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We all are aging even as you read this. It is inevitable, it exists all around us, and it is part of everyday life. You might say it is an integral and, maybe even an essential, component of the human condition. As a plastic surgeon, trying to improve or reverse the symptoms of aging is part of our everyday work. This makes us a student of aging and hopefully an astute one.

Recent studies into facial aging has brought new insights into how it happens for many people. Historically, it was believed that faces aged by falling or the descent of facial tissues. Thus the emergence of facelifting operations. Facial and neck skin was moved in an opposite direction to that which the tissues fell, forward and downward. For some patients, there is no doubt this descent is the primary reason that their faces look older as some faces do look better when the skin is lifted and pulled tight. But this is not completely true for everyone.

It is now been shown that volume loss or fat atrophy plays a significant part of what ages many faces. Today’s widespread use of injectable fillers, including fat, is the offspring of this new facial aging understanding. Interestingly, this may have been recognized over a hundred years ago when the first injectable facial fillers were used. Injecting paraffin into facial hollows was done before the turn of the century but was abandoned due to predictably high complications and infections. Synthetic fillers and fat have now emerged as the modern-day version of this old facial aging treatment concept…with more predictable results and much more limited side effects.

As part of this volume loss aging concept is the influence of one’s facial weight. Some faces are fat even when they are older and others are more thin. Usually this facial weight does correlate with one’s body weight and habitus but not always. Heavier faces have thicker skin and they wrinkle less but their heaviness leads to deeper nasolabial folds and marionette lines and ‘meatier’ sagging jowls and necks. Less heavy faces have thinner skin and develop a much larger number of wrinkles particularly around the eyes, forehead and mouth. But they do not develop large amounts of sagging neck and jowl skin until they are quite advanced in years. In essence, fat faces fall while thin faces deflate. For most people, however, their aging is a mixture of varying ratios of falling and thinning.

This new paradigm shift in facial aging understanding allows for dual and often intertwining roles for tissue lifting and volume addition. This is most relevant for those patients in their 40s and 50s where the aging process is not severely advanced and may be visually slowed to a greater degree. More limited facelifting procedures combined with volume enhancement with fat injections can be very effective and not associated with long recovery times.

Dr. Barry Eppley

Indianapolis, Indiana

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