A Natural Lifting in Daegu — What Is Actually Being Adjusted

The conclusion, first

“Natural lifting” is not an adjective attached to a result but a blank on which no scale has yet been made. Instruments capable of measuring naturalness do exist — a patient-reported scale has been validated with a reliability of ICC 0.88–0.97 (FACE-Q Aesthetics Natural Module, validation sample 1,358 people), and in double-eyelid surgery it has even been reduced to a physical quantity, “how many frames late the crease appears” (R² = 0.71). Yet in lifting nobody measures it. We went through all 126 registered trials whose outcome measure titles contain “natural”, and every trial that placed naturalness as an outcome measure used injectables (fillers · toxins · collagen boosters); we could not find a single one using energy devices such as ultrasound or radiofrequency. And where it is measured, the result always comes out at 90–100%, with the assessor in most cases being the patient or the doctor who performed the treatment. So rather than promising “we will make it natural,” we make public the parameters we can actually adjust, and the fact that those parameters have no upper-bound figure.

The order we actually work through in consultation

1. We confirm in a sentence what “natural” means to you

Where naturalness has been defined in a measurable form in the literature, the definition is not the beauty of the result but “how likely does this face look to have had a cosmetic procedure?” (1,795 facial photographs · 30 raters per photograph). That is, naturalness has been operationally defined only as a discrimination task for an observer. So in consultation we first separate out whether you mean “I do not want it to show,” “I want it still to be my face,” or “I want the change to be small.” Those three call for different designs.

2. We first work out what has descended

Before any adjusting there is the thing being adjusted. A loss of the skin’s own recoil and the structures beneath having settled downwards are different, and hollowed volume is not filled by heat. Skip that distinction and a request for “natural” gets translated into “weak,” and the direction goes astray. The layer-by-layer approach is set out in lifting treatment should change with skin thickness and fat volume.

3. We show you the parameters that can be adjusted, as they are

The right-hand column of that table is the heart of this article. The guideline writes that “used judiciously and avoiding overtreatment, a natural result can be obtained,” but the same document defines overtreatment as “excessive and uncontrolled delivery” — a circle that defines excess by excess, and there is no number a clinician can take from it. When the US FDA warned in October 2025 about burns, scarring, fat loss and disfigurement with radiofrequency microneedling, it likewise gave no numerical threshold on any axis — energy, depth or number of passes.

4. We also say that recommendations pointing the opposite way exist alongside

Within the same academic lineage two opposite recommendations sit side by side. One says “the ideal result is associated with high-density treatment” (a panel of five experts, with no evidence grading recorded); the other says “judiciously, avoiding overtreatment” (a pan-Asian consensus, co-authored by the author of the first document, both funded by the same manufacturer). Neither offers a number. In the consulting room, “doing less makes it more natural” stands on top of that gap in the evidence — which is to say it is our judgement, not an established rule.

5. We say why we do not make symmetry the goal

In measurements of 100 patients seen in consultation for upper eyelid surgery, 93% had a left-right brow difference of 1 mm or more, and 75% of 2 mm or more. In data on 201 rhinoplasty-waiting patients and volunteers, likewise, more than 89% were asymmetric across the measured items. And in both a study of 1,550 faces across 10 cultures and its independent replication (100 faces × 400 raters), asymmetry did not significantly predict attractiveness. That said, to write it honestly, we could not find in the literature any treatment recommendation to “leave asymmetry deliberately in place” — the literature speaks only of correcting it. So we do not set symmetry as a target figure, while saying that this is a judgement rather than a rule derived from evidence.

6. We fix in advance when the result will be judged

With radiofrequency, the clinician assessment was not significant at four weeks and was significant at 12, with the peak at four to six months. So we settle before treatment the very point at which “natural” is to be judged. Judge at four weeks and a normal course reads as a failure. The detail is in when results actually start to appear.

7. We check first the things that can be checked

That naturalness has no scale does not mean there is nothing to check. The device’s approval number, who performs the treatment, whether the consumable is genuine, the contract and refund terms, and the explanation of adverse effects are all things that can be checked before treatment. They are set out in five things to check before a lifting treatment.

