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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.
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.
“Scar tissue is collagen and collagen is scar tissue. The difference between them is basically branding.”
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.
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.