The Surgeon Minute

Tapping the Brakes on Facial Aging Sans Surgery

Tapping the Brakes on Facial Aging Sans Surgery

Facing aging has newer roadblocks thanks to  major developments over the past several years in non-invasive and minimally-invasive procedures. In the past, plastic surgery patients and surgeons alike relied on a few remedies for all facial treatments. Today, we have multiple modalities for specific treatments of different signs of facial aging, many of which do not involve the OR.

Dr. Sean Doherty of Boston has added many of these non-surgical procedures to his facial rejuvenation procedure repertoire. “Many people are interested in treating the first signs of facial aging without surgery,” says Doherty. “I look at every prospective patient individually and propose an all-encompassing skincare, injectable and micro-needling or laser plan.”

By using the right combination of injectable fillers, Botox and other noninvasive treatments, fine lines and wrinkles can be erased, sagging skin can be tightened and volume can be restored. Used in concert with one another, patients can realize even more synergistic results.

In designing a noninvasive treatment plan, Dr. Doherty considers three things:

  • the surface of their skin
  • their muscles moving and creating lines
  • their overall facial volume

Assessing Facial Aging: Skin Damage

There is a marked change in the quality and condition of our skin as we age.“Don’t ignore the quality of your skin,” says Doherty. “No surgical procedure or filler can substitute for great skin. Fine lines – even heavy lines – can be treated on some level with laser resurfacing or micro-needling.”

Skin that has become rough or blotchy can be refreshed through laser skin resurfacing. This procedure uses a laser to remove damaged layers of skin. As new skin cells develop, they present a firmer, more youthful appearance. Fine facial lines, age spots, sun spots, and other uneven areas of pigmentation can also be successfully treated with this procedure.

Medical micro-needling is becoming a popular method of non-surgical skin rejuvenation improving a wide variety of conditions including scarring, fine lines and wrinkles, loose, lax skin, and poor skin texture. Needles penetrate the upper layers of the skin creating tiny holes in the skin’s surface, very similar to the process of aeration. In response to the “needling,” the body creates new collagen and elastin fibers, plumping and thickening the skin. It breaks down the skin’s superficial barrier and allows a host of compounds including stem cells, growth factors, hyaluronic acid and vitamins to be introduced at a deeper level, dramatically increasing the effectiveness and penetration of active ingredients.

Skin quality and facial aging


Lines and Wrinkles

BOTOX® is a neurotoxin that “freezes” muscles of expression that cause lines to form over time. Aside from smoothing lines of expression on the forehead, Botox can also correct a saggy brow and subtle hooding on the upper lids. Crow’s feet and lines around the mouth can also appear less noticeable with the right amount.


All of us will lose volume in our face as we age. When this happens, lines, wrinkles and folds become more obvious and the structure of the face can take on a sunken appearance. Areas commonly affected are the cheeks, temples, lips, around the mouth, under the eyes, and at the jawline. Fillers require no anesthesia and can be done in less than an hour. How long they last can vary, but upwards of 2 years with some fillers like Voluma create an attractive alternative to traditional surgical techniques for some patients.

An added bonus with fillers is that some promote collagen production in the injected areas, so each subsequent time you may need less and will be able to go longer between treatments.

Doherty uses a combination of superficial and deeper fillers depending upon the patient. “As we age we lose facial volume and that is where fillers come in,” he explains. “Hyaluronic acids such as Juvederm, Restylane and Voluma are among those I use frequently.”

Facial aging timeline.

It’s important to understand that all fillers are not interchangeable. Superficial fillers such as Restylane, Perlane and Juvederm work just below the surface of the skin giving fullness and correcting moderate facial wrinkles and folds. Deeper fillers, such as Sculptra, Radiesse and Voluma are injected deeper into the dermis to fill sagging cheeks and jawlines, fill deep folds near the mouth and correct hollows under the eyes.


A Winning Combination

Doherty is most impressed with the results of his patients that have facial neurotoxin treatment with either Botox or Dysport and then two weeks later undergo a combination ablative/non-ablative laser resurfacing. Doherty has found that when facial wrinkles are relaxed with either of the neurotoxins, the laser resurfacing is even more effective. “The results are amazing.”

Doherty often performs both non-ablative and ablative therapy in the same day and has found that this combination treatment provides for even more rejuvenation of the skin.

sciton halo laser skin resurfacing

Downtime and What to Expect

A common misconception is that if there is no surgery involved, there is no downtime. Doherty sets the record straight: “I do think when it comes to treating the surface of the skin, which is a big part of facial rejuvenation, the downtime has to be discussed. It really depends. If I am aggressive, there is more downtime, but it also means greater results.”

Part of your consultation should include your expected recovery time and how long results will last. Treatments differ from type of injection, how much product is used and who performs the procedure. Results vary from patient to patient. Slight bruising, puffiness, redness, and tenderness are common side effects of non-surgical facial rejuvenation.

If you have a special event coming up, it’s best to give yourself 2-4 weeks to be sure you are camera ready.

The Facial Aging Grand Slam

Keep in mind that skincare, non-surgical procedures, and surgery are three distinct solutions for separate issues. Once skin begins to show moderate to extreme sag and looseness, only surgery can truly “lift” it back into proper position. A face lift alone, however, is only part of the equation.

“If a patient has been good about maintaining their skin quality, but has loose skin, a face lift will make an obvious improvement,” explains Doherty. “When you combine minimally-invasive modalities with surgery, you have a grand slam. If a patient is willing and they have the time, aggressive facial treatments can be done prior to a face lift. They will have a better overall result. Peels, micro-needling, or laser resurfacing are worth it in the long term.”

Doherty also cautions that a patient is never truly “done” once they have a face lift. “We continue to age so there is maintenance. For someone to think a face lift is it, that is a mistaken notion. They must maintain their appearance. Sun avoidance, laser resurfacing, aggressive skin care, fillers, and fat injections are all part of it.”

Skin Prevails

In all cases, technique and judgment must prevail. It is just as imperative to avoid the obvious overfilled look in minimally-invasive treatments as you would expect in circumventing the tight, pulled face lift. No one wants to look “done” even temporarily.

And for those who want to skip a few steps and go straight to the face lift, Doherty shares words of caution against that approach. “Tight skin is not worth anything unless it is nice skin, so making that skin better before surgery is the best plan. Skin that has been stimulated has more vigor, blood supply, strength and elasticity. Your surgical result will be better and last longer.”

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