Have you ever thought this in front of the mirror? "Surgery is scary. But doing nothing as I am is also unbearable" — the era in which an answer can be given to that conflict has arrived.
Today, we'll tell you the full strategy of the "non-surgicalfacelift" shown by the latest medical evidence.
- How to combine HA (hyaluronic acid), Botox, andthread lift
- Which layer of the face each procedure works on
- Where the difference lies from a surgicalfacelift
- What the optimal thread direction is, matched to the bone structure and skin characteristics of Asians
- How much "younger" you look after the procedure, confirmed with data from the literature
As you approach your late 30s to your 40s, sagging of the cheeks, the depth of the nasolabial folds, and slackness of the jawline begin to bother you. "Surgery is scary and I can't take downtime. But I want to do something" — as you keep searching with that thought, haven't you become unsure of what the right answer is because there is too much information?
In this article, based on international papers in aesthetic medicine, we explain only "the real story" of non-surgical lifting strategy. By the time you finish reading, what you should do should be clear.
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Why the option of "not cutting" has spread this much
First, look at the numbers.
An AI-based patient satisfaction analysis has shown that a surgicalfaceliftthat manipulates the SMAS (superficial musculoaponeurotic system) has the effect of turning back the hands of the clock byan average of 8 to 10 years(Gibstein et al. 2021). Furthermore, a study analyzing 15 years of surgical data reports that facelift surgical techniques have become more refined year by year, and the complication rate also tends to be improving (Stein et al. 2024).
The effect of surgery is real. This must be acknowledged as a fact.
So why do many people choose the non-surgical path?
The answer is simple — general anesthesia, hospitalization, weeks of downtime, scar risk. For those with work and family, these hurdles become, realistically, a wall that cannot be crossed. What has developed to bridge that gap is the "non-surgical combined approach" that combines injectables (HA, Botox) with thread lift.
Here, one important thing. The era of single procedures is already over. Now, "what you combine" and "to which layer, in which order" you work on it govern the entire result.
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Understanding facial sagging by "layers" — why a combination is necessary
About sagging, there is something many people misunderstand.
Facial sagging is not a single sheet of skin hanging down. Anatomically, the following multiple layers changesimultaneously.
- The skin layer: a decrease in collagen and elastin → reduced firmness
- The fat layer: atrophy and migration of the fat compartments → loss of cheek volume and formation of nasolabial folds
- The SMAS layer (superficial musculoaponeurotic system): loosening of the ligaments → sagging of the jawline
- Bone and soft tissue: bone resorption and skeletal change → change in the shape of the whole face
A surgical facelift directly lifts the SMAS and excises excess skin, thereby addressing multiple layers at once (Gibstein et al. 2021). In other words, the strength of surgery lies in being able to "subdue multiple layers in a single strike."
On the other hand, the non-surgical approach intervenes in each layer with a different tool. HA is for volume replenishment at the fat-layer and skeletal level, Botox suppresses the sagging promoted by muscle hypertonicity, and thread lift mechanically lifts the layer close to the SMAS.
Understanding this "division of roles by layer" is the one and only key to obtaining a natural result with combination treatment.
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The role of HA (hyaluronic acid) — "supporting" rather than "lifting"
Floating the sagging with volume replenishment
Here, let me correct a common misunderstanding.
HA is not an injection that "lifts up what has sagged." To be precise, by replenishing volume in atrophied fat compartments, it supports the skin from the inside and produces a relative effect of "appearing lifted."
To use an analogy — pulling up a tire that has gone flat does not restore its shape. You first inflate it, recover its shape, and then adjust. The role of HA is exactly this.
The atrophy and migration of the facial fat compartments due to aging are directly involved in the flattening of the cheeks, the deepening of the nasolabial folds, and the formation of the marionette lines. By injecting HA into these areas — around the zygomatic arch, the temples, below the tear trough — at the appropriate depth (supraperiosteal or the deep fat layer), the volume that once existed is reconstructed.
Synergy with thread lift — the order is everything
Thread lift lifts up sagging tissue, but pulling it while it remains atrophied carries the risk of a "hoisted, unnatural impression." By first replenishing volume with HA and then lifting with threads, a natural lift is achieved. As a rule, the order is "HA → thread lift."
