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The Injection That Melts a Double Chin
A noninvasive, nonsurgical procedure is enticing customers who might not otherwise seek out cosmetic treatments.
By Lindsey Hunter Lopez
Published in The Atlantic
I sat back, exposing the vulnerable area under my chin, bracing myself for the pinch of the needle. I clutched an ice pack, ready to apply it, and looked around as my heart raced. I was about to have vials of synthetic stomach acid shot into my double chin, erasing it, I hoped, forever.
The drug designed to treat my "submental fat" (the fat pocket under the chin) is the new cosmetic injectable Kybella, which promises to dissolve fat cells through a series of injections. There's very little downtime, it's noninvasive and nonsurgical, and there's little risk. The drug is the first (and only) injectable designed to contour away the dreaded double chin.
Approved by the FDA in 2015, Kythera Biopharmaceuticals' drug (which has since been acquired by Allergan) hit the market as an alternative to liposuction or surgery, using a synthetic version of deoxycholic acid—a salt found in human bile that aids fat digestion—to destroy fat cells. In the digestive tract, deoxycholic acid breaks down fat by destroying the cell membrane. When injected into subcutaneous fat, this cytolytic drug does the same thing—in targeted locations. The dissolved fat is now cellular debris, and gets cleared into the lymphatic and circulatory systems by specialized immunologic cells. This happens gradually over the span of several weeks. As for the deoxycholic acid, it follows the same path; it gets metabolized and broken down, and then excreted as waste.
The origins of chemical fat-dissolving (a.k.a. mesotherapy) go back to France in the '50s. By the '60s, according to Conor Gallagher, Allergan's executive director of medical affairs, European scientists started using a compound called phosphatidylcholine to break up fat for medical reasons. After a patient experiences trauma, perhaps from a fracture, tiny globs of fat can enter the circulation. "And often times they'll end up in the lungs and can cause respiratory issues," Gallagher told me. "So, they're looking for a way to disrupt fat, to help fix that or to treat that. They were using phosphatidylcholine as a potential agent to try and dissolve that fat." Cut to 1980s Europe, when cosmetic researchers started looking at the compound, thinking, If it can dissolve fat in the vessels, maybe it can dissolve fat elsewhere, Gallagher said. Bodybuilders began injecting themselves with "PC/DA" (a combination of phosphatidylcholine and deoxycholic acid) off-label to get rid of fat pockets for competition.
In the early 2000s, researchers at UCLA discovered that the fat breakdown caused by the PC/DA compound was actually due to the deoxycholic acid—the active ingredient in Kybella. And now here we are. Or should I say here I am, in Beverly Hills, with a needle in my chin.
As I hit my 30s, I began to feel a bit bothered by my so-called double chin. While not especially noticeable, this little pocket of submental fat has been a part of my profile for as long as I can remember; it's genetic. I've often wished it gone, but I never considered a surgical fix. That seemed like an extreme measure for something that's merely an annoyance in my life. I never saw myself getting any kind of cosmetic procedure at all. Then I saw a magazine ad for a new injectable, noninvasive double-chin treatment.
I was able to try Kybella courtesy of Beverly Hills cosmetic spa Alchemy 43. Anxious about being injected many, many times under the chin (the average patient receives 20 or more injections per treatment), I arrived at the "beauty lab." It's the kind of chic place you'd imagine one would visit for such a procedure, with futuristic light fixtures, high-end products on display, and luxe gold accents. It feels less like a medical environment and more like an upscale boutique, complete with a velvet couch. The young women staffing Alchemy 43 sport impeccable makeup and totally smooth faces—a look I don't often see in my life as a stay-at-home mom and writer on the relaxed east side of Los Angeles. Other services offered by Alchemy 43 include wrinkle relaxing, fillers, sculpting, and lash enhancement, and I imagine for a minute what it would be like to have the time and money to get all these treatments. I would never be able to keep up; I don't even get my hair cut more than once or twice a year.
