When you are considering which aesthetic skin tightening treatment will work best to reduce sagging skin, how do you decide? I am often asked whether a particular patient will benefit from the non-invasive treatments or will require a surgical face lift. As with most other cosmetic or aesthetic problems, the answer is—“it depends”. There are two components to the question. First, objectively, what does the physical status of the sagging skin require to achieve tightening? What, objectively, can you expect as realistic results for any treatment? Second, what degree and kind of results do you, as the patient, desire. And finally, what are you willing to do to get it? What kind of discomfort, down time, and recovery are you willing to undergo? And what are you willing to pay for it?

At times I see patients who have a mismatch between the first, second and third components of the equation. It is part of my job to try to outline for them what they can realistically expect based on the combination of their choices of desired results, down time, discomfort, risk and cost, on the background of how they as individuals likely will medically respond.

Most commonly this mismatch is seen with patients who need a significant amount of change, but want to do very little to achieve it. These patients have a lot of skin sagging (laxity), very little elasticity, and significant loss of volume where it should be (mid and upper cheeks, under the eyes, around the mouth and in the lips), and too much volume where it shouldn’t (jowls, jaw line and as bags under the eyes). When asked what kind of results they want, the answer is almost always “I just want this” as they take their hands and pull the skin back tightly several inches from their lower face toward the ears, removing all looseness and giving them a tight jaw line and upper neck. When we discuss that “I just want this” requires a surgical face lift (and often also an eyelid lift and brow lift) and adequate volume replacement they are disappointed that one syringe of filler or one treatment of non-invasive skin tightening with Thermage won’t achieve “this”. The disappointment stems from the cost involved in a facelift with adequate volume replacement, as well as the risk of surgical complications and recovery time. And of course, some patients just don’t want surgery.

On the other hand, I have many patients, the majority in fact, who say “I don’t like this turn down at the mouth and I would just like my face a little tighter.” They are willing to do a non-invasive Thermage treatment, and plan on repeating it every 2-5 years. Also they are willing to do adequate volume replacement with multiple syringes of Juvederm or several sessions of Sculptra. These patients either have early or moderate changes and only need non-invasive treatment, or they have more advanced sagging but are willing to accept a modest amount of improvement. We see a fair amount of patients who definitely fall in the appropriate for a surgical face lift category, but don’t want one. As long as their expectations are realistic, we are all happy.

For non-invasive skin tightening procedures to be effective, you have to have some elasticity left in your skin, have some underlying volume (or replace it), be of an age where the body will still produce collagen, and be a non-smoker. And it works best on early to moderate changes, not advanced sagging. The reason they work less well on advanced sagging is simply the skin has lost almost all elasticity, there is too much excess skin, and the only thing to do it to remove some of it. Since a surgical face lift involves cutting above, in front, around, and behind the ears and trimming off as much excess skin as needed as well as tightening the muscles underneath, it is no surprise that significant sagging can be corrected.

In a nutshell: If you want “this”—you need a surgical facelift. If you are starting to see some early looseness or “don’t like this turn down at the corner of my mouth and would like my face to be a little tighter”—non-invasive treatments are right for you. But you can’t have “this” with one non-invasive skin tightening procedure. When you face a situation where what you want doesn’t jive with what you want to do to get it, you have two alternatives: alter your objectives or alter your battle plan.

You will, of course, need a cosmetic dermatologist who is experienced enough to be able to predict the results a certain combination of treatments will give you as an individual based on all of the patient related variables that affect results. And most importantly, one who respects you enough to be honest with you about what you can expect, and who won’t treat you if your expectations are out of line with the results you will actually get.

So decide what you want, be realistic about what you need to get there, and discuss it with your cosmetic dermatologist or plastic surgeon.

Next: Cosmetic skin tightening procedures—what’s it going to take? Costs, number of procedures, recovery times.