Facial Ageing

Facial Volume Restoration

Written by Dr Julian De Silva

Facial ageing is a natural part of life and cosmetic surgery has been a part of this culture dating back to Roman times. Surgeons would routinely remove scars on Romans’ backs, which carried the stigma suggesting that a man had turned his back in battle or had been whipped.

This was followed by the Middles Ages (130 A.D.) in which that there were documented cosmetic surgery on both drooping eyelids and nose re-shaping. These were documented in a series of medical texts at a time when a surgeon’s skill was considered to be in the realm of magic.

Over the last 2,000 years there have been huge strides in medicine and the evolution of cosmetic surgery, however, when it comes to facial volume restoration, there remains an element of artistry.

The first symptoms and signs of facial ageing are facial lines; these commonly occur between the eyebrows, forehead, and outside of the ears. They are most noticeable in facial moving.

Facial ageing affects people at different rates depending on a mixture of both genetic and environmental factors. Although genetic factors and ethnicity are fixed, environmental factors such as sun exposure, smoking, diet and weight can all be influenced.

What Are the Symptoms of Facial Ageing?

The majority of people have few if any symptoms of facial ageing in their 20s. At this time, the face has characteristical smooth contours with the absence of lines or wrinkles.

However, in some individuals, genetic factors may lead to an early appearance of characteristics of facial ageing such as eye bags or eyelid overhanging.

In such people constantly being asked if they are tired and being mistaken for being older is common.


In one’s thirties, with good genes and some attention to healthy living (avoidance of sun exposure, non-smoking), there may be the beginnings of some wrinkles and age spots. These may present as subtle signs of ageing such as the fine lines around the eyes and mouth when the person smiles and maybe even a hint of eye bags.

Cosmetics can be used to hide some of these imperfections and a greater tendency to visit salons for facials. The thirties is a good time for action to start making changes to your lifestyle and institute appropriate skin care measures.


In one forty the signs of ageing become more apparent, including facial expression lines, frown lines on the forehead and wrinkles including crow’s feet at the outside of the eyes. The skin becomes laxer and pores become more pronounced, especially on the nose and adjacent areas.

The skin at the neck begins to slackens. Eye-bags become more prominent and greying of the hair may become more prominent.


In one’s fifties, deeper wrinkles and folds of skin develop which are present at rest. There is increased laxity of the skin with the descent of the soft tissues at the jowls over the jaw and the laxity of skin at the neck becomes more apparent.

The upper eyelids may show laxity of skin that droops forward making it more difficult to apply makeup.

In the lower eyelids there may be bag formation from fat prolapse and the appearance of dark circles around the eyes. The skin becomes thinner and drier with age spots (solar lentigines) and the beginnings of age changes (seborrhoeic keratoses). People who have sustained heavy sun exposure may develop solar keratoses.

The lips begin to thin and the corners of the mouth may turn downwards. Cosmetics, anti-wrinkle injections and fillers are less effective in camouflaging these changes and cosmetic surgery may be necessary.


In one’s sixties there is further thinning of the skin, loss of volume in the face and soft tissue descent with skin laxity at the neck. The bony foundation of the face that has been gradually reducing is more apparent, resulting in further loss of malar cheek volume and sunken nose.

The thinning volume of the skin and underlying soft tissues results in the appearance of fine vessels in the skin (telangiectasias), sun spots, enlarged pore size and deeper lines.

70s and 80s

In one’s seventies and eighties, there is continued ageing in all the layers of the face including the skin, soft tissues, underlying muscular layer and boney skeleton.

What Are the Causes of Facial Ageing?

In the past, it was thought that ageing of the face was an inevitable normal process over which we had little control. Scientific research has shown that up to 90% of skin ageing is a consequence of exposure to the sun. Sunlight accelerates the ageing process through photoaging that is preventable through sun avoidance and the use of sun protection agents.

