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Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation
Abstract and Figures
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 facial appearance have not been well appreciated. Accordingly, failure to address changes in the skeletal foundation of the face may limit the potential benefit of any rejuvenation procedure. Correction of the skeletal framework is increasingly viewed as the new frontier in facial rejuvenation. It currently is clear that certain areas of the facial skeleton undergo resorption with aging. Areas with a strong predisposition to resorption include the midface skeleton, particularly the maxilla including the pyriform region of the nose, the superomedial and inferolateral aspects of the orbital rim, and the prejowl area of the mandible. These areas resorb in a specific and predictable manner with aging. The resultant deficiencies of the skeletal foundation contribute to the stigmata of the aging face. In patients with a congenitally weak skeletal structure, the skeleton may be the primary cause for the manifestations of premature aging. These areas should be specifically examined in patients undergoing facial rejuvenation and addressed to obtain superior aesthetic results.
Level of Evidence IV
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Electronic supplementary material
The online version of this article (doi:10.1007/s00266-012-9904-3) contains supplementary material, which is available to authorized users.
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... During the growth period, the formation of facial appearance mostly concerns the development of facial form (shape and size); there is an codependent relationship between bone morphology and the volume of the soft-tissue envelope 11 . By contrast, later stages of adulthood are characterised by a combination of changes in the soft tissue (such as changes in the state of elastin and collagen fibers), with bone loss in specific areas of the facial skeleton 12,13 . That facial soft tissue and underlying bone structure may change dynamically over a life span thus suggests that the assumptions based on visible facial sexual dimorphism in a younger sample may not be usefully generalized to older adult samples 14 . ...
... The statistical significance of shape difference was coded in shades of blue (significant differences) or grey (no significant differences) on the superimposed average faces (in the lower row of smaller faces). (1-4), distances between exocanthion-nasion (1)(2)(3)(4)(5)(4)(5), nasal length (5-6), nasal width (10-11), nasal depth (6-16), philtrum height (16)(17), nasal height (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16), dimension between pronasalepogonion (6-9), mouth width (7-8), mouth height (17)(18), facial height (5-9), lower face height (9-16) and facial width (19)(20) www.nature.com/scientificreports/ Generally, the average male models tended to have more protruded lower parts of the forehead, eyebrow ridges, nose, upper lip and area of the philtrum compared to the female average; however, these differences were substantially reduced as they approached category III. ...
... The impact of age on facial variables was not confirmed only in lower facial heights (9-16, 6-9). Sexual dimorphism was apparent in almost all dimensions evaluated throughout the face, with large or medium effect sizes, except for some ocular dimensions, mouth height, ocular height (12)(13)(14)(15) and mouth width (17)(18). Overall, the male faces were significantly larger in all the evaluated facial dimensions in comparison with the female faces. ...
A detailed understanding of craniofacial ontogenetic development is important in a variety of scientific disciplines dealing with facial reconstruction, forensic identification, ageing prediction, and monitoring of pathological growth, including the effect of therapy. The main goals of this study were (1) the construction of the facial aging model using local polynomial regression fitting separately for both sexes, (2) evaluation of the aging effect not only on facial form as a whole but also on dimensions important for clinical practice, and (3) monitoring of the development of shape facial sexual dimorphism. Our study was based on the form and shape analysis of three-dimensional facial surface models of 456 individuals aged 14–83 years. The facial models were obtained using a structured light-based optical scanner and divided (for some analyses) into four age categories (juveniles, young adults, middle adults, and elderly adults). The methodology was based on geometric and classic morphometrics including multivariate statistics. Aging in both sexes shared common traits such as more pronounced facial roundness reducing facial convexity, sagging soft tissue, smaller visible areas of the eyes, greater nose, and thinner lips. In contrast to female faces, male faces increase in size until almost 30 years of age. After the age of 70, male facial size not only stagnates, like in females, but actually decreases slightly. Sexual dimorphic traits tended to diminish in the frontal and orbitonasal areas and increase in the gonial area.
