Overview of Facial Aging

Kenneth Beer, M.D., F.A.A.D.,1 and Jacob Beer1

ABSTRACT

Facial aging is a multidimensional, multifactorial process. The aging face has

traditionally been treated by each specialty in a different manner. However, by under-
standing the process from the perspective of different specialties, each physician may better

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treat the spectrum of facial aging. Whether or not the facial plastic surgeon injects products
to restore volume, uses lasers to resurface the epidermis and dermis, incorporates
cosmeceuticals to enhance and maintain improvements in the skin integrity and appear-
ance, or relaxes muscles with botulinum toxins, he or she can best advise patients and
address facial aging by having a functional understanding of these various modalities. With
this knowledge, the facial plastic surgeon can parse the component of facial aging that
enables him or her to correct each with the appropriate treatment.

KEYWORDS: Facial aging, laser, botulinum toxins, soft tissue augmentation, lasers,
fractional resurfacing, cosmeceuticals, facial plastic surgery

F acial aging is a complex four-dimensional issue.
Clearly, there is loss of volume, but injections of fat or
filler will not make the face young. Excess skin is only
one part of facial aging, and no amount of skin pulling
will restore a youthful appearance. Pigment irregularity
and low light reflectance are also parts of the aging
process, but in isolation, improving these will not be
adequate for most patients. What then, is the best means
of understanding facial aging so that the best treatments
and strategies may be employed?
To best understand facial aging, it is helpful to
divorce oneself from a simplistic notion that for a given
patient, aging face is the result of a single factor that will
respond to a solitary treatment. Each patient looks old
for their own reasons and in their own way.
Evaluation of the facial aging process should
usually begin with a photograph of the patient when
he or she was younger. Perhaps the individual had
prominent nasolabial folds when he or she was young
and filling them will not fix their facial aging but instead
make them look like someone else. For many patients,
the skin laxity that occurs with time and environmental
stressors will respond to surgical intervention that will
restore a more youthful appearance. For others, the skin
laxity may be part of their genetic makeup, and removing
it makes them look ‘‘plastic.’’ Thus, it is imperative not
only to understand that loss of volume, pigment irreg-
ularity, low light reflectance, formation of static and
dynamic rhytides, and facial descent are pieces of the
facial aging puzzle but also to understand what the
senior author refers to as the fourth dimension of facial
aging—the individual differences seen in the person that
signal the world that he or she is no longer youthful.
LOSS OF VOLUME
One of the cardinal signs of facial aging is the loss of
volume that occurs (Fig. 1). The volume lost is not
simply a deficit of fat or collagen but rather a subtle
interplay between bone resorption, fat atrophy, and
thinning of collagen and elastic fibers. Each of these
contributes to loss of facial volume but in different ways.

