Aesthetic Surgery Journal

Update on Facial Aging 30(Suppl 1) 11S-24S

© 2010 The American Society for
Aesthetic Plastic Surgery, Inc.
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DOI: 10.1177/1090820X10378696
Rebecca Fitzgerald, MD; Miles H. Graivier, MD; Michael Kane, MD; www.aestheticsurgeryjournal.com
Z. Paul Lorenc, MD, FACS; Danny Vleggaar, MD;
Wm. Philip Werschler, MD; and Jeffrey M. Kenkel, MD

Abstract
Facial aging was once thought to be the result of the relentless downward pull of gravity on skin and underlying fat. In turn, facial fat was believed to
be a contiguous sheet of tissue. However, over the past four decades, a number of investigators have examined more closely the causes of facial aging,
leading to a better understanding of age-related changes, and have confirmed and further explored the proposal by Gonzalez-Ulloa and Flores in 1965
that facial aging involves changes in muscle and bone, as well as skin and fat. Further, the recent work of Rohrich and Pessa (and other authors) has
demonstrated that facial fat is not a sheet of tissue, but rather is compartmentalized throughout the face. This discovery has allowed the evolution of
improved techniques for facial rejuvenation.

Keywords
skin, muscle, bone, fat, gaining, facial rejuvenation

In 1965, Gonzalez-Ulloa and Flores1 published a landmark by numerous investigators over the past 45 years. Authors
article on the “senility of the face,” perhaps the first com- have studied and described the processes and manifesta-
prehensive study of the elements of facial aging. These tions of aging of the facial skin, from morphology to
authors observed and described changes in external changes at the cellular level. The more recent literature
appearance over time, measuring and documenting facial has provided new insights into age-related changes in the
skin thickness and changes in fat at different ages. They skin, as well as in the underlying structures.
described the process of aging as resulting from the grad- Structural changes in all tissues lead to morphologic
ual absorption of fat, decreased thickness and elasticity of changes in the topography, shape, and proportions of the
skin, decreased adherence between the skin and subcuta- aging face. The variability of facial shape from patient to
neous tissue, sagging of the soft tissues, weakening of the patient, as well as variability in the pace of aging among
orbital muscle and septae, and the progressive decrease in patients (and, indeed, even between tissue layers in one
the volume of the craniofacial skeleton. The major individual patient), makes a uniform template for analysis
advancement that has contributed to our current knowl- and rejuvenation treatment difficult. However, some com-
edge of the anatomy of aging is research suggesting that mon themes can be observed. Stuzin4 pointed out that there
the face does not age as one homogeneous object, but as seems to be a certain age at which there is just enough
many dynamic components that are best evaluated, modi-
fied, and augmented individually.2 It is now recognized Dr. Fitzgerald is a Dermatologist in private practice in Los Angeles,
that changes that occur with facial aging may involve a California. Dr. Graivier is a Plastic Surgeon in private practice in
complex, multidimensional interaction among the under- Atlanta, Georgia. Dr. Michael Kane is an Attending Plastic Surgeon in
lying bone, skin, and soft tissue position (as with facial fat private practice in New York, New York. Dr. Lorenc is a Plastic Surgeon
descent and/or deflation), selective fat compartment defla- in private practice in New York, New York. Dr. Vleggaar is Head of
tion, and alterations in the associated support ligaments Cosmetic Dermatology in private practice in Geneva, Switzerland
and septi.3 Gonzalez-Ulloa and Flores determined that all Dr. Werschler is Assistant Professor of Dermatology at the University
of Washington, Seattle, Washington. Dr. Kenkel is Professor and Vice
four structural tissue layers—skin, muscle, fat, and bone—
Chair of Plastic Surgery, University of Texas Southwestern Medical
should be considered in aging, concluding with the recom- Center.
mendation that “the phenomena originated by facial
senility are multiple and its causes ought to be thoroughly Corresponding Author:
considered for its adequate correction.” The general obser- Jeffrey M. Kenkel, MD, 1801 Inwood Drive, Dallas, TX 75390-9132,
vations of Gonzalez-Ulloa and Flores have been confirmed USA. E-mail: [email protected]

