Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation

Abstract

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.

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Fig. 1

Orbital aging. The superomedial and inferolateral aspects of the orbit have the greatest tendency to resorb. This contributes to the stigmata of periorbital aging such as increased prominence of the medial fat pad, elevation of the medial brow, and lengthening of the lid cheek junction

Fig. 2

The piriform (piriform angle) and the maxilla (maxillary angle) significantly recede with aging, from youth (left) to old age (right) [11]

Fig. 3

In youth, the piriform (P) lies anterior to the anterior lacrimal crest (A). With aging, the piriform comes to lie posterior to the anterior lacrimal crest as a result of selective bone resorption at the piriform (below) [49]

Fig. 4

The loss of bone in the pyriform area weakens the support of the lateral crura. Deepening of the maxilla results in posterior positioning of the nasolabial crease and adjacent upper lip

Fig. 5

Arrows indicate the areas of the facial skeleton susceptible to resorption with aging. The size of the arrow correlates with the amount of resorption

Fig. 6

The darker areas are those of the greatest bone loss. The stigmata of aging, manifested by the facial soft tissues, corresponds with the areas of weakened skeletal support