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The Aging Face

Chapter · January 2016

DOI: 10.1007/978-3-662-46599-8_60

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 61
The Aging Face
BRYAN C. MENDELSON, JUSTIN X. O’BRIEN

Tempus fugit. Time flees.

Figure 61-1. Leonardo da Vinci self-portrait.

1
2 SECTION VIII - T H E F A C E – S U R G I C A L T R E A T M E N T

alf a millennium has passed since Leonardo da Vin- ding retinacular fibres cross the subcutaneous tissue layer in

L ci composed this frank, yet detailed self-portrait in

which he described the effects of time on his face.
Our preoccupation with facial aging has a long and
well-deserved history. It is difficult to envisage da Vinci’s
portrait devoid of the extensive grooves and furrows, such is
a perpendicular fashion to reach the dermis and retain the
dermis here in close proximity to the underlying ligaments.
Where soft tissue spaces are located in the fourth layer,
the overlying retinacular fibres are oriented more parallel
to the dermis, providing less restriction to movement.1
their contribution to our perception of what the artist is The third layer of the archetype corresponds to the con-
showing us. A brief glimpse of a person’s face affords a fluence of the galea aponeurotica which invests the occip-
wealth of information, including an estimate of the person’s itofrontalis in the scalp, the temporoparietal fascia of the
age, gender, emotional state, racial background, and energy temporal region, the superficial musculoaponeurotic system
levels. We use these cues, almost subliminally, to guide our (SMAS) of the face, and the superficial cervical fascia of
interactions with people, as the cues are predictive of the be- the neck. The superficial cervical fascia invests platysma in
haviour we should expect from each person in return. the same manner as the galea aponeurotica invests the oc-
Unfortunately, some age-related changes of the face can cipitofrontalis in the scalp and the SMAS invests orbicularis
incorrectly convey a person’s emotions, level of interest, oculi and platysma in the face. The fascia is thick on the
and even their overall health. When correcting these deep surface of these superficial muscles, and thin on the
changes to restore a more youthful appearance, the aesthet- superficial surface, extending into the retinacular cutis. This
ic plastic surgeon must understand and respect the anatom- allows the superficial muscles to act on the skin. Where the
ical changes occurring in the aging face, so that the facial superficial flat muscles of the face are not present, these two
expression is not unintentionally altered. fascial layers are fused and become aponeurotic.
Aging of the face is a complex and still incompletely The arrangement of the aponeurosis into three laminae2
understood process. While the visual effect is obvious, the could be sub-classified as: 3a - the thin fascia on the outer
process is not easily described, as it is the culmination of surface of the muscle, 3b - the layer of superficial flat mus-
the simultaneous changes of several different, but adjacent cle, 3c - the thicker fascia on the underside of the muscle.
tissues as well as their interaction. Where muscle is not present, the fasciae 3a and 3c fuse.
The purpose of this chapter is to introduce a systematic Additionally, in certain areas of the face, a small fat pad
approach to analysing aging of the face. Accordingly, this is interposed between the muscle and its underlying fascia,
chapter is structured around a description of the concentric as in the galea fat pad beneath the frontalis over the superi-
layered structure of the face and its regional variations. or orbital rim medially and the ROOF (retro-orbicularis fat)
Then the effect of aging on the structure of each layer is over the superolateral orbital rim.3
analysed, so that each of the characteristic stigmata of ag- In the scalp, the fourth layer is a glide plane composed
ing can be correlated with its anatomical origin. of loose areolar tissue that allows the overlying layers to
move relative to the skeleton. In the face, consistent with
the complexity of its function, the fourth layer is more
complex, as it contains more discrete areas of glide plane,
known as the soft tissue spaces. These spaces are separated
TISSUE LAYERS OF THE FACE

