Bone Health Matters More Than You Think If You're Post-Menopausal
In the pursuit of a youthful complexion, skincare is just the start.
When it comes to getting ahead of the common signs of aging, most of us spend the majority of our time, energy, and beauty budget on our skin, slathering on serums and creams that claim to induce a lit-from-within glow, indulging in fancy facials that promise immediate sculpting effects, and turning to injectables and fillers for added volume while smoothing lines and wrinkles. But one thing we don’t give enough attention to is our underlying bone structure, specifically bone density, which significantly impacts how the face ages.
As estrogen levels decline drastically during menopause, the bony structure begins to change and resorb, leading to an architectural shift deep below the surface. The foundation of the face weakens, and everything that’s built on top of it, including fat, muscle, tissue, and skin, is affected, making it seem like your face has done a complete 180 overnight.
If the underlying structure of the face is weak due to poor bone density, cosmetic treatments may not give you the results you’re after. But here’s the good news. Doing everything possible to keep the bones strong and healthy, and integrating the right type of fillers into your beauty routine, may help fortify them and prevent more severe aging. While the filler era may be slowing down for Gen Z and others, for perimenopausal, menopausal, and post-menopausal women, these miracles in a syringe may be the saving grace to tweak bone density-related changes that contribute to volume loss, sagging skin, recessed features, and deep hollows, while still retaining a natural look and not like an overfilled, unrecognizable version of themselves.
Bone Health and Facial Aging
As menopause sets in, usually between the ages of 45 and 55, estrogen levels decrease, causing changes throughout the body. Sure, there are the often discussed symptoms like brain fog, hot flashes, and night sweats. But there are also physiological changes that impact skin elasticity, moisture levels, and bone density. “Estrogen plays an important role in bone development, and around menopause is when patients are diagnosed with osteopenia (a warning sign of osteoporosis) or osteoporosis,” says double-board certified pediatric and cosmetic dermatologist Karan Lal, DO. “Bones are essential to the structural aspects of facial anatomy since the cheekbones hold up the mid-face, and the chin and jawline hold up the lower face.”
Once bone resorption (a natural part of bone remodeling that causes thin, weak bones and can lead to bone loss) occurs, the underlying scaffolding starts to deteriorate and lose its sharpness. “Fat pads that serve as cushion and lift the contours of the face aren't as robust as they were, and the muscles aren't as strong, so the underlying layer doesn't have the support it needs to let the skin shine,” says board-certified dermatologist Corey L. Hartman, MD.
Anywhere from 20 to 30 percent of bone structure becomes lost with age, predominantly affecting the upper jaw, eye sockets and orbits, the nose, and the jawbone. As bone resorption continues, naturally prominent facial features begin to recede, offering less support to the skin. “Changes in the orbital rim and pre-jowl region shorten facial structure, leading to a flatter appearance—the face starts to look more two-dimensional,” board-certified dermatologist Ava Shamban, MD, says.
The Role of Fillers In Restoring Structure
According to double board-certified facial plastic and reconstructive surgeon Anthony E. Brissett, MD, and president of The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), most doctors rely on clinical awareness and acumen to assess facial aging and evaluate bone substructure. “We work from the outside in, making sure the support is there to build upon,” he says. “We also need to look at what is happening with the midface, underneath the eye socket, above the lips, the cheeks, around the nose, and the chin and mandible area, and take note of areas that seem hollow, flat, or less prominent,” he says.
As bone resorption continues with age, naturally prominent facial features begin to recede, offering less support to the skin.
When support is lacking, fillers come into play. First, areas subject to volume loss and age-related changes are assessed to determine which product will provide the best results. In some cases, filler alone can address age-related changes; for others, a combination of treatments, including surgery, is necessary.
“The dense, high G-prime hyaluronic acid gel fillers (read: firmer products that offer more structure and support while bolstering the foundation) are great tools,” says Dr. Shamban. “They can mimic supportive structures to help lift certain areas and compensate for substantial volume loss, but they cannot replace or rebuild bone,” says Dr. Shamban. Thicker fillers like Juvederm Voluma and Volux, and Restylane Contour and Lyft are popular for adding volume to the mid-face, so the skin drapes better and the face appears more youthful. When used appropriately, they can improve projection in areas where bone density changes are apparent and recreate a natural-looking, three-dimensional shape with all the right contours.
Placement is also key, and an injector’s experience, skillset, and expertise make all the difference. To create instant volume, lift, and support, filler should be injected directly into the periosteum (a membrane that wraps around bone) and right on top of the bone to support the fat pads and surrounding tissues, and as Dr. Lal says, restore some of that lost structure to the cheeks, chin, and jawline. The deeper along the bone the filler is placed, the more natural it looks. “It won’t pooch out or move with the muscles or look weird,” Dr Hartman adds.
