Combined Facial Rejuvenation

What is combined facial rejuvenation?

Combined facial rejuvenation combines more than one non-surgical method into a single plan for the same face, with each method given its own role. It is the name not of a procedure but of a plan drawn up after a consultation: first, the components that make up the change in your face are identified, and then a separate method is considered for each component.

The starting point of this approach is that, in practice, non-surgical methods are rarely used on their own. A publication based on experience of using dissolvable (absorbable) lifting threads together with other methods groups the methods under four tasks: repositioning tissue, relaxing overactive facial expression muscles, renewing the skin surface and replacing lost volume. The publication also treats the following as part of the plan: patient selection, discussing expectations from the outset, why and in what order the methods are chosen, and how much time is left between treatments.

According to a review that looks at fillers, lifting threads and botulinum toxin together, the aim of this combination is to reach, effectively and safely, a result that looks as harmonious and natural as possible. Threads that dissolve in the body were added to this combination later, to reposition sagging tissue. A joint statement prepared by experts (a consensus statement) on using a collagen stimulator, dissolvable lifting threads and hyaluronic acid together also stresses that the plan should be tailored to the individual, according to the doctor’s skills and the patient’s preferences. These are expert opinions; the strength of the scientific evidence is a separate question.

At the clinic, a thread lift can be planned together with CaHA/PLLA treatments. Combinations with hyaluronic acid (HA) filler and botulinum toxin are also discussed in scientific publications. In everyday language, botulinum toxin is often called Botox®, a word that comes from a product name.

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Why can’t a single method address facial ageing?

Because there is no single layer of the face that changes with age. Every layer, from bone to skin, changes in its own way, and each non-surgical method targets only one or a few of these layers. So a single method may address one part of the change while leaving another part as it is.

Research shows a separate change in each main layer, from bone to skin: the facial skeleton is remodelled, the fat compartments (fat pads) lose volume or shift, muscle tension (tone) and thickness change, and the skin becomes thinner and weaker. Making this distinction can help in deciding what to prioritise in treatment and in explaining the reasons for that decision. It has been reported that reduced bone support gives the impression that the face is moving downwards, and that when the ligaments holding the face in place give less support, the overlying tissue becomes lax. Even so, how much the change in each layer contributes to appearance has not yet been well established.

A consensus statement prepared by experts on combined treatments starts from the same point: ageing arises in more than one layer of the face, through a complex interaction of internal and external factors. The statement works from the view that combining treatments aimed at different signs often gives better results than single methods, and it supports the combined approach as expert consensus. A panel of five expert doctors, meanwhile, proposes a plan that addresses the face layer by layer: the bone and the ligaments that hold tissue in place; the muscles, ligaments and the superficial musculoaponeurotic system (the layer of connective tissue that surrounds the facial muscles); the fat compartments; the dermis (the supporting layer beneath the skin’s surface layer); and skin quality. This panel’s recommendations are based on specific products.

What this means for you: a combined plan starts not from a list of methods, but from the question of which layer of your face shows the most prominent change. Ageing differs by layer and by individual characteristics; in two people of the same age, different layers may stand out, so the same plan is not applied to two people in the same way. This question is answered at your consultation.

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Thread lift and collagen stimulator: two separate jobs in one plan

A thread lift aims to change the position of tissue, while CaHA and PLLA aim to provide volume and collagen support. The reason for considering both in the same plan is that, in the same face, displaced tissue may be accompanied by reduced volume or weakened skin quality.

In a thread lift, threads with small barbs are placed under the skin along set lines, and the superficial musculoaponeurotic system is lifted. It has been reported that newer techniques using dissolvable threads cause fewer adverse effects, but that their long-term effectiveness remains uncertain. The clinic uses dissolvable threads (PLLA/PDO). “Thread lift” is the general name for lifting treatments done with threads; the French Thread Lift is one of these techniques.

On the collagen stimulator side, a systematic review that brought together studies on the use of PLLA and CaHA in the face reported significant improvement in skin elasticity, wrinkles and facial volume with both. However, more research is needed to standardise the techniques and to assess long-term safety. A dissolvable lifting thread containing PLLA/PLGA has been described as having a dual effect: it both lifts tissue and stimulates collagen production.

There is little data on these two methods studied directly together. In the laboratory part of one study, CaHA and dissolvable threads made of a lactide-caprolactone copolymer were applied together to a full-thickness human skin model. When they were applied together, the activity of genes linked to collagen and elastin production increased significantly more than when either was applied alone. The researchers started from the assumption that the effect of threads may be limited in people with poor skin quality.

In the patient part of the same study, the records of 11 women were reviewed retrospectively: 6 had threads only, and 5 had CaHA first, followed by threads. In the CaHA group, greater thickening of the skin and subcutaneous tissue and a higher aesthetic improvement score were reported at day 120; no adverse events were reported. However, these findings are based on only 11 people, a single treatment protocol and a single thread material; they cannot be directly generalised to other types of thread or to PLLA injection.