The scalp is the basic archetype for understanding facial by the immobile retaining ligaments and immobile areas of
anatomy, as it contains the same tissue layers and planes, fascial condensation that contain important anatomical
without the complexity of the modified areas of function structures, in addition to the deep layer of mimetic muscles
found overlying the bony cavities of the face proper.1 extending from their periosteal origin.4
The skin provides the visible surface that undergoes in- With regard to facial aging, there are several clinically
trinsic changes as well as reflecting changes to the deeper important spaces within the fourth layer; the preseptal space
soft tissue layers of the face. Even in this first tissue layer, of the lower lid, the prezygomatic space, and the premas-
specialisations occur, with thick dermis containing addi- seter space. Each of these spaces has a floor formed by tis-
tional collagen over the less mobile areas, such as the nasal sue of the fifth layer, and a roof formed by tissue of the third
tip, and thin dermis over mobile anatomical areas, the layer. Each space has boundary structures that have a vary-
thinnest being on the eyelids (Figure 61-2).1 ing propensity for the development of laxity with aging.
The subcutaneous layer of the scalp and face is the sec- These spaces will be discussed with respect to age-related
ond layer and is formed by the subcutaneous fat and the changes visible on the regions of the face that they underlie.
retinacular cutis that connects the dermis with the underly- The fifth tissue layer is the deep fascia and periosteum.
ing galea aponeurotica and SMAS respectively. In the The periosteum of the skull and facial bones is confluent
scalp, the second layer has a uniform thickness and consis- with the “masticator” fascia and with the investing layer of
tency of fixation to the overlying dermis, while in the face the deep cervical fascia of the neck. In the neck, this layer
proper, there is considerable variation.1 of fascia invests sternomastoid and trapezius, while in the
The arrangement of the retinacular cutis fibres of the face, the muscles of mastication are invested; temporalis,
face is not homogenous. It varies in accordance with the masseter, and the lateral and medial pterygoids. The masti-
anatomy of the fourth layer (discussed later). Where retain- cator fascia over temporalis is known as the “temporalis
ing ligaments are located in the fourth layer, the correspon- fascia”, and over masseter as the “masseter fascia”.
 CHAPTER 61 - T H E A G I N G F A C E 3

Figure 61-2. Fascial layers of the scalp and face. 1 - Skin. 2 - Subcuta-
neous tissue. 3 - SMAS. 4. Areolar tissue. 5. Periosteum. The common-
ly utilised surgical planes are shown in relation to the tissue layers.

The investing layer of deep cervical fascia affords pro- which begin as creases related directly to the contraction of
tection to the cervical plexus (deep) and the spinal accessory underlying muscles. With more advanced aging, additional
nerve (within the fascial investiture) as they course towards signs develop, not due to local contraction of an individual
their destinations. Similarly, the masseteric fascia affords muscle, but rather due to more diffuse movement of a tis-
protection to the zygomatic, buccal, and marginal mandibu- sue mass, combined with the tethering effects of the retain-
lar branches of the facial nerve as they course anteriorly, ing ligaments.
changing plane only when they approach the retaining liga-
ments of the fourth layer. It is this protection of the facial
nerve rami in the lateral face where they lie deep to layer five
that provides for safe dissection in the fourth layer spaces.
Expression lines and Wrinkles

Expression lines and wrinkles represent relatively superfi-

cial (in terms of anatomical plane) age-related change to
the face. Expression lines are produced by contraction of
the mimetic muscles and the consequent creasing of the
FACIAL AGING

The signs of facial aging are derived from anatomical overlying subcutaneous tissue and dermis (layers two and
changes across the various tissue layers. Among the first one). In youth, expression lines are perpendicular to the di-
noticeable changes are the expression lines and wrinkles rection of underlying muscle contraction and are present
4 SECTION VIII - T H E F A C E – S U R G I C A L T R E A T M E N T

