Aging has an obvious effect on how the face looks from the outside with many recognized soft tissue changes. Wrinkles, deepening nasolabial folds, crow’s feet and jowls are but a few of the effects that gravity and time cause. This understanding has led to the many well known plastic surgery procedures whose intent is to resuspend sagging skin as well as skin removal/reduction.
But much like beauty, aging goes the whole way down to the bone and is not spared. In many ways it is somewhat reflective of what has happened on the outside. Multiple studies in plastic surgery have looked at how the face ages beneath the skin. Volume loss, primarily of fat, creates an overall facial ‘deflation’ and this understanding has led to the widespread use of synthetic injectable fillers and injections of your own fat to help plump up the aging face. But loss of the deepest tissue, the bone, also makes a contribution to this volume.
Since the bone provides a scaffold onto which the overlying soft tissues drape onto, it is logical to assume that the facial skeleton changes as well. Recent studies using CT scans have looked at various areas of the facial bones and their aging changes. The width and size of the eye (orbit) increases with an almost sagging appearance to the outer lower orbital rim. The glabella (bone between the brows) and the upper rims of the eyes (brow bones) flatten. The maxilla is affected by loss of pyriform aperture and a decrease in the maxillary angle. The length and height of the lower jaw (mandible) shortens with resorption of the jaw angle. (enlarged mandibular angle)
All of these facial bony alterations with age can be correlated to associated outward soft tissue changes. The dropping of the brows and the piling of eyelid skin is a reflection of the loss of underlying bone support. The deepening nasolabial folds and the sagging cheeks are reflective of the maxillary resorption. A weaker chin, jowling and lax neck tissues are partially effected by the loss of lower jaw volume.
The facial skeletion does change with age, primarily with loss of volume of key bony support areas. This results in lessening areas of soft tissue adherence and sagging and deflated overlying soft tissues. This in addition to the loss of facial fat creates the appearance of the aging face.
Bone augmentation of the aging face with implants can be a useful surgical strategy for some patients. Reversing the age-related changes (atrophy) of certain facial bone areas can be done very simply with implants, adding volume to where it has been lost. Implants can do this in two ways, filling out concavities and bulking up weakened convexities. Tear troughs and paranasal deficiencies are examples of deepening concavities. Orbital rims, cheeks, chin and jaw angles are areas of weakened convexities.
Skeletal facial implants, while often thought of as just for younger patients seeking better facial highlights, can be useful for the aging face patient as well. They offer a permanent solution to specific aging facial areas that have ongoing resorption which contributes to loss of overlying soft tissue and skin support. They can be used in conjunction with any of the soft tissue redraping procedures to help create a better facial rejuvenative effect.
Dr. Barry Eppley