Sagging

What causes the skin to age and sag with time?

Sagging typically manifests as loose skin or excess tissue/fat around certain face areas. This could give rise to the appearance of the following:

• Jowls
• Less defined jawline
• Double chin
• Loose skin on the neck
• Under eye hollows, dark eye circles
• Droopy eyelids and eyebrows
• Sagging cheeks
• Prominent nasolabial folds/smile lines

This is seldom due to changes in just one layer of the skin. The ageing process occurs throughout all facial layers, including the skin, subcutaneous fat, facial muscles, SMAS (a layer of tissue beneath the skin that provides structural support to the face), deep fat, and bone.

How does ageing occur across the different tissues in the face?

Ageing in the face involves various tissues and structures, each undergoing specific changes over time:

Skin

There is a loss of collagen and elastin, which translates to a reduction in the elasticity and firmness of the skin. This can be addressed by treatments that stimulate collagen and elastin production, such as:

• Medical grade, evidence-based skincare
• Picosecond, non-ablative fractional resurfacing, or fractional carbon dioxide lasers
• Radiofrequency microneedling
• Injectables such as polynucleotides, 5-point bioremodelling hyaluronic acid injections, poly-L lactic acid, or a combination of hyaluronic acid and poly-L lactic acid
• High-intensity focused ultrasound

Subcutaneous fat

This is often redistributed due to a lack of support from underneath. As a result, subcutaneous fat is reduced in certain areas, such as the temples and forehead. In regions such as the nasolabial folds or smile lines, the volume of the superficial fat pads is often paradoxically increased. Changes in this layer can be addressed by:

• Radiofrequency microneedling
• High-intensity focused ultrasound
• Fillers

Facial muscles

There is a reduction in the tone of muscles with ageing. However, certain facial muscles become hyperactivated due to changes occurring in other layers of the face. A common example is forehead lines, which often become more prominent due to one trying to compensate for droopy eyelids and eyebrows. Changes in this layer can be addressed by:

• Botulinum toxin injections
• Myomodulation from fillers – injecting fillers around certain muscles to subtly reduce certain muscles' actions, reducing hyperactivity.

SMAS (Superficial Musculoaponeurotic System)

This is an important fascial layer that connects the various layers of the face. With gravity, muscle movement and ageing in general, this layer weakens with time. This layer is often targeted in facelift procedures to reposition the tissues and alleviate sagging in general. Changes in this layer can be addressed by:

• High-intensity focused ultrasound

Deep fat

The volume loss at the deep fat layer is a major contributor to the change in the contours of the face with time. Examples of this would be the appearance of eye bags, tear troughs, and Indian lines (prominent palpebromalar groove) that become more prominent when the deep fat component shrinks, and the ligaments that separate these deep fat compartments become more obvious. Changes in this layer can be addressed by:

• Fillers: fillers can restore deep, not superficial, volume. This is key to looking natural after filler injections, reducing that dreaded overfilled syndrome. A little volumisation in the deep fat layers often improves facial contours and addresses some of the lines associated with ageing.

Bone

Bone resorbs with age, and this process is accelerated postmenopausal. As such, the bony support for the overlying tissues of the face is reduced, leading to the appearance of sagging and recession in certain areas, such as the cheekbones, jawline, and nasolabial folds. Changes to this later can be addressed by:

• Fillers: strategic filler injections reinforce the receding bony structure and enhance cheekbones and the jawline.

What are the risk factors that will accelerate sagging skin/facial ageing?

Saggy skin, or skin laxity, results from various factors; these are:

• Intrinsic factors
  • Ageing: elastin and collagen, responsible for skin elasticity and firmness, diminish with age, resulting in saggy skin, wrinkles, and fine lines.
  • Weight fluctuations: weight fluctuations, such as significant and sudden weight loss with pregnancy, can accelerate skin sagging.
  • Genetics: our genetic makeup determines how our cells replicate in response to injury, how our in-built DNA repair systems fix damages that accumulate over time, and how well our body defends itself against harmful molecules (free radicals) that damage cells. All these genes contribute to how fast we age with time.
• External factors: external factors such as UV exposure, environmental pollutants, smoking, poor nutrition, and excessive alcohol contribute to the skin’s deterioration and sagginess.

What can I do to slow down sagging?

Adopting a holistic approach that focuses on lifestyle modifications, dietary habits, and skincare routines is critical to slowing down sagging.

