Costas Papageorgiou MD, London, December 2013

Recent advances in understanding facial aging indicate that the typically aged face represents a combination of changes on many levels, including bony structures, subcutaneous fat, muscle strength and skin integrity.  These structural changes, over time, can completely reshape the three-dimensional contours of the face, by altering balance, volume and proportions.


Our skin is a primary indicator of aging and both extrinsic and intrinsic factors affect its elasticity and ability to adjust to underlying volume loss.  Intrinsic aging is a genetically determined process and results from biological changes at a cellular level. Extrinsic aging results from environmental factors like ultraviolet radiation (sun exposure), nutritional toxins, cigarette, alcohol, traumatic or even emotional injuries.

Aging affects the ability of the fibroblast cells to renew collagen fibers, as their metabolism gradually declines with age. In addition, fragmentation of the collagen fibers is accelerated, as the accumulated effects of aging increase the level of the collagen degrading enzymes named matrix metalloproteinases. Fragmentation of the collagen fibers further affects the ability of fibroblasts to produce new collagen as these cells require a solid structural environment to maintain their metabolic activity. This imbalance advances the aging process in a self-perpetuating deleterious cycle.

Treatments that enhance the metabolic activity of fibroblasts and the structural support of their environment  (retinol based therapeutics, biostimulatory agents, hyaluronic acid fillers, ultrasound, radiofrequency or laser wave energy) can ameliorate skin integrity and counteract aging.


The groundbreaking anatomic studies of Rorich and Pessa  on the fat compartments of the face and Val Lambros theory on age related deflation have brought a new perspective in the way we see and treat the aging face. Their studies have demonstrated a volumetric or three-dimensional approach to facial aging.  Our face is composed of multiple discrete anatomic regions and it doesn’t age as a confluent mass due to gravitational changes as previously thought.  Volume loss in fact can mimic gravitational descent.

With this new knowledge in mind, the aging face is analyzed as a change in volume and position of these separate fat compartments situated both superficially and deeper. These compartments age independently and volume deflation in one area can greatly affect neighboring tissues, leading to a cascade of events. Reinstating volume either surgically or with volumizing agents, not only affects the three-dimensional contours of the treated area but can enhance adjacent or neighboring areas. For example augmenting the lateral fat pad (which atrophies with age), not only enhances the contours of the lateral third of the face but also improves the jaw line definition, jowling, marionette lines and nasolabial folds.


Volumetric changes of the fat compartments can affect the dynamics and resting tone of the muscles, as the latest theories suggest that the muscles of the face  adjust to underlying shifts of fat volume.  Le Louarn postulates that the shape and action of facial muscles is determined by the three dimensional projection of the underlying fat compartments.

Muscles tend to adapt to volume loss by increasing their resting tone.  This increased tone in combination with the overlying skin elasticity loss may explain the appearance of creases and wrinkles with aging. This hypothesis would also account for the rejuvenating effect of botulinum toxin injections as they balance the action of overacting muscles on a thin skin envelope.


Facial bony remodeling is increasingly recognized as a key contributor to the facial aging process and multiple studies have demonstrated significant craniofacial skeletal changes with age. The bones of the face remodel with aging and many of the changes in the contour and shape of the face reflect the underlying skeletal changes. These changes can affect the draping of the overlying soft tissues like fat, muscle and skin envelope of the face. The orbit, nose, maxilla and mandible are greatly affected by aging and studies have revealed a gender dimorphism: in men the changes are more prominent in the upper face (forehead) while in women skeletal changes tend to affect mostly the lower face.


These insights have guided an evolution in the way we treat the aging face and enable us to approach facial rejuvenation in a site-specific manner and aiming to restore the four structural planes: skeletal platform, fat, muscle and skin. A three-dimensional approach to facelift surgery involves lifting and filling areas where fat compartments in the face have degenerated with age, as opposed to previous techniques which focused mostly on pulling the skin tight. By approaching facial aging in a multilayered perspective, outcomes are enhanced and patient’s expectations can be defined adequately.


Update on Facial Aging by R Fitzgerald et al, Aesthetic Surgery Journal

The Youthful Cheek and the Deep Medial Fat Compartment by R Rohrich, J Pessa, B Ristow, Plastic Reconstructive Surgery Journal

Contemporary Concepts in Brow and Eyelid Aging by R Fitzgerald, Clinics of Plastic Surgery

Observations on periorbital and midface aging by V Lambros, Plastic Reconstructive Surgery Journal