Why Your Face Changes With Age...
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... and Why More Filler Isn't Always the Answer
ARIA SONATA CLINICAL REVIEW | Evidence-Based Patient Education
Aria Sonata Aesthetics | Keller, Texas
Abstract
Facial aging is often described as a problem of wrinkles, sagging skin, or lost volume, but current anatomical and aesthetic literature paints a much more complex picture. The appearance of the face changes through an interaction of skeletal remodeling, changes within superficial and deep facial fat compartments, connective tissue, muscle activity, and changes within the skin itself (Swift et al., 2021). These processes do not occur uniformly, nor do they affect every person in the same way.
Understanding these changes helps explain why one person develops hollowing beneath the eyes while another notices more heaviness in the lower face, why the jawline can gradually become less defined, and why simply adding more dermal filler is not always the most appropriate solution. Before deciding how to treat a face, I believe we first need to understand why it has changed.
“I Don't Look Like Myself Anymore”
This is something I hear from women who cannot always put their finger on exactly what has changed. They may notice that their cheeks do not have quite the same shape, their eyes look tired even when they are rested, the area around the mouth seems heavier, or their jawline is not as defined as it once was. Sometimes it is simply a feeling that the face looking back at them in the mirror does not quite match how they still feel.
It is easy to assume these changes are all the result of collagen loss or loose skin. It is also easy to assume that replacing lost volume with filler is the solution. Facial aging is much more complicated than either of those explanations.
Modern research suggests that the changes we see in the mirror are the result of changes occurring throughout several layers of the face, beginning with the underlying facial skeleton and extending outward through fat, connective tissue, muscle, and skin (Swift et al., 2021). Each of those layers contributes to the way our face looks, and each can change differently as we age.
That is an important distinction in aesthetic medicine because different anatomical changes require different solutions.
Facial Aging Happens From the Inside Out
One of the easiest ways to understand facial aging is to think of the face as a structure with several layers. The facial skeleton provides the foundation. Above that are deep and superficial fat compartments that contribute volume, support, and contour. Connective tissues help organize and anchor those structures. Muscles create movement and expression, and the skin forms the visible outer layer.
Researchers have described this as facial aging occurring from the “inside out” because what we eventually notice on the surface can be influenced by changes occurring much deeper in the face (Swift et al., 2021).
This means that the line, hollow, or shadow you see in the mirror may not necessarily originate in that exact location. That is one of the reasons I prefer to assess the entire face before deciding what should be treated.
Your Facial Bones Continue to Change
This surprises many people. We tend to assume that once we reach adulthood, our facial bones stay essentially the same and everything above them is what ages. The facial skeleton actually continues to remodel throughout adulthood.
Changes can occur around the eye sockets, cheek and midface, the area surrounding the nose, the upper and lower jaw, and the chin. Over time, these changes can alter the structural support available to the soft tissues above them (Swift et al., 2021).
Think about the facial skeleton as part of the architecture underneath the face. When that architecture changes, the tissues resting on top of it can also begin to look different.
Around the eyes, changes in the bony orbit and surrounding soft tissues can contribute to a more noticeable transition between the lower eyelid and cheek. This may appear as hollowing or shadowing beneath the eyes. Through the midface, changes in skeletal support and facial volume can alter cheek projection and contour. Along the lower face, changes involving the mandible, chin, teeth, muscles, and soft tissues can all contribute to the gradual loss of definition many people begin to notice along the jawline.
This is why something that appears to be a surface problem may actually have a deeper structural component.
Facial Fat Is More Complicated Than Most People Realize
Facial fat is not one continuous layer underneath the skin. It is organized into distinct superficial and deep compartments, and those compartments have different anatomical relationships and functions.
Research suggests that these compartments do not necessarily age at the same rate. In a longitudinal study published in Plastic and Reconstructive Surgery, researchers compared CT scans taken more than a decade apart and found measurable reductions in both superficial and deep midface fat, with proportionally greater loss in the deep compartments within their study population (Boehm et al., 2021).
