Introduction

Age is one of the social personal parameters of assessment of each individual in society. Perception of age during communication is made up of many details of appearance. These details consist of the state and relationships of integumentary, soft and supporting tissues of the face. Youth is not identical with beauty, but correlation of this aspect is obvious. Understanding beauty is always subjective and includes many views and opinions depending on racial and ethnic parameters specific for each era. However, youth is always subconsciously associated with health.

The appearance, corresponding to young age parameters of a person, is perceived by society as an indicator of health and general well-being. Smaller lower third of the face, more pronounced cheekbones and soft tissues of the middle and upper third determine heart-shape or diamond-shape female face. Aging is accompanied by extensibility of soft tissues, muscles and ligaments due to loss of elasticity and collagen fragmentation. Gravity-induced ptosis of soft tissues changes facial contour by analogy with a wide dress hiding the figure (Fig. 1). There are extensive data and illustrations of aging-related facial skeleton changes in the Internet and literature (Fig. 2) [1]. The studies by Lambros et al. [2] allow assessing the general trend of age-related facial changes. However, there are still no metric data on these changes evidenced in prospective trials. At the same time, the fundamental Wolff’s law and Frost’s theory [3, 4] on bone resorption under loss of load clearly justified facial changes not so much with age, but with additional factors such as smoking, loss of teeth, sleeping on one of the halves of the face. These features were described in the studies of twins [5]. It is not possible to systematize significant predictors of facial changes for each person at this stage of development of medicine and science.

Fig. 1. Age-related changes in facial soft tissues.

Fig. 2. Age-related changes in facial support tissues.

Material and methods

A retrospective analysis of medical data and digital images was performed in 132 patients for the period from 2010 to 2019. Five standard angles (front, three-quarter, left and right profile) were used. The follow-up period was 1–5 years after surgery. All characteristics of facial soft and supporting tissues were evaluated. All implants were deployed under periosteum. Zygomatic implants of various configurations were installed via transoral approach after mobilization of surfaces of zygomatic and maxillary bones. Chin implants were deployed via transoral or external approach along the border between the chin and submental areas. Implantation was indicated for patients’ dissatisfaction with appearance in comprehensive assessment of facial soft and supporting tissues. Preoperative CT was not performed routinely due to the lack of influence on treatment strategy, i.e. positive or negative decision on implantation.

Results and discussion

Perception and assessment of age consist of a complex of characteristics of all facial areas. Correction of skin and soft tissue imperfections in a certain area does not ensure the effect of rejuvenation in case of concomitant more significant changes beyond this area.

Case report

We observed a 48-year-old patient O. with gravitational changes in all parts of the face and neck. Age-related changes in the upper and lower eyelids were eliminated after previous circular blepharoplasty. However, comparison of the images before and after correction revealed no changes in the biological age (Fig. 3).

Fig. 3. Result of isolated blepharoplasty after 1 year.

a — before surgery; b — after 1 year.

In our opinion, the purpose of rejuvenation surgery is comprehensive correction of topographic and anatomical factors rather elimination of certain age-related changes per se. In this case, facial parameters in certain zones of interest will correspond to anatomical and topographic data of young face.

Importantly, facial aging always starts from one of the areas. This is either the lower third of the face or the periorbital region. This feature is natural both anatomically (according to ligamentous structures) and embryogenetically (development of soft tissue structures) [6].

In the first case, congenital structural features of the facial skeleton (weakly developed chin of the lower jaw typical for female phenotype or lower jaw underdevelopment (prognathia)) result a rapid loss of submental-cervical angle in early age and facial oval violation in the lower third with or without sagging jowls (Fig. 4). According to available scientific data, porous facial implants are currently more popular than silicone ones. Deployment of porous implants is a safe procedure, although there are certain drawbacks associated with minimal percentage of postoperative complications [7].

Fig. 4. Result of lower third facial and neck lifting.

a — before surgery; b — after 1 year.

Periorbital changes begin with demarcation of the lower orbital margin, nasolacrimal grooves and bags under eyes. This is the result of gravitational ptosis of soft tissues of middle facial compartment with demarcation lower eyelid compartments and eyelid height increase. Demarcation is ensured by the ligaments of nasolacrimal groove (Fig. 9).