Be wary of clinics that reverse this order.
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The role of Botox — "moving muscles" are accelerating aging
Relaxing the muscles that pull downward
Many people perceive "Botox = wrinkle removal." However — the true value of Botox in a lifting strategy is not that.
"Suppression of the antagonist muscles." This is the essence.
The face has muscles that lift upward and muscles that pull downward. With aging, the depressor muscles (the platysma, depressor labii inferioris, depressor anguli oris, etc.) become relatively dominant, promoting sagging of the jawline and marionette lines. When you inject Botox here and weaken the tension of the depressor muscles, the elevator muscles become relatively dominant, and a lifting effect appears in the static state.
In other words, Botox is a procedure that puts the brakes on muscles that have become an "accelerator of aging."
The technique called the "Nefertiti lift"
The "Nefertiti lift," which injects Botox into the bands of the platysma (the muscle covering the front of the neck), has the effect of tightening the jaw-to-neck line. It is effective on its own, but combining it with thread lift makes the contour of the entire jawline clearer.
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Thread lift — the "strengths and limits" honestly shown by three papers
How much does thread lift work?
Let me give the conclusion first.
There has been much debate about the efficacy of thread lift. In a 2014 clinical study from Italy, after a thread lift procedure using Happy Lift™, patient satisfaction was high, and significant improvement was confirmed especially in the cheeks, nasolabial folds, and marionette lines (Savoia et al. 2014). In the assessment at 3 to 6 months after the procedure, the objective visual improvement score showed a statistically significant improvement compared with before the procedure (Savoia et al. 2014).
However — here is the important part.
A study that comprehensively reviewed the thread lift literature reveals that its duration of effect is, in many cases,1 to 2 years, which is short compared with the 5 to 10 years of a surgical facelift (Atiyeh et al. 2021). The same study also points out that "the risk of complications (nodule formation, asymmetry, thread exposure) and the operator's skill greatly affect the result" (Atiyeh et al. 2021).
Thread lift is not "magic." Only when the appropriate indicated patient, the appropriate operator, and appropriate aftercare are all in place does it become a procedure that brings a satisfying result.
For Asians, a lift in the "vertical direction" is effective — whether you know this or not changes the result
This is a particularly important point.
Many thread lift techniques developed for Westerners are based mainly on a diagonally upward (toward the temporal region) lift. However, the Asian face has anatomical characteristics in which the cheekbones are developed and the cheek fat tends to migrate downward. This is precisely why applying Western protocols as they are tends to result in a "pulled, unnatural face."
A study published by a group of Korean dermatologists showed that, for Asians, a lift not in the diagonal direction but in thevertical direction (straight up)brings the most natural and effective lift (Kang et al. 2017). In this "vertical lift" technique, by changing the insertion angle of the threads, the cheek fat compartment is lifted straight up, sharpening the jawline while also improving cheek volume at the same time (Kang et al. 2017).
When East Asians such as Japanese, Korean, and Chinese people consider a thread lift, "whether the operator has mastered techniques for Asians" becomes the most important selection criterion of all.
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If you do nothing about "yourself five years from now" — what I want you to think about honestly
Here, let me pause for a moment; there is something I want you to think about.
Facial sagging does not stop on its own. Collagen, from the late 20s,decreases by about 1% each year, and the atrophy and migration of the fat compartments accelerate. While you feel "it's not that bad yet," the nasolabial folds deepen and the jawline blurs.
And — in the context of aesthetic medicine, the milder the change when you intervene, the more you achieve a smaller amount of treatment, lower risk, and a natural result. Trying to deal with severe sagging by thread lift alone is like trying to hide a crack in an apartment wall with paint alone. It is wise to take a preventive, stepwise approach before fundamental repair (surgery) becomes necessary.
Putting it off with "it's fine for now" narrows your future options.
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Comparison with a surgical facelift — we'll tell you only the honest data
To you who are considering a non-surgical approach, we'll tell you, including the inconvenient facts.
