Overview of Current Thoughts on Facial

Volume and Aging

David M. Kahn, M.D.,1 and Robert B. Shaw Jr., M.D.2

ABSTRACT

Facial aging is a dynamic process involving the aging of soft tissue and bony

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structures. Much is known in regards to how the face loses volume as the soft tissue
structures age. Epidermal thinning and the decrease in collagen cause skin to lose its
elasticity. Loss of fat, coupled with gravity and muscle pull, leads to wrinkling and the
formation of dynamic lines.
The aging process has also been shown to affect the facial bones. Multiple studies
suggest that the bony aging of the orbit and midface is a process primarily of contraction
and morphologic change. This loss of bony volume and projection may contribute to the
aged appearance. In this review, we will demonstrate how specific soft tissue and bony
aspects of the face change with age in both genders and what impact these structural
changes may have on overall facial aesthetics.

KEYWORDS: Facial aging, facial volume, facial bones, facial fat

C osmetic procedures both surgical and nonsur-
gical to enhance or rejuvenate the appearance of one’s face
have become well accepted by the public. Obviously,
many are pleased with the look and desire what aesthetic
surgery has to offer as demonstrated by the increasing
number of patients who undergo these procedures. How-
ever, not everyone finds that surgery results in a natural
appearance. In the lay press, one can find many comments
on the ‘‘operated’’ look of cosmetic procedures. Tyler
Brule in the Financial Times has written, ‘‘I can say with
some authority that cosmetic surgery has some way to go
to keep people looking fresh rather than freakish.’’
Surgeons have recognized this as well. As Lambros
commented, ‘‘The face lift is a highly imperfect procedure
that alters the mechanics of the face for decades,’’ and that
‘‘Most patients look increasingly odd in direct proportion
to the number of face lifts they get.’’1
The most likely cause for the more negative
connotations to the outcomes of facial rejuvenation
surgery is that there has not to date been a true scientific
understanding of what happens to the facial bone and
soft tissue structures to result in the appearance of the
aged face. Most of our assumptions are based on topo-
graphic changes, and the strategies to ‘‘erase’’ the signs of
aging are directed at those perceived stigmata. Like any
other process in medicine, the best way to develop
optimal solutions to a problem is to understand the
changes that result in that problem. Once the cause is
understood, strategies can be developed to best combat
these developments.
Facial aging is a dynamic process involving the
aging of soft tissue and bony structures. Aging represents
a transition from youth, where there is an optimal
relationship between bone morphology and the volume

1
Division of Plastic and Reconstructive Surgery, Department of
General Surgery, Stanford University Medical Center, Stanford,
California; 2Division of Plastic and Reconstructive Surgery, Depart-
ment of General Surgery, University of Rochester Medical Center,
Rochester, New York.
Address for correspondence and reprint requests: David M. Kahn,
M.D., Division of Plastic and Reconstructive Surgery, Department of
General Surgery, Stanford University Medical Center, 770 Welch
350
Road, Palo Alto, CA 94304 (e-mail: david.kahn@stanford.edu).
Fat Grafting and Stem Cell Technology; Guest Editor, Sam P.
Most, M.D., F.A.C.S.
Facial Plast Surg 2010;26:350–355. Copyright # 2010 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
DOI: http://dx.doi.org/10.1055/s-0030-1265024.
ISSN 0736-6825.