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Figure 1.  (A) Age 25. The youthful face is full of well-supported facial fat, typically located overlying the malar eminence and
along the lateral cheek, overlying the parotid and masseter. This is associated with a concavity or depression overlying the buccal
recess just anterior to the masseter. The combination of fullness in the malar region and lateral cheek associated with a concavity
overlying the buccal recess accounts for the angular, tapered appearance of the youthful face. (B) Age 55. Thirty years later, the
aesthetic effect of the descent of facial fat has become obvious, resulting in a change in facial shape. Typically, faces in middle
age are square in their configuration, with little differential between malar highlight and midfacial fat. As facial fat is situated
more inferiorly in the face, the face appears visually longer. The aesthetic consequences of a change in facial shape with aging
are as important as the depth of the nasolabial fold and facial jowling. Reprinted with permission from Stuzin JM, Baker TJ,
Baker TM. Refinements in face lifting: enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr
Surg 2000;105:290-301.

skeletal support for the overlying soft tissues (Figure 1). histopathologic changes that result from both intrinsic and
Research published by Pessa et al5 over a decade ago illus- extrinsic aging. It has been demonstrated that intrinsic
trated that this opportune time may be a point that we grow and extrinsic aging occur in all tissues of the body.
into from infancy and away from with age (Figure 2). The Intrinsic aging involves physiologic and histologic
central role of volume loss and deflation in the aging face, changes resulting from cellular apoptosis and other genet-
rather than ptosis, was eloquently illustrated by Lambros6 ically determined processes. In the skin, examples of
in a longitudinal photographic analysis of more than 100 intrinsic aging include a number of changes: thinning
patients spanning an average period of 25 years. Recognizing epidermal tissue; a decrease in Langerhans cells and
where volume has been lost (or sometimes lacking in the melanocytes; variability in the size and shape of epider-
first place) in each patient greatly enhances our ability to mal cells; the appearance of atypical nuclei; a reduced
address it with site-specific corrections that result in opti- number of fibroblasts, mast cells, and blood vessels;
mal, natural-looking results. shortening of capillary loops; and abnormal morphology
of nerve endings.7-9
Extrinsic aging results from long-term exposure to envi-
FACTORS IN FACIAL AGING ronmental insults, including dehydration, inadequate
nutrition, temperature extremes, traumatic injuries, envi-
Classic articles by Yaar and Gilchrest,7 El Domyati et al,8 ronmental toxins (such as cigarette smoke), and ultravio-
and Rabe et al,9 among others, have described in detail the let (UV) radiation.9 Photodamage, perhaps the most

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Figure 2.  (A) On a frontal view, the ratio of medial canthus (MC) to nasolabial crease (NLC) and the NLC to the lips (S, stomion)
in the infant is approximately 1:1. This ratio is attributable to lack of development in the maxilla from the pyriform to the orbital
rim. (B) From infancy to youth, the maxilla grows at a disproportionately fast rate (differential growth), which results in the
ratio becoming closer to 1.5:1 at the time of youth. (C) After this point, upward remodeling of pyriform, coupled with continued
growth of the lower maxilla, again causes this ratio to revert back toward 1:1 in an older individual. It is of interest that, if the
soft tissue contours of the 82-year-old man (C) were restored to those a youthful person, the proportions would still be those
of an older (or infant) face. The appearance of youth depends on contours and proportions as well as soft tissue signs of aging.
Reprinted with permission from Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and facial aging: nonlinear aspects of
youthfulness and skeletal remodeling, and why, perhaps, infants have jowls. Plast Reconstr Surg 1999;103:635-644.

