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Aging face: Fixing wrinkles is not enough

Facial rejuvenation typically focuses on prevention and reduction of wrinkles. Indeed wrinkles are perhaps the most obvious and easily measurable aspect of facial aging. Yet there are other factors that can contribute to the "aged look" at least as much as wrinkles. Sometimes, wrinkles and fine lines are the only sign of facial aging a person would have. This is typical of relatively young people who have spent too much time in the sun without proper UV protection. But more often wrinkles are just the tip of the iceberg. In fact, reducing or even eliminating wrinkles may sometimes do relatively little to help take years off one's face. A number of other age-related changes can contribute to facial aging to varying degree, such as skin laxity & sag; muscle laxity, sag & atrophy; loss and redistribution of facial fat; facial bone growth; and nose drooping. In this article I discuss these often overlooked aspects of facial aging as well as the available remedies.

Skin laxity and sag

As the aging skin loses its structural proteins (collagen and elastin), it becomes more lax and begins to sag, which contributes to tired and aged look. The sagging can be slowed down by stimulating the synthesis and inhibiting the degradation of collagen and elastin using topical agents. (See our articles on collagen and elastin for more details.) However, once the sag has set in, topical firming treatments (such as DMAE) tend to be only modestly effective at best.

A noninvasive procedure called skin needling (a.k.a. percutaneous collagen induction) shows some promise for modest skin tightening and has a good safety profile. It may help correct mild skin laxity. (See also our article on skin needling).

Another category of noninvasive procedures that may help reduce skin laxity and facial sag is targeted radiofrequency therapy. The early variants of facial radiofrequency treatments were inconsistently effective and associated with significant occurrence of adverse reactions. The new generations of radiofrequency treatments may be better on both counts but the jury is still out. (For more details, see our articles on radiofrequency treatments in the section on noninvasive procedures.)

In the case of severe skin laxity and facial sag, facelift surgery is likely to be the only option to provide dramatic improvement. However, surgical risks, prolonged recovery time and high costs associated with facelift procedure make it unacceptable for many people. (See also our article on facelift surgery.)

Loss and redistribution of facial fat

Young faces are supple, properly padded with facial fat in all the right places, yet without the excess of it. As we age, the distribution of facial fat tends to change. In some areas of the face (e.g. under the lower eyelid), fat can accumulate excessively, leading to the impression of permanent puffiness. More often, however, fat padding thins out and/or migrates, leading to deep creases, sunken cheeks and other unwelcome changes. Of particular cosmetic significance is the so-called malar fat pad (a triangular fat pad adjacent to the base the nose). Its thinning and shifting is a major factor in the development of nasolabial folds (deep laugh lines).

The causes of redistribution of facial fat are not entirely clear but may include age-related shifts in hormonal balance, repeated facial movements, certain disease conditions and so forth.

Again, topical treatments are not going to help. One minimally invasive approach is to "return" the fat by taking it from elsewhere in the body and injecting in the face. This approached is somewhat complicated and has a mixed record of long-term success because only a modest (and varying) percentage of the injected fat becomes permanent. Yes it has been around for a long time, is well tested and has a good safety profile. (See also our article on fat injections.)

Another approach is dermal fillers (and occasionally implants). Instead of trying to restore the lost tissue, dermal fillers fill up the space left by the fat loss, thus camouflaging the problem. This method is "farther from nature" than fat injections but easier to apply and may provide greater flexibility, reliability and, in some cases, be less costly. The risks and benefits of dermal fillers vary depending on the particular filler and the skill & experience of the provider. Generally speaking, all fillers carry some risk of rejection/tissue reaction, although for many fillers such risk is quite low. (The reactions/rejection is not a problem with fat injections because your own fat is injected.) For more information, see our section on dermal fillers.

Finally, the more complex variants of the facelift surgery include repositioning of facial fat pads to approximate a more youthful anatomy -- in particular, vertical repositioning of malar fat pad. For best results, this requires a highly skilled surgeon with extensive experience in this and other intricacies the facelift procedure.

Muscle laxity and atrophy

As we age, the natural tendency of facial muscles (just as muscles elsewhere) is to become more lax and atrophy. This contributes to facial sag, droopiness and aged look.

Topical treatments are not going to help here either. Skin tightening procedures might temporarily mask muscle sag but their results, if any, tends not to last if the underlying problem is not addressed.