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Combinations with hyaluronic acid and botulinum toxin

Some studies have looked at a thread lift combined with hyaluronic acid (HA) filler or with botulinum toxin. These studies suggest that the combination may bring additional benefit in some areas; however, each is based on a small number of people, a single area and a single treatment protocol.

One preliminary study (pilot study) used cross-linked hyaluronic acid filler in the mid-face together with barbed polydioxanone (PDO) threads. It enrolled 11 Korean participants aged 29–70, and the results were followed for 24 months. Mean mid-face width decreased from 149.27 mm to 145.00 mm at 24 months. The study was carried out at a single centre and was open-label, meaning that both the doctor and the participants knew which treatment was given. The researchers state that the findings need to be confirmed by further studies in different populations, and that the approach needs to be compared with other methods.

In a comparative study of nasolabial folds, 32 people aged 40–65 were included: 16 had a PDO thread lift only, and 16 had the same procedure followed one hour later by botulinum toxin injected into the muscles around the mouth and the muscles of the nasolabial area. At 3 and 6 months, a greater reduction in fold depth and in scores on a fold rating scale was reported in the combination group. Adverse effects were similar in the two groups: mild bruising, swelling and temporary dimpling that went away on their own; no serious adverse events were reported. However, the study abstract does not state that the groups were randomly assigned, and follow-up was limited to 6 months.

The combined use of botulinum toxin and hyaluronic acid has also been studied before. In a randomised trial (a study in which treatments are assigned at random) of 20 people with forehead lines and frown lines, one half of the face received botulinum toxin only, and the other half received hyaluronic acid first, followed by botulinum toxin. The two sides were similarly effective at weeks 2, 6 and 12; at week 24, the combination side was reported to show a longer-lasting effect on forehead expression lines and a greater reduction in frown lines. The researchers described the additional benefit of the combination as “mild”. The authors of another study that examined this combination across the whole face also note that, although it is widely used, the combination has been evaluated in only a small number of clinical studies.

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How strong is the evidence?

Limited. The view that combinations give better results than single methods rests largely on shared expert opinion, studies with small numbers of people and case series (publications that report the results of a few patients). Among the sources reviewed, there is no large comparative study showing this in general.

In a systematic review of collagen stimulators used together with botulinum toxin, fillers and energy-based devices, 29 studies out of the 1,237 records screened met the inclusion criteria; the number of participants in these studies ranged from 10 to 350. According to the review authors, differences in methods, small samples and inconsistent protocols limit the reliability of the findings. How the joint effect claimed for combinations comes about is also not understood; this limits what is known about how long the results last and how safe they are.

The evidence for thread lifts themselves is also limited. According to a systematic review of 12 publications on lifting threads that met its criteria, no notable new evidence on effectiveness or safety has been added in the last ten years, and in all but two studies the lifting effect lasted only a very limited time. The two studies that reported positive results were supported by thread manufacturers. Another review also notes that no new evidence has been added, and stresses that if you are considering this procedure, you should be well informed about side effects, how long the effect lasts and the limited data on effectiveness.

Consensus statements on combined treatments reflect this too. For example, in one statement involving 15 experts, “consensus” was defined as agreement from 75% to 94% of participants. This does not mean the recommendations are worthless; but it does show that the judgement “better together” currently rests on expert opinion and has not yet been shown by comparative studies.

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Order and timing: what does the research say?

No single correct order has been defined. Recommendations on which method should come first, and how much time to leave between treatments, come from expert consensus statements. Each statement was prepared for the methods it covers, and often for specific products. So the order in one statement cannot be transferred directly to a plan that combines other methods.

According to a consensus statement on the combined use of botulinum toxin, hyaluronic acid, CaHA and an energy-based device using micro-focused ultrasound, facial treatment begins with a detailed assessment and a plan tailored to the individual. Leaving 1 to 2 weeks between consecutive treatments gives side effects time to settle and allows the result to be assessed; if treatments are done on the same day, botulinum toxin and fillers can be given in any order. This statement does not cover lifting threads.

There are recommendations that do include lifting threads. An international panel of plastic surgeons and dermatologists counted agreement from at least 83% of participants as consensus. In its statement, the panel proposed step-by-step roadmaps (algorithms) setting out the order and intervals for using a polycaprolactone-based collagen stimulator, dissolvable lifting threads and cross-linked hyaluronic acid together in the upper face, mid-face, lower face and neck. The authors of a review on combining fillers, lifting threads and botulinum toxin also share their own treatment intervals, aimed at shortening recovery time.

Individual studies have also used different orders: in one study CaHA was given before the threads, and in another, botulinum toxin was given one hour after the thread lift. These were the protocols of those studies; they do not show which order is right for everyone. In your plan, which method comes first, which comes next and at what interval are decided at your consultation.

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Limits of this approach

Combining methods does not remove the limits of each method. A combined plan does not remove excess skin and is not a substitute for a surgical facelift; where there is marked excess skin, these methods added together will not meet that expectation either.