and surface area of the soft tissue envelope, to the
imbalances between these components that leads to the
stigmata of the aged face. To rejuvenate effectively the
aging face, it is necessary to understand the dynamic
aging process. In this article, we hope to bring the reader
up to date on the limited understanding of the facial
aging process at the current time.
SOFT TISSUE
The facial soft tissue anatomy can be described as being
arranged in a series of layers: skin, subcutaneous fat
(superficial and deep layers), superficial fascia and
muscles of facial expression, deep facial fascia (parotido-
masseteric fascia), facial nerve, and parotid. The super-
ficial fascia superficial muscular aponeurotic system
(SMAS) invests the superficial mimetic muscles and is
continuous with the superficial temporal fascia and
platysma. The deep facial fascia is a continuation of
the deep cervical fascia. The facial nerve branches are
deep to this layer. In some regions of the face, these two
fascial planes are separated by an areolar plane, and in
other regions of the face, they are intimately adherent to
one another. These layers of the facial soft tissue are
supported in normal anatomic position by a series of
retaining ligaments that run from deep, fixed facial
structures to the overlying dermis. These retaining
ligaments are defined by their origin, either from bone
or from other fixed structures within the face. With
aging, these ligaments become a fixed dam upon which
the soft tissues fall due to gravity. It is the loss of soft
tissue support with increased laxity of the soft tissue as a
result of loosening in the collagen framework that
contributes to the appearance of the aged face.2
Much is known in regard to the aging of the facial
skin and subcutaneous tissues.3–5 Epidermal thinning
and the decrease in collagen cause skin to lose its
elasticity. As the collagen and elastic fibers in our skin
break down, the skin becomes looser, and wrinkles and
folds become etched into the skin. Small lines appear
around the eyes and mouth, then deeper lines next to the
nose and chin. The loosening of aging skin is often most
noted in the neck. Aging also results in changes to skin
texture as it becomes coarse and dyschromic.6
The effect of gravity upon the lax skin envelope
and atrophied soft tissue leads to the development of
folds such as the nasolabial and labiomental. The
repeated muscle action on the dermis combined
with dermal changes results in dynamic creases such
as crow’s-feet. This knowledge has made soft tissue
redraping with malar fat pad suspension and SMAS
tightening the predominant approach to rejuvenate
the aging face. Soft tissue augmentation to replace
volume loss has become more accepted recently by
many to enhance the treatment plan for those seeking
facial rejuvenation.7–9 This soft tissue volume loss is
FACIAL VOLUME AND AGING/KAHN, SHAW 351
most likely in part due to the atrophy of the facial
fat.
The facial fat is separated into a deep and super-
ficial layer. The superficial fat is slightly larger in regard
to volume than the deep fat pads. It is superficial to the
SMAS layer, is continuous throughout the face, and is
often intertwined with fascia. The malar fat and nasola-
bial fat pad are examples of this superficial fat.
The deep fat helps to provide contour, runs deep
to the SMAS layer, and is loosely held in a honeycomb
of fascia. This layer of fat allows the skin mobility over
the body and a gliding plane for muscle movement.
The suborbicularis oculi fat (SOOF), retro-orbicularis
oculi fat (ROOF), and buccal fat pad are examples of
this deep fat. Volume loss of this deep fat in the
temporal, buccal, and sub-orbicularis oculi contributes
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to the aging process.10 A working hypothesis of facial
fat aging continues with the concept that loss and/or
ptosis of deep fat compartments leads to changes in
shape and contour. Folds, in contrast, occur at tran-
sition points between thick and thinner superficial fat
compartments.11
Rohrich and Pessa have performed multiple ca-
daver studies supporting the concept that subcutaneous
fat is compartmentalized, specifically by fascial exten-
sions that travel from superficial fascia to dermis. These
fascial extensions form a framework that provides a
‘‘retaining system’’ for the human face. Implicit in this
concept is the suggestion that the face ages three dimen-
sionally, with separate compartments changing relative
to one another by both position and volume.12
Rejuvenation of facial contour is significantly
influenced by the re-elevation of descended facial fat
through SMAS elevation and manipulation. Most plas-
tic surgeons pull the skin either directly with or indi-
rectly through the SMAS and by doing so smooth out
some of the skin demarcations.13
A large variety of technical solutions and sur-
gical techniques have been created to accomplish this
elevation. Elevation of these fat compartments, how-
ever, may not result in a cosmetically appealing result
if they are atrophic. The act of lifting or ‘‘tightening’’
skin of a three-dimensional construct in a linear vector
results in flattening of the facial contour. Soft tissue
fillers can be used successfully to restore volume loss
caused by facial aging and restore the curved contour
to the face. This is a particularly useful adjunct in the
following anatomic regions: nasolabial fold, glabellar
crease, malar region, nasojugal groove, and lips.14 As
the majority of facial volume loss through aging is
attributable to fat loss, fat may represent the ideal soft
tissue replacement. Improvements in technique have
enhanced the predictability of facial fat grafting.
When autologous fat is not an option, alternative