common cause of extrinsic aging in the face, causes SKIN

changes that include a thickened epidermis, a flattened
dermoepidermal junction, and an increase in hyperplastic Skin appearance is a primary indicator of age. During the
fibroblasts and inflammatory infiltrates.7-9 past decade, substantial progress has been made toward
A recent study of monozygotic twins10 provided statis- understanding underlying mechanisms of human skin
tical evidence regarding some of the extrinsic factors that aging. A major feature of aged skin is fragmentation of the
are known to contribute to facial aging. (The investiga- dermal collagen matrix. This fragmentation results from
tors chose monozygotic twins because of the inherent actions of specific enzymes (matrix metalloproteinases) and
control for genetic influences.) Ten facial features were can be observed in both intrinsic and extrinsic aging. Loss
analyzed: overall perceived age for each twin, skin of this extracellular collagen is responsible for loss of struc-
youthfulness, coarse and fine rhytides, soft tissue vol- tural integrity and subsequent impairment of fibroblast
ume, hair quantity, hyperpigmentation, periborbital function11 because fibroblasts that produce and organize the
aging, brow ptosis, perioral changes, and malar descent. collagen matrix cannot attach to fragmented collagen. Loss
In this study, there were statistically-significant associa- of attachment prevents fibroblasts from receiving mechani-
tions between facial aging and 10 factors. These were sun cal information from their support and they subsequently
exposure, duration of cigarette smoking, body mass collapse. Although stretching is critical for normal, balanced
index, duration of hormone replacement, marital status, production of collagen and collagen-degrading enzymes, in
alcohol consumption, and a history of the following: skin aged skin, the collapsed fibroblasts produce low levels of
cancer, outdoor activities and lack of sunscreen use, these. This imbalance advances the aging process in a self-
radiation therapy, and chemotherapy. perpetuating, never-ending deleterious cycle (Figure 3).
Other studies have been published further confirming Because attachment of fibroblasts to new, undamaged
the observation that the clinical signs of facial aging are collagen allows stretching, it in turn balances collagen
associated with changes in all structural layers (ie, skin, production and degradation, thereby slowing the aging
fat, muscle, and bone). The following sections on these process. Therefore, treatments that stimulate production
structural layers briefly review the most recent literature in of new, nonfragmented collagen should provide substan-
which the results have a bearing on the understanding of tial improvement to the appearance and health of aged
the optimum use of injectable shaping agents. A short skin. Skin improvement has been described with topicals
statement describing the implications of the studies con- such as retinoic acid, as well as with both ablative and
cludes each of these sections. nonablative laser treatments.

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Figure 3.  Fragmentation of collagen fibrils within the dermis of aged or photoaged skin causes the collapse of fibroblasts, which
leads to low production of procollagen and high production of collagenase. Reprinted with permission from Fisher GJ, Varani V,
Voorhees JJ. Looking older: fibroblast collapse and therapeutic implications. Arch Dermatol 2008;144:666-672. Copyright © 2008
American Medical Association. All rights reserved.

In terms of clinical implications, we must remember and LaTrenta15 in 2007 sought to document the subcutane-
that both intrinsic and extrinsic aging affect the ability of ous fat mass both above and below the superficial muscu-
the outer skin envelope to adjust to underlying volume loaponeurotic system (SMAS) and offered an interesting
loss. A very elastotic outer skin envelope is unlikely to illustration of these contours. The face and neck were arbi-
“lift” significantly with fillers alone and may require trarily divided into subunits according to the aesthetic
treatment with multiple modalities such as surgical lift- facial and neck subunit principle of Gonzales-Ulloa and
ing, lasers, and deep chemical peels. Adequate “filling” of Flores1 (Figure 4). After a three-layer dissection in 10 fresh
a face with very elastotic skin is challenging and may hemi cadavers, the authors found that 80% of total subcu-
require an overwhelming amount of treatment time and taneous fat mass existed in the face and only 20% in the
product. Recently, new collagen production attributed to neck. In the face, 57% of the fat mass was found above the
a stretching effect of intradermal hyaluronic acid was SMAS, with 43% below the SMAS.
described.12 It is interesting to speculate that because col- Also in 2007, the first in a series of groundbreaking stud-
lagen stimulation may produce both direct (through fibro- ies from Rohrich and Pessa16 demonstrated in the cadaver
plasia) and indirect (through increased extracellular lab that facial fat exists as multiple well-delineated, inde-
matrix and a stretching effect) stimulation of fibroblasts, pendent compartments that have specific anatomic rela-
treatments with these agents could both replace collagen tionships to one another. The authors also noted that
and slow its loss. many of the retaining ligaments that support facial soft
tissue originate within the septal barriers between these
compartments.17 In the first of these experiments, methyl-
FAT ene blue dye (chosen for its diffusion properties) was
injected into adipose tissue in various regions of the face.
The youthful face has an ample and evenly distributed The dye was noted to flow in distinctly partitioned pat-
amount of volume, which displays a smooth transition terns, departing from the traditional assumption that facial
from one area to another and confers a well-rounded three- fat is a homogeneous confluent mass. This initial discov-
dimensional topography delineated by a series of arcs and ery has been followed by a large number of detailed ana-
convexities.13 Viewed frontally, the primary arc of the jaw tomic cadaver studies defining these fat compartments
line, convexities of the temples, and the smaller secondary and their relationships to one another.18-21 These separate
arcs of the lips are evident.13 In profile, the lateral cheek fat compartments exist in both superficial and deep fat.
projection (the ogee curve) extending as an unbroken con- Some superficial compartments overlap and the deep com-
vex line from the lower eyelid to the cheek, the arc of the partments are revealed only when the superficial compart-
jaw line, and the arc of the forehead are the most definitive ments are stripped away. There is, of course, much still
features of youth.14 A cadaveric dissection study by Raskin to learn, but several of the named superficial and deep