This limit also has a measurement side. According to a review that critically examined studies published on hyaluronic acid, CaHA, PLLA and polycaprolactone, the term “lift”, often used in this field, has no agreed definition and no accepted measurement standard; nor is there a validated threshold showing which change counts as clinically meaningful. All published numerical measurements reflect changes at the skin surface. According to the authors, this does not mean that fillers have no lifting effect; it shows that this effect has not yet been defined with the precision that the claims made about it require. So names such as “non-surgical facelift” describe the aim of the treatment, not a measured amount of lift.

The second limit concerns duration. In research on lifting threads, the long-term effectiveness of techniques using dissolvable threads remains uncertain. For collagen stimulator combinations, information on how long the results last is also limited, because it is not understood how the joint effect comes about. Although a few small studies have reported a longer-lasting effect on the combination side, it has not been shown as a general finding that combining methods makes the result last longer.

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Do the methods affect each other?

This question has been little studied; the available information is limited to laboratory studies and reviews. Still, two issues are kept in mind when planning: how the materials affect each other, and the load that builds up over time with repeated treatments. Possible future surgery is a third issue taken into account in planning.

There is a laboratory example of how materials may affect each other: pieces of barbed polydioxanone (PDO) thread were kept at body temperature in hyaluronic acid at six different concentrations, and the way the threads broke down in water (hydrolysis) was seen to change with the hyaluronic acid concentration. This was a test-tube experiment; the study did not show whether the same effect occurs in tissue or whether it has any clinical consequence. Even so, it is a reminder that when more than one material is placed in the same area, they may not behave independently of each other.

The second issue is quantity. The condition known as “facial overfilled syndrome” shows up as a distorted face at rest and unnatural facial movements, linked to excessive or inappropriate use of fillers. According to a review of this condition, the cause is not only excess volume; anatomical mismatch, disruption of the face’s biomechanical balance (the balance of movement and support between tissues) and the load that builds up over time with repeated treatments all play a part. Reducing the risk of this condition depends on knowledge of anatomy and individual planning. For a combined plan, this means that more methods do not mean a better result.

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If you are considering a facelift in the future

Non-surgical treatments do not make a later facelift impossible; however, recently placed threads and fillers can increase some risks. So if you are considering surgery in the future, this needs to be discussed at the very start of the combined plan.

Recommendations prepared by seven plastic surgeons and one dermatologist, using an agreement threshold of at least 75%, address how non-surgical treatments affect later facial surgery. According to these recommendations, the risk varies with the type of treatment: collagen-stimulating (biostimulator) injections and temporary fillers generally carry a lower risk, while permanent fillers, devices that deliver energy to deep tissues, and recently placed temporary fillers or threads have been associated with a higher risk. The main problems are disruption of the tissue layers the surgeon works through during the operation, and compromise of the tissue’s blood supply.

The authors stress that the scientific data in this area are limited and that an individual approach is needed until more research is done. If you have had filler elsewhere before, you will be asked at your consultation about the type of filler, when it was done and which area was treated.

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Known risks

In a combined plan, each method brings its own risks with it. Among the sources reviewed, there is no finding that combining methods reduces the risk of each one; so you need to know the risks of each method separately. The information below comes from scientific publications, not from the clinic’s own data.

In a systematic review and meta-analysis that assessed non-surgical facial treatments together, the most common adverse effects reported were pain and bruising after lifting with dissolvable threads, and swelling and pain after hyaluronic acid fillers. Another analysis, focusing on thread lift complications, divides them into two groups. Swelling, pain and bruising within the first four weeks are early complications. Threads that can be seen or felt, skin dimpling and threads moving out of place (migration) are late complications: they last longer than four weeks and may be more clinically important. Results of studies on this topic vary considerably.

The risk specific to collagen stimulators is nodules (small firm lumps you can feel under the skin) and granulomas (an inflammatory tissue reaction the body forms against a foreign substance). According to a systematic review on this topic, all the collagen stimulators examined can cause this reaction; the reaction was reported to be noticed between one week and fifteen years after treatment, and the area around the mouth was reported to be a high-risk area. In the review of collagen stimulator combinations, redness, bruising and nodules occurred in 15% to 30% of cases; granuloma and vascular occlusion (a blocked blood vessel) were reported as rare but serious complications.

The most serious risk is the substance being injected into a blood vessel by accident. According to an expert consensus statement on CaHA, this can lead to tissue death, permanent scarring, vision problems and blindness, and it needs immediate treatment. A review of cases of vision loss linked to collagen stimulators reported at least 11 cases of vascular occlusion causing vision problems with CaHA, and 2 confirmed cases of vision loss with PLLA.

The methods also differ in whether they can be reversed. The enzyme hyaluronidase breaks down hyaluronic acid and is the preferred option for problems caused by hyaluronic acid filler. Hyaluronidase is kept at the clinic. CaHA and PLLA, however, are not hyaluronic acid. The authors of a case series on blood vessel problems caused by non-hyaluronic acid fillers state that the lack of an “antidote” for these fillers makes the situation more difficult. Before the procedure, you will be asked about blood thinners, antiplatelet medicines and supplements that can affect bleeding. Do not stop any prescribed medicine on your own. If needed, the procedure is planned or postponed after consulting the relevant doctor.

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