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Dear Dr. Joe what can I do about these wrinkles?

From time to time I get a question that I think would make good blog fodder as it both asks and answers a relevant question concerning cosmetic facial surgery.  Recently, I had a written question:

Dr. Joe,

I have had Thermage, Ultherapy, and Fraxel performed on my face and lower eyelid skin to improve sagging skin but none of these made the difference I was hoping for.  I have now spent enough where I could have paid for a surgical procedure.  What are my options?



Dear Cynthia,

Thanks for contacting me and I have been asked this question numerous times in similar forms.  The short answer is that you have to really do your homework when considering minimally invasive procedures.  In my experience, some of them are somewhat effective and others produce no significant improvement, thus leaving a frustrated patient.  Cosmetic consumers must truly do their homework before investing their hard earned money on new “miracle procedures”.  If it sounds too good to be true, it may well be.  Non-surgical skin tightening devices have been around for a long time and it seems there is a new one every year.  Some of these devices are may be somewhat effective on some patients.  That is a lot of “somes”, but I believe it is true.  Most of these treatments provide some degree of minor improvement but rarely show “big” results.  It seems that one patient may experience a noticeable result while others report no change.  Unfortunately, there is not predicting who the successful patient may be.  Also, it may take numerous treatments to notice a result and oftentimes this is hidden in the small print.  Patients must not expect big results from little procedures.  It sounds good, but technology has not advanced to that level.  Happy patients are those that don’t expect much.  If you think you are going to get a surgical result from a non-surgical treatment, you are setting yourself up for disappointment.  Oftentimes the changes from non-surgical skin tightening are so subtle that they do not show up in a before and after picture.

So…what is a patient to do?  Well, first off, the answer is homework.  If a doctor or spa is offering a minimally invasive skin tightening procedure, ask to see 10 cases that the provider considers average results.  If a provider cannot show you 10 successful cases, then you may think twice about their experience or the effectiveness of the treatment.  Also, if you are looking at before and after pictures, make sure they are actual patients of the doctor and not “corporate” before and after pictures.  Finally, make sure the photos are standardized.  If they are not the same size, the same lighting, the same poses, the same makeup, etc. then they can be deceptive.

Also ask the provider how many treatments are necessary to see improvement and how long that takes.  Also, search the Internet for reviews from other patients, although this can be variable.  You may also want to inquire about how painful the treatments are and what pain control alternatives are available. I think that the biggest complaint I hear from patients is that “I thought it would do a lot more than it did” or “I thought I was going to spend less than a surgical result would have cost”.

Keep in mind that to date, there is no nonsurgical skin tightening procedure that can duplicate the effects of laser, facelift or eyelid surgical procedures.  Maybe someday, but not today.  Surgery is not for everybody, but in general laser resurfacing or facelift are still the only procedures that can truly provide dramatic tightening of sagging and wrinkled skin.  I am not implying that other procedures are worthless, but they are absolutely less effective.

I have seen many unhappy patients that had nonsurgical procedures that failed to deliver and I have also seen patients that were happy with the small changes they received.  The happy patients were the ones that were provided honest dialogue by the treating doctor and not over promised.  They also had realistic expectations and did not expect a surgical result from a non-surgical procedure.

I have seen too many patients that did not want to spend the money for eyelid surgery or facelift, only to spend as much or more chasing procedures that cost a lot and did little.  I am not saying that surgery is the answer for every patient; I am only saying that patients need to fully understand the pros and cons of new non surgical procedures and have realistic expectations before taking the leap.

To find out more about cosmetic facial surgery by Dr. Joe Niamtu, visit


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia




Office Address

Joe Niamtu III, DMD
11319 Polo Place
Midlothian, VA 23113

Office Hours

Monday - Friday
8:00am - 5:00pm

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