There’s another under-the-radar benefit of deep placement: leveraging the body’s natural regenerative capacities. “When filler is deposited on top of the bone, the needle traumatizes the periosteum, which is where bone stem cells are located,” Dr. Shamban explains. “Orthopedic literature shows that stimulating the periosteum via needling (rather than the filler itself) stimulates fibroblast activity and accelerates bone remodeling.” While she says that fillers and injectables can’t physically regrow bone, they can provide a 3D scaffold for cell attachment and structural support.
In addition to hyaluronic acid fillers, biostimulators like Sculptra, which act more like a “skin fertilizer” than a filler, gradually increase collagen in the skin and improve its appearance. “We use it (off-label) in the temples a lot,” says Dr. Hartman, “but also superficially to stimulate collagen and smooth fine lines to give the skin added support.” However, unlike hyaluronic acid fillers, which offer immediate results, Sculptra takes time for its benefits to become apparent.
Supporting Bone Health for Optimal Results
Recognizing the importance of bone health and raising awareness surrounding the changes bones and the body undergo during menopause is rule number one for supporting bone health. “Your primary care doctor or gynecologist can help you understand where you are in your journey,” says Dr. Brissett. While estrogen supplements can help with osteoporosis, he adds that they may also improve midfacial bone density too. Vitamin D, calcium supplements and salts, and a well-rounded diet can also help minimize bone resorption. “I always ask perimenopausal patients about their vitamin D and calcium status. If they have signs of bone loss, I suggest they take the daily recommendations of both for bone support,” says Dr. Lal. He also recommends Fosteum Plus, a medical-grade prescription supplement containing genistein, a phytoestrogen similar to 17-estradiol. “In studies, it has been shown to improve bone mineral density, making it a great option for someone who doesn’t want to take hormone replacement therapy but wants bone support while receiving treatments for skin quality and structural and volume loss.”
But diet and supplements aren’t enough to safeguard bone health. Dr. Shamban says weight-bearing exercise, including strength training, body-weight activities like walking against gravity (aka, on an incline), and pilates, plays a critical role as women age. “They enhance bone metabolism and strength from head to toe while promoting bone remodeling to increase bone density.” And if there’s one thing to avoid at all costs, it’s smoking, which contributes to bone loss and fragility.
So, while protecting the health and integrity of your facial bones may be viewed as just another step in your overarching beauty routine, it serves a purpose far beyond just making the face look good. The right bone health-centric regimen, consisting of appropriate fillers and injectables, supplements, and lifestyle choices, can make all the difference and reinforce a solid underlying structure to support the skin, muscle, and tissue, even as time marches on.
Meet the Experts
Dr. Corey L. Hartman, M.D., FAAD is the founder and medical director of Skin Wellness Dermatology in Birmingham, Alabama. He is Adjunct Associate Professor of Dermatology at the UAB Heersink School of Medicine Department of Dermatology. Dr. Hartman is certified by the American Board of Dermatology and is a fellow of the American Academy of Dermatology, the American Society for Dermatologic Surgery and the American Society for Laser Medicine & Surgery. Dr. Hartman’s expertise is in tailoring dermatologic surgery and cosmetic procedures that are safe and effective for patients for all skin types, and he regularly participates in clinical trials to further this work. Dr. Hartman is internationally recognized as an expert on injectable fillers, neuromodulators, hyperpigmentation and social media in dermatology and frequently speaks at meetings around the world on these topics. He is frequently quoted in leading publications and serves on the boards of many organizations and companies including Editorial Board of the Journal of the AAD, Board of Directors of the Skin of Color Society, Dermatology Times, Men’s Health Magazine, Galderma Aesthetics, Allergan Aesthetics and Revision Skincare.
Dr. Anthony E. Brissett is President of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) and Vice Chair and Division Chief of Facial Plastic Surgery at Houston Methodist Hospital. A double board-certified facial plastic surgeon in Houston, he specializes in cosmetic, reconstructive, and nonsurgical facial procedures and is widely recognized as an award-winning Top Doctor and respected educator in the field.
Dr. Karan Lal specializes in pediatric and adult dermatology, laser surgery, soft tissue filler augmentation, body sculpting, melanocyte keratinocyte transplant surgery for vitiligo and hypopigmentation, and pigmentary abnormalities of the skin. He is an expert in atopic dermatitis, vitiligo, melasma, psoriasis, and hidradenitis and has worked in specialty clinics among experts. He is the only board-certified pediatric and fellowship-trained cosmetic dermatologist in the country. Dr. Lal is often featured in the media. He is currently a member of the DEI work group for the American Society of Dermatologic Surgery and has a passion for treating the medical and cosmetic needs of patients from all backgrounds.
Dr. Ava Shamban, FAAD, is a renowned board-certified celebrity dermatologist and founder of AVA MD dermatology clinics in Los Angeles, Santa Monica and Beverly Hills. She is also the CEO of the ATS Research Clinic, where she is the principal investigator for FDA clinical trials with Allergan, Evolus Merz, Galderma, Revance and others engaged in the pipeline of future treatments, products, technologies, and protocols. Most recently she launched Althea, a curated range of skin care based on the skin circadian and a home device, CARA, a multi-modality tool based on the best in office technology protocols.
