Effective correction of the changes in the aging face requires an understanding of the components that have changed leading to the appearance of advanced age. In the past, and up until recently, treatments have been piecemeal and incomplete. This is due to incomplete appreciation of the steps that need to be taken to lead to genuine improvement. I think it is most effective to take a ground up approach to describe the changes that we want to reverse. The components that we know change are as follows: bone, soft tissues (fat and muscle), and skin.
Thanks to studies by Joel Pessa and others we know that the lower third of the facial skeleton rotates inward toward the skull base as time passes. This effect occurs at the level at the lower border of the eye socket, leading to decreased support of the overlying soft tissues and skin. Though we know there are changes in the facial skeleton, it may be extreme to consider alteration of the facial bone structure for the sake of aesthetics if this change can be compensated for in the modification of the overlying tissues.
In the past 20 years we have developed a more nuanced understanding of the changes occurring in the soft tissues in the face. We have known for a long time that fat atrophies and sags as the face ages, contributing to the flattening of the cheek, and development of jowls. Initially we treated this tissue as a single unit, folding and elevating the tissues to restore a youthful appearance. Rohrich and others have performed anatomic studies of the facial fat compartments, and this has led to a greater understanding that these areas can be effectively treated with focused approaches to treat these areas individually via targeted injection of volume, either filler or fat grafts. I prefer fat grafting for reasons that I will explain. Overall this ability to individually treat compartments of the face improves our ability to correct problem areas that until recently have confounded aesthetic surgeons. Specifically, the areas around the eye have been challenging. We can now correct darkness and hollows under the eyes in many patients with targeted application of volume, without cutting skin of the eyelids.
This brings us to the final layer: skin. This is the level at which shows changes that most of us recognize as aging. The skin loses elasticity and becomes thinner. The result is wrinkled skin, and a crepe like texture of the tissues. Historically most intervention have been focused on skin: redraping, tightening, and removing loose skin. In the absence of correction of deep structures, these surface changes only result in temporary improvement. There is also the possibility of over-correction, which I describe as “An old person skydiving”. These un-natural results do not make the patient look younger, it just makes the patient look strange. With our improved understanding of the changes deep to the skin, we are now able to more closely emulate the appearance of youth. A key component of this approach is the use of fat grafting. Fat grafts obtained via liposuction from the patient’s abdomen allows us to restore youthful curves to the face. Another key component is the fact that this grafted fat contains stem cell that reverse age and radiation related changes in the overlying skin. The result is a restoration of elasticity and thickness of the skin. Below you will find some images that convey the ideas described above. The first set depict a 25 year old female on the left, and her mother on the right. The unveiling of the lower orbital rim is obvious in the mother, as well as deflation and descent of the cheek fat pads.
The next set of images contrasts the full shape of the youthful cheek, and soft curves of the face compared to the angular appearance of the aged face.
Below is an example of what is possible with volume restoration alone.
Newer Understanding of Specific Anatomic Targets in the Aging Face as Applied to Injectables: Superficial and Deep Facial Fat Compartments—An Evolving Target for Site-Specific Facial Augmentation
Ramanadham, Smita R. MD; Rohrich, Rod J. MD
Plastic and Reconstructive Surgery: November 2015 - Volume 136 - Issue 5S - p 49S–55S
Injectables: Original Articles
Three-Dimensional Facial Averaging: A Tool for Understanding Facial Aging
Lambros, Val M.D.; Amos, Gideon Ph.D.
Plastic and Reconstructive Surgery: December 2016 - Volume 138 - Issue 6 - p 980e–982e
Cosmetic: Ideas and Innovations
Analysis of Craniofacial Remodeling in the Aging Midface Using Reconstructed Three-Dimensional Models in Paired Individuals
Karunanayake, Mihiran M.D.; To, Frederick M.D.; Efanov, Johnny I. M.D.; Doumit, Gaby M.D., M.Sc.