Facial Volume

Content Reviewed by AEDIT Medical Advisory Board

Overview

A loss of volume in facial fat can cause a young, full face to appear older and thin. The chubby cheeks often seen on healthy babies or younger people aren't always the result of excess weight gain, but represent a smooth and firm face that hasn't yet experienced any kind of decline in the health of their soft-tissue.

The process of losing facial volume is gradual, similar to that of ripe, moist grapes shrinking into drier, wrinkled raisins. As time passes, the fresh, firm, and full grape lose moisture and volume. The loss of volume causes the skin surrounding the pulp of the fruit to sag and wrinkle.

In a likewise manner, facial skin can sag and lose laxity as the reduction of face fat occurs. Wrinkles form and the skin beneath the eyes may appear to hollow as the soft tissue withers. Facial volume loss can make individuals appear older, but there are many effective ways to combat the underlying causes of the condition — reduce the production of collagens.

While the treatments discussed in this guide also help to rid a person of fine lines and wrinkles that often accompany reduced facial fat, they mainly address the issue of facial volume, which is one of the major indications of an aging face.

What Causes Facial Volume Loss?

There are many reasons that a full and round face shape can begin to lose volume, appearing sunken and more skeletal. A loss of fat in the facial region can happen due to the natural aging process, weight loss, a shift in hormone levels, exposure to UV rays, smoking, injury, along with certain medical conditions that necessitate the consumption of specific medicines that prompt volume loss.

Lost Collagen and Reduced, Shifting Facial Fat According to Harvard Health, a reduction of collagen makes the face look older. The role of collagen is to help provide a support structure for the skin that gives it a plump and firm appearance. When collagen naturally reduces over time, the elasticity of the facial skin also wanes. Combined with the fact that facial fat shifts and declines as we age, the loss of collagen and fat can make a face appear aged.

Facial volume loss happens when the face fat that was once evenly distributed around the eyes, cheeks, forehead, temples, and mouth shifts and diminishes. Round cheeks fall downward and sink, causing hollowness under the eyes. Lips begin to lose their plumpness and appear thinner with age.

Over time, fat can gather in certain areas that were formerly more taut, such as the lower jaw. When facial fat is stored in the lower face, it can cause unsightly jowls of baggy skin to hang low on each side of the lower jaw, as well as the neck.

The daily, necessary repetitive movement of facial muscles creases the skin, causing wrinkles. The movement and decrease of facial fat further accentuate deep folds and wrinkles. Combined with a loss of collagen that helps to provide thick and supple skin, the overall effect can create a less desirable countenance.

Weight Loss and Extreme Dieting Maintaining a healthy weight can do wonders for an individual's overall health. However, losing weight can exacerbate the aging process and cause a naturally thin face to appear even thinner. When the small amount of natural fat is further reduced from an already thin face due to extreme dieting, it can create a worn out look, along with other health problems.

Individuals who are overweight and rapidly lose extra pounds will also notice volume loss in their faces. Losing large amounts of weight in a short time can cause unwanted sagging of facial skin if the body is unable to adapt to the new body contours, leaving hanging skin on the cheeks and neck. Although weight loss is typically a positive experience for an overweight individual, too much fat loss in the face can cause unintended aging of the skin.

Over-Exercising & "Gym Face" ‘Runner's face’ describes a person who spends plenty of hours in the sun, running long distances similar to a marathon athlete. Although the practice can help joggers maintain a healthy weight and clear their minds, it can also cause a gaunt-like facial appearance - especially for those older than 40 years of age who burn off so much facial fat that they are left with a sunburned and bony face.

Outdoor runners aren't the only ones who can fall victim to lost facial volume due to strenuous exercise - even though the addition of sun exposure can make matters worse. There is also a term called "gym face," which is used to describe individuals who frequently practice long distance cardiovascular exercises in the gym. A thinner face can happen as a result of engaging in exercises that melt fat all over the body, including the face. In working out so intensely to burn off the fat covering the abdominal region and thighs, you may naturally induce facial volume loss as well.