... The maxillary region undergoes continuous anterior and lateral wall resorption, with loss of malar projections and an aid in the loss of inferior support of the piriform aperture. These results have already been found by several authors [4,6,11], who carried out measurements of the maxillary projection and concluded that there is a resorption throughout life. This angle showed the greatest decrease compared to the other angular measurements. ...
Objectives: The aim was to evaluate the three-dimensional contour of the face through the morphometric analysis of three facial angles in computed tomography scans of human skulls in different age categories.
Material and Methods: The sample consisted of 123 CT scans that were divided into three groups according to the age. The Mimics 18.0 software (Materialise, NV, Belgium) was used to perform the segmentation of the images of each CT scan. Using the 3D reconstructions of the CT scans, the angular measurements were obtained for the evaluation of the orbital, piriform and maxillary angles. A significance level of 5% was considered. Descriptive statistics were performed for each measurement in each age category and sex. Two-way ANOVA was performed, with multiple comparisons by Tukey's test.
Results: In females, there was a tendency for the piriform angle to increase from the young to the middle-aged group and decrease from the middle-aged to the elderly group.
Conclusions: Females are more prone to selective resorptions than males mainly in the middle third of the face.
Clinical relevance: There is a need to know how the face is remodeled in the process of aging and to understand this bony remodeling is important for application in facial analysis for execution of surgical and aesthetic procedures.
... This obvious gap between conjunctiva and eyeball is due to the shrinkage of intraorbital fat in aging patients with consequent receding of the bulbus, causing the senile enophthalmos. 1,2 Upper and lower eyelids are fixed between the inner canthus at the nasal bone and the Whitnall tubercle inside the lateral orbital wall ( Fig. 2A). Tightening of aging, loose eyelids does not close this wind trap but rather lowers the central part of the lower eyelid, similar to shortening the latitude on a world globe. ...
Background:. As people age, the intraorbital fat may diminish and palpebral fissures may narrow, causing the eyes to increasingly tear outside in cold weather. As the bulbus recedes from the conjunctiva, a “wind trap” is formed in the lateral corner of the eye. This wind trap appears to irritate the adjacent lacrimal gland. In this article, an 84-year-old patient experienced annoying outdoor tearing despite having undergone three tarsal strip canthopexies during the past 20 years.
Methods:. Retrobulbar injections of 3.5-mL high-viscous dermal fillers (Bellafill or Radiesse) pushed the eyeballs forward, aligned the bulbus with the conjunctiva, and closed the wind trap behind the lateral canthus. Magnetic resonance imaging confirmed the filler material in the posterior lateral corner of the orbit.
Results:. The effect was immediate: the patient’s constant outdoor tearing had resolved after the first treatment of his senile enophthalmos. In addition, the narrow palpebral fissure had widened by 2 mm and rejuvenated his aging eyes.
Conclusions:. An eyeball that has receded with age can be pushed forward with a retrobulbar injection of a long lasting dermal filler to reattach to the eyelids.
... Throughout life, there is apparent descent, atrophy, or hypertrophy of certain compartments within the face that make it appear more aged [23,34,117]. Aging is manifested in the lateral translation of the orbits, glabellar protrusion, the expansion of the supraorbital ridges, the deepening and lateral expansion of the cheeks, the three-dimensional enlargement of the nose, and an increase in chin prominence, as described by Enlow [118] and Mendelson and Wong [119]. The interplay between the bony skeleton, supporting ligaments, fat compartments, and facial mimetic muscles is influenced by physiological, genetic, and environmental factors [120]. ...