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Figure 4.  (A) Arbitrarily divided anatomic units of the face after the dermis has been dissected off the cadaver’s face and neck
include the following: (1) glabella, (2) forehead, (3) temporal, (4) anterior upper cheek, (5) middle cheek, (6) posterolateral
cheek, (7) mental, and (8) anterior neck. (B) The skin, superficial fat, and SMAS have been dissected off the cadaver’s face and
neck, and the anatomic subunits have been redrawn on the discontinuous deep layer of fat. (C) The skin, SMAS, and superficial
and deep layers of fat, including the fat pad of Bichat, have been dissected off the cadaver’s face and neck, demonstrating the
near-complete loss of contour in faces bereft of fat and SMAS. Reprinted with permission. This figure was published in Atlas
Aesthetic Face and Neck Surgery, Philadelphia: Saunders; 2004. LaTrenta GS, p.2-67, Copyright Elsevier, 2004.

compartments have been elegantly described in the arti- Around the eyes, researchers have found that subor-
cles referenced above. bicularis oculi fat is composed of two distinct anatomical
There is good clinical evidence that individual fat com- compartments: the medial suborbicularis oculi fat, which
partments age independently. This may have a cascade lies between the medial limbus and the lateral canthus,
effect on adjacent areas, which has enormous influence on and lateral sub-orbicularis oculi fat, which extends from
the techniques we select for facial filling. A working the lateral canthus to the lateral orbital thickening. The
hypothesis of facial aging involves the concept that fat loss deep medial cheek fat is the most medial of the periorbital
and/or ptosis in deep compartments leads to changes in deep fat compartments (Figure 7).21 Because periorbital
shape, contour, and anterior projection. Folds, in contrast, rejuvenation has increasingly relied on augmentation with
occur at transition points between thick and thinner fillers, knowledge of the exact anatomy of the suborbicu-
superficial fat compartments; these can be seen in the laris oculi fat is important to accurately place filler mate-
nasolabial fold, the labiomental fold, the submental crease, rial. Augmenting each area has a different effect and
and the preauricular fold.18 This has led to the concept of enables the clinician to tailor his or her treatment based
“pseudoptosis”—namely, that loss of volume in one area on the individual’s particular morphology.21 Pessa21,22
may lead to the development of folds in a neighboring noted, for example, that some individuals develop a naso-
area.19 This is well-illustrated by the improvement demon- jugal crease during their early 20s. Augmentation of the
strated in the nasolabial fold and under-eye “v-shaped medial or lateral suborbicularis oculi fat is unnecessary in
deformity” when the deep medial cheek fat pad is refilled these patients, and filler injected along the medial orbital
with saline from a single injection point (Figure 5).19 rim alone, into the superior deep cheek fat, will improve
Another example of how these anatomical observations this area.
further the goal of site-specific augmentation in facial reju- This anatomical research, combined with Lambros’s
venation is demonstrated in the lip region. The discovery theory of age-related deflation,6 enables the clinician to
of fat compartments in the cutaneous portion of the lips approach facial rejuvenation in a site-specific manner.
deep to the orbicularisoris muscle in an aged cadaver with There is good clinical evidence that not all fat compart-
full lips raised speculation that filling of this area (rather ments behave identically as a patient ages and that a site-
than the vermillion border) might restore a natural, youth- specific approach is valid, making universal treatment of
ful fullness and convexity to the lip (Figure 6).20 This the nasolabial folds and marionette lines in all patients
research has subsequently guided an evolution in the a thing of the past. The relevance of new understanding
clinical placement of fillers in the labial area. of facial fat anatomy to facial rejuvenation techniques in

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Figure 5.  (A) Photograph of a deflated midface (arrow). (B) Saline injected specifically into the deep medial cheek fat restores
anterior projection, diminishes the nasolabial fold, effaces the nasojugal trough, and improves the malar region. An interesting
finding is the fact that the cheek has a natural appearance because the deep medial fat boundaries determine the anatomical
position of the cheek. Reprinted with permission from Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial
fat compartment. Plast Reconstr Surg 2008;121:2107-2112.