The other 10% of skin ageing is considered intrinsic and more difficult to influence. There is cumulative damage to the skin that occurs with sun exposure, the damage may go unnoticed until many years later, and is why it is important to take precautions from the sun from childhood.

What Happens in the Skin Layers in Facial Ageing?

The surface layer of the skin (epidermis) is thinned by about 20% by the age of 70 years and the loss of volume loss is apparent with increase lines in characteristic areas of the face, tear trough, nasolabial and marionette lines. The loss of volume also increases the laxity of the skin with jowls hanging at the jowls and laxity of the neck.

The deeper layer of the skin (dermis) is thinned due to loss of connective tissue, fluid and mucopolysaccharides. The molecular structure of the collagen and elastin fibres are effected and the skin is laxer. Thinning of the soft tissues and muscles allows fat to herniate from the eye socket resulting in bags under the eyes.

Underlying fat is further reduced, resulting in loss of fullness and sunken cheeks.

What Are the Different Layers of the Face?

There are three principal layers to the face, the foundation, the middle sandwich and the surface icing. The foundation consists of the boney skeleton and cartilage.

The middles sandwich consists of the muscles and fibrous attachments of facial expression, they also provide support to the eyebrows, eyelids and mouth. The surfacing icing is the skin, which provides a vital function in the protection of the underlying structures.

How Does Facial Ageing Affect the Different Layers of the Skin?

Facial ageing affects all three layers of the skin. The foundation boney skeleton decreases in volume and is particularly noticeable on the lower third of the face due to loss of teeth and shrinkage of the jaw bone.

The skin also loses elasticity with facial ageing, resulting in an excess of skin that sags under the effect of gravity.

There is also loss of support in the middle muscle layer that results in sagging eyelids, jowl formation and down-turning of the corners of the mouth.

Ageing Changes of Skin

  • Epidermis (superficial skin): Dryness, Enlarged Pores, Age warts, Skin Cancers
  • Connective tissue: Wrinkles and frown lines, Sagging skin, jowls, eye bags.
  • Subcutaneous fat: Fat atrophy, Thinned skin.
  • Melanocytes (pigment cells): Freckles, Age spots, Melanoma
  • Hair: Thinning, loss of hair, white hair
  • Blood vessels: red spots, fine vessels, easy bruising
Facial Ageing

Facial Aging – What Happens to the Upper Third?

The upper third of the face was defined by Leonardo da Vinci Rule of thirds and extends from the top of the head to the eyebrows. The first signs of facial ageing in the upper third of the face include the appearance of fine lines and wrinkles in the glabella (the area between the eyebrows) and forehead.

Brow and forehead lines can be effectively managed with the use of anti-wrinkle injections (neuromodulators) and injectable fillers. In some people the brows may also droop below the boney rim of the eye socket, these patients may benefit from a brow lift.

The upper lids are one of the early signs of facial ageing and begin to change in the thirties with a droopy excess of the upper eyelid skin and protruding fat bulges. Female patients may notice increased difficulty applying cosmetics to the upper eyelids and the eyes may look smaller. Upper eyelid blepharoplasty is the most common cosmetic surgery and effectively rejuvenates the upper lids.

Ageing changes in the lower eyelids may make patients look tired, the fat that normally cushions the eyeball begins to protrude through the eyelids as bulges and rings around the eye. These lumps may also produce a shadow under the lower eyes which contributes to the troublesome appearance of “dark circles”.

In addition, the combination of thinning of facial soft tissues and descent results in excess skin of the lower eyelid skin resulting in it becoming laxer and the appearance of wrinkles. Lower eyelid blepharoplasty is a common cosmetic procedure in which the fat bulges are reduced and the lower lid skin can be effectively rejuvenated with cosmetic surgery.

Facial aging: Forehead wrinkles, before and after treatment, front view, patient 1
Facial aging: Glabellar wrinkles, before and after treatment, front view, patient 2

Facial Ageing – What Happens to the Middle Third?

