fills it with saline injected though a small tube. As for the pros and cons of implant insertion methods, Del Vecchio says that many women decide against the middle surgery because they don’t want their nipples cut and don’t want to risk potential sensitivity loss. But the scars are less noticeable with this method than the underwire surgery, which leaves a small scar directly under the breast, says Del Vecchio. The belly button procedure, he says, takes longer because the incision is tiny, and placement of the implant is more difficult. The tradeoff, however, is no visible scar.

Common side effects: temporary soreness, swelling, change in nipple sensation, bruising

Risks: bleeding, infection, wide scars, uneven nipples, permanent loss of feeling to the nipples and/or breasts (rare)
Recovery: seven to 10 days
Average cost: $4,5000-$7,5000


Liposuction — one of the most frequently performed cosmetic procedures in the United States — changes body shape by removing exercise-resistant fat deposits most commonly found in the thighs, abdomen and hips. Patients range in age from 18 to 60, and they’re usually in fairly good shape but just can’t seem to lose the fat in certain areas of their bodies, says Adams. To perform this procedure, Adams first uses ultrasound to break up the fat. “I get better contour that way,” says Adams. Then he makes a small incision in the thigh — about a quarter of an inch — and inserts a vacuum-like hose to remove fat. Patients see improvement right away and the end resolution in six months, according to Adams.

Although liposuction is considered safe when performed by properly trained specialists, it’s important to note that this procedure can have life-threatening infectious complications when the practitioner lacks the surgical expertise of hospital privileges necessary to deal with problems that might arise, according to an article entitled “Fatal and Near-Fatal Complications of Liposuction” in the May 1998 Southern Medical Journal. The preferred setting for the procedure is in a hospital operating room using general anesthesia, says Adams.

Common side effect: temporary swelling, bruising, numbness, soreness and burning sensation

Risks: asymmetry, rippling or bagginess of the skin, fluid retention, lumpiness, infection, excessive fluid loss leading to shock
Recovery: one to two weeks
Average cost: $2,000-$10,000

[Before and After images of a woman]

Dr. Ramsey Alsarraf performed restorative procedures on this 46-year-old woman and injected collagen into her lips.

The open brow lift elevates the eyebrows, smooths out the horizontal lines in the middle of the forehead and eliminates crow’s feet around the eyes.

Eyelid surgery, or blepharoplasty, corrects drooping upper eyelids and puffy bags below the eyes by removing excess fat.

A face lift corrects the sagging skin on the face and neck. This woman had a deep-plain face-lift, a procedure that lifts skin and muscle for a long-lasting result (up to 10-15 years).

Injecting human collagen into the lips fills in the fine lines. The results are immediate and natural looking, and last up to six months.

[Image of a surgical procedure]

Despite the silicon scare of the late’80s, “implants are much safer now,” says Dr. Daniel Del Vecchio, shown performing a breast lift on a young woman.

Facts on article edge

7.4 million Americans had cosmetic surgery in 2000.

35- to 50-year-olds make up 44 percent of the cosmetic surgery population.

Nose reshaping, liposuction, eyelid surgery, breast augmentation and face-lift were the most popular surgical procedures.

Liposuction topped the list for women and eyelid surgery for men.

Chemical peel, microdermabrasion, sclerotherapy, Botox injection and laser hair removal were the most requested non-surgical procedures.

Men accounted for 14 percent of the total cosmetic plastic surgery procedures in 2000.

The top 5 male trends in cosmetic surgery in 2000 were eyelid surgery, liposuction, nose reshaping, breast reduction and Botox injections.

33 percent of cosmetic patients are repeat patients.

All statistics courtesy of The American Society of Plastic Surgery

Before You Go

– Find a specialist. In other words, for facial procedures, look for a doctor who specializes in facial plastic surgery
– Ask to see before-and-after photos of former patients
– Find a doctor with whom you feel comfortable. It’s important to form a relationship with him or her
– Look for a doctor who works in a hospital or is affiliated with a hospital
– Ask your friends or your primary care physician for referrals
– Check the doctor’s credibility by asking if he or she has published work. Check with the Massachusetts Board of Medicine to see if he or she has been involved in any malpractice suits
– Interview several physicians before choosing one
– Make sure the doctor tells you the downside as well as the upside of a particular procedure
– Be realistic about the results you will get from the surgery
– For more information, visit, a Web site sponsored by the American Society of Plastic Surgeons