From Layers to Loadbearing: The Face as a Prestressed Biotensegrity System.

The conceptual framework guiding facial rejuvenation surgery has evolved through distinct paradigms-from gravitational descent to volumetric deflation-yet both treat the face as an assembly of independent anatomical structures rather than an integrated mechanical system. This article proposes that the face functions as a prestressed biotensegrity system, and that aging represents a progressive, self-amplifying loss of prestress: not a linear decline but a positive feedback loop linking fascial deterioration, skeletal resorption, and mechanical destabilisation. The facial tension network-the superficial musculoaponeurotic fatty fascial system (SMAFFS) and its dermal connections- maintains baseline prestress against the discontinuous compression elements of the facial skeleton and deep fat compartments; structural stability emerges from global force distribution rather than from any individual component. When fascial prestress diminishes, bone strain drops below Frost's mechanostat remodelling threshold, initiating resorption at the orbital rim, malar eminence, piriform aperture, and mandibular border-precisely where Mendelson and Wong documented age-related erosion. Reduced skeletal support further erodes prestress, and the cycle accelerates. This mechanism integrates the independent frameworks of Moss, Frost, and Enlow into a unified account of facial aging. Within this framework, surgical rejuvenation might be reconceived as prestress restoration rather than tissue repositioning-a reframing that requires empirical validation. Prior paradigms have aimed to correct the visible output of facial aging. The biotensegrity framework generates a testable hypothesis: that restoring prestress may modify the biological course of aging itself, by rehabilitating the mechanotransduction signals governing tissue quality and skeletal mass. This narrative review synthesises evidence from cellular biomechanics, craniofacial developmental biology, fascial anatomy, and comparative clinical outcomes to construct and evaluate the prestressed biotensegrity framework and proposes a research agenda to test it.