1
Palm Beach Esthetic Dermatology and Laser Center, West Palm
Beach, Florida.
Address for correspondence and reprint requests: Kenneth Beer,
M.D., F.A.A.D., Palm Beach Esthetic Dermatology and Laser Center,
1500 North Dixie Highway, Suite #305, West Palm Beach, FL 33401
(e-mail: KenBeer@aol.com).
Skin Rejuvenation; Guest Editor, Kenneth Beer, M.D., F.A.A.D.
Facial Plast Surg 2009;25:281–284. Copyright # 2009 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
DOI 10.1055/s-0029-1243075. ISSN 0736-6825.
281
282 FACIAL PLASTIC SURGERY/VOLUME 25, NUMBER 5 2009
Figure 1 This woman has volume loss in multiple areas
including her jaw (mostly due to bone resorption), her cheeks
(due to fat pad migration and atrophy), and her temples.
Bone loss makes the jaw, cheeks, and chin recede during
the fifth and sixth decades of life. Outwardly, this may be
seen as lack of support around the mouth and zygoma.
Without this structure, the skin begins to hang and sag
resulting in jowls, redundant nasolabial creases, and
other signs of aging. Some attempts to compensate for
this change have resulted in jaw, chin, and cheek im-
plants that move the skin and soft tissue into a more
cephalad direction. However, these frequently lack the
subtlety required for an ideal outcome. Injections with
calcium hydroxylapatite, thick hyaluronic acids, or other
structure fillers such as porcine collagen fibers can help to
buttress the face in ways that implants cannot, and these
injectables may be useful for facial contouring.
Figure 2 Atrophic lips with perioral rhytides are another
cardinal sign of aging. The atrophy of the lips in women is tied
to genetic, environmental (smoking and ultraviolet damage),
and hormonal milieu. Thus, loss of volume and show of the
mucous membranous component is linked with loss of
reproductive capacity and age.
Midfacial and temporal atrophy are both frequent
sites of volume loss. For these two areas, injections with
autologous fat or with poly-L-lactic acid (PLLA) can
restore a more youthful contour to the face. These injec-
tions have effects that are seen in areas distinct from where
they are placed simply because they move the face. For
instance, the nasolabial crease and the deep shadow seen
with aging are frequently ameliorated with volume resto-
ration into the zygomatic arch and the malar area.
One other area where volume loss signals aging is
the lip (Fig. 2). The redness and volume seen in
youthful, female lips has significant impact on the
appearance of the overall face. There is anthropologic
data to support that lip fullness correlates with estrogen
and progesterone levels as well as with the reproductive
capacity of the female. After menopause and the end of
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reproductive capacity, lip atrophy and perioral rhytides
signal a turning point for facial aging. Restoring volume
to the lip using simple techniques of lip augmentation
can mitigate this.
SURFACE CHANGES ASSOCIATED WITH
AGING
The surface of the skin changes dramatically with age.
Frequently, the hallmarks of facial aging include pig-
ment irregularities, formation of actinic keratoses, telan-
giectasias, and other superficial changes that affect the
Figure 3 Many patients will present with several signs of
aging but point to the ‘‘barnacles’’ that mark them as old.
Treating these will improve their overall appearance.

