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Surgery and Cosmetics

Doris M. Hexsel, MD

Adipose Tissue and Aging

Doris M. Hexsel, MD

Friday, August 01, 2014

Adipose (or fat) tissue is at the center of mechanisms and pathways involved in longevity, genesis of age-related diseases, inflammation and metabolic dysfunction. Major changes in fat distribution and function occur throughout life, and redistribution of fat compartments is an important sign of an aging face.1

Regional distribution of adipose tissue is a key indicator of metabolic alterations.2 Excessive fat accumulation on the upper part of the body, called android or male-type obesity, represents visceral obesity whereas localized fat deposition on the lower body/gluteofemoral region is called gynoid or female-type obesity. Despite some similarities, these two regions represent elements of adipose tissue with distinct characteristics that can produce different diseases and deserve particular treatments. Visceral/abdominal obesity has a greater association with the risk of several chronic diseases than gluteofemoral obesity does.3

Another important feature of fat distribution is that the human body has two compartments of adipose tissue - visceral and subcutaneous (Table 1 and Figure 1).


Table 1. Distribution of adipose tissue in the human body (adapted from Bruce et a., 20104)





Figure 1. Abdomen of a 23-year-old patient, visualized by magnetic resonance imaging, showing 1) visceral adipose tissue and 2) subcutaneous adipose tissue (image courtesy of Dr. Doris Hexsel)


Functions of adipose tissue

Adipose tissue has sophisticated and composite functions, acting as a device for controlling the systemic energy balance, whilst also being able to modulate food intake and the metabolism of the substrata of other tissues. Other functions include energy provision, thermoregulation, insulation, body contour, endocrine system modulation, growth factor generation and production of cytokines, stem cells and fatty acids for cell membranes.4


Alterations in the adipose tissue with aging

Adipose tissue mass increases through middle age and declines in old age.5,6 Fat is redistributed among different fat depots over time, especially during and after middle age, when fat redistributes from subcutaneous to intra-abdominal visceral depots.6,7

The percentage of meal fat stored in subcutaneous depots is lower in older than younger men and women, and abdominal circumference increases, on average, by 4 cm every 9 years in adult women.8,9 In old age, fat is redistributed outside of fat depots, accumulating in bone marrow, muscle, liver and other ectopic sites. As in aging, genetic and acquired lipodystrophic syndromes are associated with adipose tissue dysfunction, subcutaneous fat loss, increased visceral and ectopic fat, and metabolic syndrome (glucose intolerance, insulin resistance, central obesity, dyslipidemia and hypertension).10

Gonzalez-Ulloa and Flores (1965) stated that facial aging involves changes in muscle and bone, as well as skin and fat.11 A youthful face is characterized by its fullness and by a smooth transition of fat between subcutaneous compartments (Figure 2). A redistribution of facial fat also occurs during aging. Here, some fatty areas of the face become reduced in size with an unwanted aesthetic aspect, other parts of the face display only minimal fat loss, while further regions have an increased amount of fat, such as those around the jowl, submental and infraorbital areas (Figure 3).12 Aging is also accompanied by changes in the soft tissues of the face, leaving atrophic regions of generalized tissue ptosis. It is known that losses of various facial tissues, including muscles, teeth and bones, and the ptosis of some soft tissues are strong contributors to the appearance of an aged face. 


Young face

Figure 2. A young face is round and presents filled fat compartments (image courtesy of Dr. Doris Hexsel)


Old face

Figure 3. An aged face shows skin laxity and an increase in fat compartments of the lower lid and around the jowl. It also presents loss of volume in the malar region as well as aggravation of the nasolabial and jugal folds (image courtesy of Dr. Doris Hexsel)