Understanding the mechanisms underlying tissue involution and age-related facial changes determines the choice of effective methods for their correction. Correct diagnosis ensures the choice of adequate treatment. This axiom is universal and true for rejuvenation surgery.

Incorrect diagnosis is followed by wrong treatment and prerequisites for unsatisfactory or unstable clinical results.

In our practice, we evaluate the following parameters:

— periorbital skeleton;

— lower third facial skeleton;

— relationships and ptosis of heads, bodies and tails of eyebrows;

— excess, turgor and tone of eyelid skin;

— pinch test;

— horizontal displacement of lower eyelids;

— facial vector;

— intercanthal vector;

— distance from lateral canthal angles of orbital fissures to outer walls of the orbits;

— vertical alternation of tarsal edge of lower eyelid;

— nasolabial folds and furrows, sagging jowls, marionette lines;

— volume and point of maximum prominence of soft tissues of the middle third of the face;

— volume of soft tissues of the lower third of the face;

— mouth corner ptosis;

— submental-cervical angle;

— condition and tone of platisma;

— condition and excess of paraauricular and neck skin.

The main targets of rejuvenation facial surgery in our practice are periorbital region and lower third of the face and neck.

Normal facial skeleton in these areas is characterized by sufficient support.

Surgery of the lower third of the face and neck

Case report. Patient M., 31 years old, rejuvenation of the lower third of the face with sufficient support of periorbital region.

It should be noted that surgery of the lower third of the face and neck is a rejuvenation surgery of profile and three-quarter image angle.

The patient insisted on lifting the lower third of the face without correction of periorbital region (there were indications for periorbital region rejuvenation) (Fig. 5).

Fig. 5. Result of lower third facial and neck lifting.

a — before surgery; b — after 1 year.

A stable result was obtained after a year (profile). However, front appearance was almost the same (Fig. 5). Thus, incorrect surgery does not result an adequate clinical outcome and rejuvenation per se that cannot satisfy the patients.

Periorbital surgery is a rejuvenation surgery of face and three-quarter image angle.

Case report. A 51-year-old patient E. with sufficient facial skeleton support underwent upper and middle third facial lifting. A stable result was obtained, a 1-year outcome is shown in Fig. 6.

Fig. 6. Result of upper and middle third facial lifting.

a — before surgery; b — after 1 year.

Importantly, middle zone lifting of the face indirectly affects the lower third of the face, but this effect is not direct and final. Therefore, we do not offer this procedure as an option. However, we obligatory talk with patients about this aspect in preoperative period. Indeed, tissue redistribution of the middle facial zone at the expense of the lower third changes the shape of the face as a whole.

Case report. A 52-year-old patient I. underwent upper and middle third facial lifting (Fig. 7).

Fig. 7. Result of upper and middle third facial lifting.

a — before surgery; b — after 1 year.

Severity and rate of gravitational changes of the face is a balance between supporting structures of facial skeleton and soft tissues. Impaired support function of facial skeleton determines the rate and degree of aging. Unfavorable predictive parameters include:

— support properties of inferior orbital edge and malar eminence are essential for the middle third of the face. These parameters determine facial vector. Zero or negative vector is an unfavorable factor;

— state of nasolabial, labiomental and submental-cervical angles is important for the lower third of the face and the upper half of the neck. Upper and lower jaw malformations are unfavorable conditions.

Facial skeleton in the middle zone and lower third of the face does not always allow obtaining a stable and significant clinical effect during surgical rejuvenation. In such cases, we use porous polyethylene foam implants. There are several offers on the market. The common factor in the use of these implants is their mechanism of action. The implants are deployed into deep layers (under periosteum) and fixed to facial skeleton. Thus, the underlying soft tissues are stretched on the implant that is not identical to implantation into the soft tissues. In the last case, an implant together with soft tissues are subject to gravitational changes and casuistic mimic animation in certain degree. Soft tissue augmentation with fillers is also not analogous to implant placement because this method increases soft tissue weight instead of enhancing support of facial skeleton.

