The Facial Aging Process From the "Inside Out"

Abstract

The normal course of aging alters the harmonious, symmetrical, and balanced facial features found in youth, not only impacting physical attractiveness but also influencing self-esteem and causing miscommunication of affect based on facial miscues. With this evidence-based paper, the authors aim to provide a comprehensive overview of the latest research on the etiology and progression of facial aging by explaining the aging process from the "inside out," that is, from the bony platform to the skin envelope. A general overview of the changes occurring within each of the main layers of the facial anatomy is presented, including facial skeleton remodeling, fat pad atrophy or repositioning, changes in muscle tone and thickness, and weakening and thinning of the skin. This is followed by an in-depth analysis of specific aging regions by facial thirds (upper, middle, and lower thirds). This review may help aesthetic physicians in the interpretation of the aging process and in prioritizing and rationalizing treatment decisions to establish harmonious facial balance in younger patients or to restore balance lost with age in older patients.

Figure 1.

Progressive bony remodeling occurs with age in areas that resorb in a specific and predictable manner. The mandibular angle in females increases, as does the anterior projection of the chin. Images show this process in a young female (A) vs older (B) adult. Panel C shows the clinical presentation during young adulthood in this female patient at 22 years of age, whereas panel D reflects changes secondary to bony remodeling of the mandible with aging in the same patient at 70 years of age. Dashed lines represent areas of the chin and jawline visibly impacted by bony remodeling of the mandible. Patient images in panels A and B provided by Arthur Swift, MD. Patient images in panels C and D provided by B. Kent Remington, MD, owner of these original images, who has granted permission to publish them.

Figure 2.

Orbital bone resorption occurs mainly in the inferolateral and superomedial regions. Images depict the integrity of the medial cheek fat pad, periorbital bone, medial brow, and lid-cheek junction in a young adult (A) vs the age-related changes in an older adult (B), including exaggeration of the brow and tear troughs as well as smaller, rounder-looking eyes. This previously unpublished, new illustration was created by Allergan Aesthetics, an AbbVie Company (Irvine, CA) who granted permission to publish it.

Figure 3.

Fat compartments in the face are broadly characterized as superficial (A) or deep (B). Superficial fat compartments (A) are separated by fascia and septae that meet at adjacent compartments, where retaining ligaments reside, with each component found in varied amounts, proportions, and arrangements in different regions of the face.^,, Deep fat compartments (B) comprise retro-orbicularis oculus fat, lateral and medial suborbicularis oculus fat, buccal fat, and deep medial cheek fat, which has medial and lateral parts.^,,, This previously unpublished, new illustration was created by Allergan Aesthetics, an AbbVie Company (Irvine, CA) who granted permission to publish it.

Figure 4.

Perioral dynamic discord is illustrated across the ages. With aging, the skin envelope deteriorates faster than the muscle strength, leading to the orbicularis oris overwhelming the perioral skin. Images provided by Steven Liew, MD.

Figure 5.

Superficial temporal compartment: volume and size by age group. Mean height increases from 2.9 cm to 12.2 cm with increasing age, and mean volume increases by 35.5% from the youngest to the oldest group. This previously unpublished, new illustration was created by Allergan Aesthetics, an AbbVie Company (Irvine, CA) who granted permission to publish it.

Figure 6.

Typical A-frame deformity in this 49-year-old Caucasian female (A) and sunken eye appearance in this 45-year-old Asian male (B). Images in panels A and B provided by Arthur Swift, MD, and Steven Liew, MD, respectively.