Sun Exposure When undoing the havoc that the sun and UV rays can wreak upon the face, the focus is usually on dark spots, wrinkles, and the threat of skin cancer. However, an excess of harmful sun exposure can also encourage facial volume loss. This is because UV rays penetrate the epidermis and speed up collagen and elastin breakdown. When those two important skin structure components decrease, facial fat can be lost.

According to the U.S. National Library of Medicine's National Institutes of Health, the sun's UV rays are made up of UVA and UVB energy. UVB reaches the epidermis and can additionally damage an individual's DNA. UV rays penetrate a deeper level of the skin by reaching the dermis. UV rays cause elastin to build up abnormally, creating enzymes that in turn make ‘solar scars,’ where collagen is broken down. The Cleveland Clinic Hospital calls solar scars a disorganized cluster of collagen fibers that contribute to skin appearing older due to sun damage.

The harmful UV rays found in other sources, like indoor tanning booths, can also damage collagen and the network of elastin fibers over time. Sun-damaged skin is generally found more often on areas of the body that are the most exposed to UV rays, such as the face, arms, and chest.

Hormone Changes Estrogen is a predominantly female hormone that dictates in part how much fat appears on the face and body, along with the quality of fat that appears. When estrogen hormone levels start to decline as women age, fat can begin to thin. The loss of fat can cause facial skin to sag.

Facial Bone and Muscle Decrease Not only do the levels of face fat decline with age, but facial bone mass also reduces. Individuals may also experience facial muscle deterioration to an extent with age, making the middle of the face appear as though it has collapsed.

These types of more drastic changes are easier to spot in patients who are 70 to 80 years of age and older, with the loss of bone tissue generally happening in the central portion of the face and the nasal area.

Severe Illnesses, Medical Conditions, and Medical Treatments Weight loss attributed to certain medical conditions or medications can have a big impact on facial volume loss. When fat tissue beneath the facial skin is lost, it can cause the face to appear flat or create a convex facial contour.

Certain chronic diseases can also cause facial thinning. If you are experiencing an unexplained loss of volume in your face, see a physician to rule out various autoimmune diseases such as HIV or connective tissue diseases. Conditions such as lupus, thyroid and immune system disorders, rheumatoid arthritis, or viral infections that destroy facial fat can have an impact on facial volume.

Facial lipoatrophy is the name of the condition whereby face fat tissue is lost in a localized form. It can happen when insulin is injected in certain regions during diabetes treatments, with human growth hormone injections, or as a result of multiple sclerosis treatments. Other medications or treatments may cause facial lipoatrophy, such as steroid treatments, iron, penicillin, chemotherapy, and antiviral drugs - along with vaccines to prevent chicken pox, whooping cough, and measles.

Facial wasting is one of lipoatrophy's main symptoms, with the loss of facial fat being one of the most recognizable traits, in addition to fat loss in the legs, arms, and buttocks. The root cause of lipoatrophy is not known.

Smoking & Nictone Use Smoking plays a vital and detrimental role when it comes to the health of facial skin and overall skin structure. Vitamin C levels in smokers are notably depleted in comparison to people who do not smoke. Lower vitamin C levels can result in a thinning of the layers of skin, a reduction of collagen and elastin, along with a decrease in muscle tone. Many of the protective factors that vitamin C brings to keep the skin soft, supple, and stronger are negatively affected when smoking, causing skin sagging and an aged facial appearance. However, chronic smokers who quit smoking can raise vitamin C levels and, in turn, improve the ability to form new collagen and the body's ability to heal wounds.

Stress Research has shown the amount of damage that stress can have on a person, even causing an individual to age more rapidly. High cortisol levels and the "fight-or-flight" feeling contributes to heart problems and high blood pressure, as well as other health problems that can manifest on a person's face. Counteracting the stress response with anti-anxiety relaxation measures helps, along with exercising.

