It’s official: We are a culture that is obsessed with sticking needles into our bodies. From botulinum toxin injections that freeze facial muscles to microneedles that stimulate the production of skin-firming collagen, noninvasive aesthetic treatments like these have skyrocketed in popularity over the last decade. The most recent figures available from the International Society of Aesthetic Plastic Surgery show that there were 18.8 million of these procedures performed worldwide in 2022, a 23% year-over-year jump, according to the latest data from The Aesthetic Society.
Less downtime, no scalpels—what’s not to love?
One of the most notable innovations to hit this market involves injecting deoxycholic acid—a bile that our body naturally produces to metabolize fat from our diet—into the skin to slim and contour. Once injected, the acid “breaks up fat, causing an inflammatory reaction as it’s eliminated from the body,“ explains Morgan Rabach, MD, a cosmetic dermatologist in New York City and assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai Hospital.
The treatment, called injection lipolysis, can expensive when performed by a board-certified dermatologist—Rabach estimates it’ll set you back around $1,500—and price could be one reason consumers are turning to the medspas that offer it on their menus, sometimes at a highly discounted rate. But seeking out a deal can come with even greater costs: Last month, the U.S. Food & Drug Administration (FDA) issued a warning against receiving unapproved versions of these treatments, documenting alarming cases of scarring and serious skin infections.
In its warning, the FDA included gruesome pictures of painful-looking injection-site knots and nodules on one patient’s upper arms—likely not the endgame you’re chasing. But like any other medical procedure, fat-dissolving injections come with potential risks. Here's what you need to know to stay safe.
What are fat dissolving treatments and what are the risks?
Currently, there is one FDA-approved injection lipolysis treatment, called Kybella, and it’s only cleared for use under the chin, though doctors may use it off-label to treat other small areas of the body. And that last part is key: “This is a medication that is designed to be hyper-targeted,” says Dr. Rabach, who explains that several small injections are made under the skin to dissolve fat in the area, which your body will eventually metabolize away. “We do use it in our practice on the right patient.”
So, who is the right patient? “I like to have the kitchenware conversation: If you have a teacup full of fat you want to get rid of, you’re a good candidate for the non-invasive stuff,” says Paul Jarrod Frank, MD, a board-certified dermatologist and dermatologic surgeon in New York City and clinical assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai Hospital. “Once you start getting into anything more than a soup bowl, the fat has to be physically removed.”
It’s important to note that even when a physician is performing injection lipolysis using the approved drug in the approved manner, there is still a risk of complications. “It's a treatment that's known to cause a significant amount of inflammation,” says Dr. Frank, who does not to offer Kybella in his practice for this very reason. In clinical trials, researchers noted side effects ranging from injection-site pain, swelling, and bruising to trouble swallowing and nerve injury to the jaw.
What’s is causing the complications the FDA is warning about?
That’s tough to say, but the FDA and the experts I spoke with have some ideas. In its report, the FDA warns that unapproved medications are being marketed and sold online under brand names like Aqualyx, Lipodissolve, Lipo Lab, and Kabelline—and unlicensed medspas may be procuring these online or through a compounding pharmacy with little to no oversight. “In these cases, it’s hard to know exactly what’s being injected,” says Dr. Frank. That’s important because, unlike Kybella, “there are no wide population studies that can demonstrate the safety and effectiveness of these unapproved medications,” adds Vanessa Coppola, a licensed nurse practitioner and owner of Bare Aesthetics Medical Spa in Closter, NJ.
And once things do go wrong, facilities using unapproved medications may be left out in the cold in terms of options to remedy the situation. “There’s no body of evidence to support solutions that address complications when they happen with a drug that's being used off-label or is not FDA approved,” adds Coppola, who only uses Kybella in her practice. “You have no guidelines to fall back on.”
What’s worse, notes Dr. Rabach, is that there is also a significant black market for these types of noninvasive aesthetic medications, including some that aren’t even approved in the United States. “And that’s where you get into the really scary stuff,” she says. “A medication has to be sterile in order to be used safely, and there may be checks and balances that are being overlooked.”
It also comes down to the skill of the injector. “In order for deoxycholic acid to work, it needs to be injected in the subcutaneous layer of skin, and if you inject too superficially or too deeply into the dermis or muscle, you run the risk of necrosis or tissue death,” Coppola says. In the FDA’s report, complications were noted on the arms—an area of the body that may simply be too large to reasonably treat. Remember, Kybella—the approved medication—is only indicated for use underneath the chin. “If the treatment area is too large, you’d have to use a lot of medication, and it may be too much for your body to handle,” hotes Dr. Rabach, who occasionally uses Kybella off-label to treat similarly small spots like behind the knees. “Ultimately, the fat is being melted and absorbed into your body to get eliminated—you don't want large volumes of fat going into your bloodstream.”
So, is it safe to get cosmetic injections at a medspa?
Both Drs. Rabach and Frank advise caution: “It's going to be very hard to find a doctor to fully support invasive procedures being done at a medspa facility,” Dr. Rabach notes. “It’s not the same standard of care you'd receive in a physician's office.” That’s because, as Dr. Rabach notes, not all medspas are created equal, which leaves much of the onus on vetting these facilities in the hands of the consumer.
However, reputable businesses do exist—these are the questions you should ask before being treated.
Is there a physician involved? Ideally, choose a medspa that’s owned, operated, or at least supervised by a medical doctor. “Having a doctor present is important because you never know when someone will have an allergic reaction to a medication, and you want to be able to provide the highest level of care,” says Dr. Rabach.
Who is doing the injecting? While laws vary from state to state on what type of professional can perform what type of procedure (Coppola says the American Medical Spa Association is a good way to find out where your state stands), you should make sure you’re under the direct care of a licensed medical professional. “A doctor doesn’t have to perform every procedure in a medspa, but it should be someone like a nurse or a nurse practitioner,” says. Dr. Frank. “Medical techs or aestheticians should not be wielding lasers or injecting.”
What product is being used? Make sure it is a brand-name FDA-approved medication that is being administered under clean and sterile conditions. “You need to know what’s being put in your body—and that goes for anything from a filler to a neurotoxin like Botox to Kybella,” says Coppola. “Ask to see the vial. Any ethical place will have no problem with that—and if they refuse to, it's a huge rig flag and I’d leave.”
Does the space look clean? You probably wouldn’t feel comfortable having surgery in dingy-looking hospital—and you should give the same consideration to any medspa you’re visiting. “You want to see the staff wiping surfaces with alcohol and using antibacterial spray on your skin before they actually inject you,” says Coppola. “They shouldn’t be holding their phone, which is dirty, to take pictures of you as they stick a needle in. Remember, it's not rude to ask a healthcare provider to wash his or her hands before touching you.”
The bottom line: To err on the side of safety, seek a doctor’s care
It’s important to remember that just because something doesn’t involve surgery doesn’t meant there aren’t risks involved—and noninvasive aesthetic treatments are no exception. Don’t be tempted by a deal: These procedures should only be performed under the supervision of a licensed healthcare provider, ideally a board-certified dermatologist or plastic surgeon.
That means you may have to do a bit of research. “By law, a medical spa’s website must disclose the professional degrees of its staff, so you can see who the medical director is and what his or her degree is in,” says Dr. Frank, who adds that a quick Google search will likely tell you all you need to know. “The warning signs for me are when you see the words ‘technician’ or ‘medical esthetician.’ There are plenty of things these professionals are qualified to do, but they should not be performing medical procedures.”
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