As our understanding of what causes facial aging advances, our approaches to this problem are advancing as well. Gravity as an explanation for the aging changes in the face has been discredited. Three factors are now recognized as important in facial aging: changes in the skin quality, mostly due to insults from the environment, but also due to biological changes that are not fully understood; repeated folding of the skin and loss of volume of the underlying tissues that support the skin. It is the last of these changes that I will discuss here.
For a while we have recognized that the loss of facial soft tissue: fat, muscle and connective tissue, have played an important part in facial aging. More recently it has become clear that loss of bone also plays a very important role. The openngs for the eyes are much larger in the skull of a 50 year old, than in the skull of a 20 year old. The jaw bone of a 20 year old is thicker and wider than the jaw bone of a 50 year old. These changes not only cause deflation of the face, but change the proportions. In the young individual the upper lip occupies 1/3 of the distance from the bottom of the nose to the tip of the chin. In the elderly it takes up 1/2.
Since these aging changes are due to changes in the volumes of various tissues, we should be able to reverse them by adding volume in the appropriate locations. Ideally we would prefer to replace the lost tissue with something that resembles it. Currently we have relatively good replacements for soft tissue, but we are only starting to develop replacements for bone, although progress is being made in this area.
If the volumes and proportions of our deep tissues are changing, producing loose skin among other changes, it doesn’t make much sense to try to correct aging changes by tightening the loose skin over the altered deeper tissues. Ideally we’d like to keep the facial volumes youthful, either by restoring what is loss or, even better, by prevent the deeper changes in the first place.
We are now closer to approaching this goal. We now know that filling less obvious areas of tissue loss, what I call pan-facial filling, can produce a fresher younger appearance. We know that significant facial volume loss begins in our early 30s, and ideally this is when filling should begin. We are fortunate in that our fillers not only replace volume, but induce our skin to make new collagen. Thus, repeat filler injections can be performed less frequently. Fillers are still expensive, but less frequent treatments reduce the cost. New products are on the horizon and hopefully competition will further drive down the cost.
My prediction is that more people will come to understand the advantages of starting fillers early, and maintaining them. These people will continue to look better than those who go untreated, they will age in appearance much more slowly and many of them will never come to the point where they want a surgical procedure.
Gerald N. Bock MD