The middle third of the face is defined, as the area of the face between the eyes and the base of the nose, and is one of the main contributors to signs of facial ageing. The youthful middle third is characterized by youthfulness and high cheek volume.

As we age, we lose fat in the cheeks that results in thinning of the face and increasingly apparent lines and wrinkles that develop as folds in the overlying skin. The use of volume enhancement with fillers is an effective way of restoring volume in the early stages, although only temporary.

Other cosmetic procedures including the use of cheek implants and fat augmentation may be used as more permanent solutions.

One common analogy that is used to describe the changes in the face is the change in facial shape. A youthful facial outline looks like an upside-down egg.

With natural ageing of the face, loss of facial volume in the middle third of the face and decent of volume to the lower third results in the shape-changing to an upside-down egg.

Facial Aging – What Happens to the Lower Third?

After facial ageing changes in the eyelids, changes in the neck are one of the earliest signs of facial ageing. A combination of soft tissue laxity and gravity results in drooping of the soft tissues (jowls) below the jawline.

Laxity of the neck becomes more apparent under the chin and the neck resulting in increased folds of skin and loss of the youthful chin-neck angle. Separation of the platysma results in vertical neck bands that have been termed a “turkey gobbler” neck. Dr De Silva would recommend a neck lift to repair the platysma muscle and restore the youthful chin-neck angle.

Dr De Silva meticulously restores the position of the platysma at both its front and back surfaces, to ensure both natural and long-lasting result.

The lips gradually thin as we age, with atrophy of the soft tissues and underlying teeth. Younger people have plumper lips that often have a natural S-shape to their lips with a sharp vermillion border (junction between the skin and lips).

Ageing of the lips results in a loss of volume, curvature and resulting in increased vertical lines. Treatment of ageing lips may involve the use of fillers and lip implants. Lip implants may offer a permanent solution to the restoration of volume to the lips.

Facial ageing of the lower third of the face includes volume loss of the cheeks and gravitational descent. The smile lines are called nasolabial folds and run from the side of the nose to the corner of the mouth.

In early facial ageing, facial volume restoration with the use of injectable fillers can plump deep smile lines and take off years in several minutes as a lunchtime non-invasive procedure.

As the lines deeper, surgical restoration is an effective long-term solution with a facelift of the soft tissues.

Facial Volume Restoration (Fat Transfer)

We know that facial ageing results in a combination of reduced volume in the face and descent of the soft tissues with gravity. Although fat is generally considered an enemy of ageing, the truth is that a youthful well-proportioned face has the correct amount of fat.

We know that from the age of 40, there is a natural loss of fat volume in the face, although this does not correspond to fat gain which common elsewhere in the body. The volume loss is often enhanced by naturally thin people or those who engage in substantial exercise and fitness.

Facial Ageing

Facial Health

Good Health

A healthy body has a multitude of positive benefits in improving the quality and characteristics of the face, ability to deal with stress, improve stamina and positive well-being. Good health requires lifestyle choices including a healthy diet, regular exercise, adequate rest, ability to deal with stress and avoidance of factors that have a detrimental impact on health.

What is Needed for Good Health and Well-being?

  • Well-balanced diet
  • Sufficient hydration e.g. water
  • Regular exercise
  • Adequate sleep and rest

What Should Be Avoided to Reduce Ill-health and Facial Ageing?

Sun worshipping or inadequate sun protection results in early ageing of the skin through damage to the skin by ultra-violet rays, this promotes wrinkle formation, sunspots and poor skin quality.

In addition, particularly in fair skins, sun damage leads to damage to the skin at a cellular level, leading to DNA change and skin cancer.

Smoking has multiple detrimental effects on the body: damages blood vessels reduces skin quality and encourages wrinkle formation, fine lines and the loss of facial volume. In addition, smoking contains toxic chemicals that promote cancer. Excessive consumption of alcohol or drugs of abuse has detrimental effects on facial health and skin quality.

What Is a Well-balanced Diet?

