Getting Injectables Now Could Complicate a Facelift Later

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Facelifts were up (pun very much intended) 18% in 2022. As this ultimate of skin-tightening procedures — and the patient demographic getting them — evolves, Allure is exploring the phenomenon of the modern facelift in our new series, Want a Lift?

Last fall, one of the world’s most respected facelift surgeons, L. Mike Nayak, MD, posted a video on Instagram comparing two faces mid-surgery: one had received hyaluronic acid fillers in the past; the other, Sculptra (poly-L-lactic acid), a collagen-stimulating injectable. The tissues in the first face appear glistening and smooth, with delicate nerves on display, while the Sculptra-treated tissues are bumpy, bloody, and chaotic. This is an extreme example of the injectable’s potential impact, says Dr. Nayak, a double board-certified facial plastic surgeon in St. Louis.

While not for the queasy, the post quickly went viral, sparking debate across the aesthetics community. “My goal wasn’t to start a controversy,” Dr. Nayak tells Allure. “It was to answer one of the most common questions I get asked: ‘Are there treatments that can make future surgery more difficult?’ I think it’s only fair to be able to ask that question and get a straight answer.”

This type of reaction isn’t limited to Sculptra — other collagen-stimulating procedures and fat-reducing technologies may cause similar effects — and it doesn’t occur in everyone who’s tried these treatments, clarifies Dr. Nayak (he also pointed this out in his post). During surgery, “sometimes everything looks perfect; sometimes we see issues we can work with; and sometimes we have real problems,” he says. What are the odds of future surgical complications arising from treatments like Sculptra? “We don’t know the answer to that yet,” he says. But unless you’ve completely ruled out a facelift, this is a risk to be aware of, because certain nonsurgical interventions can alter the tissues in ways that make surgery more arduous and less predictable with a rougher recovery.

For years, plastic surgeons have been confronting the ghosts of treatments past: scar tissue, filler nodules (lumps), stray threads (from past thread lifts), crippled blood vessels, fat atrophy, and more. With increasing frequency, they’re discussing this phenomenon in private group chats and at medical conferences. While Dr. Nayak was among the first to publicize surgeons’ concerns (with stunning visual aids), what he reveals in his video is hardly a freak occurrence.

“I see it virtually every time I operate,” says Elizabeth Chance, MD, a double board-certified facial plastic surgeon in Charlottesville, Virginia. “I’m like a forensic scientist in there, tracking the history of your aesthetic treatments under your skin.”

In an online poll of 114 facial plastic surgeons conducted by board-certified plastic surgeon Christian Subbio, MD, 82% of doctors reported finding significant scarring in facelift patients who had used Sculptra or other so-called biostimulators (injectables that spur collagen synthesis), like Radiesse. Seventy-four percent rated the effects of thread lifts as equally or more concerning. “I never want to see a thread, ever,” says Marissa Tenenbaum, MD, a board-certified plastic surgeon in St. Louis, explaining they can scar and otherwise distort the tissues. In a separate 2023 survey of 156 plastic surgeons from The Aesthetic Society, more than half claimed that repetitive full-face filler injections (namely Radiesse and Sculptra) make facelifts trickier to perform. When asked to comment on Sculptra’s potential to create scar tissue, Galderma (the manufacturers of Sculptra) said that, to its knowledge, “the majority of Sculptra patients do not exhibit scarring.” It also pointed out that “Sculptra is often not received in isolation. Aesthetic injections themselves can cause some scar tissue, as well as laser/energy-based devices which are also done in conjunction with Sculptra.” When asked to comment on Radiesse’s potential to form scar tissue, possibly complicating facelifts, Merz (the makers of Radiesse) said, Radiesse “delivers immediate results plus long-term improvement by enhancing many important factors in the skin, such as two types of collagen, elastin and hydrating proteins. With 20+ years of scientific and clinical history and more than 15 million syringes sold worldwide, Radiesse’s safety and efficacy have been demonstrated in more than 220 peer-reviewed publications.”

