The layers beneath the skin, and why they matter

This is the companion piece to why faces lose volume. That article covers what changes and in what order; this one is about why the layer matters when deciding what, if anything, to do.

The five layers

From the surface inward: skin, then fat held in discrete compartments, then a fibrous connective sheet that carries facial movement, then muscle, then bone. Each contributes something different to how a face looks, and each changes on its own schedule.

Volume loss can start in any of them. It becomes visible when more than one shifts at once, which is why the effect so often seems to arrive suddenly after years of nothing.

How each one changes

Skin

Collagen and elastin decline steadily from the third decade. Skin thins, holds its shape less well, and follows whatever is beneath it.

Fat

Not one even layer but separate compartments. The deeper ones tend to lose volume; the more superficial ones tend to descend. That combination is why a face can look hollow above and heavy below at the same time.

Connective tissue

The network that transmits expression and holds the compartments in position. As it loosens, things move as well as shrink.

Muscle

Thins with age in some areas, thickens with overuse in others — the jaw being the obvious example.

Bone

The part that surprises people. The facial skeleton remodels throughout life. The eye socket widens, the upper jaw loses projection. Millimetres over decades, but everything above depends on that scaffold.

Why the layer decides the answer

If the change is mostly in the skin, working on the skin makes sense. If the support underneath has moved, working on the surface will not do much — and doing more of it is the usual response when the first attempt disappoints.

That is the sequence that produces faces which look worked on. Not one bad decision, but a series of reasonable ones aimed at the wrong layer.

What over-treatment looks like

It is worth naming, because it is what most people are frightened of:

• Proportions that no longer read as that person’s face.
• Puffiness or firmness where there should be softness.
• Swelling that persists rather than settles.
• Changes to the tissue itself after repeated procedures.

Assessing before acting, working conservatively, spacing things out and reviewing between times is how that is avoided. It is slower. It is also the reason I would rather do less at a first appointment than more.

What I assess

Skin quality, where the fat sits, how the face moves, what the underlying structure is doing, and the history — including anything done previously, which matters more than people expect.

Sometimes the conclusion is that very little should be done, and occasionally that nothing should. Whether anything is appropriate is a matter for individual assessment. All procedures carry risks, which are discussed in detail before anything is agreed, and results vary between individuals.

This article explains a process. It is general information, not clinical advice, and it is not a recommendation for any particular treatment. Whether anything is suitable for you is a matter for individual assessment.