I. Periorbital rejuvenation with facial augmentation.

The areas of interest are tear trough ligament and orbicularis retaining ligament [8], infraorbital edge of the midface and malar eminence. Gravitational changes in this area are followed by bags under eyes, visualization of palpebromalar groove, nasolacrimal groove and midcheek groove [9] in sequestration of the malar bag (Fig. 8).

Fig. 8. Scheme of facial furrows.

Case report. A 37-year-old patient I. with congenital hypoplasia and gravitational changes of the midface, lower eyelid hernia. Rejuvenation of the upper, middle third of the face with installation of infraorbital implants was performed (Fig. 9).

Fig. 9. Result of upper and middle third facial lifting with insertion of infraorbital implants.

a — before surgery; b — after 1 year.

Case report. A 47-year-old patient S. with congenital hypoplasia and gravitational changes of the midface, scleral show. Rejuvenation of the upper, middle third of the face with installation of infraorbital implants was performed (Fig. 10).

Fig. 10. Result of upper and middle third facial lifting with insertion of infraorbital implants.

a — before surgery; b — after 1 year.

II. Rejuvenation of the lower third of the face with facial augmentation.

The object of surgical interest is SMAS structure changes in this zone (platysma). Standard vector of redistribution in manipulations with platysma is upper lateral one with various possible variants and modifications. Combination of SMAS lifting with anterior platysmoplasty is followed by medialization of medial edges of platysma via suturing anterior edges of its leaflets. Medialization of platysma is a counterdirectional vector in relation to SMAS lifting that ensures tension of platysma, clear outer oval and contours of the lower jaw. An important aspect in rejuvenation of the lower third of the face and neck is mandibular cutaneous ligament (Furnas ligament) [8]. This structure determines the mechanisms and anatomy of changes in the lower third of the face. Mandibular cutaneous ligament as a true ligament creates a pivot point and realizes appearance of sagging jowls and submental changes. This non-displaceable point does not ensure stable result during SMAS lifting. Mandibular cutaneous ligament is the object of surgical interest.

Case report. A 32-year-old patient N. with congenital hypoplasia of the chin of the lower jaw underwent deployment of chin implant (Fig. 11–12).

Fig. 11. Result of submental implant insertion. Face.

a — before surgery; b — after 1 year.

Fig. 12. Result of submental implant insertion. Profile.

a — before surgery; b — after 1 year.

Congenital lack of support function of the lower third of the face following hypoplasia of the chin of the lower jaw was compensated by installation of chin implant under periosteum.

Case report. A 48-year-old patient N. with congenital hypoplasia of the chin of the lower jaw, age-related atrophic, gravitational changes in the lower third of the face and neck underwent lifting of the lower third of the face and neck, installation of a chin implant (Fig. 13–14).

Fig. 13. Result of lower third facial and neck lifting with submental implant insertion. Face.

a — before surgery; b — after 1 year.

Fig. 14. Result of lower third facial and neck lifting with submental implant insertion. Profile.

a — before surgery; b — after 1 year.

Case report. A 47-year-old patient N. with congenital hypoplasia of the chin of the lower jaw, age-related atrophic, gravitational changes in the lower third of the face and neck underwent lifting of the lower third of the face and neck, installation of a chin implant (Fig. 15).

Fig. 15. Result of lower third facial and neck lifting with submental implant insertion. Profile.

a — before surgery; b — after 1 year.

Conclusion

Age-related changes of the face are a consequence of atrophy and gravitational ptosis of soft tissues following collagen atrophy, weakening of ligamentous structures with their extension and facial skull configuration changes, especially the upper and lower jaw.

Surgical anti-gravity treatment is required to realize anti-aging effect.

Facial augmentation ensures more significant clinical results of anti-aging surgery.

Augmentation of the lower third of the face does not affect the morphotype and preserves personal individuality. At the same time, midface correction may be followed by certain external changes. The last ones can be regarded as the features changing morphotypic identity of personality.

The authors declare no conflicts of interest.