Figure 6.  Vertical sectioning of the lower lip shows deep Figure 7.  The deep medial cheek fat is stained with methylene
submuscular fat. Of particular note, this specimen’s lower blue. This fat lies beneath the superficial subcutaneous fat
lip showed anterior projection and eversion similar to that compartments. The zygomaticus major (ZM) and buccal
seen in a much younger individual. The clinical impression fat (B) represent the lateral boundaries. Reprinted with
from this research is that the volume of deep lip fat contributes permission from Rohrich RJ, Pessa JE, Ristow B. The youthful
significantly to the appearance of the youthful lip. Reprinted cheek and the deep medial fat compartment. Plast Reconstr
with permission from Rohrich RJ, Pessa JE. The anatomy and Surg 2008;121:2107-2112.
clinical implications of perioral submuscular fat. Plast Reconstr
Surg 2009;124:266-271.
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general (and facial fillers in particular) is enormous.

Sandoval et al2 recently published a guide suggesting that
these compartments serve as a “GPS” for the injection of
facial fillers, noting that future studies at their institution
will focus on the effect of fillers on the fat compartments
and the visual changes created by their augmentation. It
also suggests that some regions of the face may improve
with what might be called “indirect treatment”—that is,
treatment of one area can beneficially affect one or more
adjacent areas.

MUSCLE
As mentioned previously, subcutaneous fat is positioned
both above and below the facial mimetic muscles. At
approximately the same time Rohrich and Pessa were con-
ducting their cadaveric research, Le Louarn and colleagues23
were working independently to define the nature and role
of facial structures, resulting in the development of their Figure 8.  Le Louarn suggested that the shape and action of
“facial recurve concept.” Le Louarn’s group performed facial muscles is determined by the position of the underlying
magnetic resonance imaging (MRI) studies on subjects of fat and that, over time, repeated contraction of the facial
different ages and documented the differences in facial mimetic muscles contribute to changes in this fat distribution.
mimetic muscle contours, as well as in the superficial and With MRI studies, they documented a loss of the youthful
deep fat pads overlying and underlying these muscles. curvilinear contour (A) and an increase in the resting tone
These authors suggested that the shape and action of facial of the muscles, thus changing the shape, morphology, and
muscles are determined by the position of the underlying three-dimensional topography of the face as it ages (B).
fat and that, over time, repeated contraction of the facial Reprinted with permission from Le Louarn CL, Buthiau D,
mimetic muscles contributes to changes in this fat distribu- Buis J. Structural aging: the facial recurve concept. Aesthetic
tion. They speculated that this mechanism leads to a loss of Plast Surg. 2007;31:213-218.
the youthful curvilinear contour and an increase in the rest-
ing tone of the muscles, thus changing the shape, morphol- and technique has led to a low incidence of adverse
ogy, and three-dimensional topography of the face (Figure effects. He feels this so-called Nefertiti lift is a mini-
8). This is in contrast to the traditional concept that facial mally invasive, effective, and acceptable alternative for
muscle laxity and weakness cause a downward displace- patients seeking an effective way to delay surgery.
ment of soft tissue. Logically, however, we can question Disappearance of the mandibular border with a forceful
whether, if the commonly held belief were true, facial mus- downward pull on the platysma at the corners of the
cle paralysis would actually cause softening of the corruga- mouth indicates the potential for successful treatment
tor, nasolabial, periorbital, and labiomandibular creases in this area. It is interesting to speculate whether the
and an improvement in senescent appearance. The authors success of this technique is related to Rohrich and
also note that although this concept of increased muscle Pessa’s recent description of the osseous attachments of
resting tone with age may appear counterintuitive at first, it the platysma along the mandibular septum.
would account for the well-appreciated clinical effects of
botulinum toxin injection. They offer corresponding hypoth-
esis that the crow’s feet wrinkles that develop with age can BONE
be seen as deriving from the persistence of orbicularis oculi
contraction or a degree of increased resting tone in the face. A review of the forensic science literature by Albert and
As described earlier, Rohrich et al19 believe that the deep fat colleagues26 concerning the adult skull and face supported
in some areas, such as the deep medial cheek fat in the the contention that there are certain age-related bony and
midface, accounts for the anterior projection of the face soft tissue changes that occur, causing (as the authors
seen in youth. The implication for treatment is that filler state) changes “in the shape, size, and configuration of
placed under the mimetic muscles may have a positive individuals over the course of the adult lifespan.” Doual
effect through more than one mechanism. et al27 reported that the most extensive changes in the
An additional (but unrelated) article on muscular appearance of the head, face, and neck attributable to
structures is worth comment in this section. Levy24 pub- underlying, age-related skeletal changes occur at about 50
lished his experience in 130 patients with a new tech- years of age in both men and women.
nique using botulinum toxin A (VistabelH; Allergan, Craniofacial bony remodeling is increasingly recognized
Irvine, California), up to 20 units per side, to drape the as an important contributor to the facial aging process and
skin of the jawline contour and provide the visual effect multiple studies have demonstrated statistically significant
of a “mini lift.” He reported that patient satisfaction craniofacial skeletal changes with age. Sharabi et al28
was extremely high, and the specificity of his dosing recently reviewed and assembled this information in a