facial fillers including collagen and hyaluronic acid
may provide excellent results.15
352 FACIAL PLASTIC SURGERY/VOLUME 26, NUMBER 5 2010
FACIAL BONE AGING
The bony components of the face are important for
overall facial three-dimensional contour as they provide
the framework on which the soft tissue envelope drapes.
If this framework experiences a morphologic change
with age, the overlying soft tissues will subsequently
project differently.
Early literature analyzing facial bone aging fo-
cused on the orbit and midface and resulted in the theory
that the bony face continued to grow with age, partic-
ularly with an increase in facial width and depth.
Behrents, in 1985, obtained follow-up cephalometro-
grams in an aging population who had similar analysis
done during childhood.16 He found that there was a
significant increase in dimension for the majority of
measurements in the older population, which led him
to believe that there was significant bony growth and
expansion during adulthood. Bartlett et al accomplished
one of the first large comprehensive studies of facial bone
aging in 1992. In this study of 80 male and 80 female
skulls (placed in two age categories) from the Smithso-
nian Institution, Bartlett et al found that the female
skulls had an increase in all transverse facial widths and
midface depth with increasing age.17
Two recent studies also have postulated that the
mandible continues to expand with increasing age. In
2006, Pecora et al studied 19 male and 20 female subjects
through the University of Michigan Elementary and
Secondary School Growth Study.19 Lateral cephalograms
were analyzed at three different age groups in regard to
soft tissue and bony aging. This study found that the
length of the mandible increased with age for both
genders with a resulting increase in chin prominence.
In 2008, Pessa et al analyzed eight male and eight
female frontal radiographs from the Bolton Brush
Growth Study in a young versus old comparison. The
mean age for the young age group was 16.2 years versus
56 years for the old age group. The first radiographs were
taken in the 1920s with repeats taken from 1978 to 1983
for the old age group. This study concluded that there
was an increase in mandible width and height with
increasing age and that there was no difference in aging
rates across gender.18
In contrast, many recent studies now suggest that
the bony aging of the midface and orbit is probably a
process of resorption and differential growth resulting in
a morphologic change of the bone. In regard to midface
aging, Pessa et al in 1998 undertook a three-dimensional
computed tomography (CT) study on 14 male and
female subjects (placed in two age categories) and found
that maxillary retrusion occurs with increasing age for
both males and females.20 Another study by Pessa in
2000, in which angular measurements were taken from
three-dimensional stereolithography images from 10
male subjects (5 young, 5 old), provided more informa-
tion in regard to midface aging. In this study, he found
that there was a significant decrease in maxillary and
piriform angles with age.21 This supported the idea that
the maxilla undergoes clockwise rotation with aging.
In 1999, Pessa et al analyzed three-dimensional
CT scans in a soft tissue format for 28 subjects and
found that the orbital rim moved posteriorly in rela-
tion to the cornea. This led Pessa et al to believe that
the orbital rim’s anterior projection diminishes with
age.22 In the same year, Pessa et al also reported that
the vertical oblique height of the orbit increased with
age as determined in their study of 30 male (3-mm
CT slice) subjects ranging from ages of 1 month to
76 years.23 This increase was not significant, but
through these two studies, Pessa et al believed that
the bony orbit remodeled with aging and experienced
an overall increase in size, with recession of the orbital
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rims.
In 2000, Pessa furthered our understanding of
orbital aging through his study analyzing the orbit angle
(line from superior to inferior midorbit in relation to
sella-nasion) in 12 male subjects in a young versus old
comparison.24 He found that there was no change in this
angle suggesting that there was no change in the rela-
tionship of the projection of the superior and inferior
orbital rim.
To analyze in more detail the changes to the
orbital rims, in 2001 Pessa and Chen studied 30 male
skulls in three age categories at the Smithsonian Insti-
tution and found that there was no change in orbit width
or height with increasing age. Pessa and Chen, however,
found that there was curve distortion of the supero-
medial upper orbit and infero-lateral orbit.25 These
findings led them to believe that the orbital rims receded
in only these regions, without an overall change in orbit
height or length.
Multiple studies suggest that the bony aging of
the orbit and midface is a process primarily of contrac-
tion and morphologic change. Past studies by our group
analyzing the midface, orbit, and mandible in 120
subjects have helped support and expand on the theory
that facial bone aging is a process of volume loss and
morphologic change.26–28 The results from these studies
have helped our group create a model for facial aging for
the following facial areas.
ORBIT AND MIDFACE
Supero-medial rim remodeling may contribute to the
unmasking of the medial upper lid fat, a change currently
attributed to weakening of the orbital septum. This in
combination with the glabellar angle becoming more
acute with age may also lead to the perceived descent of
the medial brow and the formation of glabella skin
creases. The infero-lateral rim remodeling and increase
in orbital aperture width may contribute to the forma-
tion of crow’s-feet and lower lid lag.