Recently, a study by Gierloff et al. (2012) aimed to establish a radiographic method to enable effective measurement of the midfacial fat compartments and to compare the anatomy between human cadavers of younger versus older age subjects.13 Data from computed tomographic scans of 12 non-fixed cadaver heads, divided into two age groups (Group 1: 54-75 years, n = 6; Group 2: 75-104 years, n = 6), showed that the distance between the fat compartments and the infraorbital rim was higher in Group 2 compared with Group 1. The sagittal diameter of the lower third of the compartments was higher, and the sagittal diameter of the upper third was smaller in Group 2 compared with Group 1. The authors concluded that there was an inferior migration of the midfacial fat compartments and an inferior volume shift within the compartments during aging and additional distinct compartment-specific changes (e.g. volume loss of the deep medial cheek fat and buccal extension of the buccal fat pad) contribute to the appearance of an aged face.

The factors involved in facial aging are variable and may be influenced by both intrinsic (e.g. gender, genetics) and extrinsic (e.g. photoaging, smoking, stress) factors. Changes in different tissue layers within a single individual do not occur independently, but interdependently; changes in one tissue within an individual may influence subsequent changes in other tissues.

An interesting situation can also arise during the aging process, where weight gain is associated with an increase in the adipose tissue of the face, resulting in some folds and wrinkles appearing diminished, thus reducing the need for fillers. However, this deposition of fat can also occur in undesirable facial areas.



The continuous availability of energy provided by fat is needed for a multiplicity of functions, including muscular movement, reproduction, growth, cellular maintenance and maintenance of optimal body temperature. Aging is associated with important adipose tissue changes in the body and face. To understand and recognize this transformation is crucial in order to offer a better treatment for patients. Medical advice suggests that physical activity and good nutrition can help to avoid weight gain and are strong contributors to successful aging. Moreover, aesthetic procedures are also available to offer enhanced beauty and wellness to these patients.


  1. Tchkonia T, Morbeck DE, von Zglinicki T, et al. Fat tissue, aging, and cellular senescence. Aging Cell 2010;9:667-84.
  2. Larsson B. Obesity, fat distribution and cardiovascular disease.Int J Obesity1991;15:53-7.
  3. Pischon T, Boeing H, Hoffmann K, et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med 2008; 359:2105-20.
  4. Bruce E, Katz E, Sadick NS. Chapter 2. Adipose tissue and cellulite: anatomy and physiology. In: Shiffman MA, Di Giuseppe A (eds). Body Contouring. Berlin: Springer, 2010.
  5. Visser M, Pahor M, Tylavsky F, et al. One- and two-year change in body composition as measured by DXA in a population-based cohort of older men and women. J Appl Physiol 2003;94:2368-74.
  6. Raguso CA, Kyle U, Kossovsky MP, et al. A 3-year longitudinal study on body composition changes in the elderly: role of physical exercise. Clin Nutr 2006;25:573-80.
  7. Kuk JL, Saunders TJ, Davidson LE, et al. Age-related changes in total and regional fat distribution. Ageing Res Rev 2009;8:339-48.
  8. Hughes VA, Roubenoff R, Wood M, et al. Anthropometric assessment of 10-y changes in body composition in the elderly. Am J Clin Nutr 2004;80:475-82.
  9. Koutsari C, Ali AH, Nair KS, et al. Fatty acid metabolism in the elderly: effects of dehydroepiandrosterone and testosterone replacement in hormonally deficient men and women. J Clin Endocrinol Metab 2009;94:3414-23.
  10. Garg A, Agarwal AK. Lipodystrophies: disorders of adipose tissue biology. Biochim Biophys Acta 2009;1791:507-13.
  11. Gonzalez-Ulloa M, Flores ES. Senility of the face basic study to understanding its causes and effects. Plast Reconstr Surg 1965;36:239-46.
  12. Darcy SJ, Miller TA, Goldberg RA, et al. Magnetic resonance imaging characterization of orbital changes with age and associated contributions to lower eyelid prominence. Plast Reconstr Surg 2008;122:921-9.
  13. Gierloff M, Stöhring C, Buder T, et al. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg 2012;129:263-73.