only temporarily, during dynamic movement. However, Crow’s feet lines are orientated perpendicular to fibres
years of repetition of such muscular contraction along with of the underlying orbicularis oculi. As a result, the lines ra-
changes in the elastic quality of the skin and subcutaneous diate out from the lateral canthal region like the spokes of a
tissue leads to a permanence of the expression lines as they wheel. Repetitive action of the vertical orbicularis oculi fi-
become ‘etched’ in layers one and two and remain visible bres in the region of the lateral orbicularis raphe contribute
in repose. to the formation of crow’s feet lines at their most lateral ex-
The most conspicuous expression lines that contribute to tent.6 Consequently, the lines have a more horizontal orien-
the aged appearance of the face are; glabella frown lines, tation as they extend laterally (Figure 61-3).
crow’s feet lines, zygomatic smile lines, and perioral wrinkles. Zygomatic smile lines are immediately inferior to the
Glabella frown lines are the result of repeated move- more horizontally orientated crow’s feet lines. They are
ment of the mimetic muscles in the glabella region. Each is orientated perpendicularly to orbicularis oculi muscle fi-
fixed where it inserts in the dermis (first layer) under the bres over the lateral extent of the prezygomatic space,1 and
medial end of the eyebrow. The mimetic muscles produc- are associated with elevation of the ‘cheek’ tissues that re-
ing these lines are; the medial head of the orbital portion of sults from a temporary skin excess due to the simultaneous
orbicularis oculi, depressor supercilii, and the corrugator contraction of zygomaticus major (Figure 61-3).
supercilii (Figure 61-3).5 Perioral wrinkles arise perpendicular to the purse
Glabella frown lines are of three types. Vertical glabellar string-like contraction of the underlying orbicularis oris in
lines are produced by the transverse head of corrugator su- the same manner as the crow’s feet lines are related to the
percilii, while the oblique glabellar skin lines may be caused other major sphincter in the face, orbicularis oculi. In con-
by the oblique head of corrugator supercilii or one, or all, of trast with the expression lines at the corner of the eyes,
the three medial eyebrow depressor muscles. Transverse those around the mouth are located along the upper and
glabella lines are the result of action by procerus.5 lower edges as the soft tissues of the lip lack the stiffness of

Figure 61-3. Periorbital wrinkles. 1 - Oblique and vertical glabellar lines. 2 - Transverse glabellar lines. 3 - Zygomatic smile lines. 4 - Crow’s
feet lines. Lateral brow ptosis is also depicted.
 CHAPTER 61 - T H E A G I N G F A C E 5

the lids provided by the tarsal plates, and do not have the
lateral stability provided by the medial and lateral canthal
tendons.
In general, specific correction of dynamic wrinkles, is
by use of a neurotoxin on the muscle, whereas static lines
require a tightening of the laxity of the soft tissues. The lat-
ter is usually sufficient to also camouflage the excess effect
of dynamic muscle contraction.
Expression lines develop perpendicular to underlying
superficial muscle contraction.
In youth the expression lines are only seen during mus-
cular contraction (dynamic expression lines). With aging
the expression lines persist as wrinkles during muscular re-
laxation (static expression lines).
An increase in the amount of soft tissue laxity in an area
results in a greater amplitude of soft tissue movement on
muscle contraction, which explains the increased promi-
nence of expression lines and wrinkles with aging.