Figure 1 Example of skeletal changes in the orbital shape and restoration of youthful contour with an orbital rim implant.
As we try to further develop a concept of how the
periorbital area changes with age, a possible working
hypothesis is that the bony structures undergo morpho-
logic change and also result in a widening of the orbital
aperture, which results in a change in the appearance of
the overlying soft tissue envelope. The overall widening
of the orbital aperture results in a change in the relation-
ship between the orbital contents and the surrounding
bony framework. This may result in changes such as
prominence of fat pads, deepening of sulci, or the
enophthalmos and ptosis that may be seen with aging.
The changes seen in the upper half of the orbit
may result in the soft tissues rolling into the orbital
aperture and, thus, the appearance of brow descent and
lateral orbital hooding. In the lower half of the orbit, the
tissues may roll over the recessed bony ledge leading to
lag of the lower lid, prominence of lower lid fat pockets,
and a deepening of the nasojugal groove as dispropor-
tionate tissue piles up against the orbicularis origin along
the medial rim while the origin of the orbicularis is
reshaped with its underlying bony attachment (Fig. 1).
MANDIBLE
The length and height of the mandible both significantly
decrease for each gender. These bony changes may result
FACIAL VOLUME AND AGING/KAHN, SHAW 353
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in the appearance of decreased chin projection that is
found with increased age. The mandible is the founda-
tion of the lower face, and any change in mandibular
projection, width, or height can affect overall aesthetics.
Patients with a normal mandibular ramus height and
length of the mandibular body have an excellent support
for soft tissue repositioning. In contrast, those with a
short ramus, open mandibular angle, and short mandib-
ular body have poor skeletal support for midface and
perioral soft tissue repositioning and often benefit from
volumetric augmentation to enhance their skeletal sup-
port.29 Patients with decreased chin projection and a
prejowl sulcus often benefit from alloplastic augmenta-
tion.30 Mandibular volume loss also affects the aging of
the neck as it may contribute to the increased laxity of
the platysma and soft tissues of the neck. The mandib-
ular angle increases with age for both genders and may
result in blunting or the loss of definition of the lower
border of the face. A blunted mandibular angle creates a
loss of jawline definition (Fig. 2).
Skeletal augmentation, using implants made of
porous polyethylene, is a simple and effective method to
reverse age-related changes of the facial skeleton in
patients with intact occlusion. Skeletal implants correct
concave morphology by increasing projection and pro-
vide a means to resuspend soft tissues that have de-
354 FACIAL PLASTIC SURGERY/VOLUME 26, NUMBER 5 2010
Figure 2 An example of a CT scan from a patient in the young study group.
scended off a deficient bony platform.31,32 The clinical
utility and morbidity associated with use of porous
polyethylene facial implants has been described well.
Yaremchuk reported in 2003 on 370 consecutive im-
plants with an average follow-up of 27 months. The
overall reoperation rate was 10% (n ¼ 16), which in-
cluded operations to remove implants because of infec-
tions (n ¼ 4) or to improve displeasing contours
(n ¼ 12).33 Skeletal augmentation offers a permanent
rejuvenation of the facial skeleton and may be performed
in conjunction with soft tissue redraping.
CONCLUSION
With an adequate understanding of the anatomic
changes that occur with aging, rhytidectomy can restore
facial soft tissue to its original anatomic state and
location. The degree to which the soft tissues atrophy
and the facial bones change remains the subject of some
debate, but what is increasingly clear is that volume loss
plays an essential role in the appearance of the aged face.
Procedures such as lifting the soft tissue envelope may
help to reduce wrinkles and sag, but without adding lost
volume, patients are not rejuvenated to their youthful
appearance.
Skeletal support affects not only the appearance of
the face but also how the face ages. It also influences the
redraping of the soft tissues during facial rejuvenation
procedures. As we learn and better understand the
changes in facial aging, it may be that the most effective
approach toward facial rejuvenation should be twofold:
restoring volume to compensate for changes in three-
dimensional structure, and lifting and reducing the aged
and less elastic soft tissue envelope. A balanced approach
to facial rejuvenation between volume augmentation and
soft tissue envelope repositioning and reduction will
hopefully avoid the distortions of either approach in
isolation.
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