Thread lift or fillers? How to choose: Finding the right treatment, Part 1

If sagging is your concern, start by looking at your age. If you're over 50 with significant sagging, think of a thread lift first; if sagging is mild or you're under 50, consider device-based lifting with lasers, ultrasound or radiofrequency first. For hollow areas, you choose between fillers, collagen-stimulating skin boosters and fat grafting, and each of the three has clear pros and cons.

These days the problem is too much information. Every clinic website says only good things and shows only good devices, so it's hard to tell which treatment will address your concern, and how.

So if you read this column carefully, you'll get a rough idea of which type of treatment suits your concern, even if you never come to our clinic. (Of course, people differ a lot, so wherever you go, I strongly recommend seeing a doctor for a consultation.)

And rather than setting an unrealistic goal, aim to quietly go back to the face you had three to five years ago, without anyone noticing. That's a goal anyone can reach with treatment, and if you're over 60, you can reasonably hope for the face you had five to seven years ago.

First, decide whether your concern is “contour” or “skin”

If it's your first visit to our clinic, start by thinking about which of these two groups your concern falls into.

• Is it your facial contour, such as sagging, hollowing or wrinkles?

• Or is it your skin, such as melasma, blemishes, dryness or sensitivity?

Divide your concerns this way and treat the more urgent one first. Lifting sagging areas won't improve melasma, and treating melasma won't lift a sagging face. The two are completely separate areas. (If both cost about the same, contour treatments are the ones whose effects you'll notice sooner.)

In Part 1, I'll cover contour concerns, meaning sagging and hollow faces. I'll continue with skin concerns in Part 2.

If sagging is your main concern: thread lifts and device-based lifting

It's best to think about this differently depending on your age. Even for the same person, treatment in your 20s and in your 60s is very different.

Generally, if you're 50 or older, starting with a lifting treatment is often the most cost-effective choice. In particular, after about 55 to 60, device-based lifting, which uses energy such as lasers, ultrasound or radiofrequency, starts to become much less effective.

This is called energy-based device (EBD) lifting. Rather than pulling a sagging face upward, these devices often slim the face by working vertically, compressing the tissue from the surface down.

So for people whose concern is lost facial volume, there's almost nothing among them that helps, apart from radiofrequency lifting (for example, Thermage, Oligio or Tentherma).

Instead, from 55 onward, when the jawline sags considerably, a thread lift is in most cases the most effective option.

EBD devices usually deliver energy beneath the skin to stimulate collagen regeneration, and you have to wait one to two months to see results. But after your mid-50s, your ability to produce collagen drops sharply compared with when you were young, and if your skin has already become quite thin, the noticeable effect is much smaller, no matter how good the device or how thorough the treatment.

A thread lift, on the other hand, physically lifts and anchors the tissue with threads, so in these cases the noticeable effect tends to be relatively greater.

In short, when considering a lift, a thread lift should be your first choice if you're over 50 with significant sagging. If you have very little sagging or are under 50, it's better to consider EBD before a thread lift. (Of course, sometimes the opposite is true, so it's important to see a doctor for a consultation in person.)

If volume loss and shadowing are your concern: fillers, collagen-stimulating skin boosters and fat grafting

Many people are bothered by dark circles or hollow lateral cheeks even when they're young. And deep folds such as nasolabial folds and marionette lines deepen in everyone with age; it's only a question of when.

When this happens, the face looks somehow tired and shadowed, because with age the deep fat pads in specific areas shrink: under the eyes, the nasolabial and marionette areas, the lateral cheeks, the temples and the upper eyelids.

Since this is where fat has been lost, if you want the face you had five years ago, something has to fill the space. There are three main materials for restoring volume to the face:

1. Fillers

2. Collagen-stimulating skin boosters

3. Fat grafting

Generally, the more hollow the area, the better fillers or fat grafting work, but these too have clear pros and cons.

Fat grafting

Fat grafting suits the forehead, under-eye area, temples and lateral cheeks. However, the fat has to be harvested surgically from another part of the body, and above all, it's fundamentally hard to correct the marionette area and nasolabial folds, which become the biggest concern with age. That's because grafted fat doesn't take well around the mouth, including the nasolabial and marionette areas.

Even in areas where it takes well, such as the forehead and front of the cheeks, the survival rate is around 50%. To get the result you want, you either graft twice the amount from the start and put up with an awkward-looking period of three to six months, or graft only what you need and have two or three repeat surgeries.

Also, even if the fat settles nicely at first, five to ten years later its weight can make the area sag more than natural aging would, leaving the face more uneven. That's why, over the past ten years, fat grafting has given way to fillers and skin boosters, and the number of procedures has fallen sharply.

Fillers

Fillers are an injection treatment, not surgery, so the process is simple and you can return to your daily routine the same day. That's why the number of filler treatments has grown explosively over the past decade or so. Another big advantage is that if you don't like the result, part or all of the filler can be corrected or removed with a dissolving injection.

However, fillers in areas such as under the eyes and the forehead are technically demanding and need an experienced, skilled doctor, so be sure to find a clinic that does them well. Another downside is that if too much filler goes into one area, one or two dissolving injections may not remove it all. With any treatment, the right amount is good, but too much is not.

Collagen-stimulating skin boosters

Collagen-stimulating skin boosters (collagen stimulators, or biostimulators) were developed for people who don't want either fat grafting or fillers. Well-known products include Sculptra, Radiesse and Juvelook, and many others are available.

These products don't create shape right away the way fat grafting or fillers do, so they're less of a burden for both the patient and the doctor. Most come as a powder that is mixed with saline or anesthetic solution just before treatment.

So one to three weeks after treatment, as the swelling goes down, the face returns to how it looked before. But the material left behind helps collagen regenerate, so two to three months later volume builds up naturally, and the skin itself, including pores, tone and texture, improves as well.

Hearing this, you might think these products are the best option of all. So why aren't they the most widely used?

The concept is excellent, but most of them don't create volume as reliably as fat grafting or fillers, and even when they do, a satisfying result takes at least three sessions and six months to a year at the very least. (People who want to see results quickly often find this wait very frustrating.)

Results also vary from person to person, which makes it very hard for doctors to predict the outcome precisely. What's more, people with thin faces who want more volume often don't produce much collagen, while people who are bothered by having too much volume often produce more. The rich get richer, you could say. (This isn't true of everyone, and again, you only really know once you try.)

Under the eyes, if the product is placed too superficially or not massaged enough afterward, nodules (small lumps) can very rarely form, so make sure your doctor explains everything fully and follow the aftercare instructions.

Summary: three ways to fill a hollow face

• Fat grafting has the advantage of lasting a long time, but fat doesn't take in the nasolabial folds and marionette lines, so it's hard to see results there, and you may need several surgeries. That's why the number of procedures has fallen sharply in recent years.

• Fillers are convenient, so their use has grown a lot, but they're technically demanding, so you need to find a skilled doctor, and putting too much into one area isn't a good idea.

• Collagen-stimulating skin boosters are a good concept, but it's hard to restore enough volume with them.

In Part 2, I'll go on to explain which treatments suit skin concerns such as dry, sensitive skin, melasma and blemishes.