Patients often consult with the concern that they have aged overnight. Although they may have noticed this because someone else had pointed out that they look tired or exhausted, the ageing process is multifactorial and occurs over a number of years.
I always explain the ageing process to my patients so that they can appreciate the changes involved and how these can be addressed. There are five layers of the face involved in facial ageing. This includes the bones, deep fat pads, the muscles and ligaments, superficial fat pads and the skin. All of the layers go through the ageing process and often needs addressing specifically when rejuvenation is desired.
What happens to the facial bones and deep fat pads
Ageing affects the facial bones of the skull. There is a gradual reduction in the bones leading to certain changes we see in a mature face. Imagine a table that has a tablecloth and the table starts shrinking, you get excess cloth which will sag. Here, the table represents the bones in the face. The main areas where this is relevant are the eye sockets, they become larger creating a sunken eye appearance contributing to a tired expression. The cheekbone regresses causing flattening of the cheeks while the hole where the nose connects expands deepening the folds between the nose and mouth. The jawbone shrinks causing loss of definition and heaviness in the lower face, often with a diminished chin. Any loss of teeth causes loss of support in the mouth area.
All the bony changes affect the layers above it as they form the scaffolding of the face.
The deep fat pads are stuck to the bones and are responsible for the fullness seen in a young face. They help create smooth transitions from one area to the next. As we age, these fat pads decrease in volume and move downwards with gravity compounded by the loss of bony support underneath. Movement of the deep fat pads is responsible for creases, grooves and hollowness seen in the face. They result in the apple of the cheeks appearing flattened, folds becoming more pronounced and the lower face increasing in volume.
As we age, our lips turn inwards, lose volume and definition. Lines appear around the mouth and the corners of the mouth may be downturned.
Wrinkles caused by muscles
The muscles of the face are in constant motion from the time we are born whether we smile, cry, eat, talk, grimace, shout, frown and so on. In our late twenties, we get ‘dynamic’ lines (wrinkles) which are lines that appear when we make certain movements such as frown, smile or raise our eyebrows. Over time, and with repeated contractions, the muscles remain contracted forming ‘static lines’ (wrinkles) which are visible even when one is not making these expressions. In some areas such as under the eyes, the ageing muscles are so thin and allow ‘herniation’ or poking out of structures beneath causing eye bags to form.
Ligaments of the face
Some ligaments cause tethering leading to specific areas of sagging such as the jowls while some are lax allowing the descent of structures, for example, the strong pull of the neck muscle allow the loss of definition or even disappearance of the jawline.
Superficial facial fat
The superficial layer of fat immediately under the skin is unique in that instead of becoming thinner it actually gets thicker with ageing! The consequence is that any folds in the face become more prominent such as nose to mouth lines and mouth to chin lines become more noticeable.
The skin undergoes changes with ageing. We start losing collagen in our thirties and the skin starts to lose its elasticity and water holding capacity. This results in the classic appearance of rough, uneven, loose, dry and saggy skin with deep wrinkles.
The shape of the Face
The overall effect is the loss of the inverted triangle of youth and results in the triangle or square of the aged face.
Addressing facial changes
During my consultation, the approach is to consider all layers of the face and treat where necessary starting with the scaffolding. We use dermal fillers to fill deficits. They compose of chains of sugar molecules (hyaluronic acid) manufactured specifically to last longer than our own hyaluronic acid molecules. These molecules naturally attract water and can hold up to a thousand times their weight in water. This is how they have a plumping effect on the face. Although minor changes are visible immediately after treatment, true plumping effect occurs over weeks.
Once the scaffolding has been addressed, I would consider augmenting areas of concern if required. Outcomes and longevity vary from person to person and where the filler is placed. Although they can last for 6-18months, they do have to be re-injected to maintain the effects. I only use dermal fillers that have been extensively studied and sourced from reputable UK pharmacies.
Specific muscles that create wrinkles on movement on the face can be successfully treated with Botulinum Toxin by temporarily disrupting the connections between the nerves and the muscles. When the wrinkles have become fixed and present at rest (static lines), the response is not good. They do however get softer with repeated treatments.
Skin laxity can be addressed with medical skincare or skin rejuvenation treatments like injectable skin boosters, microneedling, mesotherapy and medical skin peels in combination with dermal fillers and botulinum toxin.
Patients often come to see me to fill a line here or there but as a doctor, it is my duty to educate them about how we age so that they can better understand why they are seeing the reflection they see in the mirror.
Once we have discussed how I would plan their treatment they have a good insight about what we can achieve with the available treatments. They also understand that we cannot create what they never had instead we can enhance their own natural beauty-my ethos.