A large-scale study that analyzed before-and-after photos using AI has shown that a surgical facelift (especially techniques involving SMAS manipulation) has the effect ofrejuvenating the apparent age by an average of 8.9 years(Gibstein et al. 2021). The result was also that patient satisfaction was overall higher with surgery (Gibstein et al. 2021).
Furthermore, a study that analyzed 15 years of data from the American Board of Plastic Surgery confirmed that the safety of facelift surgery has steadily improved over the past 15 years, and that surgery by an appropriate operator is a reliable option in the long term (Stein et al. 2024).
So — does the non-surgical approach have no value?
That is not the case. The strengths of the non-surgical approach lie in the following.
- Short downtime: in many cases you can return to social life the day after the procedure
- Stepwise adjustment: you can start with a small amount and add while observing the effect
- Reversibility: HA can be dissolved with hyaluronidase
- Avoidance of anesthesia risk: the procedure can be performed with local anesthesia only
- Affinity with ongoing maintenance: the effect is easy to maintain with maintenance once or twice a year
To summarize, it comes to this — surgery is for those who want "a big change all at once." The non-surgical approach is a strategy for those who "want to change without downtime, stepwise, and naturally." It is not that one is superior; the right answer is a choice matched to your lifestyle and goals.
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Why "looking natural" is the hardest — the pattern common to failure cases
The failure stories often heard in aesthetic medicine are "I overdid it" and "it looks unnatural."
Rather than a problem of the procedure itself, this is, in most cases, a "problem of design." Let's look at this concretely.
If you put a large amount of HA into the cheeks, the face certainly becomes round and plump, but that is "puffiness," not "youthfulness." If you pull the threads strongly in a diagonal direction, the skin puckers and looks like a "pulled face." If you inject a large amount of Botox into the platysma, the expression becomes unnatural.
To achieve a natural-looking result, you need not only "where, what, and how much to put in" but also the design philosophy of "in what order, to which layer, in which direction."
This is precisely the reason you should choose a physician who can design multiple modalities, rather than "leaving everything" to a single operator. Before the skill of the procedure, look at the design ability.
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Zetith Beauty Clinic's combined lifting approach
First consultation: counseling and design
First, we grasp in 3D what is happening in which layer. We assess the state of the bone structure, fat compartments, and skin, and, together with the physician, organize "where the intervention to prioritize now is."
From the second consultation onward: stepwise procedures
Doing the whole combination all at once is not always the right answer. To safely control the amount of change, in many cases we proceed stepwise.
- Phase 1: HA injection (volume replenishment, building the foundation)
- Phase 2: Botox (suppression of the depressor muscles, 2 to 4 weeks later)
- Phase 3: thread lift (lifting after the foundation is set)
Optimization for the Asian bone structure
As stated above (Kang et al. 2017), we adopt a vertical-direction thread insertion technique matched to the anatomical characteristics of the Asian face. Rather than applying a Western protocol as is, we design it to suit the Japanese face.
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Only "those who know the information" can make the right choice
In the aesthetic medicine market, exaggerated advertising also exists. "Ten years younger in one session," "Reliably effective with zero downtime" — these are, in many cases, expressions lacking in evidence.
As the literature review of thread lift points out, the effect of thread lift differs greatly depending on the operator, the type of thread, and the indicated patient, and one cannot say flatly that it "works" or "doesn't work" (Atiyeh et al. 2021). The same study also states that "randomized controlled trials to raise the quality of the evidence are insufficient," and, honestly, long-term data on non-surgical lifting is still in the process of accumulating (Atiyeh et al. 2021).
That is precisely why — patients who, before choosing a procedure, can ask their physician "why this procedure is necessary" and "on what evidence it is based" obtain the best results. I hope this article can be a "weapon of knowledge" for that purpose.
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Frequently asked questions
Q. How many years does a thread lift last?
According to the literature, in many cases1 to 2 yearsis considered the duration of effect (Atiyeh et al. 2021). The threads themselves are absorbed within the body, but the skin-quality improvement effect from collagen neogenesis may remain even after that. As post-procedure maintenance, the effect can be extended by combining periodic injections of HA and Botox.
Q. Can HA, Botox, and thread lift be done all at once?
It is not medically impossible, but there are many cases where it is not recommended. When swelling and bruising overlap, confirming the result becomes difficult, and identifying the cause when a problem arises becomes hard. By performing the procedures stepwise, you can proceed safely while confirming the effect of each step.