Ptosis and Tethering

Other changes of facial aging are historically more recalci-

trant to surgical rejuvenation, as they result from changes
in the third and fourth layers of the face. The outer three
layers of the face behave as a composite unit that moves
over the spaces of the fourth layer. In the long term, this
composite unit undergoes ptosis over the spaces, leads to Figure 61-4. Boundaries of the frontal and upper temporal compart-
an alteration of the position of the soft tissue mass relative ments: Superior temporal septum (STS), Temporal ligamentous ad-
to the facial skeleton. hesion (TLA), Supraorbital ligamentous adhesion (SLA). Other
structures shown: Inferior temporal septum (ITS), Periorbital septum
Because they insert directly into the dermis, the retain- (PS), Lateral brow thickening (LBT), Lateral orbital thickening
ing ligaments and deep mimetic muscles produce a tether- (LOT).
ing effect at the boundaries of the spaces of the fourth lay-
er. This tethering effect is faithfully transmitted to the sur-
face of the face as skin furrows and grooves. Ptosis and cles, and the periorbital septum containing the lateral brow
tethering accentuate one another at the borders of the thickening.
spaces. Ptosis of less supported tissue overlying the spaces The ROOF underlies the lower frontalis over the supe-
results in fullness, seen as increasingly prominent folds. rior orbital rim. The periorbital septum on the superior or-
The changes in the underlying anatomy explain why the bital rim provides an indirect bony attachment for both
folds and furrows occur pari passu. the frontalis and the orbicularis oculi muscles and plays a
Ptosis and tethering in the scalp is seen as temporal role in restraining the brow and upper eyelid soft tissues.20
hooding (lateral brow ptosis) and should be considered in This firm attachment extends only over the medial two
reference to the anatomy of the frontal compartment and thirds of the orbit and corresponds to the supraorbital
the brow. ridge. Laterally, less-dense connections exist that may be
The floor of the frontal compartment is the periosteum nearly as strong in the youngr, but become attenuated in
overlying the frontal bone. The periosteum continues inferi- the elderly.6,20
orly over the superior orbital rim and into the orbit and is Temporal hooding results from attenuation of the re-
confluent with the temporalis fascia laterally (Layer 5).1,3,4,7- taining structures in the lateral brow (part of the inferior
18
The roof of the compartment (layer 3) contains the paired boundary of the frontal compartment) that allow the ROOF
frontalis muscles enclosed within their investing layer of to descend and bulge into the lateral part of the upper lid.
fascia3,6,19 (the galea aponeurotica) which is confluent with Gravitational descent is relatively unopposed over the tem-
the temporoparietal fascia laterally.1,3,4,6-13,20-38 The ligamen- ple, as there is a lack of dynamic muscular restraint to pto-
tous boundaries are summarised in Figure 61-4. sis lateral to the superior temporal septum and temporal lig-
The brow is at the inferior boundary of the frontal com- amentous adhesion, compared to the restraint provided
partment that incorporates the ligamentous attachment of over the frontal compartment by the frontalis muscle.3,6 Ad-
the frontalis as the supraorbital ligamentous adhesion ditionally, the vertically orientated fibres of the orbicularis
(SLA). Inferior to the SLA are; the retro-orbicularis oculi over the lateral orbital rim have a ‘depressor’ action on the
fat (ROOF, subgaleal fat pad) containing the glabella mus- brow soft tissues.
6 SECTION VIII - T H E F A C E – S U R G I C A L T R E A T M E N T

Figure 61-5. Dynamics of lateral brow ptosis. The

active muscular forces are indicated by dark arrows.
The effect of gravity on the soft tissue of the tempo-
ral region is indicated by the light arrow.

The composite structure (layers one, two, and three) The midcheek skeleton also undergoes aging changes
over the temporal region has less integrity than it does over that have only recently begun to be appreciated for their
the forehead. The skin is thin and is not strongly fixed to important clinical consequences. There is a significant loss
the underlying temporoparietal fascia by the retinacular of projection of the body of the maxilla below the orbital
cutis as is the skin over the scalp and also of the midcheek rim in contrast to the prominence of the zygomatic body
(fixed by the zygomatic ligaments) and the lower face that appears not to regress. These changes of skeletal pro-
(mandibular ligament). This may explain why there is more jection are important contributors to the laxity and descent
superficial laxity, and why at times, a superficial (subcuta- of the medial cheek soft tissue.39
neous) temporal lift produces better skin re-draping over The preseptal space of layer four is the central structure
the lower temple and crows feet area than that achieved by of the lower lid and it extends for several millimetres infe-
a deep (composite subSMAS plane) lift. rior to the orbital rim, to where the orbicularis retaining lig-
Ptosis of the skin of the temporal region, which con- ament attaches below the rim (Figures 61-8 and 61-9) and
tributes to temporal hooding, can be corrected by an isolat- the attachment of the arcus marginalis.
ed temporal lift, without necessarily requiring a brow lift. The roof of the preseptal space (composite layers one to
Temporal hooding is the result of ptosis of the ROOF three) is the “anterior lamella” of the lid. It is formed by the
and tissue layers one, two and to a varying extent, layer upward extension of the cheek SMAS investing the orbicu-
three of the anterior part of the temporal region. laris oculi pars palpebrae.
The absence of frontalis over the lateral brow con- The floor of the preseptal space (layer five, the “poste-
tributes to temporal hooding. rior lamella”) is mainly formed by the septum orbitale,
Attenuation of the periorbital septum over the lateral with the lowest part formed by the inferior orbital rim (Fig-
part of the orbit allows further ptosis. ure 61-9). The septum orbitale is anatomically divided into
The combination of ptosis of the midcheek tissue and two parts: an upper, reinforced portion, where the septum is
partial tethering by the retaining ligaments is responsible supported by the capsulopalpebral fascia, and a lower por-
for the gradual appearance of separate soft tissue segments tion, which is not reinforced by the capsulopalpebral fascia.
delineated by a series of cutaneous grooves (Figure 61-6). The lower part is prone to distension, with bulging of the
 CHAPTER 61 - T H E A G I N G F A C E 7

