I haven't lost weight, but my face looks gaunt
We often hear that body weight is unchanged but the face alone looks thinner. The cheeks hollow, shadows appear under the eyes, and the nasolabial region deepens.
It is hard to view this simply as the result of weight loss. The face is layered with bone, fat, fascia, and skin, and each layer changes at a different rate.
Separating out what happens in which layer makes it easier to understand why filling sometimes does not look natural, and why in some cases filling does not solve the problem at all.
Volume loss is part of the aging process, but only one strand of it.
Fat does not simply decrease
Facial fat is not one single mass. It is divided into several compartments, each sitting in its own position.
With age, these compartments do not shrink uniformly. Some thin noticeably while others are relatively maintained. As a result, borders appear on a surface that used to flow smoothly.
At the same time the fat shifts position. When the tissue holding the upper compartments loosens, fat descends. The upper area hollows while the lower area bunches up.
That is why hollow spots and sagging spots appear on the same face. Temples and under-eyes hollowing while the jawline area looks heavy is the typical combination.
Bone decreases too
This part is not well known. Facial bone also changes subtly with age.
In particular, widening of the bony rim around the eyes, a change in the angle of the upper jaw, and a reduction in the height of the lower jaw have been reported. These are not large changes, but their effect on the tissue covering them is significant.
When the support decreases, what sits on top of it loses its position. The under-eye area looks hollow, the lower face looks shorter, and the overall balance changes.
This is why filling with fat alone makes it difficult to fully reverse this change. What has to be placed, in which layer and in what amount, depends on the underlying cause.
The forces holding things in place loosen
Inside the face there are ligaments connecting the skin to the deep tissue. Their role is to hold tissue in place.
When these ligaments loosen, the tissue they were holding descends. But the points where the ligaments attach remain fixed, so the areas above and below split along those points.
This is why nasolabial folds and the sagging tissue in front of the jawline form in specific places. Sagging is not random; the shape follows the boundary lines the ligaments create.
At this stage, filling alone does not resolve it. Filling above the boundary adds weight and it descends further; filling below thickens a part that is already bunched up.
Why TheLINE separates the layers
In volume consultations, TheLINE Plastic Surgery Clinic starts by separating out which layer the issue lies in. Even for the same hollowing, the approach differs depending on whether fat has decreased, shifted position, or a border has formed because ligaments have loosened.
When fat has decreased, it is filled with facial fat grafting. TheLINE divides the fat finely and scatters it across multiple layers, and applies SVF isolated in the in-house laboratory to support the retention process.
If shifted position is the main issue, filling alone falls short. In that case Dr. Yoosuk Chung, a board-certified plastic surgeon, reviews a facelift alongside. Dr. Jaeho Cho handles the harvesting and SVF processing.
Among TheLINE patients, many plan filling procedures and lifting procedures in a separated order. Which comes first changes the result considerably.
The skin remains while the inside shrinks
The last layer is the skin. While the volume underneath decreases, the surface area of the skin stays as it was.
When you are young, the elasticity of the dermis is sufficient and it contracts to some degree. But as collagen and elastin decrease, the force that pulls it back weakens. The inside gets smaller while the outer covering stays the same.
The leftover skin descends with gravity. That is why hollowing and sagging appear at the same time.
So filling volume alone leaves fine lines and slackness on the surface. Conversely, lifting alone can make the face look flat because the inside is empty. This is why both have to be considered together.
| Cause | What happens | Whether filling resolves it |
|---|---|---|
| Fat decreases | Compartments thin unevenly, so borders appear on a once-smooth surface | Filled with facial fat grafting |
| Fat shifts position | Upper compartments loosen, so the top hollows and the bottom bunches up | Filling alone falls short, so a facelift is reviewed alongside |
| Bone decreases | The bony rim around the eyes widens and the height of the lower jaw is reduced | Filling with fat alone makes it difficult to fully reverse |
| Ligaments loosen | The area splits above and below along fixed attachment points | Filling above the boundary adds weight and it descends further |
| Skin is left over | The volume inside decreases while the skin surface area stays the same | Filling volume alone leaves fine lines and slackness |
What happens if you overfill?
Seeing a hollow spot makes you want to fill it. But increasing the amount without looking at the cause creates problems.
First, it gets heavier. As volume increases, so does the downward pull. If sagging is already progressing, this can accelerate it.
Second, expressions become awkward. Facial fat moves differently in each layer. If volume is added to the wrong layer, it does not fold naturally when you smile.
Third, borders stand out. Filling only the hollow spot can actually make the border with the surrounding area sharper. This is why placement has to follow the flow of the whole surface.
This is the background to the point that where and how much to place matters more than how much is filled overall.
It looks different at different ages
Where volume change shows up varies by stage of life.
In the thirties it often appears first under the eyes and at the temples. The skin is thin and there is little fat there to begin with, so even a slight decrease creates shadows. This is when people start hearing that they look tired.
Into the forties, the compartments in the inner cheek thin and the midface hollows. At the same time, tissue that has descended gathers in the nasolabial region and the border becomes distinct.
After the fifties, changes in the lower face are added. Volume around the lower jaw decreases and tissue descends, so the facial line breaks down. At this stage, filling alone often does not resolve things.
Of course this is only a rough progression. Individual variation is large depending on bone structure and the original distribution of fat.
Points worth knowing
Volume loss is an area of compensation rather than reversal. Changes made by time cannot be removed entirely.
Individual variation in results is large. The original bone structure and fat distribution, skin condition, and age are all involved. This is why the same procedure does not produce the same result for everyone.
It often does not finish in one session. With fat grafting, absorption is taken into account and an additional round may follow after observing the progress, and if several layers are involved the plan may be divided.
Procedures carry the possibility of swelling and bruising, nodules, asymmetry, and infection. Unexpected inflammation or bleeding may occur, and the degree varies from person to person, so caution is required.
Frequently Asked Questions
If I gain weight, does the volume come back?
When body weight increases, fat is added to the face too, but not only where you want it. The compartments that shrank and the ones that grow do not match, so the balance can change.
Can't I just fill it with filler?
If hollowing is the main issue, that works. However, if the cause is tissue that has descended, filling alone will not resolve it and can make things heavier.
Is a hollow under-eye also a volume issue?
In some cases fat has decreased, and in others the fat below the eye pushes forward so the area beneath it looks relatively hollow. The approach differs by cause.
At what age does it start?
Individual variation is large. The timing differs with bone structure and fat distribution, UV exposure, and history of weight change, so it is not judged by age alone.
How does TheLINE assess it?
TheLINE Plastic Surgery Clinic first separates whether fat has decreased or shifted position. When it has decreased, it is filled with fat grafting; when descent is the main issue, a facelift is reviewed alongside.