I consulted nearly a dozen surgeons, who use a variety of facelift techniques, and they have all, at some point, stumbled across scarring and fat loss from prior interventions. “We’re all contending with a loss of fat in the neck from deep radiofrequency microneedling,” adds Dr. Chance. These treatments, which deliver intense heat on the tips of tiny needles, are often used to try to “tighten” the neck, but can inadvertently deplete fat and fuse the skin to the underlying muscle, causing the neck to look older and making surgery more challenging.

When overused, “these devices can be very destructive,” says Ellen Gendler, MD, a board-certified dermatologist in New York City. She discourages her Instagram followers from getting radiofrequency microneedling treatments, insisting that the risks far outweigh the potential rewards. “I hear from people on Instagram: ‘I’m 27 and I’ve had seven Morpheus8 treatments.’ Seriously? Who does this to people? It’s crazy.” (There are several brands of radiofrequency microneedling devices but Morpheus8 has become the Kleenex of the category.)

This conversation is incredibly nuanced and based mainly on surgeons’ anecdotal experiences, which can breed strong and conflicting opinions. “This doesn’t mean arguments aren’t valid, but it would be a mistake to jump to conclusions or dismiss nonsurgical therapies as counterproductive or incompatible with surgical lifting,” notes Danny Soares, MD, a double board-certified facial plastic surgeon in Fruitland Park, Florida.

At the moment, there’s a dearth of reliable data linking collagen-stimulating injectables, thread lifts, or heat-based treatments to poor facelift outcomes or heightened complications. This seems to be cold comfort to those holding the scalpels, however. In Dr. Subbio’s survey, 79% of surgeons said they worry about nerve injury and skin death when operating on folks who’ve used collagen-stimulating injectables.

Meet the experts:

  • L. Mike Nayak, MD, is a double board-certified facial plastic surgeon in St. Louis and has served on advisory boards for Allergan and Galderma.
  • Elizabeth Chance, MD, is a double board-certified facial plastic surgeon in Charlottesville, Virginia.
  • Christian Subbio, MD, is a board-certified plastic surgeon in Philadelphia and a speaker for Sciton.
  • Marissa Tenenbaum, MD, is a board-certified plastic surgeon in St. Louis and is on the advisory board for Revelle Aesthetics, in which she holds stock.
  • M. Bradley Calobrace, MD, is a board-certified plastic surgeon in Louisville, Kentucky, and a speaker for Allergan, from which he has received stipends.
  • Ellen Gendler, MD, is a board-certified dermatologist in New York City.
  • Danny Soares, MD, is a double board-certified facial plastic and reconstructive surgeon in Fruitland Park, Florida, president of the American Foundation for Aesthetic Medicine, a speaker and trainer for Revance Therapeutics, and has received research grant funding from Merz Aesthetics North America.
  • Ben Talei, MD, is a double board-certified facial plastic surgeon in Beverly Hills and a speaker for Candela.
  • Sarmela Sunder, MD, is a double board-certified facial plastic surgeon in Beverly Hills.
  • Jessica Weiser, MD, is a board-certified dermatologist in New York City; a consultant for Sofwave, Lutronic, and Cutera; and a trainer for Allergan and Galderma.
  • Amelia K. Hausauer, MD, is a board-certified dermatologist in Campbell, California, and holds various roles for companies including Allergan, Galderma, and Revance Therapeutics.
  • Jason Bloom, MD, is a double board-certified facial plastic surgeon in Bryn Mawr, Pennsylvania; a consultant, trainer, clinical investigator, and speaker for Allergan and Galderma; a speaker for Sofwave; and a consultant, trainer, and speaker for Revance Therapeutics.
  • Flora Levin, MD, is a board-certified oculoplastic surgeon in Westport, Connecticut, and a consultant for Candela.
  • Julius Few, MD, is a board-certified plastic surgeon in Chicago, a former consultant to Sinclair Aesthetics (the parent company of Silhouette InstaLift), a director/consultant for and stockholder in Hydrafacial, and a consultant for Sciton (with stock options).

In this story:

Weird but true: Collagen is basically scar tissue

Since collagen is the goal of so many nonsurgical procedures, let’s start there. Collagen is a protein that exists throughout the body. In the dermis, it’s famous for lending structure and strength to the skin, but various kinds of collagen also comprise our joints, bones, and blood vessels.

