Our series, Closer Look, takes a deeper dive into the controversial, critical, and of-the-moment issues facing doctors and patients in aesthetic medicine.
But does it really work? This is honestly our first thought, whenever we hear about a new lunchtime procedure. And we’re not alone in our skepticism: we field this question from curious friends, hesitant neighbors, strangers on the ’Gram. This exact phrase—Does it really work?—appears in dozens of queries from RealSelf members, probing for Worth It-ness, determined to suss out the true efficacy of everything from microneedling to skin-tightening devices to fat freezing.
Because, yeah, the notion of treating the skin to near-surgical effect (some claim) or profoundly enough (most agree) to delay more invasive measures for a time—no recovery, scars, or post-anesthesia loopiness—can seem a little too good to be true. The thing is, nonsurgicals generally do work—to varying degrees, most of the time, at least. What we’re learning now, however, is that their performance may be to the detriment of future procedures.
“I warn patients, before we do radiofrequency (RF), Ultherapy, Kybella, thread lifts, or even ablative lasers, that if they one day decide to have plastic surgery, these treatments can make future operations more difficult,” says Dr. Sarmela Sunder, a board-certified facial plastic surgeon in Beverly Hills, California—and one of many doctors taking informed consent to the next level with this novel disclosure.
If Dr. Sunder’s words don’t give you pause, perhaps that’s because you, like so many of her patients, view noninvasives as a sort of get-out-of-surgery-free card. “It’s a real challenge to get people to understand the seriousness of the commitment they’re making with nonsurgical treatments,” she says. “They’re not thinking that they’re ever going to be a surgical candidate. But fast-forward two or five or 10 years—and, suddenly, they are.”
The hidden effects of devices and injectables
Only recently have doctors begun alerting patients to this potential downside of no-downtime tweaks—which is not to imply they’ve been deliberately withholding. It’s more that certain knife-free treatments have now been around long enough for such consequences to come to light as a percentage of their loyal users has inevitably aged into surgical territory, allowing surgeons a firsthand glimpse at the below-the-skin changes sparked by some devices and injectables.
While supporting evidence is lacking in the literature, this topic is openly discussed at aesthetics meetings—and anecdotal reports abound. “I’ve been doing so many more facelifts and neck lifts on patients who’ve been through all of these minimally invasive procedures—and, in some cases, it’s like dissecting through concrete,” says New York City board-certified plastic surgeon Dr. Lara Devgan.
Cut to thousands of readers, anxiously prodding their faces for evidence of petrified tissues. Hands down, everyone—the effects likely won’t be obvious to anyone but the surgeon you allow into your face or body. In most scenarios, what surgeons report seeing upon entry is inflammation and internal scarring, incurred by various nonsurgical technologies.
Which is, believe it or not, precisely what such treatments are designed to deliver. The goal is generally “to stimulate collagen production in the dermis, to gradually thicken and tighten the skin—and collagen is scar tissue,” explains Dr. Ashley Gordon, a board-certified plastic surgeon in Austin, Texas. “Your skin’s response to nonsurgical treatments is always the same—inflammation and the creation of scar in order to heal.” Whether a treatment “works” by generating intense heat or cold or via some type of chemical or physical reaction, the skin registers all that manipulation as an injury in need of repair.
While the collagen composing scars—its constitution and distribution—differs from the skin’s native supply, the scars and swelling generated by nonsurgicals are actually proof that you got what you paid for. And from the outside, your skin will appear a bit smoother, plumper, and firmer. But what lies beneath? A bit of a mess, according to our experts.
As Dr. Gordon explains, “the face is made up of distinct, loosely connected layers. We refer to the area between these layers as planes. When performing a face or neck lift, we dissect in [those] planes—they’re considered our safety zones.”
These surgical planes provide landmarks, guiding surgeons to an appropriate depth—one not so shallow as to thin out the subcutaneous tissue, potentially damaging and deforming the surface skin, but not so deep as to risk injuring the nerves responsible for facial expression. Hence “finding the correct plane is the key to a safe and successful facelift,” says Philadelphia board-certified plastic surgeon Dr. Christian Subbio.
In someone with previously untreated skin, “there are clear anatomic planes, which [when approached with the] appropriate skill and dexterity, kind of fall apart or are easily separated with our scalpels and cautery devices,” he adds.
