Facial rejuvenation using Thermage, Botox, Restylane and Affirm LaserBy Tran Thi Anh Tu, M.D.,Ph.D

Abstract : Facial rejuvenation is considered as a complex and most demanding treatment in cosmetic clinics. Among the various procedures done to the facial area, facial rejuvenation is increasingly popular throughout the world. The complexity of the procedures, as well as the varying demands of the clients makes facial rejuvenation one of the most challenging procedures to even skilled doctors. This article offers a discussion upon the combinational treatments of Thermage, Botox, Restylane and Affirm laser to achieve the most satisfying results.


Aging is caused by insufficient replacement of cells to maintain full function capacity. It is a devastating process in regards to its effect on people, especially to those whose appearance is vital to their job and success. The aging process begins as early as 25 years old and will continue hence forth. This process is most perceptible around the face area through the formation of folds due to soft tissues atrophy, such as tear trough deformity, deep naso-labial fold, Marionette line… Dynamic wrinkles emerge and become more apparent, examples of the crow’s feet, glabella lines, horizontal lines of forehead, Bunny lines…The skin becomes tougher, losing its elasticity while forming bags under the eyes and chins, creating double chins and other conditions. Skin dyschromia is also a sign of the aging process. The overall effect of facial aging leads to a reduction in the skin’s texture, conjuring the image of age, tiredness and inactiveness. To the modern persons, these signs affect their image, leading to the loss of self-confidence, causing great impact on their jobs and social life. Hence the demand for facial rejuvenation is valid across the globe.

The demands for facial rejuvenation revolves around the removal of wrinkles, filling of deep folds, improving the skin texture as well as skin tightening. This article aims to discuss the most effective procedure for facial rejuvenation using a combination of Thermage, Botox, Restylane and Affirm laser.

The procedures

There are 2 main approaches to facial rejuvenation with one utilizing surgery whereas the other uses non-surgical methods. These 2 distinct approaches provide differing results while having varying downtime, along with a variety of side effects. Surgical procedures to facial rejuvenation often include face-lift by traditional methods or using the Aptos® or other threads to reduce sagging skin. As oppose to invasive surgical procedures, non-surgical treatments employs waves, such as Radio Frequency, laser or injection…. The treatments, which will be analysed in depth in this article, are Thermage, Affirm laser, Botulinum toxin and Restylane.

Among the two possible approaches, non-surgical methods to facial rejuvenation are gradually gaining popularity over surgical operations, reflecting customers’ incline towards safe and less invasive treatments, even after taking into account the varying results. A major drawback of the surgical method is its devastating side-effects and dependence on the surgeon’s skill. The downtime for surgical procedures is also a realistic factor that prevents customers to seek surgical options for facial rejuvenation.

Face-lift surgery gives apparent and long lasting result. However, the operation leaves scars, despite how well-concealed it is, and the chances of complication are high. Another drawback of this treatment is its inability in improving skin texture, only aims to straighten the skin.

Thread-lift provides apparent results. In addition to the result, Aptos procedures are easy to execute by doctors, making it a popular treatment for facial rejuvenation. The complications of Aptos lie in the experience of the doctor. Within the Aptos patients, there have been cases of infections and irritation in the thread site. A small proportion of the patients experiencing irritation wanted to remove the thread due to the overall discomfort. Alongside with the discomfort due to the thread, the non-degradable thread help maintaining its supposed-effect whilst causing extrusion due to the body’s reaction to foreign objects. This forces complete removal of the thread. The doctor’s experience is also vital in the success use of the thread.

The lifting effect of the thread is temporary, couple with the excess irritation of the thread on patients and its difficulty in removal reduces the thread-lift’s popularity.


Botox is abbreviated for Botulinum toxin type A, a purified protein produced by the Clostridium botulinum bacterium. This is a product of Allergan and is approved by the FDA in 2002. It has become increasingly familiar around the globe for use as a treatment for dynamic wrinkles.

