Liquid Facelift with Collagen Stimulators

What is a liquid facelift?

A liquid facelift is the injection of substances known in the scientific literature as collagen stimulators (biostimulators) into selected areas of the face. The substances used at this clinic are calcium hydroxylapatite (CaHA) and poly-L-lactic acid (PLLA); the treatment is not a hyaluronic acid filler.

Both substances break down in the body over time (they are biodegradable) and stimulate collagen production in the tissue, but their effects appear at different speeds. With CaHA, microspheres are delivered in a carrier gel. The gel provides volume immediately after treatment and is reported to be absorbed within 3–6 months. The microspheres stay in place, act as a scaffold for new collagen formation and eventually break down into calcium and phosphate ions. The effect of PLLA is delayed: the particles trigger a controlled inflammatory response in the tissue, this response stimulates collagen production, and the improvement in volume appears gradually over months. In classifications that compare filler types, CaHA is also listed among fillers with an immediate effect, and PLLA among fillers with a delayed effect.

Studies have reported significant improvement in skin elasticity, wrinkles and facial volume with both substances. Even so, more research is needed to standardise injection techniques and to assess long-term safety. When randomised trials of PLLA (trials in which participants are randomly assigned to groups) are considered together, they show that the evidence in this area is of low quality.

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Where does the name come from?

‘Liquid facelift’ is a name that has become established in everyday language. The procedure behind the name is an injection treatment with collagen-stimulating substances.

The word ‘lift’ is borrowed from surgery, and this is where the misunderstanding comes from. A look at publications on hyaluronic acid, calcium hydroxylapatite and poly-L-lactic acid fillers shows that the term ‘lift’, widely used in this field, has no agreed definition, no accepted measurement standard and no validated threshold for what is clinically meaningful. All published numerical measurements reflect changes on the skin surface; deeper structures were not monitored separately. This does not mean that fillers have no lifting effect at all; it only shows that this effect has not yet been defined with the precision that the claims made about it would require.

What this treatment does is provide volume and support; it does not do what a surgical facelift does.

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When is it considered?

This treatment is considered when the change you see in your face comes from volume loss and the reduced tissue support that goes with it. Collagen stimulators are used on the face to improve skin quality, replace lost volume and stimulate collagen production. Because they combine a volumising effect with collagen stimulation, they are used where structural support and longer-lasting correction are needed.

In injection treatments, the basis of both correction and safety is understanding which layer an age-related change in the face comes from. Recession of the bone structure, fat compartments losing volume and shifting position, reduced support from the ligaments that hold tissues in place (retaining ligaments), and thinning and weakening of the skin are separate components. Telling them apart makes it easier to decide which treatment to prioritise, and why.

This distinction is made at a consultation.

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Why does the face lose volume?

Facial ageing is not just a change on the surface of the skin; it progresses through the layers of the face. Thinning and weakening of the skin, fat pads losing volume and shifting position, and remodelling of the bone structure all happen together in this process. Changes in muscle tension (tone) and muscle thickness are also part of the picture. With age, collagen breakdown in the skin speeds up and collagen production decreases.

The deep fat compartments give structural support to the midface and to the superficial fat compartments; when this support decreases, the superficial compartments are affected too. According to research, bone recession is especially marked in the midface; regional bone loss affects the edges of the eye socket, the upper jaw and the lower jaw. As the forward support from the skeleton decreases, the tissues look as if they are moving downwards; when support from the retaining ligaments decreases, the soft tissue over them becomes loose. Magnetic resonance imaging (MRI) scans of the same people taken years apart showed that the downward shift of the buccal fat pad in the cheek made the fold running from the corner of the mouth to the chin more prominent.

Collagen stimulator treatment targets the volume and support part of this picture; studies with these substances have also reported improvement in skin elasticity. Laxity of the ligaments and recession of the bone structure are separate issues; each is treated as a separate component of ageing that belongs to its own layer.

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Cheekbone area and midface

According to research, when the deep fat compartment in the inner cheek (deep medial cheek fat) loses volume, there is a relative excess of skin and an impression of sagging, and the nose-to-mouth line (nasolabial fold) also looks more prominent. The midface skeleton is also among the areas that are clearly prone to bone loss with age. Together, these two changes reduce the support for the soft tissue above.

