Key points

Introduction

Aging of the face is inevitable and undeniable. Facial aging includes a loss of skeletal support, soft tissue volume depletion, and a decrease in skin elasticity. Surgical rejuvenation of the face includes a variety of procedures designed to restore soft tissue volume, reestablish skeletal support, and reposition ptotic soft tissues.

To rejuvenate any face, the facial plastic surgeon must diagnose the specific cause of the aging process, requiring attention to the anatomic causes of the individual’s aging. Each face is individual in its rate and specific type of aging. Although every face is unique, certain facial types exist that loosely dictate how that face will age. This article outlines the pertinent anatomy related to facial aging and the characteristics of certain facial types and ethnicities and presents an algorithm for treatment of each aging types.

Introduction

Aging of the face is inevitable and undeniable. Facial aging includes a loss of skeletal support, soft tissue volume depletion, and a decrease in skin elasticity. Surgical rejuvenation of the face includes a variety of procedures designed to restore soft tissue volume, reestablish skeletal support, and reposition ptotic soft tissues.

To rejuvenate any face, the facial plastic surgeon must diagnose the specific cause of the aging process, requiring attention to the anatomic causes of the individual’s aging. Each face is individual in its rate and specific type of aging. Although every face is unique, certain facial types exist that loosely dictate how that face will age. This article outlines the pertinent anatomy related to facial aging and the characteristics of certain facial types and ethnicities and presents an algorithm for treatment of each aging types.

Anatomic considerations of facial aging

The anatomic layers of the face are consistent in all faces. These layers, from superficial to deep, are the skin, subcutaneous fat, superficial fascia, loose areolar tissue, and deep fascia. Although the layers in all faces are the same, the relative thicknesses and the tendency to slide on each other are variable. It is clear that the amount of fat varies in each face according to face type, genetics, body mass index (BMI), and ethnicity. Each of these characteristics contributes to the overall amount of facial volume and to the manner that the face ages.

The pathophysiology of facial aging includes (1) loss of skin elasticity, (2) soft tissue volume depletion, and (3) loss of skeletal support of the soft tissue envelope. Surgical rejuvenation of the face should be individualized to reestablish skeletal support and/or replenish soft tissue volume loss and to lift soft tissues when they are ptotic.

Mitz and Peyronie provided the original description (1976) of the superficial fascia of the face, the superficial musculoaponeurotic system (SMAS). This fascia envelopes the midface and interconnects the midfacial musculature. In all areas of the head and neck (the forehead, temple, midface, and neck), the superficial fascia connects to the deep fascia through fibrous interconnections (loose areolar tissue). The density of this loose areolar tissue is quite variable and determines the amount that the soft tissues of the face sag. The superficial to deep fascial attachment can be dense or consist of loose filmy tissue that slides easily on each other.

In thin patients with low BMI, there is relatively less subcutaneous fat and the glide plane between the superficial and deep fascia is characterized by a loose attachment. This weak attachment leads to a lack of support and ptosis of the soft tissues. In patients with denser facial fat, the thicker subcutaneous layer is usually associated with less facial rhytids and less descent of the soft tissues of the face.

Anatomic characteristics of different races

There is no standard facial type for any race or ethnicity. As societies have changed, a mingling of facial characteristics of Asian, Caucasian, and Negroid features has occurred. This cross-fertilization has blurred facial characteristic and classic distinctions between races.

In the past, it was common to hear lectures or read articles in the plastic surgery literature highlighting the specific facial characteristics of a particular race or ethnicity. Presently, it is not accurate to characterize a facial type based on ethnicity, as there is no Mestizo nose, or Asian facial type.

However, it is clear that certain faces have denser and more globular fat, and this causes aging that is different than those individuals who lose fat and facial volume as they age. The tendencies to lose versus maintain fat as one ages depends on several factors, including body weight and the individual’s particular genetic composition. For instance, if a patient’s parents tend toward good maintenance of facial volume (as they aged), the chances are high that that individual will maintain his or her facial volume as they age.

The characteristic facial skeleton in most Asian patients is a prominent zygomaticomalar region with a large bizygomatic width. The lower facial skeleton is often characterized by a less projected bony pogonion (weak chin) in the anterior-posterior direction. However, the transverse width of the mandible (from one mandibular angle to the other) is usually large. This relatively masculine trait often causes women to request bony mandibular angle reduction. The dental skeletal relation in Asian patients often reveals bimaxillary protrusion. Bimaxillary protrusion is associated with a weak position of the bony subnasale and a weak pogonion, but a prominent dental occlusion in the anterior-posterior dimension. For this reason, chin augmentation with either an alloplast chin implant or a horizontal osteotomy of the bony mentum (sliding bony genioplasty) is a complementary procedure to lifting in lower facial rejuvenation. In that bimaxillary protrusion is associated with a slightly protuberant lower lip, the lower lip should not be used solely as a reference point when deciding on the size of the chin implant and the desired amount of augmentation. Conservative augmentation of the chin should be performed in a balancing procedure ( Figs. 1 and 2 ).

( A–C ) Before and ( D–F ) after frontal, lateral, and oblique views of an Asian woman who underwent a chin implant, submental liposuction, and neck lift.

Before ( A–C ) and after ( D–F ) frontal, lateral, and oblique views of an Asian woman who underwent upper and lower blepharoplasty, deep plane rhytidectomy with submental liposuction, platysmaplasty, and chin augmentation with alloplastic implant.

Skin considerations

In most Asian patients, the skin is thicker and more fibrous than is skin in Caucasians. In addition, there is more pigment and tendency for solar lentigines. The effects of thicker skin with increased pigmentation are important for the patient desiring facial rejuvenation. On average, skin in Asian patients has increased dermal thickness, collagen content, and melanin than skin in Caucasians. Studies comparing racial differences in the structure of the stratum corneum suggest that more pigmented skin contains more cell layers when compared with lightly pigmented skin. Pigmented skin also has larger fibroblasts and higher lipid content than lighter skin.

The larger fibroblasts and increased dermal thickening in Asians affect both the manner of aging of the face and the healing after rejuvenative procedures. In 2005, Nouveau-Richard and colleagues studied aging characteristics in age-matched populations of Chinese and Europeans. This study revealed that the onset of wrinkles in Asian women was delayed by approximately 10 years when compared with age-matched French women. In addition, aging Asian women had an increased association of noncancerous pigmented lesions when compared with European women.