Non-surgical facial rejuvenation: what are the options?

What ‘non-surgical facial rejuvenation’ refers to

‘Non-surgical facial rejuvenation’ is the name of an expected result, not of a method; the same applies to ‘non-surgical facelift’. Neither term describes a single procedure. Beneath them are groups of treatments that do very different things in the tissues. This is why saying ‘I’d like non-surgical facial rejuvenation’ at a consultation does not, on its own, amount to a plan.

The reason for this lies in the structure of the face. Researchers look at the ageing face not as a single layer but as layers stacked on top of one another: the skin itself; the superficial and deep fat compartments (fat pads); the muscle–fascia layer, made up of muscle and the connective tissue that surrounds it; the ligaments that anchor the tissues to the bone; and, at the very bottom, the bony support. All of these layers change over time, but not at the same rate in the same person. The groups of treatments also differ according to which of these layers they act on.

The change has also been studied at the molecular level. In the dermis, the lower layer of the skin, the support network surrounding the cells (the extracellular matrix) breaks down and loses its organisation, and less mechanical force reaches the collagen-producing cells (fibroblasts) attached to this network. Studies report that a reduction in how far these cells spread and in the force they generate is seen together with an increase in the enzymes that break down the matrix and a fall in collagen production. However, it has not yet been established whether this chain is truly a cause-and-effect relationship in human skin. In short, the thinning and loosening of the skin is not just a change seen on the surface; the tissue’s own mechanical balance changes too.

Treatments that add volume: hyaluronic acid fillers

Hyaluronic acid fillers take up space in the layer they are injected into. The effect is visible as soon as the product is placed; there is no need to wait. Their second defining feature is that they are reversible: the gel in the tissue can be dissolved with an enzyme called hyaluronidase. Because of these two features, the scientific literature presents hyaluronic acid as the first option considered for many uses.

The products in this group are not identical. How the gel molecules are linked together (the cross-linking method), the particle structure and how easily the gel flows determine how firm it stays in the tissue, how well it resists changing shape and which layer it suits. This difference becomes visible in a face that moves. That is why choosing the product cannot be separated from deciding which layer the filler will go into.

The way fillers are used has changed in recent years. According to recent publications, small amounts placed in the right layer, rather than filling a hollow, can redistribute tension in the tissues, and injections beneath the muscle–fascia layer and at the points where the ligaments attach can provide lift in the midface and along the jawline. In other words, a filler’s job is not always to add volume; sometimes it is to redistribute the load in the tissues.

This treatment has its limits too. Whether the result looks natural depends on three factors together: the product, the person and the doctor carrying out the treatment. An international consensus statement sums this up in a single sentence: it is the person who is treated, not the photograph.

Treatments that stimulate a tissue response: collagen-stimulating fillers

Substances such as calcium hydroxylapatite (CaHA), poly-L-lactic acid (PLLA) and polycaprolactone (PCL) act like a scaffold in the tissues and trigger the body’s own collagen production. This is why the effect appears gradually, not as soon as the product is placed.

These substances set off a controlled foreign-body response in the tissues, and macrophages, a type of immune cell, gather in the area. With poly-lactic acid derivatives, macrophages have been reported to switch to a repair role, with increased production of type I and type III collagen and elastin and increased formation of new blood vessels. With calcium hydroxylapatite, stimulation of the activity of the collagen-producing cells (fibroblasts) and of the production of the support network surrounding the cells has been reported. The early inflammatory response to calcium hydroxylapatite has been found to be more pronounced than that to poly-L-lactic acid. In other words, even substances in the same group do not follow the same pathway.

Among the side effects, the most notable are nodules: small, firm lumps you can feel under the skin. They have been reported most often with poly-L-lactic acid. Reported rates vary widely from study to study, so they cannot be given as a single figure.

The difference from hyaluronic acid matters in practice: hyaluronic acid replaces missing volume immediately, whereas collagen stimulators aim to change the tissue’s own structure over time. The two do not target the same finding and are not interchangeable.

