A hallmark of facial aging is a sagging skin envelope -- fallen cheeks, jowls, turkey gobbler necks, eyelid bags.... These changes are all attributed to gravity and loss of skin elasticity due to environmental related damage (excess sun exposure, smoking, diet, etc.). The long standing and still most effective therapy to restore youthful facial contours are properly performed surgical procedures: facelifts, necklifts, browlifts and eyelifts (blepharoplasty).
The last decade has brought recognition that a significant component of the appearance of the aging face is contributed to the loss of volume of the soft tissue envelope. This has been documented by the work of Newport Beach plastic surgeon, Val Lambros, who with serial photographs of individual patients over time, has shown that certain facial landmarks retrude rather than fall with time. His efforts have supported the use of techniques to inflate the facial soft tissue envelope as a facial rejuvenation strategy.
Fillers and fat grafts have been in vogue as the latest adjuncts to rejuvenate the aging face. For that reason, the plastic surgery literature and appearance oriented magazines are replete with articles on these two soft tissue volumizing modalities. Most recently the journal of Plastic and Reconstructive Surgery published a supplement of articles addressing the use of various fillers used for facial soft tissue enhancement.
The article by Wong and Mendelson and emphasized a different aspect of the aging face and its treatment with fillers. Several researchers have shown that certain areas of the skeleton atrophy with age in predictable patterns. This skeletal retrusion results in less support and projection for the overlying soft tissue envelope. The figure on the left illustrates areas where bone resorption has been shown to occur. The split image on the right shows an aged skeleton and the resultant appearance of its overlying soft tissue envelope. Loss of bone in the orbital area leads to bags, loss along the pyriform aperture (bone adjacent to the nasal opening) aggravates nasolabial folds, while loss in the chin area leads to chin sagging and jowls.
With this knowledge, Mendelson proposes augmentation at a deeper level -- at or just above the bone. This restores, or in situations where the skeleton was never prominent in its contours, a more projecting infrastructure. In this way one can recreate, or create, a facial skeleton that can provide high cheekbones, strong chins and defined mandibles. Since the facial skeleton is the fundamental determinant of facial appearance, restoring, or creating, youthful contours to an aging skeleton can be another important adjunct to the rejuvenation process.