Dr. Devgan likens the act of operating on untouched faces to creating art with a brand-new set of paints: “The tissue is like magic,” she says. “It’s a beautiful technical and surgical experience.” In the tweakment era, however, it’s also an exceedingly rare experience. Virgin tissue, statistics show, has become a bit of an anomaly, even among the earliest beauty optimizers and prejuvenation seekers. In 2018, more than 700,000 minimally invasive procedures were enjoyed by those under 30; more than 2.5 million, by those 30 to 39.
When treatments induce scarring in and between the layers of the face, notes Dr. Gordon, “this scar formation acts like a sort of glue that eliminates discernible planes and makes dissection very difficult, because the normal anatomy—our roadmap—is gone.”
Or at least badly blurred, most of her peers would agree.
Most—but not all. “I’ve done an absolute ton of FaceTite and ThermiTite [both under-the-skin RF devices] and taken numerous patients to the OR years later without any difficulty,” says Philadelphia facial plastic surgeon Dr. Jason Bloom, who owes his outlier perspective to his preferred facelift technique—the deep-plane. “If there is any thickening or scarring, it’s in the subcutaneous tissue, but when I do face and neck surgery, I’m operating on a much deeper level.” (For the record, some surgeons validated his theory and others were more dubious.)
What does all this mean for you—the patient?
Beyond making your surgeon really earn their paycheck, technically difficult dissections increase risk. “When there’s scarring and distortion of the anatomy, a surgeon can easily get into the wrong plane, [which means] greater risk of nerve injury,” says Dr. Jason Pozner, a board-certified plastic surgeon in Boca Raton, Florida. Moreover, the slower and more meticulous a surgeon needs to be, the longer you’re on the operating table and under anesthesia. A tougher dissection also begets a tougher recovery—more bruising, swelling, and pain after surgery.
Dr. Sunder has found that patients who have surgery less than one year after select noninvasive treatments tend to have trouble healing post-operatively. “With a lot of devices, there’s little to no downtime, so people think they’re fully healed 24 hours later. They don’t realize what’s going on underneath the skin,” she says. “The healing process can actually last for many months. If we go ahead and operate while the body is actively trying to recover from previous trauma, it’ll have double the work cut out for itself.”
When patients have poor or delayed wound healing after surgery, impaired circulation is typically to blame. “We always have to consider the effects of prior energy on the microcirculation of the tissue we’re handling,” says Dr. Subbio. If heat from previous treatments has damaged the microcirculation, surgeons may need to be less aggressive when separating skin from underlying structures, he explains, “because that secondary insult to the circulation could cause tissue death.”
Which treatments pose the biggest problem to surgeons?
Every procedure will leave a mark—but some are more culpable than others.
Topping the list are technologies that intentionally or inadvertently trigger fat loss—with extreme heat (induced by radiofrequency and ultrasound energies), cell-crippling cold (aka cryolipolysis or CoolSculpting), or acidic degradation (hi, Kybella)—especially those requiring multiple sessions, since the damage tends to be cumulative.
“When these technologies remove the fat between the skin and fascia [the connective tissue surrounding muscles], the skin can become directly adherent to the deeper structures,” explains Dr. Rod Rohrich, a board-certified plastic surgeon in Dallas. With normal surgical planes all but erased—much like they are in a secondary or revision facelift, he notes—the risks of skin loss (from compromised circulation), closure irregularities, and nerve damage all shoot up.
“This layer of fat is beneficial for skin redraping and camouflaging irregularities of deeper aging structures, like muscles,” adds Dr. Gary Linkov, a facial plastic surgeon in New York City. “Destroying the subcutaneous fat can make surgical results less predictable”—and less pretty. After all, it’s that cushy layer that lends softness to our appearance and makes us look human.
“The most challenging neck lifts I’ve done are in people who’ve tried Kybella,” says Dr. Adam Rubinstein, a board-certified plastic surgeon in Miami. “Their tissues are scarred up and stiff—it’s like working with leather as opposed to silk. We can’t shape them the way we’d like, we can’t suspend the muscles as well, we can’t tighten things as much as we normally would.”
In the drug’s defense, this dermal thickening and collagen creation is what helps the skin eventually shrink up and snap back after treatment rather than hanging loose like a fat-deflated sack. “With Kybella, you get an improvement in the overall quality of the skin because of that beneficial inflammation [it causes],” explains Dr. Sachin Shridharani, a board-certified plastic surgeon in New York City. “We have histology data that shows you get a nice amount of not just scar tissue but new [normal] collagen formation helping with the retraction.”