Background and Objective: Various periorbital rejuvenation techniques have been introduced over the last 3 decades. This study highlights important milestones in the evolution of periorbital rejuvenation surgery by identifying the 100 most-cited articles in this field. Material and Methods: The Web of Science citation index was used to identify the 100 most-cited articles concerning periorbital rejuvenation. Articles published in English from January 1989–April 2020 describing periorbital rejuvenation-related surgical techniques, facial aging, and anatomy were included. The terms “lower blepharoplasty”, “upper blepharoplasty”, “browlift”, “browplasty”, “endobrow lift”, “endoscopic brow”, “Foreheadplasty”, “lower eyelid anatomy”, “upper eyelid anatomy”, “forehead lift”, “eyelid rejuvenation”, “canthopexy”, “canthoplasty”, “eyelid fat pad”, “orbital fat pad”, “tear trough”, and “eyelid bags” were entered into the citation search. Web of Science Core Collection was the database used for the search. A manual review of the initial 159 studies was performed. Articles describing reconstructive or non-invasive techniques, injectable fillers, lasers, and neurotoxins were excluded. Of the 100 most-cited articles, the publication year, specialty journal, the corresponding author’s primary specialty, the focus of the article, the corresponding author’s country of residence, the type of study, and the level of evidence were analyzed. Results: The mean number of citations per article was 75 ± 42. There were more articles published from 1989–1999 (n = 53) than later decades. Most articles originated from the USA (n = 82) and were published in plastic surgery journals (n = 81). Plastic surgery was the primary specialty of the corresponding authors (n = 71), followed by oculoplastic surgery (n = 22). Most articles (n = 69) reported on surgical techniques. Of the clinical studies (n = 69), 45 (79%) provided level IV evidence. Conclusions: Of the 100 most-cited studies on periorbital rejuvenation, studies focusing on periorbital anatomy, aging, and surgical techniques comprised the most-cited publications. An anatomically based approach accounting for age-related changes in the periorbital structures is paramount in the field of contemporary periorbital rejuvenation.
The demand for procedures aiming to rejuvenate the upper third part of the face and the periocular region has increased in the past several years. Blepharoplasty is one of the most frequently performed procedures worldwide to date. Surgery is currently the first choice in order to achieve permanent and effective results; however, it is burdened by potential surgical complications feared by patients. There is an increasing trend in individuals to request less invasive, non-surgical, effective, and safe procedures for eyelid treatment. The aim of this minireview is to present a brief overview of non-surgical blepharoplasty techniques that have been reported in the literature in the past 10 years. Numerous modern techniques that provide a rejuvenation of the entire area have been described. Numerous less invasive methods have been proposed in the current literature and in modern-day routine clinical settings. Dermal fillers are a commonly chosen option for providing enhanced aesthetic results, especially considering that volume loss can be one of the main underlying causes of facial and periorbital aging. Deoxycholic acid use may be considered when the problem is represented by periorbital excess fat deposits. The simultaneous excess and loss of elasticity of the skin can be assessed with techniques such as lasers and plasma exeresis. Furthermore, techniques such as platelet-rich plasma injections and the insertion of twisted polydioxanone threads are emerging as viable methods to rejuvenate the periorbital region.
Background
Hyaluronic acid is the most popular dermal filler in the treatment of nasolabial folds. Injection methods vary among physicians.MethodsA randomized, two-center, double-blind, intraindividual trial was designed to compare a new method of injecting ART FILLER® UNIVERSAL using the retaining ligament with the traditional method (linear threading and bolus injection) in moderate to severe nasolabial folds. Forty patients with moderate to severe nasolabial folds were randomized into groups A and B. Group A received injections via the traditional method on the left side and the ligament method on the right side, while group B received the reverse. Clinical efficacy and patient safety were independently assessed by a blinded evaluator, the injector, using the Wrinkle Severity Rating Scale (WSRS), the Global Aesthetic Improvement Scale (GAIS), and the Medicis Midface Volume Scale (MMVS) at 4 weeks (before and after the touch-up injection), 8 weeks, 12 weeks, and 24 weeks after the baseline injection.ResultsFrom the perspective of the blinded evaluator, the improvements in WSRS scores from baseline did not differ significantly between the ligament method (0.73 ± 0.61) and the traditional method (0.89 ± 0.61) at week 24 (p > 0.05). The mean GAIS score at week 24 was 1.41 ± 0.49 for the traditional method and 1.32 ± 0.47 for the ligament method (p > 0.05).Conclusions
The efficacy and safety of the ligament method for the management of nasolabial folds are comparable to those of the traditional method in terms of WSRS and GAIS score improvement in the long run. The ligament method is superior to the traditional method in that it improves midface deficits with fewer adverse events.Level of Evidence IIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.Clinical Trial Registration: This study was registered with the Chinese Clinical Trial Registry under the registration number ChiCTR2100041702.