Treatments that give mechanical support: lifting threads

A thread lift works not through heat or volume but by changing the position of the tissues; in other words, the mechanism that provides the lift is mechanical. Threads with small barbs are placed under the skin along set lines, positioned so that they carry the layer of muscle and connective tissue in the face (the superficial musculoaponeurotic system) upwards. The downward load of the tissues is spread along the line of the thread, and tissue that has shifted is physically repositioned.

What sets this group apart is that it leaves behind a structure that carries the load directly. With fillers, the lift is explained by tension being redistributed in the tissues; with threads, the load is transferred through the thread itself. These are not the same route.

Its limits are also clear. Early studies using non-absorbable barbed threads reported high rates of corrective procedures (revisions) and complications. Newer techniques using dissolvable threads are reported to cause fewer adverse effects. However, the long-term effectiveness of these procedures is uncertain, and new studies are needed to better assess both their safety and their long-term effectiveness. In an analysis that examined complications by combining data from many studies (a meta-analysis), the most commonly reported findings were swelling and bruising; visible or palpable threads (threads you can see or feel under the skin) and skin dimpling were also reported. In the same analysis, results varied considerably between studies. For this reason, it is not possible to say how long the effect lasts for any type of thread.

Treatments that reduce muscle activity: botulinum toxin

The target of this group is not volume or tissue position but movement. Lines on the face result from two things together: thinning of the dermis, the lower layer of the skin, and repeated contraction of the muscle beneath it. When botulinum toxin is given in small amounts into an overactive muscle, it relaxes that muscle locally, and the skin over the muscle smooths out.

There is an important distinction here. Lines that appear when your facial expression changes, that is, lines that come with movement, respond more clearly to this treatment than established lines that are also visible at rest. Cosmetic use has been described mainly in the upper third of the face: frown lines between the eyebrows, horizontal lines on the forehead and crow’s feet at the outer corners of the eyes.

Its timing is distinctive too. Clinical publications report that the effect takes about two weeks to develop fully and lasts about three to four months. This is why the result cannot be assessed the day after treatment.

This treatment does not lift sagging tissue and does not replace lost volume. What it does is reduce a movement; if movement is not the source of the problem, it does not meet the expectation on its own.

Treatments that work on tissue quality: mesotherapy

The target of this group is not volume, tissue position or movement, but the quality of the skin itself. Dryness, dullness, visible pores, reduced elasticity and fine lines come under this heading.

In mesotherapy, the product is not placed in a deep layer but directly into the dermis, the lower layer of the skin. In a multicentre randomised controlled trial (a trial in which participants are randomly assigned to groups), a sodium hyaluronate-based mixture injected into the dermis once a month was reported to produce a significant increase in skin hydration and elasticity. Adverse effects were mild to moderate.

Its limit comes from its definition. Even if the quality of the skin improves, the shadows and contours of the face can stay the same, because what changes here is the surface of the tissue, not its position or volume. You can read how mesotherapy is carried out at the clinic on the Mesotherapy page.

What heat-based devices do

The sixth group works with energy. Collagen is a heat-sensitive protein: when tissue is heated in a controlled way, limited damage occurs, followed by a wound-healing process. During this process the collagen-producing cells (fibroblasts) are stimulated, and new collagen production and tissue remodelling begin. This is why a large part of the effect appears not during treatment but in the period afterwards.

What distinguishes the devices in this group from one another is where the heat is delivered and how it is distributed. With radiofrequency (RF), heat is not applied from outside: the current passing through the tissue meets the tissue’s own resistance, and the heat is generated within the tissue. With focused ultrasound (HIFU), by contrast, sound waves converge on a specific point beneath the skin’s surface and leave separate, millimetre-sized points of heat there.

Researchers themselves point out the open questions in this field. When studies on focused ultrasound are assessed together, it is clear that energy settings and the criteria for deciding which patients are suitable have not yet been standardised; more research is also needed on long-term effectiveness.