The study was relatively small, so the exact findings should not be interpreted as a formula for how every person's face will age. What it does illustrate is an important concept. Facial volume change is not necessarily uniform.
This helps explain why someone can look hollow in one part of the face while simultaneously feeling that another area looks heavier. A person may notice more hollowing beneath the eyes or less projection through portions of the cheek while also noticing increasing heaviness through the lower cheek or jawline.
Those observations are not contradictory. Different structures are changing in different ways.
This is also one reason simply placing filler anywhere a hollow appears can sometimes produce an undesirable result. If we do not understand what created the contour change in the first place, adding volume can make a face look heavier rather than younger.
The Face Has Its Own Internal Support System
The tissues of the face do not simply float freely over the facial skeleton. They are organized and supported by connective tissue structures, including what are commonly described as facial retaining ligaments and associated fibrous septa.
Anatomical research has demonstrated that these structures occur in relatively consistent locations and help define facial spaces and fat compartments (Alghoul & Codner, 2013). These internal boundaries contribute to the contours, transitions, folds, and shadows that we see on the surface.
Our understanding of these structures continues to evolve. The important point for aesthetic treatment is that facial aging is much more complicated than the old explanation that everything simply becomes loose and falls downward with gravity.
Bone, fat, connective tissue, muscle, and skin interact with one another. When one part of that system changes, it can influence the appearance of another.
Muscle Plays a Role Too
Our faces are constantly moving. We smile, squint, frown, raise our eyebrows, talk, laugh, purse our lips, and make countless subtle expressions throughout the day. Over decades, those repeated movements interact with changes occurring in the skin and underlying facial structures.
This is why a line caused predominantly by muscle movement is different from a hollow caused by a change in volume or structural support. It is also why neuromodulators and dermal fillers do very different jobs.
Neuromodulators such as Botox®, Dysport®, and Xeomin® temporarily alter activity in specifically targeted muscles. Hyaluronic acid fillers are used to change volume, support, proportion, or contour. They are not interchangeable treatments, and neither one is automatically the answer simply because a line or wrinkle is visible.
Published facial assessment literature emphasizes the importance of evaluating anatomy and facial movement when planning injectable treatment rather than applying exactly the same injection pattern to every patient (de Maio et al., 2017).
Then There Is the Skin
The skin is the layer we see every day, and it goes through its own aging process. Collagen and elastin change over time. Cumulative sun exposure contributes to photodamage. Pigmentation may become more noticeable, and the skin can become thinner, drier, or less resilient. Fine lines and texture changes also become more apparent.
This brings up an important distinction that I discuss frequently with patients. Skin quality and facial volume are not the same problem.
Dermal filler cannot correct every issue associated with fine lines, pigmentation, sun damage, texture, collagen loss, or skin laxity. If the primary concern is skin quality, adding volume may not make sense at all.
Depending on the individual, treatments such as microneedling, chemical peels, professional skincare, or other treatments directed toward collagen and skin quality may be much more appropriate.
Why Do Nasolabial Folds Become More Noticeable?
The nasolabial fold is a good example of why I believe facial aging should be evaluated anatomically rather than treating whatever line happens to be most visible.
If you point to the fold extending from the side of your nose toward the corner of your mouth, the obvious solution might seem to be putting filler directly into it. In some patients, direct treatment of that area may be appropriate. In others, however, the appearance of the fold can be influenced by changes elsewhere in the midface.
Cheek structure, facial volume, tissue transitions, skeletal support, and skin quality can all contribute to what we see. Published recommendations for midface assessment emphasize evaluating these relationships when developing an injectable treatment plan (de Maio et al., 2017).
This does not mean that everyone with a prominent nasolabial fold needs cheek filler. It means that we should understand why the fold is prominent before deciding how to treat it.
That is a very different philosophy from simply filling the line.
The Same Principle Applies to the Jawline
Another common concern I hear is, “I feel like I've lost my jawline.”