CaHA and PLLA are among the firmer fillers used for deep volume support in areas such as the cheeks and jawline. In the cheek and cheekbone area, the recommendation is to place CaHA in a deep layer, on the periosteum (the membrane covering the bone), and to avoid creating lumps on the surface. The reversibility of these substances is more limited than that of hyaluronic acid.

The depth of injection is also decisive, and this choice should be based on the anatomy of the face. Researchers studying the problem of overfilling stress the need to move from simply putting back lost volume to a precise approach tailored to each layer.

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Nasolabial folds

Nasolabial folds, which run from the side of the nose to the corner of the mouth, are listed in the scientific literature among the uses of collagen stimulators. CaHA is one of the substances used for moderate to severe wrinkles and nasolabial folds; there is also a study reporting significant improvement in these folds after PLLA treatment.

However, a deepening fold does not mean that volume is lacking only in that area. Volume loss in the deep fat compartment of the inner cheek has also been reported as one of the factors that shape this fold; in other words, the fold can appear as support in the midface decreases. For this reason, the assessment is not based on the fold alone.

This area also needs particular care for safety reasons. In a pooled analysis of studies on vascular occlusion (blocked blood vessels) after filler treatment, the nasolabial folds were among the most frequently affected areas, together with the area between the brows (glabella) and the nose, which have a complex network of blood vessels.

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Jawline

The definition of the jawline cannot be explained by volume alone. According to an expert guideline on using CaHA along the jawline, the jaw angle and jawline lose definition with age because of a combination of bone remodelling and resorption, tissue laxity and volume loss in the fat pads of the lower face. A study that used a computer model to examine sagging in the lower face also showed that changes in the skin, the subcutaneous tissue and the attachment structures connecting the skin to deeper structures are necessary for sagging to develop along the jawline, but that none of them is enough on its own.

According to the same guideline, the people expected to have a higher chance of success and satisfaction are those with good skin quality and good collagen-producing capacity, and without excessive skin laxity. Whatever your age, if you have marked skin laxity, or if you have excess fatty tissue in the neck, it is not likely that injections alone will achieve the expected result; a square jaw shape, where widening of the face is not wanted, is also listed among the situations that are not suitable. In an expert consensus on the lower face, PLLA is also among the options for shaping, volumising and contour correction in this area.

You can find more details about the chin and jawline on the Chin and Jawline Filler page.

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Temples

The temple area is considered separately in this treatment. A study comparing MRI scans of the same people taken at least four years apart found that hollowing in the temples comes mainly from thinning of the superficial temporal fat compartment.

In studies on temple filler, most patients were treated with hyaluronic acid; the systematic review that brought these studies together included 93 patients treated with CaHA and 2 patients treated with PLLA. The most commonly reported adverse effects were pain, tenderness or a feeling of pressure, bruising, and swelling (oedema). Blood vessel problems and other serious adverse events were reported rarely. Deeper injections (on the periosteum, or between or within the layers of the muscle fascia) may be linked more often to pain or discomfort when chewing. The use of PLLA in the temples was later assessed separately in a multicentre randomised trial that compared it with an untreated control group.

The temple hollow is known as a ‘venous danger zone’ because it contains the middle temporal vein and its branches. An accidental injection into this vein can lead to a serious condition such as non-thrombotic pulmonary embolism (a blockage in a blood vessel in the lungs that is not caused by a blood clot). Among cases of vision loss linked to collagen stimulators, one of the two confirmed cases reported with PLLA was linked to an injection into the temple. For this reason, whether the temple area is suitable for you is assessed separately.

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Limits of this treatment

Collagen stimulator injections provide volume and support. They do not remove excess skin, they do not reposition loose tissue and they are not a substitute for a surgical facelift; these are different procedures and need a separate decision. Filler injections have their own mechanical effects: local tissue expansion, tension in surrounding structures and changes in contour. However, these effects are not the same as those achieved in surgery, where tissue is released, moved in a specific direction and fixed in its new position. In a cadaver study using hyaluronic acid, no measurable skin displacement was found in the specimen with marked skin laxity. According to the study’s authors, the method may have very little or no effect in people with skin laxity or excess skin.

