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Arrows indicate the areas of the facial skeleton susceptible to resorption with aging. The size of the arrow correlates with the amount of resorption
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In principle, to achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected. Traditionally, soft tissue lifting and redraping have constituted the cornerstone of most facial rejuvenation procedures. Changes in the facial skeleton that occur with aging and their impact on faci...
Context in source publication
Context 1
... alone. Only during the current decade, with the application of three-dimensional CT analyses, has a more accurate understanding of facial skeletal aging been possible. The current review has gathered the isolated pieces of evidence which together unequivocally show that aging of the facial skeleton includes selective resorption at specific sites (Fig. 5) (see supplemental animation video). These changes are mainly in the periorbital and mid cheek and specifically include the superomedial and inferolateral aspects of the orbit, the medial suborbital and pyriform areas of the maxilla, and the prejowl area of the mandible [8][9][10][11][12][13][14][15]. These sites pre- sumably reach ...Citations
... Facial aging is a complex, multi-layered process involving the skin, subcutaneous soft tissues, and skeletal structures [3]. At the cutaneous level, aging is primarily characterized by a decrease in hyaluronic acid and collagen content, leading to rough texture, loss of radiance, increased wrinkling, and skin laxity. ...
Facial aging involves structural changes in the skin, subcutaneous tissues, and skeletal framework. Ultra-Pulse Shockwave (UPSW) therapy, a non-thermal, high-frequency shockwave technology, has emerged as a promising, non-invasive option for facial rejuvenation. This study evaluates the efficacy and safety of UPSW in improving skin texture, reducing subcutaneous fat, and enhancing skin tightness. A clinical study was conducted with 20 participants (ages 25–60) undergoing three UPSW treatment sessions over six weeks. Objective assessments included standardized photography, VISIA skin analysis, and Paragon XHD ultrasound imaging to document and analyze treatment effects. Subjective evaluations were performed using the Global Aesthetic Improvement Scale (GAIS) to measure aesthetic outcomes and the Visual Analog Scale (VAS) to assess pain levels experienced during and after treatment. UPSW therapy significantly improved skin texture (p = 0.010) and showed promising effects on subcutaneous fat reduction and skin tightness. Wrinkles (p = 0.069) and pores (p = 0.232) did not reach statistical significance. Adverse effects, including transient erythema and mild edema, were minor and self-limiting. The mean VAS pain score was 2.8, indicating high tolerability. Ultra-Pulse Shockwave (UPSW) therapy demonstrated both safety and efficacy as a non-invasive treatment for facial rejuvenation. The findings indicate that UPSW significantly enhances skin texture while exerting positive effects on skin tightening and subcutaneous fat reduction. Despite the limitations of a small sample size, limited treatment sessions, and a short follow-up period, this study highlights UPSW’s potential as a valuable addition to aesthetic medicine. Further research involving larger cohorts, more frequent treatments, and extended follow-up durations is recommended to optimize treatment protocols and comprehensively evaluate its long-term benefits.
... Facial aging is not limited to soft tissue changes; the skeletal framework also undergoes significant transformations that affect the overall appearance of the face [7]. These skeletal changes are critical targets for comprehensive facial rejuvenation [8]. ...
The field of esthetic surgery of the facial skeleton combines the principles of cranio-maxillofacial reconstruction with advanced techniques to enhance facial harmony, symmetry, and function. By addressing the skeletal framework that supports soft tissues, these procedures significantly improve both esthetics and functionality, transforming patient outcomes. Key procedures include orthognathic surgery, which corrects jaw discrepancies while improving facial balance, and genioplasty, which reshapes the chin to achieve proportionality and alignment. Facial feminization surgery (FFS) tailors craniofacial features to align with gender identity, emphasizing softer, more delicate contours for a feminine appearance. Modern advancements, such as 3D printing and CAD/CAM-guided implants, enable patient-specific solutions, ensuring precision and long-lasting results. The integration of esthetic skeletal procedures with soft tissue modifications further enhances outcomes, addressing aging-related changes or specific contour deficiencies. This chapter explores the principles, surgical techniques, and technologies driving innovations in esthetic facial skeletal surgery, alongside case studies that illustrate its transformative impact. Additionally, it highlights the importance of patient-centered care and the ethical considerations of balancing realistic expectations with surgical possibilities. Future directions in robotics, AI-driven planning, and biomaterials promise to refine outcomes and expand possibilities in this dynamic field.
