Not a day goes by in my office without someone asking me if a “liquid facelift” would work for them. It’s no surprise patients ask about this option, as it has been promoted in the press a great deal lately. A liquid facelift refers to attempting to improve the appearance of the face with the use of injectable fillers and BOTOX® instead of surgery. I will discuss the appropriate use of fillers later in this article, but it is important here to remember the old adage that if it sounds too good to be true, it probably is.

The media is fascinated by any potential option for rejuvenation that does not involve surgery. Patients are definitely interested in the most effective procedures that are the least costly and result in the least downtime. Many of the treatments offered with these claims, however, often provide results that do not meet the expectations of the patients. They are marketed with claims that are high-flying, and while it is true that some of them provide improvements, the degree of improvement is, in my experience, much less than expected, and the longevity of the result also tends to be lacking.

I will discuss a few of the more commonly offered treatments and then discuss my approach to facial rejuvenation. Non-ablative lasers have been developed to improve on the lengthy recovery times that were associated with ablative lasers, such as carbon dioxide lasers. The most popular non-ablative laser treatment currently is Fraxel. This laser creates controlled geographic areas of tissue damage that lead to new collagen production in the skin; therefore, the treatment theoretically reduces visible wrinkling and acne scarring. It is generally performed without anesthesia and a series of three to six treatments are recommended. It does not treat brown spots that occur with sun-damage and aging. There is minimal swelling and occasional discoloration, but it only lasts briefly. In the before and after photos published in the studies promoting Fraxel, I find the results to be underwhelming to say the least. The lines and wrinkles are still prominent, and a generous estimate is that they are less visible by possibly 20%. Very few of my patients would be happy paying for six treatment sessions to obtain a 20% improvement in their appearance, even if there was no downtime.

Thermage has also become very popular. This device passes a mono-polar radio frequency electrical current through a patient’s skin, which tightens the skin and wounds the collagen, resulting in a repair process that thickens the collagen layer. It is done without anesthesia and does create a heating sensation in the skin. The authors of a recent study reported they saw a 5–20% improvement in the appearance of their patients’ skin and noted that the results were variable. They cautioned that managing patient expectations was key, and in no way should this device be purported to provide equivalent results to a facelift. Tightening of the skin was described as one to three millimeters. During a face lift, I frequently remove twenty or more millimeters of skin. While it is true that there is minimal downtime after a Thermage treatment, it also appears to be true that the result is minimal.

Fillers are a tool I use in the vast majority of my patients who desire facial rejuvenation. They are injected into the deeper layers of the skin in areas of furrows or wrinkles to fill them out. They can also be used to increase lip size. One of the more common targets are the “parentheses lines” that run from the bottom of the nose to the corner of the mouth. Results last from four months to indefinitely, depending on the type of filler chosen. I prefer Juvéderm®, which is made of hyaluronic acid, a natural component of human skin. This filler comes with local numbing medicine in it, so it can be injected in the office. There is mild bruising in some patients, but most have no downtime. The result generally persists for about one year. I do not prefer to use the fillers that have longer effects because they tend to be more palpable and have a slightly higher complication rate, such as cyst formation.

For many years, I was not a fan of BOTOX® mainly because most surgeons in the past used excessive amounts that created an unnatural look. I have subsequently learned how to use a more personalized approach at generally lower doses, resulting in softening of lines and wrinkles without creating an immobile appearance. With this method, BOTOX® can be a very useful tool in facial rejuvenation.

For any patient who wants a more youthful or rejuvenated appearance, seek out a board certified plastic surgeon for an opinion. The surgeon should listen to your goals and design a plan that will accomplish the results you desire. For patients over 45, it is most common for a three-pronged approach to rejuvenation to provide the most complete result. By this, I mean that the combination of a doctor-prescribed skin care program, injectable fillers, and facial surgery provide the best results. If the skin is not in good shape, the result can be hampered. If tension is used to stretch the skin, the results can appear unnatural. That is why I prefer to use filler to treat deeper furrows, so that tension does not ever come into play. Surgery, however, is the only effective treatment for re-positioning tissues that have given way to gravity and are sagging.

Many times, the best course of treatment is to start a skin care program and have filler treatments first, especially if surgery is out of reach or undesired at the outset. I do not recommend undergoing expensive, repeated minimally invasive treatments that just do not have enough benefit to justify their costs. If it sounds too good to be true, it usually is.

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