Age-related volume loss

Advanced nurse practitioners Ashley McGurnaghan and Julia Ogilvie consider how the structural differences between males and females affect ageing and how hyaluronic acid dermal fillers can reinstate the “Triangle of Youth”

WHAT ARE THE FACIAL STRUCTURAL CHANGES THAT WE SEE AS WE AGE?

Ashley McGurnaghan (AM): “As we age, our face undergoes structural changes that result in a reversal of the “Inverted Triangle of Youth”. This triangle is defined by three different attributes: high cheekbones, volumised cheeks and a well-defined jawline and chin. The widest part of a youthful, female face is the cheeks, making up the base of the inverted triangle at the mid-face. However, as we age, mid-face volume is reduced and excess skin slides to the lower face, flipping the triangle. The base shifts to the widest part of the aged face, around the chin, becoming what is instead known as the “Pyramid of Age.” This process occurs at every layer of the facial structure, including skin, fat pads, retaining ligaments, muscles, and bone.”

Julia Ogilvie (JO): “In regards to our skin, ageing also affects collagen and elastin – the key proteins that provide our skin with structural support, strength and elasticity. As we age, the production of collagen and elastin decreases, accelerated by sun damage, extrinsic factors and hormonal changes. This results in our skin becoming thinner, drier, and less elastic which leads to wrinkles, sagging, and a loss of contours. It’s important to consider these ageing sequences during consultations and assessing from the top down. Replacing volume in the mid-face will improve the definition and shape of the lower face as well by re-establishing the triangle.”

WHAT ARE THE DIFFERENCES AND SIMILARITIES BETWEEN WOMEN AND MEN IN THE WAY THEY AGE?

JO: “The female face typically begins to show signs of ageing from the mid to late 20s, with the skin changing in texture and tone and loss of the deep fat pockets starting to occur around the eyes.

“From ages 30-40, this deep fat pad loss extends to the mid-face and temples, significantly reducing support for more superficial structures and resulting in the beginning of the Pyramid of Age.

“From our 40s and beyond, retaining ligaments, fascia, and spaces start stretching, often forming visible “valleys” within the fat pads. Laxity of facial muscles and volume loss are some common factors that lead to sagging around the cheeks, mouth, eyes, nose and forehead, where deeper nasolabial and marionette lines become evident, alongside sagging in the jowl.

“Bone reabsorption typically begins in our 50s. Facial bones, including the orbital rim, nose and upper jaw continue to experience biological change, which also contributes to an overall decrease in volume. The most significant area of bone loss occurs mainly around the mouth, jawline and chin.

“The male face is known to age very differently, forming much deeper lines and wrinkles, except in the perioral region. The facial layer is thinner in men, regardless of age, with fewer subcutaneous fat pads in the mid-face, which results in a much flatter medial cheek and a more angular, defined lateral cheek. Their skin is thicker, sebum production is higher and there are also significant differences in the distribution of coarse hair between men and women. The loss of fat in men causes deeper expression lines and wrinkles due to their thicker skin.

“Collagen density is greater for men in the dermis than women, but as this declines, this leads to sagging even in the lower face. Structurally, men naturally have a specific bone structure where the forehead is larger, supraorbital ridges more prominent, and their jawline and chin are squarer.”

HOW DO YOU TREAT MEN AND WOMEN DIFFERENTLY?

AM: “It is important to consider the natural structures and shapes of male and female faces when treating patients. Adding too much volume to specific areas that are not classically typical for that gender could result in a much more masculine or feminine appearance.

“For example, the male jawline and chin should appear more angular and wider than that of a female. Concerning the mid-face, the gonial angle of the male should typically be the same width or extend beyond the bizygomatic distance, while the female jawline should be curved and naturally defined. Chin width should be aligned with the distance between the inside edge of the pupils, which can also correlate with the width of the lips. Over-treating the female gonial angle or jawline in this area could easily masculinise the lower face.

“In comparison to females, the male cheek is flatter but more angulated, the apex is naturally lower, more medial and subtly defined. Treating this area in males can often go wrong due to overfilling or incorrect product choice and/or technique. When treating women, it is good to elongate the chin or enhance projection as this will help to improve the jawline and jowling while maintaining the rounder, feminine chin. It is important to complete a 3D assessment at the initial consultation, as well as educate patients on the natural structures of the face to manage expectations; exaggerated by social media, requests for unrealistic and unnatural results are common and must be managed appropriately.

WHAT PROPERTIES DO YOU LOOK FOR IN A VOLUMISING PRODUCT?

JO: “For consistently natural results, it is important to truly understand the rheology of your products and how they react within the tissue. Vivacy’s volumisers STYLAGE XL and XXL are extremely versatile and perfect for replacing volume loss, or providing structure when carrying out facial rejuvenation.

“When treating the female cheek, my goal is to improve volume loss without it appearing obvious or unnatural. STYLAGE XL is the most hydrophilic of Vivacy’s portfolio (with 26mg/g of HA), yet is moldable, dynamic and designed to restore and create volume and can be injected onto the periosteum with a needle, or mid-dermis with a cannula. It can also be used for lower-face rejuvenation to provide soft but long-lasting results. Best results tend to be seen at approximately six weeks post-treatment.

“Many patients are fearful of looking overdone or not looking like themselves post injectables. Our aim is always to subtly enhance natural beauty, not to change our patients completely. To provide consistent results, it is not only important to respect the anatomical differences between male and female faces by understanding how the proportions, angles and structures differ, but also to truly understand the rheology of your products to select the most appropriate one to achieve your aesthetic goal.”

Figures 1a and 1b: A 35-year-old with mid-face volume loss following weight loss. The mid-face was rejuvenated with 2ml of STYLAGE XL, focusing on replacing volume loss medially and giving projection. On assessment of the lower face, it was clear the patient suffered some weakness in the chin alongside a hyperactive mentalis. Structure and stability were therefore required to give appropriate projection in this area. This was achieved using STYLAGE XXL, using a combination of both needle and cannula to help maintain a feminine shape while enhancing the side profile.

Figure 1a - Side profile

Figure 1b - Frontal view

Figures 2: A middle-aged patient was seeking natural rejuvenation without detectable results. STYLAGE XL was applied to the mid-face, focusing on lateral projection to the zygomatic arch where lacking. STYLAGE XL was also used for the chin and pre-jowl to sculpt a feminine shape to the chin and tighten the jawline, producing a soft, dynamic result with just two syringes.

Figure 2

Figures 3a and 3b: A 43-year-old male with volume loss to the mid-face and hollowing to the tear trough requested a subtle, undetectable rejuvenation, aiming to look “healthier”. The mid-face with two syringes of STYLAGE XXL, injected onto the periosteum, following the bone to enhance his natural structure and providing support to the tear trough.