About Face

Procedures Menu

About Face

Sagging

Chapter Two Aging Skin Factors That Age the Skin How Skin Ages Hollowing Sagging Wrinkling Vitamin A Acid Cream Nonsurgical Face-lifts Injection Treatments Peels

The second main problem people have when they age is that their skin “sags”. Sagging in the lower face produces a jowly effect. Now only does the skin stretch, but the subcutaneous fat falls, producing jowls and giving the lower face a square appearance. There are several reasons for this, the first and most obvious being gravity. Skin is an envelope that stretches with time and gravity. However, the contents of this envelope shrink due to fat atrophy and the absorption of bone, so the skin sags. The effect of gravity can be most evident in the brow area. Ordinarily, the eyebrows should lie atop the bony orbit surrounding the eyes - call it the escarpment of the forehead. With age, the forehead might sag so that the browns drop below the escarpment.

Sagging in the lower half of the face becomes noticeable gradually as people age through their late forties. This has less to do with gravity than it does with the SMAS fascia. SMAS is an acronym for the Superficial Muscula-Aponeurotic System; fascia is an anatomical expression for a sheath of connective tissue that binds or supports internal organs (in a sense, skin is also a fascia). In the face, the SMAS fascia is a delicate kind of sinew that lies beneath the deepest layer of skin. It separates the skin from the underlying glands and the muscles that produce facial expressions. To get a mental picture of the SMAS fascia, think about an embryonic sac, or membrane. As it ages, the SMAS fascia loses its elasticity, just the way the elastic waistline in your favorite old pair of pants begins to give away.

When the SMAS fascia begins to sag with age, the sagging can cause several noticeable changes in the face. People with an already-deep crease in the lip-cheek groove might find it is made more pronounced by a fleshy fold of skin that results in what we call the “hill and valley” phenomenon - where the valley is the groove and the hill is the lateral cheek mound. Or a person might begin to develop jowls, which are essentially fat-filled pockets of skin that hang below the normal jawline. Sometimes jowls are made more noticeable when a person is overweight, but often even a perfectly natural amount of fat will hang simply because the SMAS fascia and skin have lost their elasticity. When someone is overweight, the extra fat combined with a looks SMAS fascia can create both a jowly look and a double chin.

The neck can also be affected by the SMAS fascia because it is directly connected, or structurally continuous, with the platysma. The platysma is a broad, thin muscle on either side of the neck that extends from the top part of each shoulder all the way up over either side of the jawbone. (Try stretching your neck, then grimacing with your jaw clenched and the lower teeth showing, and you’ll see the outline of the platysma.) This is a muscle that causes wrinkling in the neck - the horizontal lines are caused by the folding of the skin due to the pull of gravity and the platysma muscle. The front edge of the muscle causes cording in the front of the neck and the wrinkles occur perpendicularly to the direction of muscle pull.

When facial cosmetic surgeons first began to perfect the art of the face-lift, it was common to simply pull back the skin without addressing underlying problems like the sagging SMAS fascia. As a result, the operation often didn’t last more than a couple of years. Today, depending on when a patient has a face-lift, it is possible to get satisfactory results for a much longer period of time because we can do a double-layer face-lift operation that deals separately with both the SMAS fasica and the skin.

[previous page] [next page]