Q. Please tell me the difference from a surgical facelift simply
Surgery is "bigger, longer-lasting, large downtime," and non-surgical is "the change is gentle, maintenance is needed, downtime is small." For those with mild to moderate aging changes, the non-surgical combined approach is suitable; if there is severe sagging or excess skin, considering a surgical approach is realistic (Gibstein et al. 2021).
Q. Does a thread lift work even in your 40s?
The 40s are one of the good age groups for the indication of thread lift. However, once excess skin grows from the late 40s onward, there are cases where it is difficult to address with thread lift alone. We recommend that, after receiving an assessment of your current state at the consultation, you judge whether non-surgical or surgical suits your purpose.
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Summary of this article
- A surgical facelift has been confirmed by AI analysis to have a rejuvenating effect ofabout 9 years on average(Gibstein et al. 2021), but considering the downtime and surgical risk, choosing a non-surgical approach is a reasonable option
- In the non-surgical combined approach, HA (volume replenishment), Botox (suppression of the depressor muscles), and thread lift (mechanical lifting) each act on a different layer — without "design" there is no natural result
- The effect of thread lift generally lasts1 to 2 years(Atiyeh et al. 2021), and periodic maintenance is necessary
- There is research holding that, for the Asian bone structure, not the Western-style diagonal direction but thevertical directionof thread insertion is optimal (Kang et al. 2017) — the operator's technique and knowledge govern the result
- The clinical data on thread lift is still in the process of accumulating (Atiyeh et al. 2021), and an attitude of choosing based on evidence is important
- The milder the change when you intervene, the more you achieve a small amount, low risk, and a natural result — putting it off with "it's fine for now" raises the cost
References
- Gibstein A, Chen K, Nakfoor B, et al. Facelift Surgery Turns Back the Clock: Artificial Intelligence and Patient Satisfaction Quantitate Value of Procedure Type and Specific Techniques. Aesthetic Surgery Journal. 2021.
- Stein M, Shah N, Harrast J, et al. Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery. Aesthetic Plastic Surgery. 2024.
- Savoia A, Accardo C, Vannini F, et al. Outcomes in Thread Lift for Facial Rejuvenation: a Study Performed with Happy Lift™ Revitalizing. Dermatology and Therapy. 2014.
- Atiyeh B, Chahine F, Ghanem O. Percutaneous Thread Lift Facial Rejuvenation: Literature Review and Evidence-Based Analysis. Aesthetic Plastic Surgery. 2021.
- Kang S, Byun E, Kim H. Vertical Lifting: A New Optimal Thread Lifting Technique for Asians. Dermatologic Surgery. 2017.
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References
- Gibstein A, Chen K, Nakfoor B, et al. Facelift Surgery Turns Back the Clock: Artificial Intelligence and Patient Satisfaction Quantitate Value of Procedure Type and Specific Techniques. Aesthetic Surgery Journal. 2021 DOI
- Stein M, Shah N, Harrast J, et al. Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery. Aesthetic Plastic Surgery. 2024 DOI
- Savoia A, Accardo C, Vannini F, et al. Outcomes in Thread Lift for Facial Rejuvenation: a Study Performed with Happy Lift™ Revitalizing. Dermatology and Therapy. 2014 DOI
- Atiyeh B, Chahine F, Ghanem O. Percutaneous Thread Lift Facial Rejuvenation: Literature Review and Evidence-Based Analysis. Aesthetic Plastic Surgery. 2021 DOI
- Kang S, Byun E, Kim H. Vertical Lifting: A New Optimal Thread Lifting Technique for Asians. Dermatologic Surgery. 2017 DOI
Author of this article
Hiromitsu Nakamura Ginza Clinic Physician
Zetith Beauty Clinic Ginza, Osaka Shinsaibashi, and Fukuoka clinics
He has a track record of research presentations at domestic and international academic conferences, and is also engaged in technical guidance and education for Zetith Beauty Clinic as a whole. He specializes in precise aesthetic medicine based on anatomical grounds, pursuing natural results tailored to each person's bone structure and tissue.