Owner Nicci Levy told me the spa sees about 30 clients per month for Kybella, and that all of the customers have seen a positive result. "People are very interested in this treatment," she said. "We have seen amazing results." My expert injector (or "alchemist" as they're called at Alchemy 43) Katie Saliman is a tall, blond nurse with a strong jawline. Saliman told me she loves administering Kybella because of its "wow factor." "This product can absolutely change your profile and really improve the shape and contour of your jawline," she said. I appreciated her enthusiasm.
Saliman was involved in the clinical trials for Kybella; her experience eased my fears about being stuck in the neck with needles full of acid. In studies, about 4 percent of subjects had nerve damage in the lower jaw, and this was my biggest concern going into the procedure. I asked about the possibility of hitting a nerve, and Saliman assured me it hadn't happened to any of her patients. Even if it did happen, she said, I'd have a crooked smile but only temporarily—the damage typically wears off after a few months. I guess I could deal with some nerve damage, I thought wryly.
Saliman took a series of high-tech, 3-D photos, some "before" shots, and applied numbing cream under my chin. Then she applied a temporary-tattoo dot grid; a map of injection sites. With some help from a similarly beautiful assistant, Saliman started poking. I felt each needle go in, but it wasn't unbearable. If I could survive labor and root canals, I thought, I could definitely deal with this. I started to feel a burning sensation as the drug took effect, and I iced my chin when Katie would pause for a new needle. In all, I had about 30 injections from three vials of Kybella. Though they were many, the shots themselves only took maybe five minutes or so. Saliman recommended I do two more treatments, approximately six weeks apart. "Everyone needs two to six treatments, and we are big advocates of 'treat to complete,'" Levy said.
For each treatment, the injector uses between one and three vials of Kybella, depending on how much submental fat one has. According to Deanne Mraz Robinson, a dermatologist and the director of the Body Sculpting Center at the Connecticut Dermatology Group, the cost for a single treatment ranges from $800 to $1,400, depending on how many vials you need, and the particular pricing of your doctor or spa. Kybella's cost can exceed that of liposuction (which generally runs between $2,000 and $5,000), but many clients are willing to pay a higher price to avoid going under the knife. "People are excited that there is an option for treating their double chin," Mraz Robinson, who was one of the investigators in the approval trial for Kybella, told me. "Previously, the only procedure that was available to treat submental fullness was surgical liposuction, which is an invasive procedure with its own inherent risks and benefits."
Saliman told me that I'm a great candidate for Kybella because my submental fat is genetic, rather than weight-related. And I'm 34. Younger clients typically do well because they have better skin elasticity, and are less likely to have excess, sagging skin under the chin. "It is important to make sure that the fullness under the chin is from fat under the skin and not caused by other conditions, such as laxity of the skin," Mraz Robinson explained. "Submental fat can be seen in a wide range of ages, as factors such as genetics, hormone status, and weight can influence the amount of fat under the skin."
An interesting trend came up in market research and studies, Gallagher told me: Kybella is bringing in a totally new group of injectable consumers. About 45 percent of people getting Kybella are new to aesthetic treatments—they're people who haven't previously been in a cosmetic or aesthetic physician's office. (I would be counted among this group.) And the procedure is attracting an unlikely clientele: men. "Many men who wouldn't have previously considered cosmetic procedures are coming in for Kybella to sharpen their jawline," Mraz Robinson noted. Levy also told me that she's noticed a younger group coming in for "sculpting" procedures like Kybella. Millennials are interested in injectables, it seems.
I've never felt more L.A. than I did driving through Beverly Hills with a medical compression bandage around my head. My chin was pretty sore for about two hours after the injections, but I started feeling better fairly quickly. As predicted, the injection area started puffing up like a bullfrog. I slept with my head propped on two pillows, the bandage around my chin.
Swelling typically peaks at 24 hours post-treatment and can last from two days to three weeks. It took me about three weeks to get back to baseline. But that's normal, according to Saliman. I was told not to drink alcohol or take painkillers for 48 hours before my injections, and luckily I developed only one tiny bruise (the day after treatment). The inflammation wasn't pleasant, but swelling means the medication is working to dissolve fat—no pain, no gain. The swelling is caused by the active medication breaking down the fat cells, and some of the volume can be attributed to the solution itself. Sometimes I'm incredulous that I actually went through with something so vain, and sometimes I'm proud that I actually withstood all those needles. "You tolerated it like a CHAMP!" Saliman emailed me afterward. This makes me feel tough, which is weird and horrible because we're talking about getting injectable cosmetic treatments in Beverly Hills. But I'll take it! I am a true warrior.