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Figure 9.  Sample computed tomographic scans of, A, a male subject in the young age group and, B, a male subject in the old age
group, with mean pyriform aperture area applied. Reprinted with permission from Shaw RB Jr, Kahn DM. Aging of the midface
bony elements: A three-dimensional computed tomographic study. Plast Reconstr Surg. 2007;119:675–681.

Figure 10.  A, This 48-year-old man presented for treatment of facial lipoatrophy. This patient’s loss of facial fat makes it easier to
identify the convexites due to muscle and bone such as the zygomatic arch, the masseter, and the perioral muscular prominence.
Note that the perioral muscular prominence is made visible by the loss of facial fat both above and below it. Note also that it
is found in the same location that one would find a “marionette” fold. It is obvious that this will be improved not by “filling
the fold,” but by replacing the missing volume superior and inferior to the prominence. B, Midtreatment. He was treated with
three vials of PLLA per session over three sessions spaced six weeks apart (for a total of nine vials). C, Three months after his
last treatment. D, This 42-year-old woman presented for treatment of aging. E, Midtreatment. She was injected with two vials
of PLLA per session over three sessions spaced four weeks apart (for a total of six vials). F, One year after her last treatment.
She was treated in the same areas as the patient in parts A-C (temporal and lateral cheek fat pad, deep medial cheek fat pad,
medial and middle cheek as well as submental fat pad), resulting in a nice improvement even in areas not treated directly, such
as the tear trough, nasolabial and marionette folds, and the along the jawline. By virtue of what their anatomy and “empty” fat
compartments reveal, severely lipoatrophic faces like these, may offer a “road map” of how to effectively treat younger faces or
plumper faces with similar but less obvious changes. Perhaps this anatomy is obscured in fuller faces by the folds it creates (the
concept of “pseudoptosis”). Photos courtesy of Rebecca Fitzgerald, MD. Reprinted with permission from Jones DH. Injectable
Fillers: Principles and Practice. Wiley-Blackwell, London 2010.

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Figure 11.  A, This 58-year-old woman presented for treatment of nasolabial folds. B, Midtreatment. C, Four months after the
final treatment. This patient was injected two vials of PLLA per session over three sessions (for a total of six vials vials total)
in the area of the temporal and lateral cheek compartment, the middle cheek compartment, and supraperiosteally along the
maxilla and mandible. Note that treatment of the deep medial cheek fat pad improved the contour of the cheek, as well as
indirectly softening the nasolabial fold and tear trough. Note also the change in facial shape brought about by this treatment.
Photos courtesy of Rebecca Fitzgerald, MD. Reprinted with permission from Jones DH. Injectable Fillers: Principles and Practice.
Wiley-Blackwell, London 2010.

Figure 12.  (A) This 35-year-old female presented for nasolabial fold treatment. (B) One month after treatment with one vial
of poly-L-lactic acid (PLLA) injected in the area of the temporal and lateral cheek fat compartment, as well as the deep medial
cheek fat pad. Note the improvement in anterior projection and contour of her cheek. Note also the subtle change in facial
shape brought about by this treatment. Photos courtesy of Rebecca Fitzgerald, MD. Reprinted with permission from Jones DH.
Injectable Fillers: Principles and Practice. Wiley-Blackwell, London 2010.
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Figure 13.  (A) This 28-year-old woman presented for subtle feminization of her facial shape. (B) Four months posttreatment.
She was injected with one vial of poly-L-lactic acid (PLLA) to fill out her temples and cheeks, as well as 20 units of botulinum
toxin type A in each masseter to provide a more oval shape to her face. Photos courtesy of Rebecca Fitzgerald, MD. Reprinted
with permission from Jones DH. Injectable Fillers: Principles and Practice. Wiley-Blackwell, London 2010.

