Originally the theory on the major cause of facial aging was the looseness of the skin, which led to sagging and wrinkles. Then, it was discovered that the skin is not the primary problem in a mature facial appearance, but instead it was centered around a gradual descent downward of the tissues beneath the skin. Therefore, procedures (such as the SMAS facelift) that addressed this downward movement have resulted in a much more natural rejuvenation through facelift surgery.
More recently, however, my discipline has been realizing that there is a loss of overall facial volume as we age, and to get a truly rejuvenated appearance in some patients will require a natural replacement of that volume. For some patients fat grafting at the time of surgery is the best option, but for others facial volumizing agents such as Sculptra are best administered either before or after facelift surgery. The goal is a balanced, natural result that looks and is a subtle rejuvenation. Now specialists realize that skin, structures beneath the skin (such as the SMAS) and the overall facial volume play an important role.