Three-Dimensional Approach of Cosmetic Patient: Aging Gracefully

  • Eliandre C. PalermoEmail author
  • A. Anzai
  • A. L. Jacomo
Living reference work entry

Latest version View entry history

Part of the Clinical Approaches and Procedures in Cosmetic Dermatology book series (CAPCD)


Aging is a complex process that involves intrinsic and extrinsic factors and result in modifications in all tissues of the body. The aging of the face comprise a set of changes in bone support along with atrophy and flexibility of soft tissues such as skin, muscles, fat, and ligaments. Anatomically, the face can be divided in two regions: anterior and lateral. In the anterior part, there is predominance of the structures related to facial expression, while in the lateral region muscles related to mastication stand out. Another way to divide the facial components is related to general stratification in five basic layers joined by a system of facial retention ligaments. To promote the mobility required for facial expression independent of the basic functions of the face, particularly chewing, a number of soft tissue spaces are incorporated into the face architecture. This arrangement, most clearly seen on the scalp, also exists on the rest of the face, although with significant modifications. Understanding the anatomy of the aging process, in other words, the impact of facial skeletal aging and its correlations with soft tissue changes, will lead to an understanding of the current perspective of a three-dimensional approach to injectable procedures that are much more effective in preventing and treating the signs of aging.


Aging Anatomy Fat compartments Ligaments Malar Rejuvenation Botulinum toxin Fillers Biostimulators 