Botox is administered into different parts of facial muscles responsible for causing the motion lines. The protein works upon selective muscle denervation in the face area. It interferes with the acetylcholine receptors, effectively relaxes the muscle and eliminate dynamic wrinkles.

The injection technique used is given by Allergan’s guidelines. Since Botox is a form of neurotoxin, it has to be administered by trained physicians and requires adequate sterilization, as well as equipments for cases of side effects during the injection.

Figure 1: Botox injection techniques 
BOTOX® Cosmetic is to be reconstituted only with 0.9% sterile, non-preserved saline (100 Units in 2.5 mL saline) prior to intramuscular injection.

The dosage commonly injected is about 50 – 70 units for the upper face. This creates apparent results with the removal of wrinkles, elevation of eyebrows, crow’s feet, Bunny lines, etc. Botox also has limited diffusion rate, hence the toxin is contained within the intended area, reducing unwanted effects in other facial area. Associated complications of Botox injection are the hyperelevation of eyebrow’s tail, lower eyelid sagging, bruises at the injection site, ptosis, diplopia … The side effects I’ve encountered are temporary, occurring in rare cases. The effects of Botox lasts from 3 – 6 months depending on the client’s adaptability to the injection and the dosage used.

These are a few results from the sole use of Botox:

Figure 2: This 34 year old male is treated with 50 units of Botox in the upper face’s wrinkles. 2 weeks after the injection, he looks comparatively younger than his lower face.

           Before injection                2 weeks after Botox injection

           Before injection                 2 weeks after Botox injection

            Before injection                2 weeks after Botox injection

Figure 3: This 41 year old female has 50 units of Botox injection on her upper face. Even so, her severe degree of aging elevates the disharmony between the upper and lower face.

Despite its satisfying result, Botox can only treat wrinkles caused by contraction of muscles in the facial area. For aging skin with reduced elasticity, constant wrinkles will leave folds on the skin, forming deep lines even when the muscles are relaxed. These lines can be diminished by the combined use of fillers and Botox. The filler that I want to discuss within this article is Restylane.


Restylane is the commercial name for Q-Med’s filler. It is a type of hyaluronic acid with nonanimal origin. Due to its composition of hyaluronic acid, present on the skin, eyes and joint, Restylane is highly compatible to human body, eliminating the risks of extrusion. However, Restylane’s effectiveness is from 9 – 12 months. After that period, subsequent injections can be performed.

The use of Restylane focuses in treating deep wrinkles such as frown lines, or softening folds as tear trough deformity, deep naso-labial fold, Marionnette lines… The dosage used is 1 to 2ml in one treatment due to its price and apparent results. Larger dose of Restylane would compromise between its aesthetic results with the client’s natural beauty. Restylane’s strength is that it provides instant result. Besides, Restylane also softens deep folds, helps improving skin’s humidity and collagenesis. The procedure is simple with minimal downtime, nonpermanent and versatile.

Restylane comes in colourless fluids administered in 30G needle. There are a variety of techniques for Restylane injections in Q-Med’s guidelines and from other documents. The preferred techniques used are linear threading and fanning.

Figure 4: Restylane injection method

Complications due to the injection of Restylane are usually mild and transient, lasting for only a short period of time. The complications encountered with Restylane are swelling, bruising, skin unevenness, Tyndal effect, over-filled, vascular occlusion… However, during our practice, we have not come across complication of vascular occlusion after the injection. The result is instantly and will last from 6 months – 1 year, hence client’s satisfaction is high.

               Before injection                           Immediately after
                Before injection                          Immediately after
Figure 5: This 38 year old woman had 1ml of Restylane injected to relieve her deep naso-labial folds.