There can be several reasons for that change. Chin projection, mandibular structure, soft tissue distribution, prejowl volume, skin laxity, mentalis activity, masseter anatomy, platysmal activity, and overall facial proportions can all influence the appearance of the lower face.
Published consensus guidance describes the lower face as an anatomically complex region that requires careful assessment when injectable treatment is being considered (de Maio et al., 2017).
For that reason, the answer to a changing jawline is not automatically to place filler along the jaw. Structural support may help one person. Muscle activity may be an important part of the problem for another. Skin laxity may be dominant in someone else. Another patient may benefit more from treatment directed toward collagen and skin quality.
There are also times when injectable treatments simply cannot create the degree of tightening or structural change a patient wants. Being able to recognize that is just as important as knowing how to perform the treatment.
Why More Filler Is Not Always Better
Hyaluronic acid filler is an extremely useful tool when it is used thoughtfully and for the right reason. It can restore selected areas of volume deficiency, improve facial proportion, provide support, and enhance contour.
It is still only one tool.
Faces naturally contain highlights, shadows, convexities, concavities, angles, and movement. Those characteristics are part of what makes a face look human and recognizable.
If every depression is filled and every shadow is eliminated, those natural transitions can gradually disappear. A face may become fuller without necessarily looking younger or more refreshed.
For me, the goal of aesthetic treatment is not to make someone look filled. I want the result to make sense with the rest of her face.
So What Treatment Does Make Sense?
The answer depends on what is actually creating the concern. This is why I prefer to begin with facial assessment rather than choosing a treatment based only on the area someone points to in the mirror.
Hyaluronic acid dermal filler may be appropriate when selected volume restoration, structural support, proportion, or contour is the goal. For example, age-related changes in lip volume and proportion may sometimes be addressed conservatively with lip filler, while changes elsewhere in the face require an entirely different assessment.
Wrinkle relaxers may be more appropriate when muscle activity is contributing significantly to what we see. Treatments such as Xeomin and Dysport are used to soften selected dynamic lines while preserving appropriate facial movement and expression.
Biostimulatory treatments work differently from traditional hyaluronic acid filler. Sculptra is a collagen-stimulating treatment intended to create gradual change rather than simply providing immediate HA volume. For the right patient, this may make more sense when the goal is progressive support and rejuvenation rather than filling one isolated line or hollow.
When skin quality is an important part of what has changed, microneedling may be considered to support collagen remodeling and improve concerns such as fine lines, texture, pores, and overall skin quality.
Chemical peels address a different layer of facial aging. Depending on the peel selected, they may be useful when uneven tone, rough texture, visible sun damage, or other surface changes are part of the concern.
Sometimes the priority is not changing facial structure at all. Custom facials can be used to address the skin's current needs, including hydration, brightness, texture, and maintenance of overall skin health.
The important point is that none of these treatments should automatically be selected simply because of age. The treatment should match the anatomical or skin-related change we are trying to address.
Not Sure Which Approach Fits What You're Seeing?
If you recognize some of these changes in your own face but are not sure whether the better starting point is wrinkle relaxers, restoring volume, supporting collagen, or improving skin quality, you do not need to diagnose your own face before coming in.
The Aria Sonata Treatment Guide was created to help you compare these options according to what you would actually like to improve. You can explore wrinkle relaxers, lip filler, Sculptra, microneedling, chemical peels, and custom facials and see how the treatments differ before deciding whether you are ready for a consultation.
If you would rather talk through your concerns first, an individualized aesthetic consultation is a good place to begin. We can look at facial movement, structure, skin quality, and your priorities together, then decide whether treatment is appropriate and what makes the most sense to address first.
Sometimes the Best Treatment Is Restraint
This is an important part of how I approach aesthetics. There are areas where we can technically place filler, but that does not automatically mean that doing so is the best choice.
Sometimes the appropriate recommendation during a consultation is, “I don't think filler is the best treatment for that.”
That is not a failed consultation. In my opinion, that is good aesthetic judgment.
If adding volume is likely to make an area heavier, alter someone's natural proportions, or simply fail to address what is actually bothering her, I would rather explain why and discuss other options.