Can anything be done? The simplest, safest and arguably cheapest approach is to try facial exercise. Body exercises tone and bulk up the muscles, making them plumper and less saggy. In theory, the exercises targeting facial muscles should be no different - hence they may reduce facial sag, add volume to the face and tighten up the skin (by propping it up with the increased muscle bulk). Facial exercise has been a popular topic in the media and lay skin care literature. Unfortunately, the rigorous scientific proof of its effectiveness is scarce due to relative lack of scientific studies. (This may be partly due to the lack of funding - facial exercise is next to impossible to patent.) Still, before considering more drastic measures, facial exercise may be worth a try even before there is more scientific proof to support its effectiveness. After all, the downside of trying it is so much less than that of the alternatives (like facelift).

Notably, facial exercise has an "automated" cousin, the facial electrical muscle stimulation. This method employs a device (typically called facial muscle stimulator or toner) that sends electrical impulses making your facial muscles contract (as opposed to nerve signals that make muscles contract during real exercise). This approach may produce more consistent results than facial exercise but also lacks sufficient support by clinical studies. Facial electrical muscle stimulation may cause side effects (usually minor), such as skin irritation from electrodes.

The ultimate long-term (albeit still not permanent) solution for facial muscle laxity is facelift surgery where the surgeon repositions the muscles to achieve a more youthful anatomy. Not all variants of facelift surgery include muscle repositioning but the more comprehensive ones often do. For best results, this requires a highly skilled surgeon with extensive experience in this and other intricacies the facelift procedure.

Bone structure changes

Many human bones, such as bones in the arms or legs, do not change much once you have reached adulthood while other bones continue to grow and readjust as we age. Unfortunately, facial bones appear to belong to that "until-death-do-you-grow" category, their continuous changes contributing to the aged look.

Several studies, conducted at such prestigious medical schools as Stanford and Duke, have looked into this matter using sophisticated computerized tomography of skull bones. The overall conclusion was that facial bones grow and readjust throughout life. One important consequence is that forehead moves forward and the cheekbones move backward. There are also indirect repercussions. Dr. Richard Woodward, a Duke researcher who co-authored one of the studies, explains: "The facial bones also appear to tilt forward as we get older, which causes them to lose support for the overlying soft tissues. That results in more sagging and drooping."

Furthermore, age-related facial bone changes may impact more that one's appearance. For example, as the growing brow bones protrude, the drooping of the tissue around the eye increases, which may lead to vision problems, dry eyes or, conversely, excessive tearing.

The degree of age-related facial bone changes appears to vary considerably from person to person. Overall, the effects appear to be greater in women than in men. It is unclear whether menopausal hormonal changes (and the resultant osteoporosis) are a contributing factor.

Can something be done about this sneaky problem? Unfortunately, as of the time of this writing, the only available solutions come from the field of reconstructive plastic surgery. Furthermore, most reconstructive plastic surgeons do not perform facial bone reshaping just for the sake of cosmetic rejuvenation. As a result, such procedures are not common and the best operating practices are not standardized. Still, a few surgeons do offer variants of facial bone surgery for purely cosmetic rejuvenation (e.g. forehead reshaping and brow bone reduction procedures).

Nose shape changes

As if all the above problems weren't enough, there's more: the shape of your nose may also be affected by aging. This subject has not been studied much but it appears that the nose may undergo subtle age-related changes, such as drooping and soft tissue growth, contributing to the aged look.

The rhinoplasty surgery (a.k.a. nose job) can reduce or eliminate the problem. However, rhinoplasty is not commonly performed to address the age-related nose changes alone.

Since some of the nose consists of soft tissue, a radiofrequency treatment, which tightens and shrinks soft tissue, might in theory "tighten up" the nose and reduce its droopiness. However, whether this approach can safely and effectively work in practice is unknown.

Bottom line

Facial aging is not just about the skin surface. Therefore getting your skin to look wrinkle-free is not always enough to avoid the aged look. For more dramatic results you may need to analyze (preferably with the help of experts) what factors contribute the most to your facial aging and look into possible remedies. However, some of the remedies, even if available, may have significant limitations and costs. This is one of those situations where the ends do not always justify the means.

Related Links

Skin needling
Radiofrequency and combinations
Dermal & soft-tissue fillers
Facial implants
Facelift surgery
The youthful cheek and the deep medial fat compartment
Common Questions on Forehead Reshaping and Contouring
Science News: Facial Aging Is More Than Skin Deep
Medscape: Facelift anatomy (Caution: graphic anatomic imagery)


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