Basically, there are two effects of aging on the face: loss of elasticity and loss of volume.

Elasticity is lost from our skin’s elastin fibers, and is caused by too much sun or tanning bed exposure, and smoking.

An additional cause is a phenomenon called “glycation.” This is when sticky molecules clog up elastin, collagen, enzymes and other molecules. It is caused by eating simple carbohydrates and rapidly cooked foods.

Glycation occurs in the entire body and results in hardening of the arteries, causing heart, kidney and brain disease as well as cancer. So, diet matters.

Volume loss of both fat and, surprisingly, bone occurs with aging. Bone loss in the face is mostly noticed in the orbital area (around the eyes), the maxilla (the bone that houses the midface and upper teeth), and the mandible (jaw).

Fat loss occurs over the entire face. An analogy would be a beach-ball deflating. The beach ball sags, as do our faces. Return the volume to the face – and air to the beach ball – and the sagging and creases disappear.

Why do some people have more fat loss than others? Genetics plays an important role, as does weight. Thinner people usually have more volume loss. Long distance runners who have low BMI ( body mass index) tend to have more noticeable loss of volume.

The simplest way to correct volume loss is with “fillers,” most of which are Juvederm or Restylane products. Each person must be assessed individually and skillfully because volume loss is different in each person.

The most common area for fillers is the mid-cheek area. This is one of the first areas to lose volume, causing deeper smile lines and “marionette” lines.

Many people request fillers into those areas alone. However, it is important to note that those depressed areas are a result of volume loss in the cheek and mid-cheek areas.

The goal is to make the shape of the face more youthful looking, not just fill in the obvious creases.

With this in mind and the knowledge that there is bone loss as well as fat loss, an effort also must be made to replace volume in the maxilla, the mandible, as well as around the orbital bone when needed.

For elasticity loss, the gold standard is a facelift, which can turn back the clock 10 years or more when properly performed. With a facelift, one will always look younger than her actual age; however, a facelift will not stop the aging process.

A facelift also returns facial volume, eliminates the jowl, and tightens the neck.

For lesser tightening needs, there are two options to tighten the skin without surgery.

A Fraxel CO2 laser (Restore), which can remove up to 20 percent of facial skin, tightens the skin without surgery.

The InstaLift, an office procedure, is a newer type of string lift with absorbable one-way bands that stimulate collagen production and volume, while pulling the soft tissues of face and neck upward and back. InstaLifts are “mini-procedures” designed for those with less volume loss and sagging who want minimal recovery time.

E. Ronald Finger, MD, FACS is a board certified plastic surgeon with offices in Savannah and Bluffton.