Wrinkles are perhaps the most obvious and easily measurable aspect of facial aging. Yet there are other age-related changes that can contribute to the “aged look” at least as much as wrinkles. These can be changes that contribute to facial aging to varying degree, such as skin laxity & sag; muscle laxity, sag & atrophy; loss and redistribution of facial fat; facial bone changes; and nose drooping.

Skin laxity or sag/drooping is caused by factors (intrinsic and external) that result in the changes in skin structure and facial muscles:

• Loss and damage of collagen and elastin fibers in the dermis reducing skin strength and elasticity
• Reduction of the subcutaneous fat cells
• Gravity, which allows the lax tissue to sag
• Laxity, sag and atrophy of facial muscles
• Shrinking/changes of the facial bones – facial bones tend to change continuously contributing to the aged look of facial skin

The resulting facial sags and bags:

• Brow ptosis (the forehead sags so the eyebrows drop over the eyelids, which then feel heavy)
• Eyelid ptosis (the upper eyelid drops, sometimes obscuring the pupil)
• Baggy upper and lower eyelids
• Ectropion (sagging lower eyelids) is the turning out of the eyelid (usually the lower eyelid) so that the inner surface is exposed and is caused by the aging process and the weakening of the connective tissue of the eyelid
• Hollow look to the eyes
• Tired-looking eyes with a prominent groove beside the nose (tear-trough deformity)
• Jowls (loss of jaw line) is the puffy loose and excess skin along the jawline below the corner of the mouth and is an early sign of facial aging. A smooth clean jawline is important to a young looking face. Jowls is caused by skin laxity, facial volume loss and repeated mouth movements. Exercising the face and neck muscles can help promote a firm jaw line
• Loss of neckline – The sagging skin on the neck is often called a wattle, referring to its similar appearance to a turkey’s neck.
• Elongated earlobes
• Dropping of the tip of the nose
• Thinning of the upper lip

Ptosis is a drooping or falling of the upper or lower eyelid. Ptosis occurs when the muscles that raise the eyelid (levator and Müller’s muscles) are not strong enough to do so properly. It can affect one eye or both eyes and is more common as muscles in the eyelids may begin to deteriorate with aging. Puffiness and bags under the eyes can also be due in part to skin laxity.

Once the sagging skin is formed, topical firming creams (such as DMAE – a well known ingredient in firming creams) can only be modestly effective at best. Some noninvasive skin procedures such as skin needling and radiofrequency therapy can treat sagging skin. Surgical facelift are used to treat severe skin laxity and facial sag. Facial exercise is the simplest, safest approach to minimize and prevent laxity, sag and atrophy of facial muscles.