INTRODUCTION
AN AGING FACE is characterized by uneven, focal ptosis of the soft tissues of the infra- orbital, zygomatic, buccal, mental, and submental areas.(1–3) Fat tissue in the zygomatic area is closely connected to the skin and the arch of the zygomatic bone by solid intersection with the subcutaneous muscular aponeurotic system (SMAS) and rarely sags(2) (Fig 1). Subcutaneous fat of the adjacent areas (infraorbital, buccal, malar, and partially mandible) is suspended from under the soft tissues of the zygomatic areas. While the contour of the skin of the young is smooth and even, changes occur from the effects of age, degree of development of the subcutaneous fat, its structural pattern, as well as the relationship to the SMAS, and the work of the mimic and masticatory muscles. In places where the connections are weak or the influence is more intensive, gravitational sagging of these areas occurs, with the appearance of lachrymal grooves, deepening of the nasolabial folds, and wrinkling (rhytids)(3)(Fig. 2).
Involutional alterations in the suborbicular areas has been ascribed to the gradual sliding down of such tissues as the suborbicular ocular fat (SOOF).(4) In the lower portions of the face, sagging of the subcutaneous fat is prevented by the neurovascular bundle originating from the mental foramen as well as by a more or less solid adhesion of soft tissues along the lower jaw. The overhanging tissues appear as wrinkles of “mourning.”(5)
These involutional alterations have previously been considered to be due the aging pro- cess of the integument. The solution consisted of lifting and excising the excess skin. Since 1974, such operations have been complemented by lifting the soft tissues under the SMAS.(6) Some surgeons have postulated a role of the facial skeleton in the aging process and have devised supraperiosteal and subperiosteal SMAS lifts especially with endoscopic equipment.(4,7,8) Facial and neck rejuvenation now includes skin peeling, contour injection of a variety of gels, and skin reinforcement with 24-karat golden threads.(9,10) Filling in folds and wrinkles with injectable materials can result in a pasty-appearing, puffy face with unnatural contours. Skin peeling results in skin tightening but does not lift tissues or form a new contour.
