Structural Facial Ageing Resulting From Muscle Activity: A New Approach To Facial Rejuvenation

This article outlines a novel approach to the underlying causes of age-related changes in the face, which are associated with the performance of its key functions (vision, breathing, eating, speech and emotion). It forms the basis of Smart Cosmetology, capable of offering personalized facial upgrades depending on the type of functional disruption manifested as external problems on the face.
Elena Shchelokova
Founder and Medical Director
Face Clinic
13, Prechistenka
119034, Moscow, Russia

Email for correspondence:
Elena Shchelokova
Founder and Medical Director
Face Clinic
13, Prechistenka
119034, Moscow, Russia

Email for correspondence:

Structural Facial Aging

Today, when life expectancy is increasing, people want to enjoy better lives, to stay healthy and not to show any pronounced signs of aging. But, despite a wealth of experience accumulated by practitioners, the causes of age-related changes on the face are still not entirely clear. Currently, cosmetology is a mere spectator in the theater age-related facial deformation, without the possibility of accurately predicting their future location on the face and the degree of severity in each particular case.

It is generally recognized that all layers of the face undergo age-related changes. It is believed that their main triggers are gravitational pull, hormonal imbalances, lack of trace elements, exposure to sunlight, and overall quality of life. However, without denying these internal and external factors, I propose we consider age-related changes from the point of view of facial functions, their interaction and influence on each other as well as on a person’s facial appearance.

For many years we have associated the face with the notions of beauty, health and age. However, the face is much more than that. In my view, it is an individual system of the body alongside the digestive, respiratory, nervous etc. systems.

What is surprising is that in the context of aesthetic medicine I have not come across any mention of the face as a separate system of the body that supports several physiological and psychological functions.

Nevertheless, there are “gateways” on the face for vision, breathing and eating - three internal body functions that are crucial for its survival. There are two more external functions - emotion and speech - that are important for a person’s survival in a social environment.

As these five functions are necessary for a person’s well-being, the main role of the face is to ensure their interrupted work. Due to the uniqueness of facial anatomy (the ability of the muscles to displace the skin), any disruption of these functions will be manifested by characteristic external signs.

Since the performance of facial functions is associated with movement (opening and closing the eyes, nose and mouth movements), I maintain that muscle activity is the main cause of all facial changes, starting from the facial skeleton and ending with the skin.

A lack of understanding of facial functions and their influence on the facial appearance, in some cases, leads to undesirable side-effects, complications and insufficient results.

As I suggest below, this new point of view on the face also explains why, in order to obtain the best results in facial longevity, treatment should begin at an earlier age, as soon as the first signs of functional disruption are detected, but the face does not yet display any pronounced deformation.

Types of Faces

For the convenience of understanding and describing the processes occurring with the face, I have identified several facial types depending on the location of key changes:

  • The Ophthalmic Face
  • The Nasal Face
  • The Dental Face
  • The Neural Face
  • The Mixed Face

It is evident that in most cases there is more than one function that suffers, however, there is usually one key functional disruption that spoils the face the most. I believe that the above classification will allow us to find the most effective personal course of treatment.

I call this approach Smart Cosmetology. It encompasses all aspects of the face - facial features, facial expressions, facial manners, etc. - to offer highly individualized solutions.

Physiology and Biomechanics of the Face

Facial muscles perform contractile and displacement roles. Depending on the role performed, the muscles affect the underlying tissues in different ways. If we look at the location of the muscles on the face, they are strategically located around the "gateways" (eyes, nose, mouth) and are interconnected to amplify or support each other’s activity if necessary (Fig. 1A).

Many researchers of facial bone structures note that changes in the bones of the facial skeleton occur only in certain places1-9.

These are orbital and piriform aperture expansion, bone resorption, decreases in bone height, and changes in the angle of inclination. If we compare these changes with the location of the muscles on the face, it is quite obvious that bones undergo modification in places where the greatest muscle power is applied (Fig.1B)
Fig.1 (A) - Distribution of muscles on the face
(B) - Changes in the facial skeleton. Reprinted from Aesthetic Plast Surg. 2012; 36(4): 753–760.
It is generally believed that bone resorption is associated with a lack of Ca+ in the blood. However, the location of bone changes in the face appears to be correlated with muscle contractions in these places.

