“Fillers are dead! Long live the facelift!” Or so we’re told. Once upon a time we whispered about facelifts in hushed tones, the preserve of women (and men) of a certain age and bank balance.
Now, according to the aesthetic–industrial complex, they’re the sophisticated choice the final solution to any hint of sag. And fillers? Lumped in with TikTok mishaps and Real Housewives pillow-faces.
How did we get here? Pull up a chair, it’s quite the tale.
When the Needle was Queen
When I landed in London in 2000, the most decadent facelift in town was performed by a French surgeon called Céline, a man (despite the name), whose fee hovered around £10,000 to £12,000, cash-only if you believed salon lore. He was the apex of discretionary transformation; clients vanished to Provence for a “rest” and returned two weeks later looking like their more glamorous twin.
Back then, hyaluronic acid (HA) fillers felt like a revolution. A touch here, a smidge there, and five years evaporated without a bandage in sight. In expert hands, HA integrates, looks like you (on eight hours sleep), and crucially is reversible.
Over time, the right work coaxes your own collagen to behave. In my clinic I’ve treated up to 5,000 patients a year for two decades; done judiciously, filler delays the scalpel for years, sometimes entirely.
We had proof, too. Rajiv Grover’s work with facelift patients showed that those who’d had regular HA filler arrived in theatre with firmer, more collagen‑rich tissue. Translation: the best “prep school” for later life can be good filler done well.
Where it went wrong
The downfall was pure theatre: celebrity absurdity, corporate excess, and a generational crisis of taste.
ACT I: The Kardashian effect
Kim and sisters recast beauty as hyper‑curated spectacle: sculpted cheeks, razor jaws, hourglass figures that defied basic geometry. Instagram amplified it until a proportionate face looked unfinished. Patients arrived, screenshots in hand, demanding to be “snatched” by lunch.
ACT II: Corporate overfill
Allergan, maker of Juvederm, promoted “Facial Codes” fronted by Dr Maurizio de Maio. The takeaway on the conference circuit? Up to sixteen syringes in a single sitting. Sixteen. Veterans winced; novices took notes. Cue overstuffed cheeks, migrating gel, and a generation of chipmunks with credit cards.
ACTIII: Practitioners who couldn’t preach natural
A telling study found aesthetic practitioners are four times more likely than their patients to suffer from body dysmorphic disorder. Many of the new generation were raised on filters and makeover shows; they injected the faces they wanted for themselves, not the faces their patients actually owned. Subtlety never stood a chance.
The Detours that didn’t help
As filler’s star waned, new miracles were wheeled out. Biostimulators such as Sculptra and Radiesse, semi‑permanent and collagen‑provoking, were rebranded “natural”. In practice, they can leave ropey deposits and complicate surgery later.
Then came the heat darlings: Thermage, Morpheus8, HIFU. Sold as “non‑invasive lifts”, they function by cooking tissue until it contracts. Yes, you read that right. You get scar collagen and altered fat pads, not the bouncy architecture of youth. I’ve never advocated them: they’re not reversible, and the damage is forever.
The Facelift lobby pounces
Surgeons, watching the filler boom erode their diaries, spotted an opening. Horror stories, many involving biostimulators or overfill, not plain HA, became morality plays. The nuance evaporated; all “fillers” were thrown under the same bus while the facelift was refurbished as the sensible, elegant fix.
And the prices? Stratospheric. That £12,000 Céline lift of yore now fetches £50,000 to £100,000 at the top end. Across the pond, rumours swirl of half‑million‑dollar jobs on American royalty.
True or not, it sets a tone: when everything else is PR‑poisoned, the scalpel can name its price.
Reality without the PR gloss
Facelifts are not an afternoon in Mayfair. They involve incisions, deep‑tissue dissection, nerve risk, and weeks of swelling and bruising. Mortality is rare, but not zero. Recovery means drains, dressings, and a face that doesn’t feel entirely yours for a while.
And the satisfaction? Working with a facelift surgeon in 2000, I watched the human side: perhaps three to five in ten patients were truly delighted; the rest were underwhelmed, over‑tightened, or struggled to reconcile the mirror with the mind. Operate too young and you age into a look that nature can’t soften.
For perspective, the bit no one puts on Instagram: Brazilian Butt Lifts carry some of the highest mortality in aesthetics, somewhere between one in a few thousand to one in tens of thousands. Liposuction’s historic mortality has been quoted around one in five thousand. Yet these are marketed like spa days, while hyaluronic filler (the reversible one) gets the cautionary-headlines treatment.
The big unfashionable truth
If you strip away the hype, HA fillers remain one of the safest interventions in aesthetic medicine. In the US alone, roughly three to three‑and‑a‑half million filler treatments are performed each year.
Globally, plastic surgeons alone account for over six million HA procedures annually, yet the true total is much higher once you include dermatology and other trained injectors.
Across three decades, the number of published catastrophic injuries such as vision loss sits in the low hundreds worldwide. Per treatment, the risk is vanishingly small, rarer than lightning striking your Birkin on Bond Street, but serious enough to demand anatomical expertise and restraint.
The moral?
What we need isn’t team Needle or team Scalpel. It’s taste. Balance. Honesty. Use HA conservatively, in harmony with anatomy. Educate patients about the difference between reversible HA and everything else. Be candid about surgical risks and recovery. And retire celebrity distortion as the standard of beauty.
The best work remains invisible. The compliment we’re chasing is still: “You look fantastic, have you been away?” Not: “Who did your face?”
Dr Michael Prager