Understanding the Aging Face
As we age, we all undeniably see changes in our face and body. And sometimes these changes are often out of proportion to how we feel, often leading to decreased confidence and feeling of self-worth. One of the most common complaints we hear as surgeons is “ I look older than I feel”. We all know WHAT this looks like, but in order to understand how to combat these changes, it helps to understand HOW this happens.
There are several factors that contribute to the aging face:
- Skin changes affected by time, genetics, and sun exposure
- Fat volume changes: loss in some regions and accumulation in others
- Loss of tone of facial muscles and ligaments
- Facial bone loss
As skin ages, it loses its elasticity, and becomes thinner and drier. These changes adversely effect skins ability to reform its original form when it stretches. Over time this leads to wrinkles (rhytids) overlying areas of muscle contraction. Furthermore, pigment changes occur, a process accelerated by sun exposure and hereditary factors. Skin reparative abilities also wane with time, which can sometimes lead to skin cancers.
Facial Volume Changes
We can all appreciate the plump, vibrant appearance of a baby’s face. This is due to abundant facial fat underlying the skin. As we age, certain changes occur to our facial fat that lead to what we recognize as an aging face: We lose fat in the region of the brow, temple and cheeks. This hollows the temple, deflates the eyebrow, and flattens the cheeks. Fat also diminishes in the upper eyelid and bulges in the lower eyelid due to changes within the eye socket fascial compartments and gravity effects. This leads to a hollow upper eyelid and baggy lower eyelid. And finally, fat accumulates in the neck region leading what is sometimes referred to as the “turkey waddle”.
Loss of Elasticity of Facial Tissues
Similar to the changes that occur within the skin, the deeper tissues of the face also suffer from loss of tone and elasticity. This occurs to muscles, ligaments that anchor muscle and skin to bone, and the tissue scaffolding of the face itself. This leads to hollowing of the transition zone between the eyelid and cheek (tear trough), jowling at the jaw line, increased folds around the nose and chin, and banding of the neck.
Facial Bone Loss
Just as we lose bone density in the long bones and spine, the facial skeleton also resorbs with age. This leads to a larger eye socket, flatter cheekbones, and a receding chin, which further accentuate the soft tissue changes. And, of course, GRAVITY is the final culprit in bringing together all these factors that lead to the facial aging changes that we see in the mirror. Now that we understand HOW we change with age, we can now focus on the steps we can take to fight these changes.
Evaluation of the Aging Face- an overview
Now that we better understand the aging process of the face, how is a patient evaluated?
The most important aspect of a proper evaluation is understanding the patient’s concerns. Listening to the patient can properly guide and focus the evaluation. Though our overall goal is to achieve harmonious facial rejuvenation, each patient has different perspectives, needs, and expectations. This means that patients with very similar anatomic features, may want completely different surgical plans.
So first and foremost, Dr. Amadi questions the patient’s concerns: “What is bothering you the most? What are you unhappy with?”. Once that is fully appreciated, he then moves forward with his evaluation.
As Dr. Amadi is an Oculofacial plastic surgeon, his focus begins with the eyes and upper face. This includes the eyebrows and forehead, the upper and lower eyelids, as well as the cheek. The upper eyelids cannot be properly evaluated without taking the eyebrows into consideration as they are intimately associated. The eyebrow position and projection can determine the fullness of the upper eyelid, so it cannot be ignored when examining the upper eyelid. Furthermore, it is essential to understand the gender differences in facial anatomy and ideal aesthetics, as this determines proper evaluation of eyes and eyebrows.
Similarly, the lower eyelid cannot be properly evaluated without examining the cheek position and volume. A volume deficient and descended cheek mound can accentuate the lower eyelids bagginess by creating a visible depression between the two, commonly named the “tear trough”. Cheek descent can also lead to more prominent “nasolabial folds”, the fold of the smile line that extends from the bottom edge of the nose down to the corner of the mouth.
Once the upper face is properly evaluated, Dr. Amadi then transitions to the lower face. Though the eyes are often the central focus of the face, the idea facial rejuvenation has to address the lower face and neck to achieve upper-lower face harmony. The lower face aging changes that need to be identified include loss of lip volume and projection, jowling seen at the jawline, a receding chin due to bone loss, and fat accumulation in the neck region.
Throughout this evaluation, Dr. Amadi is also identifying skin texture changes such as wrinkling and pigment changes, as these features cannot be ignored if one is to achieve ideal rejuvenation.