... The mandible borderline lifting technique has emerged as a solution that addresses these challenges while respecting natural anatomic boundaries and structures. [6][7][8] Understanding the complex interplay of anatomic structures in the mandibular region, particularly the platysma-auricular ligament and mandibular septum, is crucial for the successful implementation of thread-lifting techniques. This knowledge forms the foundation for safe and effective procedure execution. ...
This review presents a comprehensive analysis of mandible borderline lifting, a minimally invasive procedure designed to enhance jawline definition using barbed threads. The technique addresses age-related tissue laxity along the mandibular border by utilizing the anatomic structure of the platysma-auricular ligament as an anchor point. Recent changes in facial morphology among Korean populations, coupled with increased orthodontic interventions, have shifted esthetic focus from chin projection enhancement to overall jawline definition, similar to Western esthetic preferences. The procedure involves careful thread insertion through cannulas along the mandibular septum, engaging both inner and outer aspects of the jawline margin. Special consideration is given to anatomic structures, particularly the marginal mandibular branch of the facial nerve and critical blood vessels near the antegonial notch. The technique employs multidirectional barbed threads, with gauge selection based on individual patient characteristics. This method effectively restores jawline definition while maintaining natural anatomic contours, resulting in a more youthful appearance.
... In the midface, the orbital aperture increases, the maxilla retrudes, and the inferior aspect of the piriform aperture widens. These bony changes contribute to appearance of a lengthened, drooping nose along with posterior displacement of the nasal alae resulting in a more pronounced nasolabial fold [33][34][35][36][37][38] (Fig. 1a, 1b). In the lower face, jowling around the mandibular cutaneous ligaments results in the appearance of an elongated and widened jawline. ...
Purpose of Review
The purpose of this review is to summarize the current literature regarding cheek augmentation in the context of gender-affirming facial surgery, providing a guide for surgeons in selecting the optimal approach based on each patient’s anatomy and goals.
Recent Findings
Cheek augmentation can be achieved through a variety of injectables and implants and tailored to each patient’s goals and anatomy. Currently, the most commonly used injectables include hyaluronic acid, calcium hydroxyapatite, Poly-L-Lactic Acid, allograft adipose matrix, and autologous fat. Alloplastic implantation is a more permanent option compared to the first three injectable materials, with superior aesthetic outcomes in patients requiring more aggressive augmentation to achieve their goals. This review explores the applications, advantages, and disadvantages of these interventions and outlines the senior author’s approach to clinical decision-making in cheek augmentation for gender-affirming facial surgery.
Summary
Patient goals, in addition to the nuances of facial dimorphism and aesthetics, must be considered when applying established methods for cheek augmentation to those seeking gender-affirming facial surgery.
... Reduced facial bone density, including in the mandible and maxilla, has been linked to increased wrinkles and decreased facial expressions due to the subsidence of the base and ridge of the skin covering the facial bone [39][40][41]. The decreased mandibular bone mass has also been associated with increases in the marionette line and maxilla, including the periorbital area, to the nasolabial groove [41][42][43]. This highlights the importance of maintaining bone density for cosmetic reasons, as changes in facial bone density affect apparent age. ...
Background/Objectives: Facial bone density, including the jawbone, declines earlier than that of the lumbar spine and calcaneus. Calcium maltobionate is reported to mitigate bone resorption and maintain bone density of the lumbar spine in post-menopausal women, but its effects on facial bone density remain understudied. Therefore, this study compared variations in facial bone mineral density with variations in calcaneal bone mineral density and bone resorption markers among healthy women, examining differences between pre- and post-menopause and the effects of continuous calcium maltobionate intake. Methods: This randomized, double-blind, placebo-controlled, parallel-group trial involved 48 healthy Japanese women aged 30–69 years, divided into two groups. The test food group received tablets containing calcium maltobionate, while the placebo group received tablets containing a maltose and calcium carbonate mixture for 24 weeks. Calcaneal and facial bone densities were measured pre- and post-intervention in both groups. Results: Post-intervention calcaneal bone mineral density and bone resorption marker deoxypyridinoline (DPD) showed no statistical difference between groups in pre-menopausal women. However, in post-menopausal women, the test food group exhibited significantly higher calcaneal bone density and lower DPD levels compared with the placebo group. Facial bone mineral density increased significantly in the test food group compared with the placebo group in post-menopausal participants, with similar trends observed in pre-menopausal participants. Conclusions: Facial bone mineral density could serve as a useful indicator for monitoring bone health from middle age onward. Moreover, continuous calcium maltobionate intake appears to mitigate bone density decline in pre- and post-menopausal women, contributing to osteoporosis prevention (UMIN-CTR ID: 000046391).
