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Research supports multidimensional approach to rejuvenation

Article-Research supports multidimensional approach to rejuvenation

NATIONAL REPORT — New research is shedding light on the precise anatomical changes that occur as the face ages, the results of which may influence the approach surgeons take to achieve facial tightening with truly natural-looking results. Two recent studies specifically pinpoint facial qualities of bone and fat and offer insights on how the two fluctuate with age.

Dr. Woodward
COMPROMISED COMPARTMENTS It is commonly believed that the face ages as a confluent or composite mass, but one study instead proposes that aging occurs in grouped sections of fat, with soft tissue malposition possibly resulting as the compartments are compromised over time.

"I think that eventually this will dramatically change how we do facial rejuvenation and surgery because it allows us to analyze the patient's face, correlate it with the anatomy of the facial fat compartment, and then do the restorative augmentation with fat and lifting techniques to restore facial shape and form," says Rod Rohrich, M.D., F.A.C.S., lead author on the study and chairman of the Department of Plastic Surgery at the University of Texas Southwestern Medical Center in Dallas.

Researchers made the observation in 30 hemifacial cadaver dissections that were injected with methylene blue dye. They found that subcutaneous fat of the face was partitioned into compartments, with the nasolabial fold in a unit with distinct boundaries of its own, and malar fat composed of medial, middle and lateral temporal-cheek fat. The study also suggests that the forehead is divided into three anatomical units of central, middle and lateral temporal cheek fat, and that orbital fat is also in three compartments determined by septal borders.

"This is really a breakthrough in facial aging," says Dr. Rohrich. "It's not just sagging of the skin — it's also atrophy of the face [that] ...helps explain...why we have that inverted 'V' below the eyelid and why we get a tear trough." The findings offer new guidance to achieve "a more youthful appearance to avoid that tell-tale, operated-on look," he tells Cosmetic Surgery Times .

SKELETAL STRUCTURE Recent research provides evidence that bone remodeling also occurs in the face. Researchers at Duke University Medical Center report that the bony structure of the skull appears to change as people age. As presented at the annual meeting of the American Society of Ophthalmic Plastic and Reconstructive Surgeons, in a retrospective review of 100 patient CT scans, a rotation was observed in which the frontal bone moved anteriorly and inferiorly, while the maxilla moved posteriorly and superiorly.

The effect was slightly more pronounced in women than in men, and the researchers suggest that the rotation also causes bony angles that likely impact the position of overlying soft tissue. "There are clearly a lot of changes going on in the structure of the face," says Julie Ann Woodward, M.D., head of oculoplastic and reconstructive surgery at Duke University Medical Center and a study coauthor. "The skeleton doesn't have the exact same shape for the rest of its life. There are certain areas where one side creates new bone and the other side resorbs a little," she says. "So there is this constant shift throughout one's life, and aside from the soft tissue drooping, you can get a more aged look due to the shape of the bone."

DIMENSIONAL THINKING The two studies' findings contribute to the body of research that is making cosmetic surgery much more of a multidimensional endeavor, says Wm. Philip Werschler, M.D., assistant clinical professor of medicine and dermatology at the University of Washington School of Medicine, Seattle.

"[Cosmetic surgeons] are beginning to reassess their approach to facial tightening to focus on the three ways to tighten the face — with tension, thermal lifting and volumetric lifting," Dr. Werschler explains. "The latter, used either on its own or in combination with the others, is where much of the new focus is, and filling agents are really finding their greatest utility as facial shaping agents."

The research fits in with the essential pieces of the facial aging puzzle that cosmetic surgeons need to consider, ranging from lipoatrophy, dermal atrophy and muscle atrophy to osteoporosis and osteopenia in the facial skeleton, and the breaking down of collagen and elasticity from photodamage, Dr. Werschler explains. "The skin loses its elasticity and drapes over this loosened frame of a skeleton, and that's the aging process," he says. The entire broadening picture challenges doctors to reconsider the relatively simplistic notions of wrinkle smoothing, and take a much more holistic approach to facial rejuvenation, Dr. Rohrich adds. "No longer do we have to just pull up — we have to lift and fill and that goes along with a more natural-looking facelift."


Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219-2227.

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