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What’s Important?

  1. The various ethnicities age differently.

  2. Women’s faces are more often curved while men more often have angular faces and these are considered aesthetic ideals.

  3. Terminology helps patients communicate their aesthetic goals.

What’s New?

  1. Bone loss, rather than gravity, is the main cause of facial shape changes with aging.

  2. HA fillers prevent aging by increasing collagen production and improving the ECM.

  3. Botulinum toxins prevent the development of fine lines.

  4. Lengthening of the lip occurs with aging rather than volume loss.

What’s Coming?

  1. Medications and supplements may be developed to reduce bone loss in the face.

  2. The exact effects of hormone status and facial bone loss are unknown, but may be elucidated with ongoing research.

  3. Use of injectables to “prejuvenate” the face and prevent aging.

Faces differ according to gender, ethnicity, genetics, and aging. In general, faces can be classified by shapes. Square and rectangular facial shapes are perceived as more masculine while round and heart-shaped faces are seen as more feminine. With aging, the face becomes more square-shaped as the brows lower, cheeks flatten, and jowling occurs. Overuse and improper placement of dermal fillers can result in an exaggerated heart shape. It is important to consider face shape when deciding placement of dermal fillers (Fig. 7-1).


The face is composed of skin, fat, muscles, cartilage, and bone: each of these changes with age. The skin thins, sags, and develops an uneven tone. Although the skin becomes thinner with loss of collagen, hyaluronic acid (HA), and other components, it is the loss of fat, muscle, and bone that causes the shape and volume alterations characteristic of facial aging. An understanding of the changes in facial shape and volume with aging is important when approaching the patient who desires facial rejuvenation. Skin aging is discussed in Chapters 5 (Intrinsic Aging) and 6 (Extrinsic Aging). This chapter focuses on the changes in the other layers of the face that lead to an aged appearance.

The main changes seen in an aged face are (Fig. 7-2):

  • Decreased forehead fullness

  • Concavity of the temple

  • Lowered brows

  • Increased size of the orbits

  • Increased length and width of the nose

  • Hollowing of the cheeks

  • Loss of distinctive arches and curves on the face

  • Lowering and widening of the chin

  • Loss of jaw definition

  • Squaring of the face


Face shape changes with aging.


There are two main theories of why aging occurs in the face: the gravitational theory and the volumetric theory.1 Both theories have credence and are not mutually exclusive. The gravitational theory focuses on ...

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