Trauma and Injury Any physical injury to the facial region - which is termed maxillofacial trauma - can cause a loss of facial volume. According to the Mayo Clinic, burns, fractures, and cuts can damage the soft tissue areas around the eyes or the face, causing disfigurement to bones and fat pads.

Accidents may also create facial scars that leave indentations in the face or hollow regions. Trauma to the facial skin and underlying structures also includes severe cases of acne that may go so deep as to damage the supporting tissue beneath the skin.

Slowed Collagen Production

The natural aging process can affect the skin's firmness and elasticity due to decreased collagen production. Some surprising factors can contribute to the dermal layers of the skin losing their strength, such as a diet. A diet high in sugar creates AGEs, which are advanced glycation end products. AGEs are caused when sugar floating in the bloodstream mixes with fat and protein. AGEs stay in tissues, changing the quality of the skin by negatively affecting collagen and elastin. The visible results of such aged skin shows up most prominently on the face. However, changing the diet to reduce the amount of sugar consumed can help reverse the problem, along with taking supplements that contain hydrolyzed collagen and hyaluronic acid.

Changing diet habits might be one of the simplest ways to try and increase collagen production and slow the signs of aging. Approaching facial volume loss issues with a multi-pronged approach, including improving lifestyle habits such as reducing sugar intake and avoiding harmful sun exposure can combine with professional treatments to help bring about the best results to increase collagen production.

Fat Pad Reduction: What are the buccal and malar fat pads?

Buccal and malar fat pads are fat pads that appear in the face, in differing areas of the cheek region. The size and position of these fat pads have a great impact on facial volume.

Lifting the Malar Fat Pad When the malar fat pad sags, it causes the nasolabial folds to become more apparent - but the malar pad can be lifted via surgery. The Cleveland Clinic Hospital considers the malar fat pad as the most "critical" for determining the appearance of aging in the mid-face. The malar fat pad resides in the cheek, sitting near the cheekbone area beneath the eyes. The fat pad provides a youthful curve to the face and makes the area around the eyes and cheeks look full. Over time, the malar fat pad slides in a downward direction due to the normal pull of gravity. That movement creates deep nasolabial folds while the relocated fat makes the eyes look hollow.

The Buccal and Deep Fat Pads There are additional facial fat pads besides the superficial malar fat pad, which the U.S. National Library of Medicine’s National Institutes of Health calls the deeper buccal and temporal fat pads. The face's buccal space - which can be found on both sides of the face in the lower cheek region - is a valuable area wherein dermal injections can have lasting fullness effects for patients, persisting for up to 24 months.

When there is a loss of facial fat and a patient chooses to receive dermal filler treatments, it is essential that the injector understands the relationship between fillers and facial fat pads. A deep understanding of the facial anatomy and the way that fillers interact with fat pads in the face will provide the best aesthetic results from such procedures.

Whereas certain patients seek plastic surgeons to reduce their prominent malar fat pads or remove outsized buccal fat pads, others desire to add volume to the area that has atrophied. While slim facial fat pads and high cheekbones can give some individuals a chiseled look, others may experience a sunken cheek look when their fat pads lose volume.

Signs and Symptoms of Facial Volume Loss

It is estimated that individuals can lose 20% to 50% of facial fat during the natural aging process. Volume loss is most evident in certain parts of the face, such as around the eyebrows, where a reduction in fat can reveal the shape of the brow bone that was previously concealed. A skeletal appearance around the brow and cheek regions, lips that shrink and lose volume, and skin that appears more wrinkled, thinner, and not as moisturized are all signs of facial volume loss.

Volume Loss in the Cheeks The cheeks can sag due to the lost face fat, moving from the eye area to a lower position. If your cheeks appear flatter and are sagging with loose skin near the area where the jaw meets the neck, which is called the jowls, you have likely lost part of your cheek fat.