If you are making your decision with the future in mind, there is one more important detail. According to a review of microneedling RF treatments, these treatments can lead to collagen build-up and fibrosis (the formation of hardened connective tissue) in several tissue layers. These changes can alter the tissue planes, that is, the layers the surgeon works in, in any surgical facelift you may have in the future. For this reason, it is recommended that this issue is discussed before treatment.

What ‘non-surgical facelift’ does and does not mean

The term ‘non-surgical facelift’ describes an expected result, not a mechanism: lift. All six groups of treatments respond to this same expectation by different routes. The term does not tell you which route is used, so two ‘non-surgical facelift’ titles you see side by side in search results may be describing two completely different procedures.

It is also important to know what the term does not describe. A surgical facelift does two things: it removes excess skin and it repositions the muscle–fascia layer. None of the non-surgical treatments does either of these. These treatments redistribute tension in the tissues, replace missing volume, stimulate the tissue’s own response or reduce a movement. In the scientific literature, the correction this group provides is described as temporary.

This is not a flaw; it follows from how these treatments are defined: non-surgical treatments are not a substitute for a surgical facelift. The direct consequence is this: where there is marked excess skin, a treatment that does not remove excess skin is not expected to meet this expectation on its own. Hiding a treatment’s limits does not make it more useful; knowing these limits from the start is healthier than finding out about them later.

Which examination findings point to which type of treatment

The choice starts with the examination findings, not with the treatment. You can think of the breakdown below not as a prescription but as a map showing which questions are asked at a consultation.

If the main problem is the quality of the skin (dryness, dullness, visible pores, reduced elasticity), treatments aimed at skin quality are considered.

If the main problem is lines that appear with movement (lines that are not visible at rest and appear with facial expressions), treatments that reduce muscle movement are considered.

If the main problem is volume loss, meaning the contours have sunk inwards and the shadows have deepened, fillers that replace missing volume or fillers that stimulate the body’s own collagen production are considered. The choice between these two depends on whether the correction is expected immediately or over time, and on which layer is being targeted.

If the main problem is downward displacement of the tissue, meaning the tissue as a whole has sagged noticeably, thread-lifting treatments that reposition the tissue are considered.

If the most prominent problem is loss of skin firmness and the tissue as a whole has not shifted, heat-based devices are considered.

If advanced sagging comes with marked excess skin, the excess skin needs to be removed; in this case surgery is considered, and non-surgical treatments are not enough on their own.

In most faces these patterns do not appear alone but overlap; which one is dominant can only be seen at a consultation. Knowing how the patterns differ is a useful guide, but it is the examination, not an article, that shows which one you have.

Limits shared by these groups

The first limit relates to dose. Using filler in excessive amounts or in the wrong layer has been described as a distinct condition: distortion of the facial contours and unnatural movement during facial expressions. Research does not attribute this condition to a single cause; a mismatch with the anatomy, disruption of the face’s biomechanical balance and the accumulated load of repeated treatments are considered together. Preventing this condition depends on knowledge of anatomy and individual planning; if the condition has been caused by hyaluronic acid filler, ultrasound-guided hyaluronidase is an established solution.

The second limit concerns the evidence itself. The meta-analysis of thread complications found high variability between the results of the studies, and energy settings for focused ultrasound have not yet been standardised. This does not mean the treatments are ineffective; it means there is not yet a single rule for which settings will produce a response, in whom, and to what extent.

The third limit is personal. The same treatment does not produce the same response in two different people; the response is determined by skin thickness, the structure of collagen, which changes with age, and general health.

The fourth limit is the limit of general information. Knowing how the treatments work does not tell you which one is right for you; suitability is determined at a consultation, not by an article.

Treatments offered here

The clinic offers hyaluronic acid fillers, collagen-stimulating fillers, thread lifts with dissolvable threads, botulinum toxin and mesotherapy. Where needed, this also includes filler dissolving with hyaluronidase.

Each treatment’s own page explains how it is carried out, who can have it and who should not. Which one may be considered for you is assessed at a consultation, based on which of the patterns described above is dominant in your case. This guide does not tell you what treatment to have; it explains the differences and leaves the decision to you.