Facial Skin Tightening Options

I'm open to a face lift or facial plastic surgery but wanted more opinions on a variety of skin tightening options to tighten jowls and skin laxity in the face in general.

Doctor Answers 68

Facial rejuvenation options

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How We Age

The effects of gravity, sun exposure, intrinsic aging, and the stresses of daily life take their toll on our faces over time.

On the surface, the skin accumulates sun damage, leading to age spots, blemishes, and fine lines. Deeper lines and creases develop as the skin loosens and sags.

Beneath the skin, the support structures of the face (muscles, ligaments, etc.) loosen, and the soft tissues atrophy so that our face loses volume. This causes a constellation of age-related changes to the face – the nasolabial folds deepen, the jawline slackens, fat collects beneath the chin, the eyelids droop and fat protrudes from the lids, the eyebrows, cheeks, and tip of the nose go southward.

How To Turn Back the Clock

The first step to turning back the clock is to maintain a proper lifestyle, including a healthy diet rich in antioxidants, regular exercise, the avoidance of smoking, and proper skin care.

Treatments for the aging face include nonsurgical cosmetic treatments and cosmetic surgery. In general, nonsurgical treatments are best suited as main treatments for younger patients with milder signs of aging or as adjunctive treatments for older patients. Older patients with more pronounced signs of aging typically need surgery (in addition to the nonsurgical treatments) to produce effective results.

Improving the skin’s quality, texture, and appearance can benefit many patients both younger and older. Options to achieve this include:

  • Topical medicines (e.g. proven medicines, such as tretinoin, hydroquinone, Obagi, etc.)
  • Chemical peels
  • Dermabrasion
  • Laser skin resurfacing

Additional nonsurgical cosmetic treatments, such as Botox and injectable fillers, can also play an important role in facial rejuvenation. Botox reduces smile lines by inactivating facial muscles. Fillers, such as Restylane, Juvederm, Radiesse, Artefill, and autologous fat, plump up areas that have “hollowed out” over time, such as the nasolabial folds, lips, and around the eyes.

Noninvasive “tightening” procedures, such as Thermage, Titan, etc., may tighten the skin, but to date patient satisfaction rates have been low.

Older patients with more pronounced signs of aging, including sagging skin, prominent jowls, etc., typically need cosmetic surgery to produce good results. Surgical options include the face lift, forehead lift, eye lift, midface lift, and neck lift. These procedures are often done in combination along with nonsurgical treatments.

If you are a patient interested in turning back the clock, I recommend that you see a qualified cosmetic specialist (e.g. plastic surgeon) who can offer you the full range of cosmetic treatments so that you can choose the best options for your particular needs.

San Francisco Plastic Surgeon

Limited alternatives to surgery, if surgery is indicated

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I use the "onion" as a good analagy of how we are put together anatomically.

The skin is the outer layer, followed by a layer of fat, and then, a strength layer, fat pads, and neres/muscles/blood supply.

Procedures like chemial peels, laser, coblation, are great for tightening the skin, and reversing the signs of premature aging due to sun, cigarette smoke, and environmental oxidants, etc. This will do nothing for lifting the deeper layers that have descended over time as a result of time and gravity. On the other hand, facial rejuvenation procedures such as face lifting, are great at restoring the deeper structures to a more youthful state, but they do not restore the skin (outer layer of the onion) to a more youthful condition.

The deeper layers contribute to the nasolabial folds (the ()'s) around the mouth, the jowls, the hollowness of the cheeks, and the loss of crispness of the neck. The face lift procedures are ideally suited for correcting the problems that are deeper than skin deep.


Tightening sagging facial skin

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The answer, simply put, is a facelift. There's lots of hullabaloo about lasers and Thermage tightening the layers of the face, but in the absence of real controlled and peer-reviewed data (not provided by the manufacturers of the devices) and before and after photographs documenting any longterm results of these methods (and thousands of dollars/ multiple treatments later), the facelift is still the gold standard for lifting and tightening sagging facial skin and soft tissue.

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Thermage:The Best Way to Tighten Sagging Facial Skin.