... These changes can result in TMJ dysfunction, contributing to symptoms like pain, reduced mobility, and altered jaw alignment (11). Studies have also noted that the coronoid process may change shape with age, affecting muscle attachment and potentially altering the functional mechanics of the jaw (11,12). ...
Background/aim:
This study aimed to investigate age- and sex-related morphological variations of the mandibular condyle, sigmoid notch, and coronoid process in a mid-sized German population using panoramic radiographs.
Patients and methods:
A total of 150 participants (89 males, 61 females) aged between 18 and 80 years were included. Participants were divided by age and sex. Panoramic radiographs were obtained, and the right and left condylar processes, sigmoid notches, and coronoid processes were evaluated for shape variations.
Results:
Age-related differences were found in the mandibular condyles, with younger individuals exhibiting round-shaped condyles more frequently, while older participants showed a higher prevalence of flat-shaped condyles (p<0.001). Sex-related differences included females displaying more diamond-shaped condyles (p=0.033) and triangular-shaped coronoid processes (p=0.004), whereas males exhibited more round condylar processes.
Conclusion:
This study highlights significant age- and sex-related morphological variations in the mandibular condyles, sigmoid notches, and coronoid processes. These findings have important clinical implications for the diagnosis and treatment of temporomandibular joint disorders and maxillofacial surgery. Understanding these variations can improve diagnostic accuracy and surgical outcomes in patient-specific care.
... Changes with age in the facial bones are most frequently observed in different areas: 1) Orbital zone, presenting lateral translation of the orbit, protrusion of the glabella, expansion of the supraorbital rim; 2) Malar zone, an increase in the depth and expansion of the cheeks; 3) Nasal zone, increase in the length, width, and vertical dimension of the nose and 4) Occlusal zone, with an increase in the vertical height in the occlusal region associated with the increase in mental prominence. The muscles and ligaments associated with facial aging are described in Image 1 [4,5,6]. ...
El proceso de envejecimiento facial es el resultado de cambios anatómicos en los huesos y músculos faciales que finalmente se expresan en la elasticidad de la piel. Se han propuesto diferentes estrategias para el manejo del fotoenvejecimiento como la radiofrecuencia, rellenos, láser ablativo con láser de erbio:YAG (Er:YAG) y láser de dióxido de carbono; estos últimos métodos han demostrado beneficios en la efectividad para el rejuvenecimiento de la piel. La técnica mínimamente invasiva de endolifting facial reporta ventajas fototérmicas, fotoquímicas y resultados a largo plazo.
... The understanding of facial aging has evolved from a simplistic view of volume loss to a more comprehensive appreciation of the anatomical and structural changes that occur over time. [2][3][4][5] The aging face is complex and encompasses fundamental changes in the bone, muscle, fat, ligaments, and overlying skin. This enhanced understanding has led to a paradigm shift in the use of dermal fillers, from treating isolated areas to adopting a holistic approach that considers the entire facial architecture. ...
... Midface aging can be characterized by predictable volume loss in the body skeleton and facial fat compartments of the face. 4,12,15 The bony layer of the face undergoes reabsorption, particularly around the orbital and periorbital, malar and mandibular areas. 4 Soft tissue descent secondary to recession of the zygomatic maxillary bone and atrophy of deep fat pads with hypertrophy of superficial fat pads can increase the appearance of the nasolabial folds. ...
... 4,12,15 The bony layer of the face undergoes reabsorption, particularly around the orbital and periorbital, malar and mandibular areas. 4 Soft tissue descent secondary to recession of the zygomatic maxillary bone and atrophy of deep fat pads with hypertrophy of superficial fat pads can increase the appearance of the nasolabial folds. 3 This bony recession of the maxilla contributes to the blunting of the midface and loss of support for the periorbital tissues. ...