  1. Brandt MG, Hassa A, Roth K, et al. Biomechanical properties of the facial retaining ligaments. Arch Facial Plast Surg. 2012;14:289–94.PubMedGoogle Scholar
  2. Chao YYY, Chhabra C, Corduff N, et al. Pan-Asian consensus – Key recommendations for adapting the world congress of dermatology consensus on combination treatment with injectable fillers, toxins, and ultrasound devices in Asian patients. J Clin Aesthet Derm. 2017;10(8):16–27.Google Scholar
  3. Cotofana S, et al. Midface: clinical anatomy and regional approaches with injectable fillers. Plast Reconstr Surg. 2015;136:219S.PubMedGoogle Scholar
  4. Cotofana S, Fratila AA, Schenck TL, Redka-Swoboda W, Zilinsky I, Pavicic T. The anatomy of the aging face: a review. Facial Plast Surg. 2016;32(03):253–60.PubMedGoogle Scholar
  5. Farkas JP, Pessa JE, Hubbard B, Rohrich RJ. The science and theory behind facial aging. Plast Reconstr Surg Global Open. 2013;1(1):8–15.Google Scholar
  6. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11.PubMedGoogle Scholar
  7. Ghassemi A, Prescher A, Riediger D, Axer H. Anatomy of the SMAS revisited. Aesthet Plast Surg. 2003;27(4):258–64.Google Scholar
  8. Gierloff M, Stöhring C, Buder T, et al. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012a;129:263–73.Google Scholar
  9. Gierloff M, Stöhring C, Buder T, Wiltfang J. The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides. J Plast Reconstr Aesthet Surg. 2012b;65(10):1292–7.PubMedGoogle Scholar
  10. Gladstone GJ, Myint S, Black EH, Brazzo BG, Nesi FA. Fundamentals of facelift surgery. Ophthalmol Clin N Am. 2005;18(2):311–7. viiGoogle Scholar
  11. Gosain AK, Klein MH, Sudhakar PV, et al. A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg. 2005;115:1143–52. discussion 1153–1155PubMedGoogle Scholar
  12. Hellman M. Changes in the human face brought about by development. Int J Orthod. 1927;13:475.Google Scholar
  13. Ilankovan V. Anatomy of ageing face. Br J Oral Maxillofac Surg. 2014;52:195–202.PubMedGoogle Scholar
  14. Jacono A, Rousso J. An algorithmic approach to multimodality midfacial rejuvenation using a new classification system for midfacial aging. Clin Plast Surg. 2015;42:17–32.PubMedGoogle Scholar
  15. Kim SJ, Kim SJ, Park JS, Byun SW, Bae JH. Analysis of age-related changes in Asian facial skeletons using 3D vector mathematics on picture archiving and communication system computed tomography. Yonsei Med J. 2015;56:1395–400.PubMedPubMedCentralGoogle Scholar
  16. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120(5):1367–76.PubMedGoogle Scholar
  17. Lee S, Yen MT. Nonsurgical rejuvenation of the eyelids with hyaluronic acid gel injections. Semin Plast Surg. 2017;31(1):17–21.PubMedPubMedCentralGoogle Scholar
  18. Liew S. Ethnic and gender considerations in the use of facial injectables: Asian patients. Plast Reconstr Surg. 2015;136:22S.PubMedGoogle Scholar
  19. Mendelson BC. Advances in the understanding of the surgical anatomy of the face. In: Eisenmann-Klein M, Neuhann-Lorenz C, editors. Innovations in plastic and aesthetic surgery. Chapter 18. New York: Springer; 2007. p. 141–5.Google Scholar
  20. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments. Clin Plast Surg. 2008;35:395–404.PubMedGoogle Scholar
  21. Mendelson BC, Facelift anatomy, SMAS, retaining ligaments and facial spaces. In: Aston J, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. London: Saunders Elsevier; 2009:53–72.Google Scholar
  22. Mendelson B, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthet Plast Surg. 2012a;36(4):753–76.Google Scholar
  23. Mendelson BC, Wong CH. Chapter 6: anatomy of the aging face. In: Neligan PC, Warren RJ, editors. Plastic surgery. 3rd ed, vol 2: Aesthetic. New York: Elsevier; 2012b p. 78–92.Google Scholar
  24. Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthet Plast Surg. 2008;32(2):185–95.Google Scholar
  25. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58:80–8.PubMedGoogle Scholar
  26. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000;105(4):1475–90.PubMedGoogle Scholar
  27. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110(3):873–84.PubMedGoogle Scholar
  28. Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg. 1993;91(3):463–74.PubMedGoogle Scholar
  29. Pessa JE, Zadoo VP, Adrian EK Jr, Yuan CH, Aydelotte J, Garza JR. Variability of the midfacial muscles: analysis of 50 hemifacial cadaver dissections. Plast Reconstr Surg. 1998a;102(6):1888–93.PubMedGoogle Scholar
  30. Pessa JE, Zadoo VP, Adrian EK, et al. Anatomy of a “black eye”: a newly described fascial system of the lower eyelid. Clin Anat. 1998b;11:157–61.PubMedGoogle Scholar
  31. Pilsl U, Anderhuber F, Rzany B. Anatomy of the cheek: implications for soft tissue augmentation. Dermatol Surg. 2012;38(7Pt2):1254–62.PubMedGoogle Scholar
  32. Richard MJ, Morris C, Deen BF, Gray L, Woodward JA. Analysis of the anatomic changes of the aging facial skeleton using computer-assisted tomography. Ophthal Plast Reconstr Surg. 2009;25(5):382–6.PubMedGoogle Scholar
  33. Rohrich J, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219–27.PubMedGoogle Scholar
  34. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2008;121(5):1804–9.PubMedGoogle Scholar
  35. Sadick NS. Volumetric structural rejuvenation for the male face. Dermatol Clin. 2018;36(1):43–8.PubMedGoogle Scholar
  36. Shaw RB Jr, Katzel EB, Koltz PF, et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strategies. Plast Reconstr Surg. 2011;127(1):374–83.PubMedGoogle Scholar
  37. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):441–9.PubMedGoogle Scholar
  38. Sundaram H, Liew S, Signorini M, Vieira Braz A, Fagien S, Swift A, De Boulle KL, Raspaldo H, Trindade de Almeida AR, Monheit G. Global aesthetics consensus: hyaluronic acid fillers and botulinum toxin type A – recommendations for combined treatment and optimizing outcomes in diverse patient populations. Plast Reconstr Surg. 2016;137(5):1410–23.PubMedPubMedCentralGoogle Scholar
  39. Swaddle JP, Cuthill IC. Asymmetry and human facial attractiveness: symmetry may not always be beautiful. Proc Biol Sci. 1995;261:111–6.PubMedGoogle Scholar
  40. Swift A, Remington K. BeautiPHIcation™: a global approach to facial beauty. Clin Plast Surg. 2011;38(3):347–77.PubMedGoogle Scholar
  41. Sykes JM, Cotofana S, Trevidic P, et al. Upper face: clinical anatomy and regional approaches with injectable fillers. Plast Reconstr Surg. 2015;136(5, Suppl):204S–18S.PubMedGoogle Scholar
  42. Thomaidis VK. Cutaneous flaps in head and neck reconstruction: from anatomy to surgery. Berlin: Springer; 2014.Google Scholar
  43. Thornton GM, Lemmex DB, Ono Y, et al. Aging affects mechanical properties and lubricin/PRG4 gene expression in normal ligaments. J Biomech. 2015;48(12):3306–11.PubMedGoogle Scholar
  44. Wan D, Amirlak B, Rohrich R, Davis K. The clinical importance of the fat compartments in midfacial aging. Plast Reconstr Surg Global Open. 2013;1(9):e92.Google Scholar
  45. Wan D, Amirlak B, Giessler P, et al. The differing adipocyte morphologies of deep versus superficial midfacial fat compartments: a cadaveric study. Plast Reconstr Surg. 2014;133(5):615e–22e.PubMedGoogle Scholar
  46. Weinkle S, Susan SM. Approach to the mature cosmetic patient: aging gracefully. J Drugs Dermatol. 2017;16(6 Suppl):s84–6.PubMedGoogle Scholar
  47. Wollina UJ. Facial rejuvenation starts in the midface: three-dimensional volumetric facial rejuvenation has beneficial effects on nontreated neighboring esthetic units. J Cosmet Dermatol. 2016;15(1):82–8.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Clínica Saphira- Dermatology, Cosmetic, and Mohs Surgery CenterSão PauloBrazil
  2. 2.Medical School University of São PauloSão PauloBrazil

Personalised recommendations