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By far, the best way to tighten sagging facial skin without surgery or downtime is Thermage. Thermage uses radiowaves to tighten the collagen in the deep layers of the skin, and is very useful to clean up jowls and a loose jaw line. Thermage has been getting mixed reviews, and in fact on the REALSELF.COM website, only 35% of patients felt that Thermage was "worth it". However, do not let this discourage you from exploring this very useful technique. Dissatisfied Thermage patients are not the result of the technique itself but, of improper applications as follows: A). Patient selection is critical. If Thermage is tried on a patient who has a great deal of jowling and skin laxity in the neck, it is quite predictable that the improvement is going to be insufficient, and that a patient like this will really only be helped by surgery. There is no age cut off, but younger patients do better with Thermage. B). Thermage has to be done just right. It requires a great deal of experience and a good eye. As with anything else in Cosmetic Medicine, the machine is only as good as the person using it. If you are going to have Thermage, make sure that you go to an office where they do a lot of it, and ask to speak to a patient who has had it. C). Very often, not enough energy is used in Thermage to save money. An individual head has to be bought for each patient, and heads come in different sizes, ranging from 200 pulses to 900 pulses. The greater the number of pulses, the more the energy delivered to your skin, and in general the better the result you will get. The problem is that the larger heads with more pulses cost more money, and there are practices that cut corners and use small heads which provide inadequate energy. Predictably in this situation, the result will be disappointing. We only use 750 pulse and 900 pulse heads, depending on the individual patient and the individual area. D). The final point to make about Thermage is that patient education is important, and you have to have realistic expectations. You can expect very significant improvement but, the results will not be as dramatic as with a well performed scarless mid-facelift or with a short scar facelift.

George J. Beraka, MD (retired)
Manhattan Plastic Surgeon

The Essential Truths of Facial Rejuvenation

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There are several essential truths that must be stated in order to fully answer this question completely.

  • There is an old saying that states: "Small surgery, small results." With rare exception, this continues to ring true. This also applies to treatments in general.
  • A patient and a procedure must match each other in two key ways:
    • A patient's anatomy must be appropriate for the proposed surgery, because surgeries are based on anatomy.
    • A patient's expectations must be appropriate for the expected results.
  • A patient's goals must be clearly understood by the physician so that the appropriate treatment plan can be made.
  • If something sounds too good to be true, then it probably is.
  • Try not to be the first person on the block having a new procedure.

If you remember these facts when considering treatment options, then you will likely make the right decision about cosmetic treatments for facial aging.

There are so many options available to patients that it can be quite difficult to reach an informed decision. Trends are constantly changing and new treatments emerge, while others disappear.

Therefore, if you have a small problem with photoaging of the skin, then topical therapies (Retin-A, acid peels), non-ablative lasers, Botox, and volume fillers will all likely help you achieve your goals. These treatments, in general, have shown benefits in the vast majority of patients and are reliably safe.

If you facial aging problem is severe, then it is likely you will need some of these treatments as well as surgery. Facelifts of all varieties help to elevate the skin, but do not create changes to the skin itself. That is why a comprehensive program involving skin care, sun avoidance, laser therapy or chemical peels are usually suggested to patients undergoing this procedure.

Those patients that fall into the middle category are the most challenging to treat. Although some patients will opt to wait a few more years for formal treatment, many want improvements now. Thermage, stronger laser treatments, Portrait plasma resurfacing, and modified facelifts (with small incisions and quicker healing) are perfect solutions, as long as the patient understands the limitations of each therapy and the likely need for further treatments in the future.

So think of your problem, your goals, and your lifestyle needs.

If your problems are small or your goals are modest, then quick, minimal downtime solutions are probably right for you. If your problems are big or your goals are big, then you will likely be disappointed with simple solutions and probably need comprehensive treatment, likely including surgery.

Most facial surgery will required 1-2 weeks of downtime before you feel comfortable socializing with others.

Facelift Information

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Ideally a patient should have a consultation in a plastic surgery practice that offers a full range of surgical and non-surgical options so that an appropriate, comprehensive and highly individualized treatment plan can be developed.

Surgical or even non-surgical treatment of facial aging changes must be carefully individualized to match each patient's aesthetic needs and desires. In helping a patient to make decisions about plastic surgery for facial rejuvenation, I always examine and assess how each aesthetic area or 'unit' of the face contributes to an individual's overall appearance: the brows and eyelids, the cheeks or 'midface', the lower face and chin, and the neck. An individualized plan is then developed which addresses each patient's specific concerns and needs.