• Moderating weight changes: ensure any weight loss is gradual, ideally not exceeding 0.5 kg per week.
• Refining skincare products: integrate proven skincare ingredients into your routine, emphasising the use of vitamin C and vitamin A derivatives (retinol, retinoids).
• Protecting against UV exposure: UV exposure accumulates over time, and photoprotection can slow ageing and protect against skin cancer.
• Optimising nutrition: select a diet rich in antioxidants and nutrients and reduce the consumption of processed food.
• Limiting harmful habits: cut down on smoking and excessive alcohol intake, as these can accelerate the ageing process.

Adhering to these guidelines can significantly influence your skin's ageing process, promoting a more youthful and resilient complexion over time.

What are the treatment options for sagging skin?

Addressing sagging skin involves a comprehensive strategy combining skincare, effective treatments, and lifestyle adjustments. At Lumine Dermatology & Laser Clinic, we advocate for a tailored approach, ensuring treatments match individual skin types and concerns.

• Skincare regimen optimisation: utilising scientifically supported ingredients is key. From hydration to renewal, a personalised skincare plan can significantly improve skin health. Consulting with a dermatologist is crucial to selecting the most effective products.
• Laser treatments: lasers offer a versatile solution to skin rejuvenation. Options range from fractional ablative lasers (Deka Smartxide) for intensive repair to non-ablative fractional lasers (MOXI), and picosecond lasers. Each technology has unique benefits, from texture improvement to pigmentation to reducing the appearance of fine lines and wrinkles.
• HIFU: high-intensity focused ultrasound (HIFU) is a noninvasive option that targets the dermis, subcutaneous fat, and SMAS to lift and tighten sagging skin. It is particularly effective for enhancing firmness and improving contours.
• Skin boosters: skin boosters offer deep hydration and improve skin texture and luminosity. At Lumine Dermatology & Laser Clinic, we use a combination of hyaluronic acid and PLLA skin boosters.
• Polynucleotide treatments: polynucleotide treatments help enhance hydration, boost skin renewal, and reduce inflammation.
• 5-point bioremodelling HA treatment: 5-point bioremodelling HA treatment supports natural collagen and elastin production, producing visibly firmer, smoother, and hydrated skin.
• Dermal fillers: fillers work by replacing the volume loss in the deep fat or by strengthening bone that resorbs with ageing. Depending on your preference and skin type, hyaluronic acid fillers or collagen-stimulating fillers, e.g. PLLA or PCL, may be suitable.
• Botulinum toxin: Botulinum toxin can be injected superficially  at strategic areas of the face to effect a natural lifting. This is known as dermalift.

For the best results, consult your dermatologist to help tailor a treatment plan unique to you and your ageing concerns.

Frequently asked questions

Can weight loss cause sagging skin?

Rapid fluctuations in weight can generally cause sagging skin. This is due to the rapid distension of the skin with weight gain, which causes the skin to stretch and lose elasticity. The skin cannot retract fully when subsequent weight is lost, leading to the appearance of overhanging loose skin. A common example of this is weight fluctuations during pregnancy.

Weight loss and gain often lead to fat redistribution in the fat compartments of the face. Rapid weight loss associated with weight loss medications (e.g., semaglutide) is an example. This has led to the description of an “Ozempic face,” where the profound loss of facial volume and fat results in a hollowed-out and gaunt appearance.

Can I get non-surgical treatment for sagging skin?

Yes, there are non-surgical options available for sagging skin. Laser treatments, radiofrequency microneedling, dermal fillers (hyaluronic acid, PLLA, PCL), and HIFU can enhance collagen production and tighten the skin.

However, the results of surgery, which lead to a significant lift in sagging tissues and restoration of contours associated with youth, cannot be replicated with non-invasive treatments.

Consult with a qualified practitioner to explore the most suitable non-invasive solution for your specific needs.

Is sagging skin preventable?

We can’t alter our genetics or stop the clock on ageing, but lifestyle and skincare choices can significantly impact the rate at which our skin ages.

This includes adopting a reasonable and efficient skincare routine that incorporates important active ingredients. We can also do our best with sun protection measures and a healthy lifestyle that incorporates good nutrition, exercise, and sleep. These little things go a long way in slowing the ageing process, and it will show on our skin.

You can also consider professional treatments, as non-surgical options can help prevent and treat skin sagging by stimulating collagen production. These include laser therapy, microneedling radiofrequency, fillers, and HIFU.