The multilayer injection technique for dermal fillers has emerged as a promising strategy in facial rejuvenation, aiming to restore volume, enhance contours, and achieve a more natural and youthful appearance by strategically placing fillers of varying rheology in multiple facial planes. This contrasts with more traditional, single-layer injection techniques. This scoping review aims to critically evaluate evidence around the feasibility, procedural approaches, outcomes, and complications associated with the multilayer approach. A review of the literature was conducted across multiple databases, including Medline, Web of Science, and Embase, for studies published between January 1, 2010, and June 4, 2024. The search included keywords related to dermal fillers, facial rejuvenation, and multilayer injection techniques. Experimental studies, including randomized control trials (RCTs), observational studies, retrospective studies, case series, and cadaver studies were considered eligible for review. The search yielded 6 studies that met the inclusion criteria: 2 cadaver studies with associated prospective studies and 4 retrospective reviews. The studies collectively involved 464 patients and 15 human cadavers. The cadaver studies focused on establishing the anatomical justification for the multilayer technique, while the clinical studies reported high patient and physician satisfaction with few complications. The multilayer injection technique is a promising approach to facial rejuvenation, offering natural-looking results with a sound anatomical basis and low risk of complications. However, the existing literature is limited by methodological shortcomings, including variations in study designs, lack of control groups, and reliance on subjective assessments. Further rigorous research is needed to validate the efficacy and safety of this technique in live patient settings.
... The goal of these methods [15,17,28,32,39,62,68] is to modify the shape and texture of the face to create the desired re-aging effect, while preserving the individual's unique identity, along with the pose, lighting, and style of the input image. However, facial aging is often highly dependent on several factors, such as ethnicity, gender, genetics, lifestyle, and health conditions [33,52], which makes it challenging to model. ...
Facial aging is a complex process, highly dependent on multiple factors like gender, ethnicity, lifestyle, etc., making it extremely challenging to learn a global aging prior to predict aging for any individual accurately. Existing techniques often produce realistic and plausible aging results, but the re-aged images often do not resemble the person's appearance at the target age and thus need personalization. In many practical applications of virtual aging, e.g. VFX in movies and TV shows, access to a personal photo collection of the user depicting aging in a small time interval (2040 years) is often available. However, naive attempts to personalize global aging techniques on personal photo collections often fail. Thus, we propose MyTimeMachine (MyTM), which combines a global aging prior with a personal photo collection (using as few as 50 images) to learn a personalized age transformation. We introduce a novel Adapter Network that combines personalized aging features with global aging features and generates a re-aged image with StyleGAN2. We also introduce three loss functions to personalize the Adapter Network with personalized aging loss, extrapolation regularization, and adaptive w-norm regularization. Our approach can also be extended to videos, achieving high-quality, identity-preserving, and temporally consistent aging effects that resemble actual appearances at target ages, demonstrating its superiority over state-of-the-art approaches.
... 1,[11][12][13][14][15] With aging, bone resorption in the anterior and inferior aspects of the maxilla leads to retrusion of the mid-face, which, in addition to working as a true slide for the descent of the mid-face soft tissues, further decreases bone support for the zygomatic cutaneous ligament to maintain its tensile strength. 16,17 Approaches to sagging appearance entail repositioning of descended soft tissues to the anatomical position of the youth. 18 In this setting, enhancement of the supportive effect of the ligaments, in its bone or skin insertion, could help restore the soft tissues to their original anatomical positions and achieve a lifting effect. ...
... They also have a high lifting capacity to provide bonelike structural support for overlying soft tissues and compensate for the natural volume decrease caused by age-related bone resorption. [15][16][17]32 Fibroblasts observed by electron microscopy in the periosteum may account for the neocollagenesis observed after CaHA deposition at the supraperiosteal level. 33 Furthermore, the microboluses injected along the zygomatic arch aim to support the part of the zygomatic-cutaneous ligament that extends along the entire length and width of the zygomatic arch, 19 CaHA was the product of choice because of its unique rheology and versatility. ...
The mid-face has been rendered as the cornerstone of facial aesthetic improvement, since treating the mid-face has also beneficial effects on neighboring esthetic units and therefore should be one of the first areas to be assessed. Retaining ligaments (RL) bind soft tissue layers of the face to the underlying facial skeleton. It remains controversial whether RL suffers laxity with aging or if changes in 42 bone and other structures where ligaments are inserted lead to altered mechanical function of the latter. Enhancement of the supportive effect of the ligaments could help restore the soft tissues to their original anatomical positions and achieve a lifting effect. While injectable hyaluronic acid implants have been used to improve ligament support, calcium hydroxylapatite has one of the highest viscoelasticities when compared with other dermal fillers and can induce collagen synthesis, which could provide long-term laxity correction. In this preliminary report of a case series, our goal was to describe the use of calcium hydroxylapatite in different dilutions and combinations for different aging profiles to treat the midface as an alternative for hyaluronic acid injections and to describe the ultrasonographic behavior in the long run.
