Improving face-lifts: Beauty more than skin deep

David Kahn

Gravity and sagging skin aren't the only roadblocks to a perpetually youthful face. Aging facial bones may be just as guilty of the telltale signs of advancing years, according to new research from the medical school.

This "dramatic" aging of facial bones also happens at a significantly younger age for women than men.

"As the skin sags, the bony framework underneath the skin deteriorates as well, contributing to the development of new folds, creases, wrinkles, droops and valleys," said David Kahn, MD, assistant professor of plastic and reconstructive surgery.

Crow's-feet, drooping brows, sagging facial folds—it's not just skin deep.

Two studies by Kahn and Robert Shaw, MD, a resident at the University of Rochester Medical Center who was a medical student at Stanford when the research was conducted, document this problem. The second study was presented Oct. 10 at the American Society of Plastic Surgeons yearly convention in San Francisco; the first was presented at the same conference last year and is scheduled for publication this winter.

Kahn and Shaw's findings go beyond most previous research on facial aging, which focused primarily on changes to the skin, the researchers said. They sought to understand better the entire aging process of the face.

They hypothesized that it was necessary for plastic surgeons treating patients who are hoping to reverse the aging process to consider what's going on beneath the skin.

"If plastic surgeons attempting facial rejuvenation are only considering skin changes, it's not enough," Kahn said. "Skin tightening, collagen and fat injections, Botox injections, don't take into account changes to the bones."

Today's single-dimensional approach to facial rejuvenation, Kahn said, may explain the sometimes-negative results of plastic surgery to the face that can result in odd, distorted looks.

"After you do a face-lift on some patients and look at photos of them when they were young, they look very different," said Shaw. "Part of that may be the tightening of the skin over a bony scaffolding that has deteriorated and changed in shape from when they were 18."

There's a change in morphology or shape to the bones as well as a general shrinkage, Shaw said.

For the two studies, the researchers analyzed 30 men and 30 women separately using advanced, three-dimensional, computerized reconstruction of the facial skeleton. The participants were separated into three different age groups identified as young (25 to 44), middle-aged (45 to 64) and old (65-plus). They then measured the various bony structures in the face—the slope of the cheekbone and the opening for the nose, for example—and compared these changes between age groups and genders.

"In general, for most of our measurements, women experienced aging between young and middle age, and the men between middle age and old," Shaw said.

Specific changes to different bony structures in the face seem to correlate with the various well-known visible changes to the face due to aging, Kahn said. Changes to the orbital aperture, or bony area around the eye, for example, could account for crow's-feet and the drooping of the skin above the eye.

Aging bones in the cheeks could be part of the cause of the deepening of the creases between the lips and the nose and could cause the fat pad in the cheeks to sag and become more prominent. Much of these changes may be due to decreasing bone support, Kahn said.

"It's a dynamic process," Kahn said, which means it will continue to change after those face-lifts. "It's important to realize that you're not working with the same facial skeleton as an 18-year-old."

The solution?

"The most effective approach toward facial rejuvenation should be twofold: restoring volume to compensate for the loss of bony volume, and lifting and reducing the aged and less elastic soft tissue," Kahn said. "Plastic surgeons can't turn back the clock. It's more of a 'freshening up'."