Background:
Soft tissue fillers have been widely used for the correction of chin volume loss because of congenital conditions and aging.
Objective:
This study aimed to discuss anatomical concerns for chin filler injections, which may help to reduce the incidence of severe intravascular embolization complications and improve patient satisfaction.
Methods and materials:
We scanned 40 cadaveric heads with a contrast agent using a 64-row spiral computed tomography scanner. The scan was visualized by a Philips IntelliSpace workstation and analyzed by Materialise's interactive m image control system software to measure and quantify the arterial data. Twenty of 40 cadavers were dissected to define the layers of tissue.
Results:
In total, 221 arteries passed through the sagittal plane of 40 specimens. The number of superficial arteries (163 of 221) was much greater than the number of deep arteries (58 of 221). The number of arteries gradually decreased with distance from the lower lip vermilion border plane, which formed the lower third of the face.
Conclusion:
This study introduces a safe and effective technique for administering chin filler injections that minimizes risks and improves patient satisfaction.
The search for a skin similar to that obtained through filters of social networking applications is increasingly present in the complaints and desires of patients who arrive at the office. As the skin is the organ that most reflects the effects of the passage of time, in addition to genetic factors, hormonal status and metabolic reactions, such as oxidative stress, your health and appearance are directly related to the eating habits and the chosen lifestyle. The current challenge is the search for minimally invasive facial rejuvenation treatments with a lower risk of complications. A clinical case was reported in this article using only ozone applied subcutaneously to the submental region and neck. Clinical case: patient I.V, female, 60 years old, sought a private practice complaining of sagging skin in the papillae and neck region that bothered her. After careful examination and skin evaluation, it was proposed to the patient that we start the collagen induction protocol with ozone. Thus, we can conclude that the use of this aforementioned technique is an excellent alternative (safe and effective) for a more youthful and rejuvenated skin.
Background:
Age-related changes in the periocular areas are mainly caused by anatomical changes of the bony orbit and orbicularis oculi muscle (OOM). To achieve effective rejuvenation, it is necessary to understand these anatomical changes according to age.
Objectives:
We analyzed the configuration of the bony orbit and OOM using computed tomography (CT) and evaluated the effects of aging on these structures.
Methods:
A total of 220 orbits and OOMs of 110 Japanese participants (55 males, 55 females) aged 20-87 years were enrolled. The long diameter of the orbits, orbital ellipticity, OOM thickness, and OOM attachment to the inferior orbital rim were analyzed. These variables were statistically evaluated for their relationship with age.
Results:
The long diameter of the orbit was significantly longer in those over than in those under 60 years, with a moderate and significant positive correlation between orbital ellipticity and age. OOM thickness and age showed a strong negative correlation. The degree of OOM attachment to the inferior orbital rim decreased significantly with age.
Conclusions:
This study showed that age-related changes of the bony orbit in Japanese individuals tended to be the same as those in Caucasians, but there were differences in degree of changes observed. As a new finding in the Japanese population, the OOM not only thins with aging, but also gradually loosens from the facial bone. In the elderly, only the nasal side of the OOM was attached to the bone. In clinical application, this could contribute to the development of cosmetic surgeries.
I-Principles.- 1 Treatment Planning: Aesthetic Goals.- 2 Treatment Planning: The Role of Facial Disproportion.- 3 Treatment Planning: Prediction Tracings and Model Surgery.- 4 Surgeon-patient Communications.- 5 Aesthetic Orthodontic Considerations in the Surgical Patient.- 6 Technical Considerations.- II-Surgical Corrections.- 7 Facial Concavity and Anterior Divergence: The Class III Deformity.- 8 Facial Convexity and Posterior Divergence: The Class II Deformity.- 9 Vertical Facial Excess.- 10 Vertical Facial Deficiency.- III-Adjunctive Considerations.- 11 Chin Surgery.- 12 Adjunctive Soft Tissue Surgery.- 13 Aesthetic Postoperative Considerations.
The traditional and time-honored goals of any orthognathic surgical correction have attempted to address both stability and aesthetic concerns. Stability issues relate to establishing a healthy, functional occlusion, whereas aesthetic considerations have focused on normalizing facial balance and proportions as much as possible.