Four layers change together
When you look in the mirror and feel that things have sagged, what you are seeing is the skin. But underneath it, several layers are changing together.
The face is structured with fat resting on bone, fascia wrapping the space between, and skin covering the top. Each layer changes at a different pace.
So no single method solves everything. There are places that need filling and places that need lifting, and there are parts where the skin itself has to be addressed.
Breaking down what happens in each layer makes it easier to understand why several methods are discussed together at a consultation.
The support underneath shrinks
At the very bottom is bone. It is not widely known, but the bones of the face change with age as well.
Changes are reported in which the rim around the eyes widens, the angle of the upper jawbone shifts, and the height of the lower jaw decreases. The extent is not large, but the effect on the tissue covering it is considerable.
When the support shrinks, what rests on top loses its place. The area under the eyes looks hollow and the balance of the lower face changes.
Pulling the skin alone does not reverse this change. That is why approaches that add volume are discussed alongside.
Fat decreases and shifts position
The fat of the face is not one single mass but is divided into several compartments.
With age, each compartment changes differently. Some thin noticeably while others hold. Borders appear on a surface that used to flow smoothly.
At the same time it descends. As the tissue holding the upper compartments loosens, the fat moves. The upper part hollows while the lower part bunches up.
The combination of hollow temples and under-eyes with a heavy-looking jawline area comes from here. It is why the impression changes without your having lost or gained weight.
The fascia loosens
Between the skin and the muscle there is a fascial layer called the SMAS. It runs across the whole face like a net, holding the tissue.
When this layer loosens, the fat and skin resting on it come down together. The structural cause of sagging lies here.
This is also why methods that pull only the skin do not last. Unless the holding force on the inside is restored, everything comes down again.
Conversely, if this layer is lifted and fixed, the skin settles without having to be pulled excessively. This is why the facelift of today addresses this layer.
Ligaments create the borders
There is a reason sagging does not occur at random. Inside the face there are ligaments that hold tissue at specific points.
Even as the surrounding tissue descends, the spots where the ligaments attach stay fixed. So the areas above and below are divided at those points.
This is why nasolabial folds and the sagging tissue in front of the jawline always appear in similar places. The shape follows the lines created by the ligaments.
At this stage, filling alone will not tidy things up. Filling above the border adds weight and it descends further; filling below thickens tissue that is already bunched.
Including a step that releases the ligaments in a facelift comes from the same context.
The skin thins and is left over
Changes occur in the skin at the very top as well. As the collagen and elastin in the dermis decrease, thickness and elasticity decline.
While the volume inside decreases, the surface area of the skin remains. With the return force weakened, whatever is left over sags.
If UV damage has accumulated, it happens faster, because the structure of the dermis is already weakened.
So sagging, fine lines and a rougher texture generally appear together. Their cause lies in the same layer.
| Layer | Changes that occur with age | How it shows on the surface |
|---|---|---|
| Bone | The rim around the eyes widens, the angle of the upper jawbone shifts, and the height of the lower jaw decreases | The under-eye area looks hollow and the balance of the lower face changes |
| Fat | Each compartment thins differently and descends | The temples and under-eyes hollow while the jawline area looks heavy |
| Fascia (SMAS) | The net-like layer that held the tissue loosens | The fat and skin resting on it come down together |
| Ligaments | The surrounding tissue descends but the ligament attachment points stay fixed | A similar border always forms at the nasolabial folds and in front of the jawline |
| Skin | Collagen and elastin decrease, lowering thickness and elasticity | The volume inside decreases while the surface area remains, so it sags |
The order differs by area
There is also a tendency in the order in which sagging appears.
The eye area and under-eyes generally come first. The skin is thin and there is a lot of movement, so changes show early. Even a slight hollow casts a shadow.
Next is the midface. As the fat of the cheek thins and descends, the border of the nasolabial area becomes more distinct.
The jawline appears a little later. Tissue that came down from above gathers at the border created by the ligaments, and the area in front of the jawline becomes heavy. This is the stage where the shape of the face starts to look different.
The neck is the last, but once it progresses it is easy to notice. This is why addressing only the face creates a border.
What TheLINE separates out in a sagging consultation
TheLINE Plastic Surgery Clinic starts a consultation by separating out which layer is the main problem, because each layer requires a different method.
If reduced volume is the main problem, we fill with fat grafting. If the main issue is tissue descending as the fascia loosens, we review a facelift. If the quality of the skin is the problem, approaches dealing with stem cells and ECM are discussed alongside.
In most cases several layers are mixed. Then we set an order, because which comes first changes the result significantly.
Dr. Yoosuk Chung, a board-certified plastic surgeon, performs the facelift, while Dr. Jaeho Cho handles the harvesting and SVF processing. Many TheLINE patients set the order at the consultation and then proceed in stages over several months.
Expressions and habits leave traces too
Besides structural change, repeated movement is involved as well.
When the same spot creases every time you make an expression, that line is gradually etched in. When you are young the elasticity of the dermis smooths it out, but once collagen decreases it remains even after you relax your expression.
Posture matters too. Spending long periods with your head bent makes the skin of the neck and under the chin fold repeatedly, and that load acts as a downward pull.
The habit of sleeping pressed on one side can leave wrinkles on that side only. It is one of the reasons the two sides look different.
Large swings in weight leave traces as well. When the cycle of stretching and shrinking repeats, the force that pulls the skin back weakens.
Different choices by age group
In the twenties and early thirties, the quality of the skin is the main concern. The texture roughens and fine lines appear, but it is not yet at a stage you would call sagging.
From the late thirties into the forties, changes in volume are added. The cheeks and temples hollow and the border of the nasolabial area becomes distinct. This is the range where filling approaches are mainly reviewed.
From the late forties onward, sagging comes to the fore. Filling alone no longer tidies things up, and surgery that lifts becomes a realistic option.
That said, age is only a reference. Individual variation is large depending on genetics, UV exposure and weight-change history, so we assess based on the actual condition of the tissue.
Frequently Asked Questions
Did it sag because I lost weight?
Weight change is involved, but it is not the only factor. It is the result of bone, fat, fascia and skin each changing differently, so we look at the causes separately.
Can lifting procedures reverse it?
It depends on the degree of sagging. In the early stages there is room to approach it with non-incisional methods, but when tissue has descended significantly there are limits.
Does filling improve sagging too?
If hollowing is the main problem it helps, but filling excessively when tissue has already descended adds weight and can be unfavorable.
At what age does it start?
Individual variation is large. Collagen starts to decrease from the twenties and changes in bone and fat appear later, but the timing differs with genetics and lifestyle.
How does TheLINE decide?
TheLINE Plastic Surgery Clinic first separates whether the issue is reduced volume, descended tissue or the quality of the skin. If several layers are mixed, we set an order and proceed in stages.