Before injection                2 weeks after

Figure 6: 45 years old female injected with 1ml of Restylane to treat her tear troughs and naso-labial folds

Before injection                           Immediately after

Before injection                            Immediately after

Figure 7: 65 years old female treated with 1ml Restylane

Restylane is hence suitable in treating deep lines and folds in the face. It allows the face to achieve a more youthful appearance, rejuvenate the aging process caused by skin’s degrading laxity. Even so, the use of Restylane alone will not effectively achieve a satisfying result for motion lines. The combination of Restylane and Botox achieves excellent results. Both affect on different wrinkles and folds in the face, eliminating signs of the aging process on the client.



Figure 8: The combination of 50 units of Botox and 1ml of Restylane has improved the client’s face naturally while leaving no scars and no side effects. There is virtually no downtime, although anesthetic was applied 45 minutes prior the injection. Both these injections are performed consecutively.

However, the sagging skin, especially on the submental area was not improved. Similarly, the issue of skin’s laxity remains on this man.



Thermage is produced by Solta Medical. As opposed to Botox and Restylane, Thermage works to improve skin texture, along with eliminating wrinkles and temporary treating cellulite. Thermage utilises monopolar capacitive radio frequency in tightening the skin, along with encouraging self-collagenesis. It applies the heat to deep layers of the skin without burning the surface. Its effective cooling system enables the machine to reach deep into the dermis and subcutaneous layer, enabling better result than normal RF-induced machineries.

The machine that we use is Thermage NXT, incorporating a wide range of tips for treatment in specific areas. For the face, STC 600 and STC 900; for eyelid treatment ST 225 is used. These tips vary depending on the number of shots and treated area. For patients aiming to rejuvenate the face area, we recommend using the STC 900 tip for the most desirable result. After treating the face, the STC 900 allows us to treat the client’s upper neck area, hence harmonizing the treated area to create the natural look. The treated areas are the face and upper neck using baselines and vectors. The number of passes for each vector depends upon the aging change of the area, usually ranging from 4 – 6 passes per vector for optimal results. Cases of severe aging require more shots to achieve equal results using fewer shots on a younger face. Treatment level varies on the facial areas:

+ upper eyelid: 4 – 5 = 64 - 72 J/cm²

+ upper face: 2.5 – 4.5 = 27 - 50 J/cm²

+ middle face: 2 – 4 = 20 - 44 J/cm²

+ lower face : 1.5 – 3.5 = 15 - 38 J/cm²

Figure 9: Thermage techniques

Via the use of Capacitive Radio Frequency, Thermage enables the procedures to show results instantly. Improvements will be seen immediately after the treatment, continuing up to 2 to 6 months post treatment and last for 1-3 years. The treatment will last from 45 minutes to 1 and a half hours, pending on the treated areas. With its non-invasiveness, no injection, no downtime and only require one treatment to attain results, Thermage is suitable for busy clients who are in need of effective, limited-risk facial rejuvenation.

Thermage presents itself as a competitive alternative to face lifts.

Before face lift operation                1 month after operation

Figure 10a: Facelift

          Before                                  Immediately after

Figure 10b: Thermage (STC 900)

Figure 10: As observe the sagging skin in the lower face of these 2 women do not differ a lot. The woman in the lower picture had improvement immediately after Thermage and is scar-free with no downtime. Furthermore, Thermage also helps to encourage collagenesis and improve skin’s texture.


The drawbacks of Thermage are its high consumable costs, including the tips, grid paper and cooling gas. Complications are mild and transient, ranging from skin redness, swelling on upper eyelids to blister or indentation. However, we have not come across any cases of blistering or indentation. Patients’ satisfaction with Thermage is very high.

       Before                                   Immediately after

Figure 11: This woman had Thermage treatment with STC 900. 15 days post treatment, the sagging of jaw line and submental area improved. Her skin becomes radiant and tightened.

Combination of Thermage, Botox and Restylane

The combination of Thermage, Botox and Restylane provides a desirable result. The combination of the 3 procedures utilises their strengths and improves the overall rejuvenation process.

Before treatment                       1 week after treatment

Figure 12: 57 years old female, Thermage: STC 600 and ST 225, Botox: 50 units, Restylane : 2ml. Her face has improved drastically in just 1 week post treatment.