What we do not do

• We do not use “we will make it look natural” as a promise. We could not find a single registered clinical trial in lifting that measured naturalness as an outcome. What has not been measured cannot be promised.
• We do not guarantee naturalness with before-and-after photographs. In the trials where naturalness was actually measured, the assessor was the patient or the doctor who performed the treatment, and the result was 90–100% without exception.
• We do not present “not overdone” as though it were evidence. The definition of overtreatment in the literature is circular, and there is no upper-bound figure.
• We do not present a high number of shots or lines as an advantage in itself. Only a lower bound has been agreed; an upper bound appears in no document.
• We do not use expressions such as “the best,” “the only” or “side-effect-free,” and we do not disparage other clinics’ treatments.
• We distinguish between “we could not find any” and “there is none.”

Five questions you can ask at any clinic

1. “What do you judge naturalness by?” The honest answer is “in lifting there is no trial that measured it.” A place that gives that answer is, if anything, a place that has read the data.
2. “In my case, has it descended, hollowed, or has the skin thinned?” If the settings are fixed without that distinction, there is room for the direction to be wrong.
3. “On what basis did you decide this number of lines and this energy?” What the consensus documents contain is a lower bound. If an answer comes back citing an upper bound as its basis, you may ask for the source.
4. “When do you judge the result?” The point at which the clinician assessment became significant with radiofrequency is 12 weeks.
5. “How do you know whether this setting is excessive for me?” Whether they also tell you that the literature contains no upper-bound figure is itself material for a judgement.

In summary — what is confirmed, what is inferred, what we could not confirm

Where this article was written

• Miso Clinic, Daegu · 4F Bombom Building, 125 Dongdeok-ro, Jung-gu, Daegu, Republic of Korea (near Kyungpook National University Hospital station)
• Director Lee Chi-Hak · Tel. 053-428-2700
• This column was written by the director and reviewed in September 2026.

This article was written not to recommend a particular treatment but to set out the extent of the data needed for a decision. Judgement about an individual condition requires examination, and this article does not substitute for medical care. On the point at which a face begins to look done, see what makes a face look natural rather than done; on the individual devices, see the Density · XERF · Oligio Kiss references.