Gallagher confirmed that swelling was a good thing. And puffiness after subsequent treatments won't be as extreme. There may also be bruising, pain, numbness, redness, and areas of hardness (which can feel lumpy, or like small pea-like nodules, caused by swelling) in the treatment area. All of these, he tells me, should be temporary. I did experience numbness and a little pain at the onset, but my side effects were tolerable.
The process can be relatively slow, with results taking weeks or, more often, months. This can be discouraging, especially to people who are self-conscious about their chins to begin with. The good news is that once your monthslong process is completed, those fat cells are not coming back. There is no upkeep to consider, or future costs. "You take those fat cells away, they won't re-create themselves," Gallagher said. Safety studies have been done on the long-term results, and "in general, between 75 and 90 percent of patients are still maintaining their response at up to five years." Gallagher also noted that most patients really turn a corner after the second treatment, seeing a noticeable reduction in fat.
I haven't fully seen my results yet, but in more than 20 studies, nearly 70 percent of the thousands of patients reported physical and emotional improvement. That sounds promising. Two U.S. trials put before the FDA showed that nearly 80 percent of those treated with Kybella noticed a reduction of their submental fat and thus had improved satisfaction about their appearance. And doctors are also happy about the advent of this drug. "Physicians have really enjoyed the precision and the efficacy of Kybella, I'd say," Gallagher noted. "It does what it's going to do … it's gonna kill fat cells wherever it's injected." Well, wherever it's injected within reason.
Kybella could be used on various other small areas. From a clinical standpoint, Allergan is looking at the "bra fat" area—the roll of fat that can be present under the bra line or between the bra and the armpit—and the jowl. "Sometimes that's just skin laxity, but there are times when that's due to fat, as well … so we are certainly actively considering whether we would go into a clinical program there, looking at jowl fat," Gallagher said. Mraz Robinson told me that "Kybella will likely be approved for use on body areas to reduce subcutaneous fat," and my injector agreed, noting, "This type of practice is already being studied in the anterior bra-fat area and upper knees." So although larger areas have been ruled out (an ample stomach, for instance, would need too much product and would require too many needles), whether other small pockets of fat could be helped with Kybella is currently being investigated. Studies would be needed before use on these other areas would be approved by the FDA.
I didn't see much of a difference after my first treatment, but deoxycholic acid is currently popping fat cells after my second treatment, which was about two weeks ago. I'm just starting to notice a reduction. The second treatment is often the turning point, the experts told me, and Saliman is optimistic that I won't need a third go. I had lidocaine numbing injections plus the Kybella shots for the second treatment, and the increased volume caused more swelling. Overall, the second treatment was a little more painful than the first, and I experienced more bruising. One thing I've noticed while scrutinizing profile photos through my "Kybella journey": Perhaps there wasn't much of an issue to begin with! Maybe that softness in my profile is more common than I realized, and not the "double chin" I imagined. But if Kybella does work? I'll be more than happy to have a slimmer chin.
Khloe Kardashian Kicks Off Kybella's Live Chin Up Campaign
Allergan, the maker of Botox, kicked off their Live Chin Up campaign at an exclusive event in New York City today, hosted by television personality and New York Times best-selling author Khloé Kardashian. The Live Chin Up campaign is designed to help encourage people to not let the things that bother them get in their way.
At the event, Kardashian moderated a distinguished panel of experts which included a dermatologist who discussed submental fullness and treatment options, including Kybella (deoxycholic acid) injection. Additionally, a patient joined the panel to discuss her experience with submental fullness.
"We are very pleased that Khloé was able to serve as the host of our event and discuss how she lives chin up," said Philippe Schaison, EVP and President of Allergan Medical. "As someone who lives life in the public eye, Khloé embodies what it means to live chin up by refusing to let negativity stand in her way. We feel she is the perfect person to kick off this inspiring campaign."
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