“We have over 28 types of collagen throughout our body,” says Ben Talei, MD, a double board-certified facial plastic surgeon in Beverly Hills. And while we’ve all been taught that collagen is central to youthful skin, it’s merely one variable, along with “elastin, hyaluronic acid, fat, and a thousand other elements which are difficult to understand,” he says.

But here’s where things get really interesting: During my interviews, doctors kept using the terms “collagen” and “scar” interchangeably, which I found a bit perplexing until Dr. Chance broke it down like this: “Scar tissue is collagen and collagen is scar tissue. You could get super-nerdy about it, but the difference between them is basically branding.”

In the context of nonsurgical treatments, collagen is often a euphemism for scar tissue: Collagen-stimulating devices and injectables “create controlled injuries,” explains Sarmela Sunder, MD, a double board-certified facial plastic surgeon in Beverly Hills. In response, “scarring is the reparative process whereby new collagen is formed.” And even though “we like to think we’re doing it in a controlled way, you can never fully control how the body scars,” Dr. Tenenbaum says. That’s why biostimulators make some doctors uneasy. The result — be it underwhelming, robust, or just right — is largely out of their hands, driven instead by an individual’s anatomy and genetics as well as the whims of their immune system.

What’s more, the collagen born of cosmetic treatments doesn’t necessarily mirror our native supply. It may be organized differently or sprout where it shouldn’t. Injecting biostimulators under the skin, for instance, “tends to create localized collections of collagen that are unevenly distributed,” says Jessica Weiser, MD, a board-certified dermatologist in New York City. If the products are placed improperly, these “rope-like bundles” can grow in layers of the face where collagen is not normally found, like in the fat lining the underside of the skin or in the muscle below.

Our intention here isn’t to scare you or put any brand on blast. These collagen-building procedures are generally FDA-cleared or FDA-approved and regarded as safe and effective. “When used well, they are very successful,” says Dr. Chance. “This is not like The Emperor’s New Clothes, where people are saying, ‘This is really working’ when it’s not.”

While no one loves the idea of scar tissue, in some cases “that irregular architecture is actually what we’re aiming for,” adds Amelia K. Hausauer, MD, a board-certified dermatologist in Campbell, California. It’s conferring the desired effect: Biostimulators’ collagen clusters fill out hollows. The scarred or contracted tissue from radiofrequency makes skin feel a little firmer. When asked to comment on whether scar tissue creates Sculptra’s desired effect, Galderma said, “Sculptra promotes tissue regeneration and improves skin quality by helping to restore the skin’s own collagen and elastin.”

Each treatment may have its own implications for future facelifts

Given the absence of conclusive evidence, there are few black-and-white truths on this topic. Still, when asked which types of interventions tend to cause the biggest headaches during facelifts, most surgeons cite the same ones: biostimulators, thread lifts, and deep-energy treatments (radiofrequency and ultrasound) that purport to “tighten” or “lift.” Fat-freezing and overly-aggressive past surgery (including liposuction) are two others that come up.

When facial tissues have never been touched, they glide and divide effortlessly. The anatomical terrain is familiar and easy to navigate. Surgeons can rely on consistent landmarks to guide them safely through the facial layers. But when tissues are scarred and muddled from previous treatments, surgeons can lose their bearings and the journey becomes more perilous.

Scar tissue in the deeper layers can upend surgical plans and “may cause an elevated risk of injury,” says Dr. Soares. If nerves are accidentally bumped or nicked, parts of the face can be temporarily weakened or even permanently paralyzed. “We need to take the layers of the face and neck apart so we can manipulate them independently and then put them back together in the right shape,” explains Dr. Nayak. It’s facelifting 101. But when previous procedures muck up those layers, this basic task becomes daunting.

Ready for some good news? Following all of these procedures, “inflammation and scarring does subside over time,” says M. Bradley Calobrace, MD, a board-certified plastic surgeon in Louisville, Kentucky. Blood vessels can regenerate and tissues can normalize to a degree after several years (between two and five, doctors estimate). “I personally see fewer problems from treatments done further in the past,” notes Dr. Calobrace.