Volume Loss Under the Eyes Not only can a loss of facial volume occur above the eyes around the eyebrows, but it can also happen beneath the eyes. Losing orbital fat near the area of the lower eyelids can create a hollow-eyed look circling the eye sockets.

Volume Loss in the Lips One of the biggest indicators of the volume being lost in the lips is when fine lines begin to appear around the mouth. Once full lips may deflate and have less definition than before, looking smaller and thinner. Facial aging includes a loss of lip contour and volume, which becomes more noticeable as the patient ages.

Treatments to Increase Facial Volume and Reverse Signs of Aging

There is no need to despair if you have discovered that your face has lost volume. There are many steps you can take to help reverse the signs of aging: from do-it-yourself solutions such as a change in diet and ridding yourself of harmful habits such as exposure to UV rays, to non-invasive treatments or plastic surgery procedures that can help you turn back the clock to a more voluminous face.

Facelifts, neurotoxin injections, or dermal fillers can help smooth and add volume to fine lines and wrinkles all around the face. No matter the budget or preference for minimally-invasive treatments or surgical procedures, there exists a method of dealing with facial volume loss.

Specific techniques using dermal filler injections that are tailor-made for the patient - including possible low dose botulinum toxin injections - can provide a dramatic improvement to the lips when there is a loss of lip volume. Dental restorations to restore volume deficiencies from lost tissue and bone can also improve the look of the lips.

Surgical Procedures

Facelift A surgical facelift - also known as rhytidectomy according to the American Society of Plastic Surgeons - lifts the skin of the face and neck, removes excess tissue, and repositions the face into a tighter, more youthful position. There are different facelift techniques to target different concern areas of the face, whether the cheeks, jowls, or neck.

Thread Lift A thread lift is a procedure that lifts the skin by using temporary sutures instead of excising excess facial skin. During the procedure, a cosmetic surgeon places the threads beneath the skin to lift the neck, jowls, and middle face region. Next, the threads are pulled to lift the skin. The process also helps promote collagen production as the body sends healing agents to the area of perceived injury. Thread lifts may last up to two years.

Implants

Jaw Implant A jaw implant is surgically inserted into the lower jaw area, which can add volume and definition to the jawline region. This procedure does not require the jaw bone be cut to have the jaw augmented, meaning there will be no visible scarring.

Cheek Augmentation (Cheek Implants) Cheek implants are a permanent solution to facial volume loss rather than augmentation with temporary dermal fillers. Those with skin healthy and thick enough to support the cheek implants are the best candidates for the procedure that helps provide a youthful look to the facial feature and restore balance for those with uneven or injured facial structures.

Lip Implants Lip implants permanently enhance the shape of deflated lips and add volume. Implant materials range from custom silicone inserts to pieces of SMAS tissue harvested during a facelift procedure.

Non-Surgical Treatments and Procedures

Patients who prefer to address their facial volume loss in a non-invasive manner have a variety of options to choose from, including microneedling - also known as dermarolling - as well as several dermal filler injections.

Microneedling Microneedling is a quick procedure that involves the skin being cleaned and then stretched manually as an instrument with several hundred tiny needles is rolled across the epidermis to encourage new collagen production.

Microneedling may cause pinpoint bleeding in a uniform pattern across the surface of the skin on the treatment area, with the goal of the procedure being to increase collagen production. With little downtime and a short recovery period, microneedling allows patients to return to their normal activities the following day, with results being visible approximately three to six months following the treatment as new collagen continues to form.

There are several variations of microneedling, including the PRP facial or "vampire facial", which involves using plasma-rich proteins (PRP) and stem cells to help rejuvenate older sunken skin and damaged tissues. According to the Cleveland Clinic Hospital, a PRP facial involves having a small amount of your blood extracted and spun to extract platelets and the all-important platelet-rich plasma.