Apparently though, such side effects can also make subsequent liposuction procedures more of a chore. “When the fat is fibrotic, it doesn’t suck out easily,” says Dr. Gordon. Doctors will often lean on VASER energy to soften such fat. “The more fibrous the tissue, the higher the energy needed to break it up,” she says—but boosting the energy can lead to superficial burns and seromas (collections of fluid under the skin). “And seromas are associated with an increased risk of contour irregularities, so it just becomes a vicious cycle.” (By the same token, VASER repercussions can make subsequent procedures, like tummy tucks, trickier.)
Likewise, “liposuction following CoolSculpting can be challenging, because the tissue is frequently fibrotic—it often feels like a firm block,” notes Dr. Umbareen Mahmood, a board-certified plastic surgeon in New York City. “Liposuction cannulas glide through healthy fat fairly easily, but in areas that have been treated with CoolSculpting, there’s significant resistance.” It’s still possible to lipo these areas, she notes, but it often takes longer and requires more energy to achieve a good aesthetic result.
The impliable scar tissue forged by energy-based body treatments—all of them, not just CoolSculpting—can also make it difficult for surgeons to get a supersmooth result during abdominoplasties, notes Dr. Subbio.
Aside from fat-squelching technologies, surgeons say, face-hiking threads—both the old-school permanent kind and the newer absorbable ones—can also cause headaches. “They create so many different types of [anatomical] changes,” says Dr. Devgan. “They’re a physical object present in the tissue [and they also cause] mechanical and chemical inflammation.” Plus they’re not always placed precisely or predictably, she adds, which can be exasperating for surgeons, especially when they’re an unexpected discovery.
“I’ve found permanent threads wrapping around blood vessels and branches of the facial nerve—and they really should be removed, so long as it’s not dangerous to do so,” says Dr. Sunder. “The newer threads, I’ve noticed, sometimes leave behind nodules—like little collagen balls—when they dissolve, and that can make things difficult during surgery as well.”
Temporary hyaluronic acid fillers are generally a nonissue in the OR—they can be melted before surgery or suctioned out during—but nonreversible fillers can be a nuisance. According to Dr. Linkov, longer-lasting fillers, like Radiesse (calcium hydroxylapatite), can stymie blood flow. Many times, “even if a filler doesn’t cause an acute vascular event by blocking a larger artery, it can occlude small vessels, negatively affecting the vascularity of the area,” he explains. “During surgery, we rely on that microcirculation to nourish skin flaps [sections of uprooted skin], and these may not be as robust after chronic filler use, which can hinder healing and the overall cosmetic result.”
That said, no injectable can out-nightmare silicone. “It builds up scar tissue like an onion, layer by layer, so what you end up with over time is this nodule that just keeps getting bigger,” says Dr. Rubinstein. “Trying to dig out silicone and its scar from the soft tissues—without disturbing the facial nerves, damaging structures, or leaving divots—is incredibly difficult and risky.”
So what’s the modern beauty lover to do?
Relax, aesthetics enthusiasts. No one is expecting you to cold-turkey your favorite treatments.
“Operating on previously adulterated tissue does add time, complexity, and nuance to a surgery, but this is just our new normal—and you can still get an excellent result,” Dr. Devgan assures us. After all, “there are few people who would choose not to do anything for the sake of a facelift at 50.”
Indeed. Nonsurgical interventions are the very things “that allow someone to look essentially the same between age 30 and 60,” she adds.
It’s crucial to recognize their inherent limits, however. “I’m a big fan of noninvasive technologies, and they will only continue to improve,” says Dr. Pozner. “But you don’t want to push them past what they can do.” When their effects cease to impress—or even register—doubling down will only ravage your tissues further (and with zero upside).
If and when surgery becomes an option, make sure your medical history includes all your nonsurgical treatments—no matter how trite or forever-ago they may seem. These details could influence your surgeon’s operative approach or pre- and post-op planning.
Dr. Sunder, for instance, requires patients to wait about one year after having Kybella, threads, and various devices before undergoing surgery. “I want to get beyond a certain threshold of time so we’re not worried about healing issues,” she says. While the tissues never really go back to normal—the scar tissue persists—the initial inflammation that can derail healing tends to abate within a year. “The tissues start behaving better, and the risk posed by surgery is lessened,” she notes.
If, for some reason, she finds herself operating before that one-year mark, she’ll order hyperbaric oxygen for the patient post-op, to prevent wound-healing hiccups.
Bottom line? Nonvirgin skin may require more patience and savvy in the OR, but in the right hands, it’s hardly a roadblock to surgical success. Rest assured, says Dr. Devgan, “we can still create a beautiful work of art using a set of paints that’s been opened before.”
