Women Are Ditching Lip fillers
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’m like a forensic scientist in there, tracking the history of your aesthetic treatments under your skin.”
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.
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.
Surgeons rely on consistent landmarks to guide them safely through the facial layers. When tissues are scarred and muddled, surgeons can lose their bearings.
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 biostimulators
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.
Deep-energy treatments
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.
“It’s like if you were to microwave crayons. They’d go from red, blue, and green to a brown mess.”
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.”