The second limit concerns the area. It is recommended not to use PLLA around the eyes and mouth, because it can form visible nodules (small firm lumps), especially at high doses. CaHA is not recommended in fine lines, in the lips or around the eyes. A systematic review of foreign body granulomas (small inflammatory lumps the body forms in reaction to a foreign substance) linked to collagen stimulators also reported the area around the mouth as a high-risk area.

The third limit concerns quantity. ‘Facial overfilled syndrome’ is a condition caused by excessive or inappropriate use of fillers: the shape of the face is distorted even at rest, and facial movements do not look natural. This condition cannot be explained by excess volume alone; the cumulative load of repeated treatments also plays a part. After injection, a persistent foreign body reaction (with CaHA) or an inflammatory response (with PLLA) can lead to uneven or increased volume in the area. There are not yet any objective measurement standards for assessing this condition.

Knowing where to stop is as much a part of the work as knowing what to do.

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How it differs from hyaluronic acid filler

Hyaluronic acid fillers can be dissolved with an enzyme called hyaluronidase. This enzyme breaks down the hyaluronic acid molecule and is the preferred method for managing problems caused by hyaluronic acid filler. When filler types are compared, hyaluronic acid is classed as a reversible filler.

With calcium hydroxylapatite and poly-L-lactic acid, the situation is different: both are classified as fillers that cannot be reversed. A multicentre case series on blood vessel problems caused by fillers other than hyaluronic acid also stressed that the lack of an ‘antidote’ for these fillers makes the situation particularly difficult.

This does not mean that hyaluronidase is never used with these substances; it simply has a different role. According to an expert consensus on CaHA, hyaluronidase is recommended when vascular occlusion (a blocked blood vessel) is suspected, whatever the type of filler. The aim is not to dissolve the filler but to use the enzyme’s ability to reduce swelling (oedema) and calm inflammation.

What this means for you: if you do not like the result, this treatment cannot be reversed with an enzyme. It is important to know this difference before you decide.

RELATEDCollagen Stimulator Treatments

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Known risks

Collagen stimulator injection is a medical procedure and has risks.

In studies of PLLA and CaHA treatments on the face, the most commonly reported adverse effects were mild; the main ones were pain and swelling at the injection site. These studies also reported a serious case with CaHA: pressure-related tissue death (compression necrosis). In randomised trials of PLLA, the main adverse effects were bruising, a collection of blood under the skin (haematoma), tenderness, nodules and swelling (oedema).

The risks specific to this group of substances are nodules and granulomas. Research shows that all the collagen stimulators studied can cause foreign body granulomas. This reaction was noticed anywhere from one week to fifteen years after treatment, and the area around the mouth was reported as a high-risk area. The most common treatment was a steroid injection into the lesion, but symptoms often improved with surgical removal of the lesion. With PLLA, nodule formation appears to be linked to the reconstitution protocol (how the powder is mixed with a sterile liquid before injection), the preparation method, the injection technique and the injection depth.

The most serious risk is the product being injected into a blood vessel by mistake. According to an expert consensus on CaHA, this can lead to tissue death, permanent scarring, visual impairment and blindness, and it needs immediate treatment. A systematic review of vision loss cases linked to collagen stimulators reported at least eleven cases of vascular occlusion causing visual impairment with CaHA, and two confirmed cases of vision loss with PLLA. These events are rare; but being rare does not mean they can be reversed when they happen.

These substances are not dissolved by the enzyme hyaluronidase; you can find more under How it differs from hyaluronic acid filler. What these risks mean for you is discussed at the consultation, together with your medical history.

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Liquid facelift or botulinum toxin?

These two are not alternative options for the same problem; they work through different mechanisms.

Botulinum toxin, often called Botox®, blocks the release of acetylcholine (the substance that carries the signal telling the muscle to contract) from the nerve ending and temporarily weakens muscle contraction. This is why it is used for dynamic lines caused by muscle movement. Lines that are not caused by muscle movement, such as those caused by sun damage and age-related changes, do not respond to this method.

Collagen stimulators address a different problem. They both add volume and stimulate collagen production; this is why they are used where structural support and longer-lasting correction are needed.

So the real question is not whether one method is better than the other, but which change is most prominent in your face. This is answered at the consultation; which route you take is your decision.

RELATEDBotulinum Toxin

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