Thus, the orbits can expand outward due to the work of m. orbicularis oculi, the expansion in the superior medial corner is due to the pronounced activity of the glabella muscles, and that in the inferior lateral corner is caused by powerful zygomatic muscles (Fig. 2A, B)11.
Fig.2 (A) - The orbits at a young age.
(B) - Age-related changes in the orbits. Adapted from Aesthetic Surg Jour. 2008; 28(3): 258-264.
Atrophy of the maxilla, a change in the angle of inclination of the bones in the central zone, and the expansion of the piriform aperture are all associated with the muscles of the nose and the paranasal region (Fig.3 A-С)10.
Fig.3 (A) - Facial skeleton at a young age.
(B) - Age-related changes in the facial skeleton. Reprinted from Aesthetic Plast Surg. 2012; 36(4): 753–760.
(C) - Area of greatest muscle activity leading to pronounced bone changes.
Bone changes in the mandible occur mainly in the central area, where the platysma and chin muscles are both attached (Fig.4 A-C).
Fig.4 (A-C) - Advanced age-related bone changes in the mandible.
Such changes are seen only in bones affected by the work of muscles with displacing ability. Completely different bone changes occur in places where muscles that perform only a contractile role are attached. For example, the work of the masseter leads to hypertrophy of the mandibular angle.

The Impact of Muscle Activity On Other Facial Structures

Fat compartments, which are located in a mosaic pattern, perform a shock-absorbing role, facilitating the movement of muscles and other tissues of the face relative to each other and thus protecting blood vessels and nerves (Fig. 5). Depending on the size of the area where the muscle is attached to the bone, the angle of attachment and gravitational pull, the marginal load on the bone and the pressure from the muscle on the underlying deep fat compartment may be greater or lesser (Fig. 6).
Fig.5 Distribution of fat compartments.
Bone Fat compartment Muscle

Fig.6 Effects of muscle activity on the bone and the underlying fat compartment.
Long-term marginal load on the bone leads to its atrophy, a change in its shape and, in some cases, a change in its angle of inclination also. As a result of constant pressure, the underlying deep fat compartments become thinner or flatter, or even disappear altogether 12,13. Because of this, the muscle shifts in relation to the underlying tissues, but its length most likely remains unchanged (Fig.7, 8).
Fig.7 Change in the position of the muscle due to a decrease in the volume of the fat compartment.
Fig.8 Effect of muscle activity on the underlying structures.
In superficial fat compartments, due to a lack of pressure from dense structures (muscles and bones), better preservation is seen, which is manifested, in particular, in the retention of or increase in volume in their projections on the face.

Due to these internal changes, the volume of the face is redistributed with noticeable volume decreases in certain zones. As a result, a characteristic age-related shape is formed (Fig.9).

Fig.9. Characteristic changes in the shape of the face in the elderly.

Changes in The Activity of The Vascular Network of The Face

The vascular network forms complex transport routes protected by adipose tissue from excessive traumatization from the outside and from injuries during muscle contractions (Fig.10).
Fig.10. The vascular network.
However, with a decrease in adipose tissue, the number of microvessels decreases. Similar changes occur in the body with weight loss. As a result, proper nutrition of the skin is disrupted, which is manifested by a deterioration in its quality.

Pathophysiology of The Face

All systems (visual, respiratory, digestive) of the face are interconnected at the gateways through muscles, vessels and nerves. Any malfunctioning in the work of facial muscles triggers the activation of muscles from the other systems of the face, as a kind of insurance mechanism, and leads to the appearance of additional individual facial patterns in the form of folds and wrinkles (Fig.11 A, B).
https://www.drdavidrosenberg.com/results/facelift-86/ https://vk.com/wall53596800_4621?lang=en

Fig.11 (A) The most pronounced age-related changes are seen in the lower third of the face. (B) Most changes are concentrated in the upper third of the face.
For example, in the case of visual impairment, in addition to m. orbicularis oculi, other facial muscles will be involved - the glabella muscles, m. nasalis, m. levator labii superioris and m. levator anguli oris. The most pronounced changes will be concentrated in the upper third of the face. This is the Ophthalmic Face (Fig.12).

Fig.12. Habitual squinting and corresponding muscle activity lead to the formation of the Ophthalmic Face.
When nasal breathing is obstructed, hypertension of the muscles in the central part of the face (around the nose) develops in order to widen the nostrils and increase air flow. The most pronounced external changes are seen in the middle third of the face: nose wrinkles, deepened nasolabial folds, midcheek grooves, drooping corners of the mouth, swelling of the lower eyelids, and telangiectasia on the alae nasi. This is the Nasal Face (Fig. 13).
Fig.13. Typical examples of the Nasal Face.
Malfunctioning of the dental system leads to changes in the middle and lower thirds of the face, because these zones are formed by the maxilla and mandible. We see changes in the shape and volume of the face, nasolabial folds and marionette lines, wrinkles on the upper lip and cheeks, distorted facial contours and a double chin. These manifestations are very diverse, and it is these changes that are most often called age-related. This is the Dental Face (Fig. 14)
Fig.14. The Dental Face
In neurological pathology, the Neural Face is formed (Fig.15).
Fig.15 The Neural Face

Smart Cosmetology

Smart Cosmetology is a facial upgrade program that allows us to maximally prevent aging or eliminate problematic pattern formation taking into account individual anatomy and physiology.