A well-balanced diet includes regular meals and a balance of proteins, carbohydrates and fats from a variety of food sources including meat, poultry and fish, cereals and grains, milk and dairy products, vegetables and fruits.

  • Eat a variety of foods, different food groups for lunch and dinner
  • Eat smaller amounts of higher calorie foods
  • Eat more high fibre foods like fruits, vegetables, wholemeal bread and cereals

A balance between food types is required as taking a sufficient volume of food is not sufficient, a person can be overfed and overweight, and still be undernourished. The excessive consumption of animal fats, sugar and processed foods that are rich in calories yet not nutritious will promote poor skin quality.

A diet rich in fruits, vegetables and fibres and low in fats and calories promotes health and good skin quality.

Woman's face, female model


Vitamins A, C and E are antioxidants that improve health and resistance to illness and infection. Vitamin C is important for the synthesis of collagen in the skin and is often used as a treatment for skin wrinkles. Anti-oxidants neutralize free radicals that damage the body and are thought to be involved in ageing.

Free radicals are caused by smoking, ultra-violet sun rays and environmental agents such as pollution. Certain food types including green vegetables and fatty fish are rich sources of anti-oxidants. The human body is not able to generate these vitamins, so for a balanced diet, they need to be taken in food or as supplements.


Water is essential for keeping your skin hydrated and for eliminating waste products. Drinking should include at least eight glasses of water a day. Coffee, tea and alcoholic beverages tend to cause the body to pass more urine and become dehydrated, so require increased water consumption to maintain a hydrated body.

Physical Exercise

Physical exercise increases the circulation of blood to all parts of the body including the skin, it improves the cardiovascular physiology of the body making it more able to withstand stress. Exercise burns off excessive calories (carbohydrates and fat) and relieves stress.

A minimum frequency of aerobic and anaerobic exercise is considered three times a week. Although fitness advisors often advocate a variety of exercises that may be on a daily basis. The intensity of the exercise should result in sweating and deep breathing.

As a general guide, stretching exercises should be used to warm-up and cool down to avoid injury. Aerobic activities (including running, cycling, and swimming) with each session should last approximately thirty minutes. A personal trainer can substantially improve the ability to exercise and provide expert guidance on training.

Physical Exercise for woman's face, wrinkles areas (eyes, lips, forehead, face)

Adequate Sleep and Rest

You need adequate rest to recharge your batteries. A lack of sleep may encourage the development of unsightly dark rings under the eyes and best to sleep on your back to avoid getting sleep lines.


Smoking is detrimental to general health, including the body’s ability to cope with stress and the quality of the skin. Chemical agents in the smoke trigger constriction of blood vessels in the body, reducing the amount of oxygen that is available to the skin.

Over time this results in promoting ageing of the skin with the formation of lines, wrinkles and loss of facial volume. In addition, the contraction of the lips while smoking results in the promotion of lines and wrinkles around the mouth. Wrinkles also develop around the eyes due to smokers closing their eyes to avoid the smoke and a loss of facial volume.

Smoking also results in the generation of carbon monoxide in the blood, this induces the formation of free radicals that are harmful to soft tissues and cells promoting toxicity and facial ageing. Cigarette smoke contains nicotine that promotes constriction of blood vessels in the body, reducing blood flow and oxygen transport to the skin.

Facial Ageing

What Is Ageing?

There are two forms of ageing, chronological and biological ageing. Chronological ageing is your age in years and increases day by day. Biological ageing is your body’s functional age which is a component of genetic, lifestyle choices and the environment. In the face, ageing involves a stepwise progression of symptoms and signs described in decades on the facial ageing page.

Can Anything be Done to Reduce Skin Ageing?

Biological ageing of the skin can be classified into endogenous (genetic) ageing and exogenous (environmental elements) ageing. Sun-induced damage to the skin contributes to over 90% of skin ageing. A truck driver that had sun exposure to the left side of his face for over twenty years, shows the dramatic impact of ultraviolet rays on the skin.

