Understanding How We Age
The anatomy behind why our faces change over time — and why the right treatment starts with understanding what's actually changing.
Daniel J. Givens, MD · Double board-certified facial plastic surgeon
If you've had a consultation with me, you've probably heard me say, “Let's start with an anatomy lesson.”
Before we talk about surgery, lasers, fillers, or skincare, it's important to understand why our face changes over time. One of the biggest misconceptions about facial aging is that it is primarily a problem with the skin. Skin quality is incredibly important, but it is only one part of a much larger process. Understanding what is actually causing the changes we see is the first step in deciding which treatments may—or may not—be appropriate.
Most of my patients aren't trying to look dramatically younger. What I hear much more commonly is, “I just want to look the way that I feel. I still have a lot of energy and I'm very active, but I don't look that way anymore.”They want to look more refreshed and energetic while still looking completely like themselves. Understanding why the face has changed is the starting point for figuring out how—or whether—we should treat it.
IN THIS GUIDE
01
Soft Tissue Descent
The gradual descent of the face's soft tissues — brows, cheeks, jowls, jawline, neck.
02
Volume Loss
How the fat compartments of the face change and lose fullness over time.
03
Skin Quality
Collagen loss, thinning skin, sun damage, and pigmentation.
04
Skeletal Remodeling
How the bones of the face — the eye socket, brow, nose, and jaw — continue to change.
AGING HAPPENS GRADUALLY...UNTIL IT DOESN'T
One of the most common things I hear from patients is, "I feel like I suddenly look older." Aging itself is a gradual process — genetics, sun exposure, nutrition, sleep, stress, and overall health influence our tissues over many years. But patients often experience it differently: a heavier jawline, a change around the eyes, a neck that seems older than it did six months ago.
THE FOUR DRIVERS OF FACIAL AGING
Aging is more than skin deep.
Although facial aging is extraordinarily complex, it is helpful to divide it into four major processes: soft tissue descent, volume loss, skin quality, and skeletal remodeling. Most patients have some combination of all four — this is why treatment needs to be individualized.
01 | Soft Tissue Descent
For many patients, the most significant contributor to facial aging is the gradual descent of the soft tissues of the face. The brows become heavier, the cheeks descend, jowls develop, the jawline loses definition, and the neck begins to sag.
Quite honestly, we don't completely understand why this happens. It is probably a combination of changes in the retaining ligaments and deeper supporting structures, repetitive movement, gravity, and other changes that occur within the tissues as we age.
There is a fascinating video of a woman undergoing high-G centrifuge testing. As the G-forces increase, you can actually watch the tissues of her face move downward and she temporarily takes on a much older appearance. When the force is removed, the tissues return to their normal position. This obviously isn't the same thing as facial aging, but it is a remarkable visual demonstration of how much tissue position contributes to the way we perceive age.
02 | Volume Loss
We also lose and redistribute facial volume as we age. The fat compartments of the face change, and some areas gradually lose the fullness they once had. Significant weight loss can make this particularly obvious, something we are seeing more frequently in patients who have lost substantial amounts of weight while taking GLP-1 medications.
Volume can be restored with fillers or fat grafting when volume loss is the problem. However, volume replacement and tissue repositioning are two very different things.
During a consultation, I'll often demonstrate this by physically lifting the cheek with my hands. That's repositioning tissue. Adding filler creates volume, but it doesn't move descended tissue back to where it started. If the primary problem is sagging, adding volume can simply create more volume in a sagging position.
That doesn't mean filler is bad. Filler is an excellent tool when we are treating volume loss. The problem comes when we expect filler to correct tissue descent.
A KEY DISTINCTION
"Nothing lifts except lifting"
Daniel J. Givens, MD
03 | Skin Quality
Skin quality is tremendously important because ultimately the skin is what we see. As we age, collagen decreases, the skin becomes thinner, sun damage and pigmentation accumulate, and lines and wrinkles become more apparent. These changes also affect the way light reflects from the skin and can have a significant impact on whether someone looks youthful and healthy.
Improving skin quality is one of the reasons we spend so much time with laser resurfacing, medical skincare, and other treatments designed specifically for the skin. Improving the skin can make someone look significantly younger and more refreshed even if we don't change the deeper tissues at all.
But these treatments have limitations. A laser can improve skin quality, but it cannot produce a facelift. The same is true of radiofrequency and ultrasound skin-tightening treatments. They may create improvement in appropriate patients, but they cannot reposition significantly descended cheeks, jowls, or neck tissues.
The opposite is also true. I can perform an excellent facelift and reposition the deeper tissues, but surgery itself doesn't create beautiful, luminous skin. These are different problems, and sometimes the best treatment plan addresses both.
04 | Skeletal Remodeling
One of the least understood aspects of facial aging is that the bones of our face also change as we get older. The facial skeleton isn't a static structure that stops changing once we reach adulthood.
The bony orbit around the eye gradually enlarges, particularly along its lower and outer portions, changing the support beneath the lower eyelid and surrounding tissues. The bones around the brow remodel as well. The area around the opening of the nose—the piriform aperture—changes with age, and the upper jaw can remodel in ways that alter the support beneath the central face.
These are relatively slow changes, but they help explain why facial aging is much more than loose skin. Our skin, fat, deeper soft tissues, and even the skeleton beneath them are all changing over time.
WHY DO WE AGE DIFFERENTLY?
Genetics are a major part of the answer, along with sun exposure, smoking, nutrition, and overall health. Stress is also a major driving factor — most of us have seen someone go through a major illness or a prolonged period of stress and age considerably over a short time.
DIAGNOSIS BEFORE TREATMENT
Different concerns require different tools.
IF THE PRIMARY ISSUE IS
Tissue Descent
Skin tightening alone is unlikely to produce a facelift result.
IF THE PRIMARY ISSUE IS
Skin Quality
Surgery alone won't create healthy, luminous skin.
IF THE PRIMARY ISSUE IS
Volume Loss
Filler and fat grafting help — but adding volume to sagging tissue just creates more volume in a sagging position, not a lift.
IF THERE'S
More Than One Component
Treatment frequently involves some combination of approaches.
DR. GIVENS ' APPROACH
Understand first. Treat second.
01
Understand the Anatomy
Identify which process is actually creating the change you're seeing.
02
Identify the Concern
Skin quality, volume, tissue position — most patients have more than one.
03
Choose the Right Tool
Identify the problem first, then choose the tool that actually addresses it.
04
Decide Whether to Treat
Sometimes the right decision is not to do anything at all.
LOOKING THE WAY YOU FEEL
This brings us back to what patients so often tell me: “I just want to look the way that I feel.”
Facial rejuvenation isn't about creating a different person or eliminating every sign of aging. Most patients simply want their appearance to better reflect the energy and vitality they still feel.
One of the most rewarding parts of a consultation is when a patient begins to understand why they're seeing the changes that brought them into my office. Once we identify the primary drivers of facial aging, the treatment options usually become much easier to understand.
Sometimes the right decision is not to do anything. If a patient leaves my office without booking a procedure but feels educated about their face and their options, I still consider that a successful consultation. Ideally, they leave feeling empowered to ask better questions, continue their own research, and decide what makes sense for them.
That's why every consultation starts with an anatomy lesson.
NEXT STEP
Not sure which of these applies to you?
Every consultation starts with an anatomy lesson — understanding what's actually changing before deciding what, if anything, to do about it.