The discrete lumps of collagen that surgeons sometimes see in Sculptra patients can act like 3-dimensional drops of glue in the face, Dr. Nayak says, binding together layers that normally peel apart easily. To grasp the ramifications of this, imagine those layers like the diaphanous pages of a time-worn classic. Now picture them haphazardly dotted with adhesive. In leafing through, “you may mean to end up between page 67 and 68, but because they’re fused together, you’re at 69 — where vital structures live.”

The act of separating one layer from the next can leave tears and thin spots in the tissue, says Dr. Nayak, which may manifest as divots or ripples in the skin, “making the quality of the final product [i.e. your facelift] not as good.” Or as strong: Moth-eaten tissues don’t hold sutures well and may fail to stay lifted after being tacked into place.

Wading through scarred tissues can stir up swelling and cause excessive bleeding. “When the tissues are oozing, the patient will have more bruising and downtime,” Dr. Nayak notes. The risk of developing a hematoma during recovery also shoots up. When these pools of blood form under the skin, they commonly have to be drained in the OR.

While Sculptra may be associated with stickiness, Radiesse can stiffen tissues either by infiltrating them directly or via its intense collagen deposition, Dr. Nayak says. He can often tell it’s going to be “a challenging day” if his needle struggles to pass through the skin when he’s injecting numbing fluid before surgery. Occasionally, Radiesse “makes it nearly impossible to cut through certain areas during a facelift,” says Dr. Talei, which can limit the results.

Not every facelift surgeon views biostimulators as a hindrance. Jason Bloom, MD, a double board-certified facial plastic surgeon in Bryn Mawr, Pennsylvania, routinely operates on faces he’s previously treated with Sculptra and believes proper injection technique can minimize the side effects his peers are seeing. Dr. Bloom injects Sculptra right below the dermis, fanning it out evenly, and finds this method yields “the most collagen stimulation” and the fewest complications. Other injectors prefer to place Sculptra deeper, in the tissue that overlies bone, where there’s also a high concentration of collagen-making cells.

Theoretically, if Sculptra is injected correctly, either superficially or deeply, it shouldn’t pollute the surgical territory sandwiched between those two zones. But Dr. Subbio makes the point that it can be “really tough” to target the sub-dermal tissue without hitting the muscle just millimeters below, underscoring the importance of choosing an experienced practitioner.

Another consideration with biostimulators is where on the face they’re being used. Flora Levin, MD, a board-certified oculoplastic surgeon in Westport, Connecticut, thinks it’s wise to avoid injecting the product in areas where scalpels are known to travel, like in front of the ears, in case patients want a facelift down the road. She says Sculptra is less likely to interfere with a facelift when placed in the temples, which don’t usually factor into the surgery.

Heat-based treatments that penetrate deeply can also affect facial tissues. “It’s like if you were to microwave crayons,” says Dr. Chance. “They’d go from red, blue, and green to a brown mess — same thing with the face and neck.”

Because plastic surgeons love analogies, Dr. Nayak offers us a cheese sandwich: “If you haven’t grilled that sandwich, you can take the layers apart and put them right back together the way they’re meant to be.” Heating the sandwich changes its properties, merging its layers, so you can’t move them freely or raise the bread without ripping it.

Deep-energy devices can also “seal off blood vessels,” which carry oxygen and nutrients to the skin, for a time, says Dr. Sunder. If skin with sluggish circulation gets lifted up and then stitched back down during a facelift, it can take a long time to heal; its edges could even blacken and die. A study published in Plastic and Reconstructive Surgery (PRS) in 2023 acknowledges this risk and likens facelift patients who’ve had prior deep-energy treatments to smokers, a group that has a notoriously hard time healing after surgery.

In Dr. Sunder’s practice, people who’ve been slowest to heal following facelifts are those who had Ultherapy within one to two years of their surgery and neglected to tell her. She always asks about past procedures, but sometimes patients forget or don’t know exactly what they’ve had done. Normally, when patients report having Ultherapy in the recent past, Dr. Sunder will send them for hyperbaric oxygen sessions before surgery to give them “a better shot at healing.” You can “avoid a lot of pitfalls,” she says, by disclosing your treatment history. When asked to comment on whether Ultherapy might complicate facelifts, including by possibly creating scar tissue, Merz (the maker of Ultherapy) said, “Ultherapy is a microfocused ultrasound device cleared by the FDA that works safely and effectively by stimulating the production of new collagen and elastin, which tightens and lifts the skin. It has been on the market for 14 years, with over 2.5 million treatments delivered globally to date. The Ultherapy technology is supported by more than 60 clinical studies and more than 120 published peer-reviewed papers.” It also pointed out, “as with all energy-based devices, proper application by a trained professional is key to a safe and satisfactory outcome.”