Figure 14.  In these photographs of one 40-year-old man (A) and one 76-year-old man (B) with advanced lipoatrophy, the
reader can easily observe the shape and proportions of the craniofacial skeleton under the skin. The orbital rim changes can
be easily noted, as well as the change in the position of the nose and in the perioral ratios seen with aging. Photos courtesy of
Rebecca Fitzgerald, MD. Reprinted with permission from Jones DH. Injectable Fillers: Principles and Practice. Wiley-Blackwell,
London 2010.

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Figure 15.  (A) This 30-year-old, “baby-faced” woman presented with poor craniofacial support. (B) Four months after her final
treatment. She was injected with two vials of poly-L-lactic acid (PLLA) per session over two sessions spaced two months apart
(for a total of four vials). The product was placed along her superior lateral orbital rim, lateral zygoma, anterior maxilla, canine
fossa, and along the mandible in roughly the same area that would be treated with a solid implant. The patient received no other
treatment. Note the brow elevation and change in the perioral area and facial shape with these treatments. Photos courtesy of
Rebecca Fitzgerald, MD. Reprinted with permission from Jones DH. Injectable Fillers: Principles and Practice. Wiley-Blackwell,
London 2010.

concise and cogent fashion. The results of their review of gender dimorphism was revealed with regard to the abso-
work from Bartlett et al,29 Pessa,30-35 Levine et al,36 Farkas lute angular measurements, in that men demonstrated a
et al,37 Mendelson et al,38 and Shaw and Kahn39-41 indicate trend toward more acute measurements in the upper
that significant and consistent changes occur as the face—specifically the glabellar and orbital angles—
craniofacial skeleton ages. The most consistent findings compared with women in the same a cohort. Women
included a change in contour of the orbit (with superior demonstrated a trend toward more acute angular meas-
medial and inferiolateral remodeling as described by Pessa urements in the lower face—the maxillary and pyriform
over a decade ago42), decreased midface vertical height in angles—compared with men in the same age cohort. Such
edentulous patients, and a decrease in the glabellar, pyri- differences between the genders might be expected when
form, and maxillary angle. one considers that men are known to have more promi-
In addition, a recently published retrospective review nent foreheads and superior orbital rims than women,
from Richard et al43 of computed tomography (CT) scans whereas women are known to have a more diminutive
of 100 consecutive patients at Duke University Medical midface than men.
Center included 50 men and 50 women from two age Although longitudinal studies would be ideal, the data
groups, younger (aged 18-30 years) and older (55-65 described above were all found to be statistically signifi-
years). Those authors found similar changes in the glabel- cant. In Figure 9 (a CT image of patients from the younger
lar, pyriform, and maxillary angle. They noted that their and older age group of the study by Kahn and Shaw40
findings were in agreement with the early work of illustrating the orbital, glabellar, maxillary, and pyriform
Enlow44 and the “clockwise rotation” of the maxilla and changes), the shape and proportions of the younger and
mandible when viewed in profile, as hypothesized by older craniofacial skeleton without any intervening fat can
Lambros and Pessa45 over a decade ago. The study was in be seen. The orbital rim changes can be easily noted, as
fact carried out to expand Pessa’s work by increasing the well as a change in the position of the nose.
sample size, including measurements of the orbit, and Finally, age-related bony remodeling causes a decrease in
examining the role of gender in such aging changes. A the space available for the soft tissue in the midface;

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 22S Aesthetic Surgery Journal 30(Suppl 1)

Figure 16.  (A) This 50-year-old man presented for treatment of a “tired appearance.” (B) One year after final treatment. He was
injected with one vial of poly-L-lactic acid (PLLA) per session for three sessions carried out several months apart (for a total of
three vials). The product was placed along his lateral supraorbital rim, lateral zygoma, and canine fossa, as well as along the
mandible to address bony remodeling. Note the improvement seen from a very subtle change in facial shape and proportions.
Photos courtesy of Rebecca Fitzgerald, MD. Reprinted with permission from Jones DH. Injectable Fillers: Principles and Practice.
Wiley-Blackwell, London 2010.