A "liquid facelift" is a procedure that is performed using temporary dermal fillers like Juvederm Restylane or Perlane. There is little to no downtime with a liquid facelift. This might be an ideal treatment for some, but the results are temporary and it does not address excess skin.

Structural fat grafting, sometimes referred to as microfat grafting can provide fullness to lips, cheeks, hollowed upper or lower eyelids and can fill lines and wrinkles on the face. Unlike the liquid facelift, the results from structural fat grafting can be permanent

Laser Skin tightening is a non-invasive treatment with little to no downtime. For individuals with early signs of aging, uneven skin tone, scarring or large pores a laser skin tightening procedure can provide dramatic results.

Full Facial rejuvenation or a full facelift may be the answer for some. Some people looking for facial rejuvenation are interested in the lower face, midface and eyes, others are interested in one area only. Surgical treatment of facial aging changes must therefore be carefully individualized to match each patient's aesthetic needs and desires. No two 'facelifts', by necessity, are the same. In helping a patient to make decisions about plastic surgery for facial rejuvenation, I always examine and assess how each aesthetic area or 'unit' of the face contributes to an individual's overall appearance: the brows and eyelids, the cheeks or 'midface', the lower face and chin, and the neck. An individualized surgical plan is then developed which addresses each patient's specific concerns and needs.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Sagging face - consider fat grafting and surgery

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Hello Ms Anne,

Lots of great answers to your question here. I wanted to specifically also recommend the option of autologous fat grafting for sagging cheeks. As you have learned by now aging changes related to volume loss are best addressed by volume correction.

The BEST way to tighten jowels? Vertical elevation with cranial suspension. Sorry but that is surgery!

Kamran Jafri, MD
New York Facial Plastic Surgeon

Fill the face with volume, tighten the skin with Fraxel repair

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Sagging facial skin results from the loss of volume from the face, and the aging of the superficial skin.

Traditionally surgeons correcting the problem pulled the sagging tissue and cut away the excess. You can tell who those patients are when you see them walking down Rodeo Drive in Beverly Hills, Park Avenue in Manhattan, and Collins Drive in Miami.

Natural results can be obtained today by restoring volume to the face, and then by treating the face and neck with Fraxel repair. Fraxel repair will tighten the skin, reduce wrinkles, improve the eyelids, and improve the tone, color, and texture of the skin.

In the great majority of my patients this will restore an amazing youthful, rested appearance to the face. This will not leave a patient as "tight" as they might be after a surgical facelift. In some cases of excessive skin "sag", traditional surgery may still be needed.

Michael A. Persky, MD
Encino Facial Plastic Surgeon
4.8 out of 5 stars 36 reviews

The most effective and best way to get rid of jowls is...

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The most effective and best way to get rid of jowls is with surgery.

  • My favored procedure is a mini face-lift called an S lift. This procedure involves incision lines that are hidden behind the ear and thus create no visible scarring. The downtime is shorter than a traditional face-lift (usually only 4 to 5 days), and the procedure can be performed under local anesthesia.
  • For those with less advanced jowl drooping (usually people in the forties), I perform an endoscopic face-lift procedure called a ScarFree Facelift which I helped pioneer. This procedure utilizes two small incisions the width of a drinking straw in the hair bearing scalp. Through these incisions, micro instruments and a surgical endoscope are used to lift the drooping face.
  • Short of surgery there are facial tightening devices that use radio frequency energy that helps the skin shrink wrap. The two most commonly used are Titan and Thermage. The results from these treatments are subtle (usually a 5-10% improvement), and often require multiple treatments so they can be costly.
  • Some doctors perform procedures called Thread Lifts that lift the skin with threads placed under the skin. These treatments provide a subtle result as well, but the problem is that the effect is short lived, lasting only 9 months. The company that made these threads has stopped producing them due to these problems.

Facelift and LiveFill

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Most modern approaches to the face tighten and replace volume. The patient's own tissues placed into hollow areas give the longest lasting, most stable results. LiveFill and fat injection are two techniques that use the patient's own tissues to restore fullness to the face, and are often used in combination with facial tightening procedures.

Brent Moelleken, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 188 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.