Again, we’re not looking to shame specific devices — in many cases, when heat-based treatments go awry, it’s because they were misused. The majority of machines have adjustable settings, which allow doctors to customize temperature and depth. But according to Dr. Sunder, some providers go overboard when attempting to deliver a “nonsurgical facelift” with a radiofrequency or ultrasound device. “They crank it up as high as possible to try to give lifting and tightening — and they’re causing fat loss and significant scarring under the skin,” she says.

When aiming to boost collagen, doctors should target the lower dermis, says Dr. Talei, which is about one-and-a-half to two millimeters down in most parts of the face. But some devices have the ability to penetrate four or five millimeters or even deeper, Dr. Sunder points out — “and that’s the depth we may be working on in surgery, depending on the facelift technique.”

Many plastic surgeons prefer Sofwave to other skin-tightening modalities because its ultrasound energy penetrates to a max of one-and-a-half millimeters, theoretically safeguarding deeper tissues. Board-certified Chicago plastic surgeon Julius Few, MD, will even send thin-skinned patients for Sofwave six to 12 weeks before surgery, believing that the treatment improves skin quality and “amps up” his facelift results without a downside, since it’s unlikely to affect fat or muscle. (Others argue that any device that makes heat can melt fat. Caution should be taken, especially in areas where the skin can be less than one millimeter thick, like around the eyes, in the temples, and in the aging neck, says Dr. Weiser. Always get your surgeon’s approval before having anything done prior to a scheduled facelift.)

When asked to comment on whether Morpheus8 might complicate future facelifts, including by possibly creating scar tissue, Spero Theodorou, MD, chief medical officer at InMode Ltd. (the maker of Morpheus8) said, “radiofrequency energy has been used since the inception of modern day surgery, so its safety profile is unparalleled. While there is always an element of ‘scarring’ when utilizing any procedure to enhance collagen production the key is on how the energy is applied and to what effect. Our patented bipolar RF technology targets specific temperatures in the dermis to cause dermal contraction as well as internally for collagen remodeling. This allows for ideal tightening without the side effects that other non-targeted energies display.” And according to Dr. Theodorou, “from what we have seen over 15 years of our doctors utilizing [Morpheus 8 and our family of RF products] in the field, [they] have no bearing on future aesthetic operations.”

Threads can also promote scarring, especially when haphazardly placed. And since they don’t always absorb as advertised, surgeons often find them studding the deeper layers of the face or snaking precariously around nerves. Dr. Soares says that the threads themselves and their collagen byproducts can “create unnatural tethering,” leading to a pulled look or odd expression.

Dr. Few, who performs thread lifts in his practice, refutes the popular belief that threads unequivocally make facelifts harder. When threads are placed appropriately, he says he has no trouble operating behind them years later. “I’ve done over 100 facelifts in my Silhouette [thread lift] patients, and find it actually makes it easier — it almost gives me a runway,” he explains, since the tissues tend to be somewhat thicker than normal and better able to hold surgical sutures. However, when practitioners indiscriminately insert 50 or 100 monofilament threads all over the face in the name of collagen synthesis, “that’s a different animal,” he says. “[That patient is] getting a lot more inflammation.”

Can hyaluronic acid filler affect a facelift?

Hyaluronic acid filler is more of a nuisance than a real obstacle during surgery. Some doctors suggest dissolving it with hyaluronidase beforehand, though, for a couple of reasons.

First, residual hyaluronic acid, especially around the eyes, can lead to dramatic and prolonged swelling after any facial surgery. Hoping to prevent it in patients having eyelid lifts, “I now insist that anybody who’s had filler in the past 10 years dissolves it about a month ahead of surgery,” says Dr. Levin. Filler can hang around for years in the tear troughs, blocking the lymphatics and causing persistent puffiness.