the result is a “folding in” of the soft tissue in a configura- provided by Global Academy for Medical Education, LLC,
tion that resembles an accordion, referred to by Pessa and an Elsevier company, and Joanne Still, medical writer in
colleagues5 as the “concertina effect.” The value of this the development of this continuing medical educational
work lies in its implications for treatment—that is, that an supplement. These services and assistance were funded by
inadequate underlying bony structure may be augmented grant support from sanofi-aventis.
by solid implants or even by injectable shaping agents (such
as polylactic acid [PLLA]), resulting in the restoration of soft Disclosures
tissue support and therefore a reversal, to some degree, of Dr. Fitzgerald is a consultant for sanofi-aventis. Dr. Graivier is
the concertina effect. A series of patient photos (Figures a consultant for Coapt Medical, Elemé Medical, and Evera
10-17) demonstrate these concepts in clinical practice. Medical and is on the speaker’s bureau for Medicis and Sciton.
He has stock interests in BioForm Medical. Dr. Kane is a con-
sultant and/or speaker for Allergan, Canfield, Coapt,
CONCLUSIONS Galderma, Johnson & Johnson, Medicis, Mentor, QMed, Reva-
With an understanding of the facial aging process in the nace, sanofi-aventis, Shire, and Stiefel. He has stock interests
four structural planes—skeletal platform, muscle, fat, and in Allergan and Medicis. Dr. Lorenc is a consultant for John-
skin—clinicians are better able to employ the available son & Johnson. Dr. Vleggaar is a consultant for sanofi-aventis.
injectable shaping agents to improve a patient’s appear- Dr. Werschler is a consultant for and has received grant
ance, either with nonsurgical treatment only or as adjuncts support from Allergan, Clarisonic, Galderma, Genentech,
to surgical correction. With this in mind, in the next sec- MyoScience, sanofi-aventis, and SkinMedica. He is also a
tion, we will address the importance of a careful aesthetic speaker for and has stock interests in Allergan, BioForm, Clar-
analysis. ismiz, Medicis, MyoScience, sanofi-aventis, and SkinMedica.
Dr. Kenkel is a consultant for Ethicon, Ethicon Endo-Surgery,
Acknowledgments and UltraShape. He has received grant support and/or equip-
The faculty acknowledge the writing assistance and editorial ment for research from Eclipse, Lumenis, Sciton, and
services including fact checking, referencing, and graphics UltraShape.

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 Fitzgerald et al 23S

Figure 17.  (A) This 60-year-old man presented for treatment of general facial aging. (B) Six months after the final touch-up
treatment, which took place six months after the original injections. He was initially injected with two vials of poly-L-lactic acid
(PLLA) per session for three sessions over six weeks. Touch-up treatment included two vials of PLLA and took place one year after
the last initial treatment. The patient treated with supraperiosteal injections along the lateral supraorbital rim, lateral zygoma,
anterior maxilla, canine fossa, and medial mandible, as well as in the temple and the deep medical cheek fat pad. The repositioning
of his nose and eversion of his lips are clearly evident. Photos courtesy of Rebecca Fitzgerald, MD. Reprinted with permission from
Jones DH. Injectable Fillers: Principles and Practice. Wiley-Blackwell, London 2010.

Funding to facial rejuvenation. Plast Reconstr Surg 2009;123:

This CME activity is supported by an educational grant from 1050-1062.
sanofi-aventis. Funding was provided for the development   4. Stuzin JM. Restoring facial shape in face lifting: the role
and execution of an expert consensus roundtable and the edi- of skeletal support in facial analysis and midface soft
torial development, publication and accreditation of this tissue repositioning. Plast Reconstr Surg 2007;119:362-
continuing medical education supplement. 376; discussion 377-378.
  5. Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and
Statement of Peer Review facial aging: nonlinear aspects of youthfulness and skel-
All supplement manuscripts submitted to Aesthetic Surgery etal remodeling, and why, perhaps, infants have jowls.
Journal for publication are reviewed by the Guest Editor(s) of Plast Reconstr Surg 1999;103:635-644.
the supplement, by an outside peer reviewer who is indepen-   6. Lambros V. Observations on periorbital and midface
dent of the supplement project, and by the Journal’s aging. Plast Reconstr Surg 2007;120:1367-1376; discus-
Supplement Editor (who ensures that questions raised in peer sion 1377.
review have been addressed appropriately and that the sup-   7. Yaar M, Gilchrest BA. Skin aging: postulated mechanisms
plement has an educational focus that is of interest to our and consequent changes in structure and function. Clin
readership). Geriatr Med 2001;17:617-630.
  8. El Domyati M, Attia S, Saleh F, et al. Intrinsic aging vs.
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