Sometimes another treatment makes more sense. Sometimes a combination of treatments performed gradually is the better approach. Sometimes the right answer is simply to leave an area alone.
A Better Question Than “Where Do I Need Filler?”
Instead of beginning an aesthetic consultation by asking where we should put filler, I prefer to begin with a much more useful question:
What has changed, and why?
From there, I can look at the underlying structure, facial volume, soft tissue, muscle activity, skin quality, facial proportions, and the concern that actually brought you in.
Only then does it make sense to talk about treatment.
Sometimes the answer will be filler. Sometimes it will be a neuromodulator. Sometimes improving collagen or skin quality should come first. Often, a thoughtful combination of treatments performed gradually makes more sense than trying to accomplish everything during one appointment.
And sometimes the answer is, “Not yet.”
The Goal Is Not to Look Younger at Any Cost
Aging is not a defect that needs to be erased.
There is a significant difference between trying to look twenty years younger and simply wanting the face in the mirror to better reflect how you still feel.
Most of the women I meet are not asking to become someone else. They want to look less tired, a little more rested, slightly more defined, healthier, or simply more like themselves again.
I think that deserves a thoughtful approach.
Evidence-Based Facial Rejuvenation at Aria Sonata Aesthetics
At Aria Sonata Aesthetics in Keller, Texas, facial rejuvenation begins with assessment rather than a syringe. I look at your anatomy, proportions, facial movement, skin quality, what has changed over time, and most importantly, what actually bothers you.
From there, we can discuss whether dermal filler, wrinkle relaxers, collagen-stimulating treatments, microneedling, chemical peels, professional skincare, or a thoughtfully staged combination makes sense.
Successful aesthetic treatment should not be measured by how much product was used. It should be measured by whether the treatment made sense for the person and the face being treated.
If you have noticed changes in your cheeks, under-eye area, lips, lower face, or jawline but are not sure which treatment you actually need, an individualized consultation is a much better place to begin than choosing a treatment from a menu.
Aria Sonata Aesthetics serves Keller, Southlake, Westlake, North Fort Worth, and surrounding DFW communities.
Schedule an individualized aesthetic consultation →
References
Alghoul, M., & Codner, M. A. (2013). Retaining ligaments of the face: Review of anatomy and clinical applications. Aesthetic Surgery Journal, 33(6), 769–782. https://doi.org/10.1177/1090820X13495405
Boehm, L. M., Morgan, A., Hettinger, P., & Matloub, H. S. (2021). Facial aging: A quantitative analysis of midface volume changes over 11 years. Plastic and Reconstructive Surgery, 147(2), 319–327. https://doi.org/10.1097/PRS.0000000000007518
de Maio, M., DeBoulle, K., Braz, A., & Rohrich, R. J. (2017). Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fillers: Focus on the midface. Plastic and Reconstructive Surgery, 140(4), 540e–550e. https://doi.org/10.1097/PRS.0000000000003716
de Maio, M., Swift, A., Signorini, M., & Fagien, S. (2017). Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fillers: Focus on the upper face. Plastic and Reconstructive Surgery, 140(2), 265e–276e. https://doi.org/10.1097/PRS.0000000000003544
de Maio, M., Wu, W. T. L., Goodman, G. J., & Monheit, G. (2017). Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fillers: Focus on the lower face. Plastic and Reconstructive Surgery, 140(3), 393e–404e. https://doi.org/10.1097/PRS.0000000000003646
Swift, A., Liew, S., Weinkle, S., Garcia, J. K., & Silberberg, M. B. (2021). The facial aging process from the “inside out.” Aesthetic Surgery Journal, 41(10), 1107–1119. https://doi.org/10.1093/asj/sjaa339
ARIA SONATA CLINICAL REVIEW | Evidence-Based Patient Education
Aria Sonata Aesthetics | Keller, Texas
This article is provided for educational purposes and is not a substitute for individualized medical assessment. Treatment recommendations depend on anatomy, medical history, treatment goals, and clinical evaluation.