Treatments vs surgery: which facial tweaks are best for you?

In-clinic aesthetic treatment menus have never been longer. We’re seeing high performing and safer injectables, more sophisticated devices, and regenerative treatments that are genuinely changing what results are possible without going under the knife.  

Concurrently, the same can be said about advancements in facial plastic surgery, which makes it harder to know what’s the best option for your concern.  

We spoke to Consultant Plastic Surgeon, Paul Banwell, and Aesthetics Doctor and Layered Expert, Ahmed El Muntasar, to break down the most common facial concerns and give an honest assessment of where non-surgical treatments deliver, where they fall short, and when surgery is more appropriate.

Under-eye bags

You may look at your under-eye bags and think they’re simply one problem, but oftentimes they are several issues compounded, and what’s caused your bags plays a major role in their fix. 

Prominent fat pads, volume loss creating shadows, poor skin quality, fluid retention and genetics can all produce a similar appearance, but each requires a different approach.

“When hollowing or skin quality is the dominant issue, non-surgical treatments like tear trough filler, skin boosters, and regenerative treatments can work wonders. The problem arises when the real issue is fat protrusion, because what the above cannot do is remove or reposition prominent fat pads,” says El Muntasar.

Banwell regularly sees patients who have undergone multiple rounds of dermal filler without the improvement they hoped for. 

“One common scenario is a patient who has had repeated tear trough filler despite having prominent fat pads. The filler may initially disguise some of the contour irregularity, but over time the underlying problem remains, and the area can start to look increasingly heavy,” he explains. That’s where surgery comes in.  

“A lower blepharoplasty which is where we surgically remove or reposition fat to improve the contour of the lower eyelid, can make for the best course of action,” shares Banwell.

Unsurprisingly, both experts believe a combination approach delivers the best overall outcome because surgical and non-surgical treatments address different aspects of ageing.

“A lower blepharoplasty can correct the structural issue by dealing with excess fat or skin, while non-surgical treatments can be used to improve skin quality, address pigmentation, soften fine lines or optimise the surrounding tissues,” explains Banwell.  

Eye area drooping

Heavy eyes are one of the most common ageing concerns, but the source of that heaviness - brow descent, excess eyelid skin or both - determines everything about how it should be treated. 

“Some patients think they have excess eyelid skin when actually the main issue is that the brow has dropped. If you don’t identify where the problem is coming from, you can end up treating the wrong thing and the patient won’t get the result they’re looking for,” says El Muntasar.

Where brow descent is the primary driver and changes are still mild, botulinum toxin injections can provide a subtle lift by relaxing the muscles that pull the brow down. It’s effective in the right patient but has a clear ceiling – think a few millimetres of elevation rather than significant repositioning. 

Radio frequency and ultrasound devices can provide additional support and collagen stimulation, making them useful for early or preventative treatment.

“I often explain that non-surgical treatments can improve skin quality and provide some tightening, but they cannot remove a fold of excess skin. Once that skin is physically present, surgery is often the most logical next step,” says Banwell. 

Modern brow lifts and blepharoplasty produce natural, rested results that are very different from the pulled, surprised appearance associated with older surgical techniques. In some patients, both procedures are performed together to address what each cannot achieve independently.

Volume loss

Just like you can’t naturally control where you lose fat in the body, you can’t control facial volume loss either, and it’s never uniform. The temples, mid-face, under eyes and lips each lose volume at different rates and in different ways, think fat loss, muscle loss, bone degradation and skin laxity. 

What works in one area can be entirely wrong in another, meaning treatment needs to be tailored accordingly, with an eye on the face as a whole, rather than individual features in isolation.

Dermal fillers provide immediate, targeted volume, while biostimulators made from poly-L-lactic acid (PLLA) or calcium hydroxylapatite (CaHA), stimulate the body’s own collagen production gradually, improving tissue quality and firmness. 

“I often describe fillers as replacing some of what has been lost, while biostimulators are improving the foundation and quality of the skin itself,” says El Muntasar. In practice the two approaches are increasingly used together to address hollowed temples, flattened cheeks, under-eye hollowing, and sagging of the lower face. 

The trick is to get the balance right. “Patients often assume that looking older automatically means they need more volume, but that is not always the case. Sometimes the issue is that tissues have shifted position rather than disappeared altogether,” says Banwell. 

When descent is significant, fat transfer using the patient’s own tissue or surgical repositioning aka a lifting procedure, becomes the more anatomically appropriate approach. Together they can restore tissue closer to its original position and add fullness where needed.

Skin laxity

When it comes to excess, loose skin, non-surgical treatments like radio frequency, ultrasound, laser, and plasma energy can stimulate collagen, improve firmness and create meaningful tightening in some patients. 

“They’re best suited to patients who want subtle tightening, better firmness and a fresher appearance, rather than a surgical-style lift,” says El Muntasar.

Jowling is where the limits of non-surgical tweakments become most apparent. In the earlier stages, a combination of filler, biostimulators and energy devices can improve jawline support and definition. But once tissue descent becomes significant, the conversation has to shift.  

“Dermal filler can support and camouflage, but it cannot truly reposition descended tissues. When a patient wants a clearly defined jawline and there is significant tissue descent, a facelift becomes the more predictable and anatomically appropriate option,” says Banwell. “And it’s very different from the overly tight results people often imagine – the aim is to restore the deeper tissues to a more youthful position and create natural-looking definition,” he adds.

The neck follows suit. Non-surgical devices, collagen boosting and muscle relaxing injectables can meaningfully improve skin quality, firmness and early crepiness. But when there is substantial loose skin or significant loss of definition between the jawline and neck, surgery physically removes and repositions loose tissue in a way that devices simply cannot replicate. 

Perioral ageing

The skin and tissue surrounding the mouth is one of the most complex parts of the face to treat. It’s common for people to experience lip thinning, vertical lines, loss of definition and downturned corners all at once. 

Lip filler is often the first thing people reach for, but an ageing lip doesn't necessarily need more volume. "As we age, the lips do not simply lose volume. The upper lip can lengthen, the border may become less defined, the surrounding skin can develop fine lines and there can be changes in support from the underlying structures. If those factors are ignored and volume is added indiscriminately, the result can look unnatural," says Banwell.  

For vertical lines and skin texture specifically, CO2 laser resurfacing remains one of the most effective options, as it stimulates new collagen while smoothing the surface. Radio frequency with microneedling to target the dermis more deeply is also increasingly used in this area: the dual action stimulates collagen and elastin production at a deeper level than either treatment can achieve alone, making it particularly effective for fine lines and skin laxity around the mouth. 

Skin boosters like Profhilo and polynucleotides can improve hydration and skin quality, while carefully placed botulinum toxin can soften dynamic lines, though the high mobility of the area means a light touch is essential. 

"Surgery-wise, lip lifts are probably one of the most overlooked procedures. In the right patient, they can create a more youthful upper lip shape and improve proportions in a way that filler alone often can't achieve," says El Muntasar. 

Banwell shares that a facelift can also significantly improve the perioral area by restoring lower face support and softening marionette lines, addressing the structural root rather than repeatedly treating the symptom.

The verdict

Across all concerns, it’s clear that understanding what is actually driving the concern before deciding how to treat it is key. There’s a place for surgical and non-surgical options, and according to El Muntasar, "good aesthetic medicine isn't about avoiding surgery at all costs. It's about being honest with patients and helping them understand what will genuinely give them the best outcome." 

Non-surgical treatments have expanded what results are possible, but they haven’t replaced the need for surgery altogether.