1- Plastic surgeons adopted for a long time lifting and tightening the skin, fascia and muscle by transposing or shortening them, to allow higher placement of the different sagging problems, as well as replacement. This creates an unnatural (plastic surgery) look, because it fails to address the loss of volume. The new trend is transposing fat to achieve some volume replacement. However fat intake at the new site is unpredictable and fluctuates with weight. Also, the exact location of replacement is difficult and cannot correct all these problems. Even in an ideal world that will never restore the natural youthful look, because it takes correction of the precise transition areas and compartments of the face and fails to address the lost bone mass, as well as muscle mass, skin thickness and collagen.

2 - On the other hand, dermatologists came up with a plethora of new lasers and fillers to resurface the skin and reduce fine lines and wrinkles. They will most likely correct the skin, however they lack significant volume replacement because they ignore the lost volume in the bone, muscle and fat. The current placement of these fillers emphasize heavily on deep dermal placement and not subcutaneous replacement. Of these current devices are: Fraction Non-Ablative and Ablative Resurfacing.

3 - A third concept, co-developed by both dermatologists and plastic surgeons, are the skin tightening devices that tighten the deep dermal collagen and may be the fibrous septae, that connects the dermis to the deep facial fascial layer. The best example is a monopolar radio-frequency device called Thermage ™, which will solve part of the problem of the stretch of the fascial layer and induces collagen remodeling, but lacks any significant volume replacement effect.

4 - Some concepts combine a variety of different technologies without any coherent pattern, which replaces all these layers in a consistent fashion tailored to the patient's unique pattern of volume loss, wrinkle and sagging. Others prefer to do regional filler replacement, however the placement site is too superficial to be significant in the total volume replacement needed. Also compartmental replacement or regional improvement ignores the essence of our normal continuum of the face compartments and the beauty of a freely flowing contour. For example: getting rid of the lines around the mouth and ignoring the deep grove between the lower eyelids and the cheek and leaving the cheeks in a lower position (sagging) and flat, can cause a fuller lower face and heighten the contrast of lost volume of the mid-face, cheeks, tear trough and lower eyelids. That can lead to a far less aesthetic result than doing the mid-face at the same time. That can be said about the upper face too (eyebrows, upper eyelids and the periorbital area). Also, the face contours should flow naturally from one area to another, the same should be done depth wise for all the 5 essential layers, in order to achieve a really natural and youthful flawless look of the face.

How does volume loss occur ?

1- Facial bone resorption (flattening or recession,) due to increased bone loss relative to bone production, followed later by different degrees of osteoporosis (usually starts at mid thirties).

2- Facial muscle volume loss, due to predictable muscle fiber loss by 2 %, for every year after age 40.

3 - Loss and degradation of the collagen layers of the deep facial support: the strong collagen tissue sheets that extend around the muscle and have been well described to attach themselves to bone anchor points and to hold compartments together in a more or less firm or stable pattern. That loss causes distortion of these compartments and a predisposition for displacement of these various compartments. That effect can be even exaggerated and made much worse with significant volume loss. The gravity needs less pull to exert more downward displacement on a smaller volume than a larger one.

4 - Subcutaneous fat loss in different regions of the face, which are highly variable from once person to another, but constitute one of the most important elements of volume loss of tissue of the face; it probably accounts for 50-80% of total volume loss. A cent article published in the Plastic and Reconstructive Surgery Journal (the official journal of American Society of Plastic Surgeons and American Society Aesthetic Plastic Surgeons (ASAPS)) in June 2007, debunked the long held belief that facial sagging occurs due to the effect of gravity, but asserted, according to an extensive fat pathology analysis, that it occurs due to regional (compartmental) fat loss in the subcutaneous areas. This is what they believed led to making the skin sag or more prone to the effect of gravity with the subsequent stretch and in some people led to the recession of the lower orbital rim (concave area underneath the lower eye lid). In others, the muscle and tissue that was there sagged from its position and formed deep lines around the mouth, as well as cheeks. That drooping and sagging of the mid-face muscle, just inferior to the lower eyelid, caused loss of volume support for the eyelid. That causes the skin to stretch and sag with the formation of dark circles, eye bags and puffiness of the lower eyelids (eye bags). Laser resurfacing or surgery address the sagging of skin and removing puffiness, but do not address the original problem of mid-face muscle sagging and loss of support, which lead to recurrence or extortion (eye lid that is turned inside out,) or worsening of the tear trough deformity and caving of the area underneath the eyes, which gives a terrible result.

5- Finally, the skin and dermal layer lose plenty of collagen with the aging process, ground substance (hyaluronic acid) and elastin, as well as the thickness of the epidermal layer. This, combined with sun damage, make the skin less pliable, less elastic and prone to develop wrinkles, both superficial and deep, especially with some degree of loss of volume support.

Introduction: With the normal aging process, there are predictable events that happen to the face, which include: sagging of the upper eyelids, drooping (low position) of the eyebrows, eye bags, tired look of the eyes, dark circles or hollow areas around the eyes, drooping of the cheeks and/or hollow and flat cheeks , deep lines around the mouth (nasolabial folds), smile lines (marionette lines) and drooping jowls with neck sagging. This can be combined with recession (concavity at the bridge of the nose, as well as flattening of the nasal profile, recession of the chin area, and thinning out and loss of the volume of the lips. They are all different stages of same problem. All these problems were mistakenly traced to the effects of gravity, as was long thought by the plastic surgery community for decades. Another misunderstanding was by the dermatologists, who attributed the problems to loss of deep dermal collagen and elastin. It is mainly due to the predictable pattern of multi-layered volume loss of the tissues from the skin to the bone. With age, volume loss occurs in the face and can start as early as the late teens, to the mid-twenties or early thirties, during which time many people achieve their maximal facial growth. The rate of volume loss, sequence of the events as they occur in the face, degree of loss and location are complex and highly dependent on multiple factors including: genetics, nutrition, anti-oxidant intake/free radical production and stress, all of which affect the programmed cell death (apoptosis,) as well as fluctuation in weight, due to dieting and many more factors.