What causes sagging?
Sagging of the face is not just loosening of the skin; it is the combined result of changes in several layers. For this reason, a method that targets a single layer should not be expected to solve the problem entirely.
- Skin: collagen and elastin fibres decrease; the skin becomes thinner, loses its elasticity and returns to its former state more slowly when stretched.
- Fat tissue: some of the fat pads of the face lose volume, and some shift downwards. The cheeks flatten, and fullness collects along the jawline and at the sides of the mouth.
- Ligaments and muscles: the ligaments that attach the skin to the underlying tissues slacken; the edges of the thin muscle in the neck may become prominent as vertical bands.
- Bone: with age there is some loss of volume in the facial bones, which reduces the support for the tissues above.
Factors that speed up this process include sun exposure over many years, smoking, weight lost over a short time or repeatedly, and genetic predisposition. Protecting yourself from the sun and not smoking do not stop sagging; however, they help the skin to wear more slowly.
Why does the degree of sagging matter?
What can be expected from which method is determined above all by the degree of sagging. The table below is a rough framework; the real assessment is made by examination.
| Degree | Typical appearance | General approach |
|---|---|---|
| Mild | Slight loss of definition along the jawline, slight flattening of the cheeks; the appearance improves when the skin is lifted a little with a finger | Sun protection and skin care; non-surgical methods can be considered if wished |
| Moderate | Noticeable fullness at the edge of the jaw, deepening of the fold between nose and lip, mild laxity in the neck | Non-surgical methods can provide a limited improvement; expectations should be discussed openly |
| Marked | Loss of the jawline, excess skin and bands in the neck, marked downward shift of the cheek | The contribution of non-surgical methods is often insufficient; a surgical assessment is a more realistic step |
What can creams and home methods do?
Creams and lotions promoted as firming cannot lift sagging tissue back into place, because they do not reach the deep layers where sagging originates. The effect seen is mostly due to moisturising and disappears when use is stopped. Creams containing retinoids may provide a small improvement in skin quality; however, this does not amount to a lifting effect. The evidence for the effect on sagging of facial exercises, massage devices and tapes is limited.
Non-surgical options and their limits
Non-surgical methods share the following features: recovery time is short, the effect is modest, and the result varies from person to person and lessens over time. Those who benefit most from these methods are people whose sagging is mild.
| Method | How it works | What can be expected | Limits and risks |
|---|---|---|---|
| HIFU (focused ultrasound) | Stimulates collagen production by creating small points of heat in the layers beneath the skin | A modest tightening that appears over months | Most studies are small and follow-up periods short; the procedure may be painful; burns, numbness and nerve effects have been reported rarely |
| Radiofrequency and radiofrequency microneedling | Stimulates collagen production by heating the skin and the tissue beneath it | Gradual, mild to moderate tightening; often more than one session | Does not correct marked sagging; there is a risk of burns, pigmentation and, rarely, loss of fat tissue |
| Thread lift | Mechanically lifts the tissue with threads placed under the skin that are absorbed over time | An improvement seen immediately after the procedure | The durability of the lifting effect is limited; dimpling, asymmetry, palpable threads and infection can occur |
| Hyaluronic acid filler | Supports the tissue by replacing lost volume | A more rested appearance in faces where volume loss predominates | Does not lift tissue; trying to hide sagging with filler can make the face look heavy and puffy; there is a rare but serious risk of vascular occlusion |
| Laser resurfacing | Tightens by renewing the upper layers of the skin in a controlled way | Tightening of the skin and a reduction in fine lines | Recovery time is longer; there is a risk of pigmentation and scarring; does not correct sagging in the deep tissues |
A systematic review bringing together the studies on HIFU reported that the method provides a moderate improvement in the face and neck and appears safe in the short term; however, the studies used different measures and most had no long-term follow-up. For details, see the articles “HIFU (High-Intensity Focused Ultrasound): How Effective Is Non-Surgical Tightening?” and “Radiofrequency Skin Tightening and Radiofrequency Microneedling: What Can You Expect?”.
A systematic review on thread lifts, for its part, stated that in most of the studies examined the durability of the lifting effect remained very limited, and that the few studies reporting positive results were carried out with support from the manufacturer. For this reason, the evidence for the effectiveness of thread lifts should be regarded as limited. Details of the method are given in the article “Thread Lift (Non-Surgical Facial Lifting Threads): Who Is It For, How Long Does It Last, and What Are the Risks?”, and a comparison of the two methods in the article “HIFU or Thread Lift? Comparing Two Non-Surgical Methods for Mild Sagging”.
Filler is a treatment for volume loss, not for sagging. In properly selected cases it can give the face support; however, it does not remove excess tissue. For how filler is given and its risks, see the article “Hyaluronic Acid Filler: What It Is, How It Is Done and What the Risks Are”.
Non-surgical methods can provide a modest improvement in mild laxity, but in marked sagging they do not take the place of surgery. Discussing expectations openly from the outset is as important as which method is chosen.
Dr. Hamza GemiciMedical Director, DoktorClub · Aesthetic Medicine Physician
When is a surgical assessment needed?