If you don’t melt filler pre-op — or even if you do, but stubborn gel remains — it can be a pain to operate around and an enormous time-suck to remove in the operating room. Dr. Chance recently spent an hour and a half manually extracting “buckets” of leftover Voluma from a facelift patient, attempting to spare her an extra-lengthy recovery.

What about previous facial surgery?

Surgery itself introduces scar tissue and swelling, while also affecting blood flow to the skin. So fans of nonsurgical treatments often argue that any surgeon capable of performing a secondary or revision facelift should be able to manage the effects of injections or heat.

What’s the difference, really?

It relates to the nature of the scar left behind. “With injectables and devices, the scarring is from the surface down through the tissues,” says Dr. Calobrace. In one way or another, these modalities quilt the facial layers together, making them harder to work with during surgery.

A well-done facelift, on the other hand, typically creates even, horizontal sheets of scar tissue. While thicker and perhaps less pliable than virgin tissues, these sheets are “easier to handle than the shotgun lumps of scar” left by biostimulators, explains Dr. Nayak. They’re clearly defined and “we can dissect right along them.” Some surgeons even find secondary facelifts easier to perform for this reason.

What can I do if I plan on someday getting a facelift?

If a facelift isn’t for you, carry on with your favorite tweakments, being cautious and conservative. For the best experience, Allure recommends connecting with a board-certified dermatologist or plastic surgeon who has a deep understanding of facial anatomy, offers an array of cosmetic services, and curates treatment plans based on long-term goals.

If you are entertaining a lift — well, you’re not alone. New data from the American Academy of Facial Plastic and Reconstructive Surgery shows facelifts are up 60% since 2017, with interest steadily increasing among those 35 to 55.

It’s folks in this age group, doctors say, who are grappling with the onset of sagging and deflation and feel most conflicted about how to address their aging reflections. (I, for one, can relate.) If you’re not quite ready for a facelift, but don’t want to risk burning that bridge, what can you do, in this moment to look and feel better?

Some plastic surgeons say that if you’re a candidate for a facelift — in good health with pronounced jowling and neck laxity — then skip the nonsurgical collagen-building substitutes, because they’ll likely disappoint and could compromise future surgery.

Others take a less stringent stance. “There are a lot of patients in the gray zone, on the cusp of getting a lift,” says Dr. Sunder. “And we can offer them treatments to push off surgery a little bit, if we do it in a thoughtful manner.”

Dr. Bloom worries that 40-somethings are getting scared away from nonsurgical aesthetic options (many of which are maligned on social media) and rushing into surgery before they’re truly ready. Some see it as their best or only option — and wind up with “shitty chop-shop surgery,” he says, because they’re not spending the money on a quality facelift.

For those who aren’t fully prepared — emotionally, physically, financially — to go under the knife, Dr. Bloom will often use Sofwave “to try to tighten down the tissue” and thwart early signs of laxity. If volume loss is bothersome, he may inject dissolvable hyaluronic acid fillers, strategically and in small doses, to camouflage areas of sinking or sagging.

Additionally, “you can never go wrong improving the quality of your skin,” Dr. Tenenbaum adds. Intense pulsed light, nonablative lasers like the Fraxel Dual or Moxi by Sciton, mild chemical peels, gentle microneedling, and neuromodulators, like Botox, can all enhance the skin’s tone and texture without jeopardizing future surgery.

The general consensus on biostimulators, threads, and deep-energy devices is to avoid them in the lead-up to a facelift. Dr. Sunder will wait up to two years before operating on a patient who’s recently had Sculptra, Radiesse, Ultherapy, or certain radiofrequency microneedling procedures. If someone’s had threads, she delays even longer, “waiting for that inflammation to settle down.”

Try not to stress too much about past procedures, though. “What’s done is done,” says Dr. Nayak, “and the preponderance of people do just fine,” he assures me. Facelift specialists have grown accustomed to operating in patients who’ve had biostimulators or radiofrequency in the past. Still, being mindful about your treatment choices now could mean a safer, better facelift in the future.

To read more about facelifts in Allure’s new series, Want a Lift?:

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