Young faces tend to be full and smooth.

Replenishing volume may be your way forward.

When Madonna was in the “Holiday” and “Material Girl” phase of her career she had a wonderful Italian fresh youthful fullness to her face as she bounced along with her excessive jewellery and bare belly.

Twenty-something years later she remains in great shape, and as hers is such a public face I hope she doesn’t mind me commenting that her face today quite nicely demonstrates the volume loss that occurs with time in those committed to keeping a great figure. I believe Coco Channel once said that as a woman ages she must choose between her figure and her face, and I believe Catherine DeNeuve put it a little more succinctly: “face OR waist”.

Of course, as we age we tend to put on more weight, but Nature has another trick to help the world discern a young person from an old person. The fatty tissue gets rearranged. As fat is deposited in the hips, it is lost from the face. This adds to the appearance of facial wrinkles, as the facial skin becomes deflated like yesterday’s party balloon. Temples become dish-shaped, bones more prominent, cheeks become hollow, individual muscles become more apparent.

Madonna has rightly focused on waist, because the thinness of her face can be treated.

Tissue lacking in volume can be most conveniently treated with dermal fillers. Dermal fillers are safe and straightforward to inject for those of us with experience. There is also Agent A for permanent effects. In between, Agent RR gives you two years of filling, and is new. These fillers are widely popular for treatment of lips, nasolabial folds (but see our section on “deep folds” about this) and can be used in other areas, commonly over the cheekbones to give fullness and definition.

These fillers are great for relatively small areas, but they are not cost-effective for larger areas, Hollow cheeks do better with Agent S (I think Madonna could really do with some Agent S). After several Agent S treatments the skin of the cheeks can be seen to firm, and the hollowness reduces even to the point of returning to fullness, depending on the individual patient and number of treatments applied.

Agent S is great for patients with “runner’s face”; that thin dried look that fair-skinned distance athletes all seem to get.

Some patients feel they lack tissue volume but on closer examination are found to have experienced a sinking or redistribution of fat rather than a fat loss. For example, the combination of flat cheekbones together with jowls can be improved with the use of a Peach loop lift, to elevate the fat back to where it belongs.

Then again, patients needing a lot of volume replacement need to think about fat transfer. In this procedure we draw fat out from an area in which it is unwanted (usually the abdomen), and then reinject it where we do want it (usually the face). We reverse the aforementioned trick Nature plays to make us look older, and move the fat back to where it belongs.

Fat transfer is an attractive procedure, because the fat itself is free and you can’t be allergic to it. The downsides of fat transfer include the need to draw out the fat from another site, and the fact that fat transfer is less reliable than the dermal fillers in giving a result. You see, some of the transferred fat survives, and some doesn’t. The fat that doesn’t survive is obviously broken down and your body removes it. Therefore we cannot be certain, when performing a fat transfer procedure, how much of the transfered fat will persist to give the effect we are looking for. In response to this problem an excess of fat is drawn at the time of fat harvesting from the abdomen, and this excess is stored so that if more fat is needed to get the best facial result we have some on hand.

In consultation we can assess where the volume is lacking, how much you need, and decide on the best approach for you.

Finally, “lack of tissue volume” might relate to nutritional and/or hormonal issues. If you lack muscle volume perhaps your exercise regime needs reviewing. Again, this should be sorted out in consultation.