reflectance of light and perception of youthfulness.
‘‘Moles’’ (frequently seborrheic keratoses that are easily
treated) crop up, and patients begin to feel like they are
turning into their parents or grandparents (Fig. 3).
These, as well as skin cancers that tend to form with
facial aging, are the most obvious manifestations. Facial
plastic surgeons need to be aware of the role the growths
have in both appearance and self-perception of the
patient. Removing the lesions can be accomplished using
a variety of modalities including laser, liquid nitrogen, or
electrosurgery or with a referral to a dermatologist.
Pigmentary irregularity may be the result of
hyperpigmentation due to melanin, hypopigmentation
due to disease or scarring, or erythema from telangiec-
tasias. Melanin may be corrected (assuming that it is
due to a benign process) with lasers, prescription
strength bleaching products such as tretinoin or hydro-
quinone, or with cosmeceuticals. Intense pulsed lights
are frequently employed to treat this condition because
the broad spectrum of light emitted will improve not
only brown pigment but also red pigment. Combining
these with photoprotection and topical treatments can
make a dramatic difference in the appearance of the
skin.
Light reflectance has significant impact on the
appearance of the skin. Frequently, the importance of
this facet of facial aging is not adequately addressed. In
addition to the health risk posed by actinic keratoses,
they also scatter light unevenly. This latter factor con-
tributes to the low light reflectance seen in photodam-
aged skin. Treatment of these lesions, whether by topical
5-fluorouracil, imiquimod, photodynamic therapy,
chemical peels, or laser treatment, has significant impact
on the appearance of the skin.1 Indeed, simply eradicat-
ing the actinic keratoses in a patient with Fitzpatrick I
to III skin will make a dramatic difference in their
appearance.
FACIAL DESCENT
One of the sentinel events associated with facial aging is
descent of the mid and lower face. As elegantly outlined
by Rohrich et al, the midfacial fat pads descend from the
zygomatic and periorbital areas.2 These pads also assume
different conformations and frequently become smaller
or less rounded. The caudad migration contributes to
the formation of the nasolabial crease and also to the
‘‘jowling’’ seen with facial aging. Facial plastic surgery
that repositions this fat pad or that restores an atrophic
midfacial fat pad can have dramatic results for facial
rejuvenation. Moving the midfacial fat structures in a
cephalad direction with the use of a midface lift can
markedly improve the nasolabial crease without any
direct filling of this region.
Facial descent also affects the lower third of the
face and creates another significant stigmata of facial
OVERVIEW OF FACIAL AGING/BEER, BEER 283
aging. Surgically addressing the jowls may involve re-
moval of excess skin and tightening of the superficial
muscular aponeurotic system (SMAS). Plication of the
platysmal bands and/or removal of excess neck skin can
make a dramatic difference in the appearance of patients
sagging in the lower face. Nonsurgical tightening of
this area may also be achieved, albeit to a lesser degree,
by energy sources such as Thermage (Sotto Lasers,
Hayward, CA) and also by the collagen stimulation
achieved by injections of poly L lactic acid (PLLA).
Suspending facial structures with sutures or other
suspension instrumentation has largely been nonproduc-
tive for the cosmetic patient. Primarily, this has been due
to the failure of the materials used rather than of the
potential for vertical nonsurgical lifting. Future develop-
ments that use biodegradable materials such as poly
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lactic acid, collagen, or other products may have poten-
tial to perform better than the nylon sutures used in prior
iterations. Placement of these sutures may eventually be
guided with endoscopic visualization, which could be a
marked improvement over the blind insertions used
previously. Replacing stretched suspensory ligaments
with artificial materials holds the potential to reverse
some of the major aspects of facial descent, and it will be
worthwhile to observe as this technology develops.
LINE FORMATION
As Hemingway, in The Old Man and the Sea, writes of
the ‘‘deep wrinkles’’ that mark Santiago, many of our
patients are marked as being old by the wrinkles on
their faces. These wrinkles may be static (present at
rest) or dynamic (dependent on muscle movement).
Many patients with facial aging present with wrinkles
that are combinations of static and dynamic. The
treatment of dynamic wrinkles has involved the use
of botulinum toxins for more than a decade, whereas
the treatment of static rhytides has been addressed
with soft tissue augmentation products for more than
two decades. One new opportunity for physicians
dealing with facial aging is the plethora of new
materials available for relaxing muscles and filling lines
as well as newer techniques used to combine these two
methods.
Dynamic lines are best visualized by observing
the glabella and periorbital rhytides in a young person.
The muscles that act upon the glabella will crease the
skin, but once relaxed, the skin retains the elasticity to
return to its prior state. As facial aging progresses the
elasticity of the skin decreases and the lines become
etched in. To fix these latter rhytides, it is necessary to
use a filler to return the skin to its unwrinkled con-
formation.
Dynamic lines may be adequately treated with
injections of botulinum toxins. At the present time, there
are two type A toxins approved (Botox and Dysport).
284 FACIAL PLASTIC SURGERY/VOLUME 25, NUMBER 5 2009
Whereas it is beyond the scope of this review to elaborate
upon the similarities and differences between these
products, it shall suffice to say that each physician using
them should be aware of the differences in onset,
diffusion, and dilution required to obtain consistent,
optimal patient outcomes. These products remain
among the products that are consistently rated with
high satisfaction by patients, and it is likely that as
more of these products are brought to market, their
use will continue to grow.
Static rhytides require volume correction to ef-
face them. As the list of products available for this
purpose grows, it becomes increasingly confusing which
ones are best for which facets of facial aging. The senior
author prefers to use thicker, structural molecules for
sculpting and lifting (including Radiesse, Perlane, and
Evolence) and more flexible molecules (including
Restylane, Prevelle Silk, and Juvederm) for filling fine
lines. Certain anatomic areas such as the tear troughs
warrant special consideration as they are covered by
very thin skin, and the distance between the area
corrected and the surface of the skin is rather small.
For these areas, smoother, transparent molecules
should be used.
As Carruthers and Carruthers demonstrated, the
synergistic effects of botulinum toxins with fillers can
dramatically improve some of the major features of facial
aging.3 Injections of botulinum toxins with fillers can
not only improve the appearance of the glabella, mario-
nette lines, and other areas more than might be expected
but also increase the duration (and thus the patient
satisfaction) dramatically.
CONCLUSION
Any worthwhile overview of facial aging will present
some of the different facets that are responsible for
looking old. The job of physicians engaged in treating
facial aging is to understand not only what causes the
face to appear old but also the various opportunities to
address them. Whether surgical intervention, injections,
lasers, or topical products are used, combination ap-
proaches that treat the underlying problems will benefit
the patients we care for.
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2107–2112
3. Carruthers J, Carruthers A. Prospective, randomized, parallel
group study analyzing the effect of BTX-A (Botox) and
nonanimal sourced hyaluronic acid (NASHA, Restylane) in
combination compared with NASHA (Restylane) alone in
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