A clinical example.
The patient's facial expression in Fig.16A is associated with obstructed nasal breathing. Negative changes are concentrated mainly in the middle third of the face. A decrease in muscle tone with botulinum toxin in the central zone and injection of hyaluronic acid in the middle third of the face made it possible to improve facial expression and significantly enhance the aesthetic result (Fig.16B).
Fig.16. The patient before (A) and after (B) correction.


Thus, the main function of the face is to maintain the uninterrupted functioning of the "gateways" and their smooth interaction for correct vision, breathing, nutrition, emotional expression and speech.

Over time, the work of the “gateways” leads to the following changes in the structure of the face:
  1. Structural bone changes occur in specific places due to the multiplicity and activity of the muscles attached to them.
  2. Changes in the volume of fat compartments depend on their position relative to the dense structures of the face, which leads to a redistribution of its volumes and a change in the position of facial muscles.
  3. A decrease in the capacity of the vascular network leads to a decrease in blood supply and deterioration of skin quality.

Smart cosmetology is the first systematic program that takes into account the functions of the face (vision, breathing, nutrition, speech and emotions). This allows us to predict, with a high degree of confidence, possible changes in the face, as well as treatment outcomes, and preserve individuality, preventing the development of undesirable changes in facial appearance.
Options for botulinum therapy for different face types are shown in Fig.17 (A, B).
Fig.17(A). BTA therapy for the nasal face.
Fig.17(B). BTA therapy for the dental face.

Patient Consent

Patients provided written consent for the use of their images.


  1. Shaw RBJr, Kahn DM. Aging of the midface bony elements: a three-dimensional computed tomographic study. Plast Reconstr Surg. 2007 Feb;119(2):675-81.
  2. Kahn DM, Shaw RB Jr. Aging of the bony orbit: a three-dimensional computed tomographic study. Aesthet Surg J. 2008 May-Jun;28(3):258-64.
  3. Shaw RB Jr, Katzel EB, Koltz PF et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strategies. Plast Reconstr Surg. 2011 Jan;127(1):374-83.
  4. Cotofana S, Gotkin RH, Morozov SP et al. The Relationship between Bone Remodeling and the Clockwise Rotation of the Facial Skeleton: A Computed Tomographic Imaging-Based Evaluation. Plast Reconstr Surg. 2018 Dec;142(6):1447-1454.
  5. Kim SJ, Kim SJ, Park JS et al. Analysis of Age-Related Changes in Asian Facial Skeletons Using 3D Vector Mathematics on Picture Archiving and Communication System Computed Tomography. Yonsei Med J. 2015 Sep;56(5):1395-400.
  6. Karunanayake M, To F, Efanov JI et al. Analysis of Craniofacial Remodeling in the Aging Midface Using Reconstructed Three-Dimensional Models in Paired individuals. Plast Reconstr Surg. 2017 Sep;140(3):448e-454e.
  7. Buziashvili D, Tower JI, Sangal NR et al. Long-term patterns of age-related facial bone loss in black individuals. JAMA Facial Plast Surg. 2019 Jul 1;21(4):292-297.
  8. Paskhover B, Durand D, Kamen E et al. Patterns of Change in Facial Skeletal Aging. JAMA Facial Plast Surg. 2017 Sep 1;19(5):413-417.
  9. Shaw RB Jr, Katzel EB, Koltz PF, Kahn DM, Girotto JA, Langstein HN. Aging of the mandible and its aesthetic implications. Plast Reconstr Surg. 2010 Jan;125(1):332-42.
  10. Mendelson B and Wong CH. Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation. Aesthetic Plast Surg. 2012; 36(4): 753–760.
  11. Kahn DM and Shaw RB Jr. Aging of the Bony Orbit: A Three-Dimensional Computed Tomographic Study. Aesthetic Surg Jour. 2008; 28(3): 258–264.
  12. Gierloff M, Stöhring C, Buder T, Gassling V, Açil Y, Wiltfang J. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012 Jan;129(1): 263-273
  13. Le Louarn C, Buthiau D & Buis J. Structural Aging: The Facial Recurve Concept. Aesthetic Plast Surg. 2007 (31): 213–218.