Structural aging: the facial recurve concept.

During the remaining three-fourths of a century that followed the introduction of the modern face-lift by Bettman in 1920, the dominant theory of facial aging remained soft tissue descent under gravity, abetted by senescent loss of skin support, turgor, and elasticity. The paranasal soft tissue redundancy at the nasolabial fold became the key marker for facial aging, and its effacement the key yardstick for measuring success in facial rejuvenation. By the 1990s, deeper soft tissues were added to the targeted list for resuspension, particularly the socalled ‘‘malar fat pad,’’ as first pursued by Hamra, but named and popularized by Owsley. Others broadened the target to include the entire midface. After Chajchir s introduction of effective and reliable fat transfer by the injection technique, Coleman, who expanded upon and codified the concept, added to the prevailing aging theory of descent his fin-de-siecle theory of soft tissue volume attrition through atrophy. Whereas the vast majority of plastic surgeons (including myself) continued to regard gravitational descent as the primary factor in facial aging, some (including myself) came to regard volume attrition and loss the more important factor in at least the periorbital zone. In any case, soft tissue facial augmentation, whether by fat addition, fat transfer, or nonautologous means, has become an important adjuvant to suspensory techniques. Now 7 years into the new century, LeLouran and colleagues would have us believe there is a third and more dominant force at work, as they present their theory of facial aging based on mimetic muscle activity. Specific facial muscles or muscle segments (‘‘age marker fascicules,’’ they call them) through their frequent and powerful contractions eject their underlying deep fat pads into superficial locations as they themselves flatten and shorten, developing increased muscle tone at rest and diminished amplitude of contraction over time. Only then, the authors reason, does gravity begin its work on these superficial ectopic fat deposits of age, abetting the structural aging we recognize in the jowl, the nasolabial and marionette lines, the tear trough, and the upper orbital hollow. It is no particular surprise that the predominant theory of aging focused so long on the gravitational descent of skin and soft tissue alone. From the time of Madam Noel and before, such soft tissue redundancy was the obvious marker for facial aging. Nor is it surprising that Hamra, stimulated by Skoog as he delved ever deeper into more invasive mobilizations of the facial soft tissues, would come to advocate a need to resuspend deeper components of the facial mass. It also is not surprising that Coleman, having become adept at fat transfer by needle, would conclude that fatty volume loss is more critical in facial aging than fatty descent. Of course, it is equally unsurprising that LeLouran, an acknowledged master of chemical paralysis of the facial muscles for rejuvenation, would formulate an aging theory based on the actions of these muscles he understands so well. I find enormous value in the concepts that the authors propose and suspect they are correct in much of their analysis. Most important, their theory adds an engine for facial aging, a kinetic force with major energy implications. And although this surely is important in soft tissue aging, I am certain that it is even more important in a widely overlooked component of facial aging that they touch on only tangentially, that of bony aging. Pessa s radiologic investigations into such aging concluded that there is a maxillary and nasal spine retrusion in the face of zygomatic stability. Correspondence to J. William Little, M.D.; email: jwilliamlittle@erols.com Aesth. Plast. Surg. 31:754 756, 2007 DOI: 10.1007/s00266-006-0249-7