Frequently asked questions

Who wrote this

References

1. The operational definition of naturalness — Klepetko H et al., Aesthetic Plastic Surgery 2026;50(13):5689–5703. 1,795 standardised facial photographs · 30 raters per photograph. Naturalness defined as “the likelihood that the face presented has had a cosmetic procedure” (r = 0.87, ICC = 0.86). It is a study with no answer key as to whether a procedure was actually had, and some of the authors hold equity in, or are employed by, the company developing the algorithm.
2. Patient-reported naturalness scale — Klassen AF et al., Aesthetic Surgery Journal 2024;44(7):733–743, PMID 38180487. Concept elicitation 26 people → cognitive debriefing 184 people → field validation 1,358 people. ICC of the three scales 0.88 / 0.94 / 0.97. It is entirely patient-reported, and no item is linked to depth · energy · dose.
3. Complete check of registered clinical trials — on checking the 126 registered trials whose outcome measure titles contain “natural”, the aesthetic trials were without exception fillers · toxins · collagen boosters, and we could not find a single one with an energy device such as ultrasound or radiofrequency. This is the result within the range we checked, and does not mean that none exists.
4. Ceiling effect in naturalness figures — in a randomised · evaluator-blinded trial (n = 62) the practitioner-assessed naturalness was 100% in both arms, the primary endpoint of a single-arm trial (n = 30) was likewise 30/30, and in a single-arm · unblinded trial (100 enrolled) it was 90.5%. There are cases in which, even in a blinded trial, the naturalness item alone was assessed by the doctor who performed the treatment.
5. Focused ultrasound expert consensus — Park JY et al., Journal of Clinical and Aesthetic Dermatology 2021;14(5):E70–E79. Energy 0.4–1.2 J/mm², depths 1.5 · 3.0 · 4.5 mm, 800–1,200 lines appropriate for the full face and neck. It writes that “used judiciously and avoiding overtreatment, a natural result can be obtained” while defining overtreatment as “excessive and uncontrolled delivery.” The authors themselves recorded their literature review as “extensive but neither exhaustive nor systematic”, there is no voting procedure or evidence-grading scheme, and it received manufacturer funding.
6. The recommendation pointing the other way — Fabi SG et al., Journal of Drugs in Dermatology 2019;18(5):426–432. A panel of five experts, with no evidence grading recorded. It recommends that “the ideal result is associated with high-density treatment.” A co-author of the consensus above is an author of this document, and both documents were funded by the same manufacturer.
7. The split-session protocol — Corduff N · Lowe S, Plastic and Reconstructive Surgery Global Open 2023;11(8):e5184, PMID 37583398. Mean 4 sessions (range 3–5), mean 280 lines per session. It is 12 enrolled · 10 analysed · single-arm · no control · manufacturer-funded, and with no comparison arm it concludes that it is “non-inferior to the standard single-session protocol.” Naturalness was not measured.
8. The only discrimination figure on the energy-device side — Hwang Y, Wan J, Yi KH, Journal of Cosmetic Dermatology 2025;24(2):e70069, PMID 39973106. 50 people enrolled · 34 completed, single-arm. One blinded clinician correctly identified the post-treatment photograph 73.5% of the time (25/34). This is a change-detection task, and the word natural does not appear in the body of the paper.
9. The structure of the focused ultrasound evidence — Amiri M et al., Aesthetic Surgery Journal 2025;45(3):NP86–NP94, PMID 39540440. 4,019 papers screened → 42 included, of which 2 controlled clinical trials · 9 observational studies · 31 before-and-after comparisons. Satisfaction was 84% satisfied at any level, but 62% where a “neutral” option was offered, and the authors recorded that misclassification of neutral responses could overstate the effect.
10. Regulator — US FDA safety communication on radiofrequency microneedling, 15 October 2025. Reports of burns · scarring · fat loss · disfigurement · nerve injury. It gives neither the number of reports nor any numerical threshold for energy · depth · number of passes.
11. Baseline prevalence of asymmetry — Macdonald KI et al., Journal of Otolaryngology – Head & Neck Surgery 2014;43(1):36. Retrospective photographic measurement of 100 consecutive patients seen in consultation for upper eyelid surgery. Mean left-right difference at mid-brow 1.77 mm. 1 mm or more 93% · 2 mm or more 75% · 3 mm or more 37%. The authors’ conclusion is not correction but to check and explain it before surgery. Also, in Carvalho B et al., International Archives of Otorhinolaryngology 2012;16(4):445–451 (201 people), more than 89% were asymmetric across the measured items.
12. Asymmetry and attractiveness — Kleisner K et al., Evolution and Human Behavior 2023 (10 cultures, 1,550 faces) and the independent replication, Lee AJ et al., Scientific Reports 2025;15:5498 (100 faces × 400 raters). In both studies asymmetry did not significantly predict attractiveness. Meanwhile a narrative review dealing with the correction of asymmetry (Journal of Clinical Medicine 2025;14(24):8828) contains no recommendation to leave asymmetry in place.
13. A field where naturalness has been measured as a physical quantity — Zhang C et al., Aesthetic Surgery Journal 2025;45(3):241–248, PMID 39487798. 60 women; the delay with which the eyelid crease appears was scored and correlated with third-party assessment of dynamic naturalness at R² = 0.71 (P < .0001). It is simply that no such physical quantity has been defined for lifting.
14. The level of the energy-device evidence overall — Atiyeh B et al., Aesthetic Plastic Surgery 2025;49(18):5186–5198. A systematic search found “low-level evidence”, and it points out that most studies fail to distinguish contraction following volume reduction from a genuine improvement in skin biomechanics.
15. When to judge — in an evaluator-blinded study of 20 Korean women, radiofrequency was not significant on clinician assessment at four weeks and was significant at 12, with the peak at four to six months.