The daily use of Sun Protection Factor (SPF) creams is an effective way to reduce skin ageing.

Skin Protection

Basic Skincare

Skincare is necessary to facilitate the removal of surface debris and old skin, as well as clean and protect the skin. There is a large range of skin products on the market and to add to the confusion, every actresses and model appear to endorse different brands of skincare regime to protect and revitalize the skin.

So, What Can You Believe?

There are four main stages for maintaining good skincare:

  1. Cleansing
  2. Toning
  3. Moisturizing
  4. Protecting
Skin Protection: Basic skincare - Cleansing, Toning, Moisturizing, Protecting (Photo: Truck Drivers Face)

What is Cleansing (Stage 1)?

The outer layer of the skin (stratum corneum) contains dead cells and are shed off. Cleansers remove dirt, dead skin cells and make-up that have collected on the skin surface. They are two main categories non-lathering cleansers and foaming cleansers.

Non-lathering cleansers:

The non-lathering cleansers were formulated as early as 100AD by the Greeks, and originally contained olive oil, beeswax and rose petals. The three ingredients were a combination of oil (disperses dirt and dead skin cells), an emulsifier (beeswax) that combined oil and water and fragrance (rose petals).

Cold cleansing creams (named after producing a cooling sensation) are essentially variations of the original Greek’s formula. Cleansing milk is similar to cleansing creams with additional water to make them more liquid. Non-lathering cleansers may be wiped off with tissue or rinsed-off with water.

Cosmetics that contain oil or wax, need an oil-based cleanser to dissolve it before it can be wiped off, as a result, non-lathering cleansers make excellent cosmetic cleansers.

Foaming Cleansers

Lathering or foaming cleansers may come in several forms including lotions, gels or bars. The foaming cleansers also contain oil and a detergent to wash them off. Lathering cleansers may be soap-based or soap-free, depending on the detergent used. Soap is a mixture of animal or vegetable fat and alkali salt (e.g. sodium cocoate).

A drawback of the soap products is their alkaline properties which result in a tendency for them to leave behind a residue with hard water. The soap-free cleansers, use synthetic detergents which are petroleum derivatives and less alkaline (pH-balanced).

As a result, they work well in hard avoiding leaving behind a residue. Other components are often added to soaps to give them more specialist properties:

  • Fats are often added to lathering cleansers to make them less drying
  • Oatmeal may be added for its soothing soaps
  • Peeling agents (benzoyl peroxide, salicylic acid) for acne soaps
  • Antibacterial chemicals (triclosan and ingarsan) for deodorant soaps
  • Abrasive agents (polyethylene granules, ground fruit pips, sodium for cleansing
What is Cleansing (woman's face)

What Are Skin Toners (Stage 2)?

Toners contain water, alcohol, witch hazel and a moisturizer. They remove traces of cleanser and produce a refreshed feeling as the alcohol evaporates. Toners tighten pores temporarily and have a tendency to dry the skin as they contain alcohol (20 – 60%).

Toners may not adequately remove all traces of cosmetics, particularly if you have oily skin, in which case you should use a lathering cleanser before a toner.

There are other components of the toners for more specialist properties:

  • Fresheners are similar to toners except that they contain minimal alcohol (0 – 20%).
  • Alcohol-free toners contain glycerol or rose water in place of the alcohol.
  • Clarifying lotions and astringents are toners with more alcohol and as a result, are more drying. Glycolic acid and salicylic acid are added for exfoliation.

What are Skin Moisturizers (Stage 3)?

Moisturizers reduce skin flakiness by making the surface skin layer (stratum corneum) cells stick together and make the skin appear smoother.

The smoother skin surface results in greater reflection of light, brightness and glow. Moisturizers also provide a smooth base for cosmetics to go on.

Many creams that are marketed for their anti-wrinkle, rejuvenating and cell renewal properties are good moisturizers. Special ingredients such as collagen and elastin, supposedly to replace those damaged skin, in truth are too large to be able to penetrate the dermis.