That PRP substance is then spread across the face and microneedles are rolled across the forehead and cheeks to help the skin absorb the proteins. With collagen production being encouraged via the process, the skin's tone and elasticity can improve. PRP has been used for many years by orthopedic doctors to help patients heal from joint injuries, but it is finding newfound popularity by being used as part of the PRP and facial microneedling process to stimulate collagen growth.

Dermal Fillers Dermal filler treatments can help restore plumpness to facial areas that have lost volume. However, there are many different types of fillers - including temporary, semi-permanent, and permanent ones.

Dermal fillers include those comprised of hyaluronic acid - which is a naturally occurring substance found in the body praised for its water retention properties to help the skin's elasticity - and collagen fillers. Both types of fillers are injectable and can help increase volume in areas of the face that have lost volume.

While the hyaluronic acid fillers work to help internally plump and moisturize the lips, collagen fillers work to increase collagen production. Collagen fillers are usually garnered from bovine or human cadavers and are used to perfect minor skin problems.

Sculptra®, derived from polylactic acid, is one of the most popular brands of collagen boosting fillers which stimulates the body to produce more collagen. Sculptra® is used to enhance lips with fullness, fill in laugh lines, and improve deep nasolabial folds. Radiesse is a hyaluronic acid filler that helps to boost collagen and can be used to treat deep facial wrinkles, the nasolabial folds, and the back of the hands.

Temporary fillers come in a variety of names and forms, with different molecular structures that work best for different areas of the face. Juvéderm VOLUMA® XC works best in the cheek area. JUVÉDERM VOLLURE™ XC and JUVÉDERM® XC injections are designed for severe facial wrinkles and the nasolabial folds. JUVÉDERM VOLBELLA® XC and JUVÉDERM® Ultra XC are designed for lip augmentation. Restylane® Lyft (formerly known as Perlane) is a hyaluronic acid filler that adds volume to facial wrinkles, the cheeks, and hands. Restylane® Defyne and Restylane® Refyne treat the deep wrinkles caused by repeated movements such as laughing in the nasolabial folds and marionette lines.

Semi-permanent dermal fillers, including Aquamid™ and Sculptra®, have longer lasting results as the typically encourage natural collagen production for sustained fullness.

Permanent dermal fillers, such as Bellafill™ (Polymethylmethacrylate or PMMA), is a filler that treats the lips, medium or deep wrinkles, as well as nasolabial folds. Surgeons using permanent fillers such as Bellafill™ tend to fill conservatively with the bovine collagen and synthetic implant material during the first procedure, only adding more if necessary.

Fat Fillers Fat transfers can be used to add volume and smooth wrinkles in the face. Facial fat grafting is more invasive than dermal fillers since a liposuction procedure will need to be performed first to extract the adipose tissue. Although not permanent, fat grafting is a long-lasting option for patients who are allergic to other types of dermal fillers.

How to Prevent Volume Loss

One of the best ways to not deal with a face that has lost a lot of volume is to try and prevent the facial volume loss from occurring in the first place. Some preventative practices include the following:

Avoid the Sun - The amount of sun protection and avoidance you practice can be vital to keeping your skin plumper and healthier, including safeguarding yourself from harmful UV rays in tanning beds. A study confirmed that excess exposure to UV rays can age the skin.

According to Harvard Health, practicing sun protection is the best way to keep the face looking younger. Stay away from damaging UVA light spectrum by wearing UVA- and UVB-protection sunscreen and wearing wide-brimmed hats.

Don't Smoke - Smoking doesn't just hurt the lungs but hurts the skin's ability to heal.

Diet & Lifestyle Habits - Eating a balanced diet that helps maintain a healthy weight can have a positive effect on how the face ages. By constantly gaining and losing weight from crash diets, the ligaments that support facial tissues get stretched. The constant changes can mean a loss of facial volume and reduced elasticity, which makes people look older. Diet and various lifestyle habits such as the amount, manner, and choice of exercises can play a big role in how a person's facial fat appearance changes over time.