Before treatment           1 week after treatment

Figure 13: 48 years old female, Thermage: STC 600 and ST 225, Botox: 50 units, Restylane : 2ml. Her face looks younger in rest as well as when she’s smiling. Improvement in her upper eyelid skin is apparent by the combinational effect of Thermage and Botox.


Affirm Laser

Affirm Laser is a registered trademark of Cynosure Inc, America. Affirm laser incorporated the MultiPlex™ technology with Combined Apex Pulsesm (CAP) technology and Xenon Pulsed Light (XPL) technology into one machine. Having 2 wavelengths 1320nm and 1440nm, Affirm laser works to improve fine lines, skin texture, acne scar, melasma… It also improves collagenesis of the body by using heat to stimulate and remodel collagen. Treatment parameters are:

Complications of Affirm Laser are usually mild as skin redness, swelling, hot and pain during and shortly after treatment. Post inflammation hyperpigmentation is rare and mild, although patients need 1 to 2 days downtime.

        Before treatment                2 months after treatment

Figure 14: This woman’s hollow face is improved after the combined treatment of Thermage, Botox, Restylane and Affirm laser.

           Before treatment (11/2006)            After Affirm session and Botox (9/2008)

2 months after Restylane and Thermage (11/2008)
Figure 15: 49 years old, Botox: 50 Units, Restylane: 1ml, Affirm LASER: 6 treatments, Thermage: STC 600. This woman had Affirm laser treatments, in session of 6 treatments from 2 to 4 weeks apart. After that, she had the combined treatment of Thermage, Botox and Restylane. Beside the improvements of jawline, neck sagging… her skin texture and acne scar were improved. Despite the 2 years time difference, she looks younger than before.

      Before treatment                    After combined treatment

Figure 16: 36 years old, Thermage: STC 600, Botox: upper face and masseter muscles =100 units, Restylane: 1ml, Affirm laser : 6 treatments. He received 6 Affirm laser treatments followed by a combined treatment of Thermage, Botox and Restylane. 100 units of Botox were used to remove the wrinkles of upper face and to shape the face by masseter muscle injection.

Combination of procedures has many benefits, some are:

- Improves many aging changes

- Gives maximal results without surgery so that the patient satisfaction is high.

- Needs little or no downtime

- Saves the client’s time: only in 1 visit the patient can have the treatment of Thermage, Botox and Restylane. We do the Thermage treatment first, followed by Botox and Restylane injection. The additional Affirm laser treatment is done before or 2 weeks later in session of 5 to 6 treatments, 2 to 4 weeks apart.


In conclusion

The combination of Thermage, Botox, Restylane and Affirm laser helps improving the changes resulted from facial aging:

- Thermage lifts and tightens the face, softens the folds, improves the facial contour.

- Botox reduces the motion lines

- Restylane reduces the sinking

- Affirm laser refines the skin, improves the fine lines, melasma, acne scar…

The combinations of all 4 procedures provide excellent results for facial rejuvenation while boosting patients’ satisfactions.



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2. Douglas Hamilton, Nonsurgical facial rejuvenation. In: Master techniques in facial rejuvenation. Saunders Elsevier, 2007: 267-269.

3. Rhoda S. Narins, J. Michaels, Joel L. Cohen, Hylans and soft tissue augmentation. In: Soft tissue augmentation. Saunders Elsevier,2008: 42-49.

4. William J. Lipham, Cosmetic applications of Botulinum Toxin. Cosmetic and Clinical applications of Botulinum Toxin. SLACK Incorporated,2004: 65-86..

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6. B. Biesman, Kenneth A. Arndt, Periocular Treatment. In: Botulinum Toxin, Saunders Elsevier, 2005: 45-56.

7. Botox Dosing handbook for basic and advanced indications, Allergan.

Thermage technology overview, http://www.thermage.com/Pages/TheTechnology.aspx

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