Collagen and elastin have good water-binding properties and as a result, make good moisturizers.

Moisturizers can be divided into day-time and night-time moisturizers. Day-time moisturizers contain less oil and soak quickly into the skin night-time moisturizers contain more oil and more effective at reducing skin dehydration during the night.

Moisturizers are not able to prevent wrinkles as they cannot stimulate collagen synthesis, they do is plump up the surface skin layer making the skin appear smoother.

Water moisturizes the skin by stopping “transepidermal water loss” (TEWL) i.e. evaporation of water from the skin surface.

There are two groups of ingredients in moisturisers that reduce evaporation. The first is lubricants (mineral or vegetable oil, lanolins and silicones) that reduce water loss through evaporation by occluding the skin with a waterproof layer.

The second group of ingredients are humectants (e.g. lactic acid, urea, hyaluronic acid, propylene glycol, glycerin, sorbitol, gelatin, lecithin, and butylene glycol).

Emollients are products that make the skin softer but there is so much overlap between emollients and moisturizers that they can be considered almost synonymous. Sun protection is considered more important than moisturizing, as not everyone needs moisturizing especially if the skin is oily.

What is Skin Protection (Stage 4)?

Skin protection means defending the skin against sun-damage (ultra-violet rays) which are the main cause of ageing. This means the use of Sun Protection Factor sunscreens and is an essential component of the daily skincare regime.

Skin protection will reduce the ageing damage to the skin by the ultraviolet rays which are present in all months of the year, with or without sunshine.

What Are Different Skin Types?

  • Dry skin: Pale in colour with thin skin, rough to touch, flakiness especially after washing. There are underactive oil glands, with a predisposition to fine lines around the eyes and a tendency to develop telangiectasia (fine spidery blood vessels). Dry skin requires greater moisturizers to maintain skin hydration.
  • Normal skin: Looks clear with even colour, soft to touch, feels neither greasy nor rough to touch.
  • Oily skin: Sallow complexion with thick skin, overactive glands causing a shiny appearance, open pores that are prone to whiteheads and blackheads. Oily skin requires greater cleansers to remove oily secretions prior to toners or moisturizers.
  • Combination skin: Oiliness in the T-zone (defined by forehead, nose and chin), dryness on the cheeks, with occasional breakouts in the oily areas.

Is Vitamin A (Retinoic Acid) Beneficial to the Skin?

Cosmetic manufacturers have made claims that untreated dehydrated skin may lead to wrinkles. This is not necessarily true as dry skin lines are caused by dehydrated skin and can be treated with moisturizers.

Wrinkles are caused by thinning of the skin, including the degeneration of collagen and elastin fibres in the dermis. The only topical medication product that has been proven to be effective in repairing the skin is Retinoic Acid (vitamin A).

Usually, creams for normal skin type will contain between 0.025% and 0.05% of retinoic acid. Below is a photograph of facial wrinkles and lines treated with topical retinoic acid for 18 months.

Are Antioxidants Beneficial To the Skin?

Antioxidants have been shown to improve the appearance of fine wrinkles and skin elasticity when taken as oral supplements. These include Vitamin E, Vitamin C, Carotenoids (lutein, lycopene and zeaxanthin), Lipoic acid and Soy isoflavones.

A whole host of other anti-oxidants have been proposed my cosmetic companies, for most of this scientific evidence is currently lacking.

What is ALA and Is It Beneficial To the Skin?

Alpha-lipoic acid (ALA) is an advanced glycation inhibitor and a potent antioxidant. ALA has multiple properties including antioxidant, anti-atherogenic, metal chelator, anti-inflammatory and a neuroprotective agent.

Foods rich in alpha-lipoic acid are potatoes, carrots, broccoli, yams and red meat. ALA has been shown to reduce nerve damage in ageing and improve memory and performance.

Retinoic: Alpha-lipoic acid (ALA) - before and after photos

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