A Modern Approach to Facial Aging

As the understanding of facial anatomy deepens, so too must our approach to treating the aging face. Aging, in essence, can be viewed as a pathological process affecting each layer of the soft tissue envelope in unique ways. The face is structured into five primary layers—skin, superficial fat, muscle/fascia, deep fat, and bone. There are some exceptions to this simplified view—eg, the temple or infraorbital hollow—but the underlying concept remains the same. For clinicians aiming to restore youthful function and form, understanding the interplay between these layers is essential. By targeting pathology at its source, and utilizing regenerative therapies, we can create outcomes that harmonize with the natural biology of the patient and stand the test of time.

Aging is characterized by specific changes within each tissue layer. For instance, skin undergoes solar elastosis, wrinkling, photodamage, and a loss of proteoglycans, leading to thinning, crepiness, and pigmentary issues. Superficial fat, which gives the face its youthful fullness, atrophies, creating hollows and a loss of volume. The fascia and supporting ligaments weaken, allowing for tissue descent and sagging. Muscle can either hypertrophy or atrophy, impacting facial dynamics. Deep fat also atrophies and descends, while bone resorption diminishes the scaffold that suspends the soft tissues. These changes collectively contribute to the hallmark signs of aging: sagging, hollowing, wrinkling, and pigmentary changes.

The first step in addressing aging is diagnosis—identifying the specific pathologies within each tissue layer. From there, we select the appropriate treatment modalities from our ever-evolving armamentarium. It is through this systematic and layered approach that we achieve long-lasting, regenerative results that replace form and function naturally, rather than relying on temporary, space-occupying products.

For the skin, a variety of therapies can address pathology at the cellular level. Skincare, laser and other energy-based therapies, microneedling, and microcoring provide pathways to reverse solar damage, stimulate collagen, and improve the overall quality of the skin. Emerging treatments such as exosomes and nutrient-rich mesotherapy offer exciting possibilities for cellular repair and rejuvenation. By targeting these interventions to the skin layer, we create a healthier epidermis and dermis that not only look better but also function more like youthful skin.

When addressing superficial fat, which is prone to thinning and atrophy, we have several tools at our disposal. Biostimulators, low G’ fillers, and decellularized fat allograft matrices are among the most effective. These treatments not only restore volume but, in some cases, improve skin quality. Superficial fat provides structural support for the overlying skin, and its careful restoration creates a balanced, natural result.

Neuromodulators remain the cornerstone for treating dynamic wrinkles by targeting muscle hyperactivity. Additionally, in cases of muscle atrophy, we have begun to explore regenerative strategies to restore muscle tone. The muscle and fascia layer are responsible for much of the facial movement and expression, and by addressing the balance between muscle strength and relaxation, we create harmony in facial dynamics.

The deeper fat compartments and bone present different challenges. High G’ fillers and decellularized fat allografts provide structure in the deep fat compartment, helping to lift and restore volume where atrophy and descent of deep fat has occurred. For bone resorption, treatments like calcium hydroxylapatite, combined with high G’ fillers, and potentially other biostimulators, offer structural support, mimicking the scaffolding that bone naturally provides.

Perhaps most exciting is the rise of systemic anti-aging treatments such as mTOR inhibitors and metformin, amongst others, which hold the potential to impact aging at the cellular level across multiple tissue layers. These systemic therapies, combined with targeted regenerative treatments, represent the future of anti-aging medicine. Rather than simply delaying the signs of aging, we may be on the cusp of truly reversing it.

By taking a layered, regenerative approach to facial aging—diagnosing and treating pathology at its source—we can offer patients results that are natural, long-lasting, and biologically aligned. As the science continues to evolve, so too must our techniques. The future of aesthetics lies not only in filling or lifting but in healing and restoring, replacing like with like, and giving our patients back their own tissue. This is where science meets artistry.