A surgical face and neck lift repositions slackened tissues and removes excess skin; particularly for sagging of the lower face and neck, it provides a noticeable change that cannot be achieved with non-surgical methods. In the situations below, obtaining a surgical opinion before starting another non-surgical procedure may be a more realistic route:
- If the jawline has clearly been lost and there is sagging tissue at the edge of the jaw
- If there is excess skin or marked vertical bands in the neck
- If there is excess skin on the upper eyelid that affects vision or how far the eye opens
- If non-surgical methods have been tried but the expected change has not been achieved
- If it is thought that ever-increasing amounts of filler are needed to hide the sagging
- If loose skin has developed on the face and neck after marked weight loss
Surgery is not without limits either. An operation does not change the quality of the skin, dark spots or fine lines; ageing continues after surgery. It carries risks such as bleeding, infection, loss of sensation or movement due to nerve damage, asymmetry, noticeable scarring and hair loss around the scar. It should be understood that bruising can be visible for at least two weeks, that recovery takes weeks and that the final appearance settles over months. No firm promise can be made about the result; some people may not achieve the change they expected.
The decision on surgery is made with the physician in the relevant surgical specialty who will perform the operation, with general health, medicines taken, smoking and expectations all assessed together. Because smoking impairs wound healing, it must be mentioned at this consultation.
Normal, see a physician, or an emergency?
| Situation | What it may mean | What to do |
|---|---|---|
| Sagging that progresses slowly over years and is similar on both sides | An expected result of ageing | No need to seek advice on health grounds; if it bothers you, you can discuss the options with a physician |
| Drooping of the eyelid that affects vision, or new drooping of one eyelid | Excess skin, or a problem with the structures that lift the eyelid | See an ophthalmologist |
| A newly noticed swelling or lump in the neck or under the chin | A cause other than sagging | See a physician without delay |
| Sudden drooping on one side of the face, the corner of the mouth pulling to one side, speech problems, weakness in an arm | May be a stroke or facial paralysis | Call 112 (or your local emergency number) immediately |
Do not wait if you have these symptoms after a procedure
- A change in vision after filler: call 112 immediately
- Severe and increasing pain, whitening of the skin or net-like bruising after filler: contact the physician who performed the treatment without delay; if you cannot reach them, go to an emergency department
- A blistering burn, numbness that does not pass or reduced movement in part of the face after an energy-based procedure: see a physician the same day
- Increasing redness, warmth, discharge, fever or a thread coming out through the skin after a thread lift: see a physician the same day
The warning signs related to filler are described in detail in the article “After Fillers: When Is It an Emergency? Vascular Occlusion and Other Warning Signs”.
Realistic expectations
- Non-surgical methods do not give the result of a facelift operation; what can be expected of them is a modest improvement in mild laxity.
- The effect lessens over time, and with most methods repeat treatment is needed to maintain it; how often it will need repeating should be discussed in advance.
- The same procedure does not give the same result in every face; in some people no noticeable change may be seen.
- Having several non-surgical procedures one after another does not take the place of surgery in marked sagging.
- Having nothing done is also a valid option; sagging is not a health problem.
Questions to ask your physician
- Is my sagging mild, moderate or marked, and is it skin laxity or volume loss that predominates?
- How much change do you realistically expect in my face from the non-surgical method you recommend?
- How long does this effect last, and how often does it need repeating to maintain it?
- How strong is the evidence for the effectiveness of this method?
- In my situation, would it be better for me to obtain a surgical opinion?
- What are the common risks of this procedure, and the rare but serious ones?
- How long is recovery after the procedure or operation, and when can I return to work?
- If there is a problem, how and at what times can I reach you?
Frequently asked questions
Can non-surgical methods take the place of a facelift operation?
No. Non-surgical methods can provide a modest tightening in mild laxity; however, they do not remove excess skin or reposition slackened deep tissues. In marked sagging they should not be expected to give the change that surgery provides.
Do firming creams correct sagging?
Creams do not reach the deep layers where sagging originates. The effect seen is mostly due to moisturising, is slight and disappears when use is stopped.
Does filler lift sagging?
Filler replaces lost volume; it does not lift tissue. It can provide support in faces where volume loss predominates; however, trying to hide sagging with filler can make the face look heavy and puffy.
When is the effect of HIFU or radiofrequency seen?
Because these methods work by stimulating collagen production, the effect does not appear immediately but usually gradually over months. The effect is modest and varies from person to person.
How long does a thread lift last?
A systematic review bringing the studies together reported that the durability of the lifting effect of thread lifts remained limited in most studies. How long it lasts varies with the person, the type of thread and the degree of sagging.
At what age does sagging start?
There is no particular age. Genetic make-up, sun exposure, smoking and changes in weight affect when and how quickly the process advances.
Do facial exercises prevent sagging?
The evidence that facial exercises prevent or correct sagging is limited.
One side of my face has suddenly drooped; could this be sagging?
No. Age-related sagging develops over years and similarly on both sides. Sudden drooping on one side of the face, especially if accompanied by speech problems or weakness in an arm, is an emergency; call 112 immediately.
Sources
- Many ways to firm sagging skin — American Academy of Dermatology (AAD)
- Facelift (rhytidectomy) — NHS (United Kingdom), 2023
- Systematic review and meta-analysis of safety and efficacy of high-intensity focused ultrasound (HIFU) for face and neck rejuvenation (Ayatollahi A et al.). PMID: 32026164 — Lasers in Medical Science, 2020
- Thread-Lift Sutures: Still in the Lift? A Systematic Review of the Literature (Gülbitti HA et al.). PMID: 29481392 — Plastic and Reconstructive Surgery, 2018
- Dermal Fillers (Soft Tissue Fillers) — U.S. Food and Drug Administration (FDA), 2023
Medical Aesthetics Expert Board
This article has been reviewed by the DoktorClub Medical Aesthetics Expert Board.