Figure 61-6. The midcheek.

Structurally, the midcheek is
formed by the convergence of
three adjacent but separate
anatomical components: the lid-
cheek segment, the malar seg-
ment, and the nasolabial segment.
When the segments appear with
aging, they are separated by the
three cutaneous grooves on the
midcheek: the palpebromalar
groove (1), the nasojugal groove
(2), and the midcheek furrow (3).4

orbital fat over the lowest part of the floor. With less sup- because the anterior lamella covering it is now thinner and
port of the lower part of the septum orbitale and possibly a the cheek below has retruded.4
small amount of resorption of the bone of the inferior or- The shape and lower limit of descent of the lower lid bags
bital rim40, there is a greater tendency for it to weaken and is defined by the ORL which is the anatomic structure re-
allow the central lid fat to bulge. One reason for the appar- sponsible for defining the palpebromalar groove.4,43 The po-
ent thickness of the Asian lower eyelid may be the large sition and shape of the lid-cheek junction changes dramati-
area of unsupported orbital septum, which in the central cally with aging as it descends into the lid-cheek segment.
part averages 3 mm longer in Asian lids than it does in Cau-
casian lids.41
Lower lid bags become prominent over the lid-cheek
segment as the septum orbitale weakens and distends,
bulging over and then below the inferior orbital rim onto
the anterior surface of the maxilla. A small amount of pro-
lapsed orbital fat on top of the projection of the rim gives
an exaggerated look, suggestive of a larger volume than is
really present. At the same time, the roof of the preseptal
space (layer three) undergoes distension and allows a slight
descent of the thicker part of the roof off the same bony
prominence. On account of the posterior angulation of the
maxilla immediately inferior to the prominence, the de-
scended part of the upper midcheek loses projection. A
thinner part of the roof is now over the bony prominence.
The magnification of these small changes, caused by the
prominence of the orbital rim leaves the displaced lid fat Figure 61-7. The effect of loss of maxillary projection over a decade
projected as well as lower and at the same time ‘‘revealed’’ of aging on the position of the soft tissues over the upper mid-cheek.
8 SECTION VIII - T H E F A C E – S U R G I C A L T R E A T M E N T

Figure 61-8. The preseptal space.

IBTP - Inferior border of the tarsal
plate (Superior boundary). ORL -
Orbicularis retaining ligament (In-
ferior boundary).

Figure 61-9. Anatomy of the lid-cheek region in

youth (left) and with advanced age (right). ORL -
Orbicularis retaining ligament. With aging, the
lower part of the lid descends into the upper cheek.
 CHAPTER 61 - T H E A G I N G F A C E 9

Figure 61-10. Lower lid bags. Comparison between the youthful and aged lid. The blue line indicates the location of the bony orbital rim.42

This bulging convex contour alters the shape of the lower Accentuation of the nasojugal and palpebromalar
lid, giving the appearance of a ‘‘new’’ lid-cheek junction grooves occurs at the lower borders of the lid-cheek seg-
below the bulge. It is still referred to as the lid-cheek junc- ment. These signs of aging are the product of changes that
tion even though the ‘‘new’’ lid-cheek junction contour occur mostly in Layer four, at the lower boundary of the
transition has moved off the anatomical lower lid and into preseptal space, compounded by recession of the maxilla.4,45
the territory of what had previously been the upper cheek.4 Malar mounds, also called malar bags, and double bags
Medial orbital fat bulges, in contrast to those laterally, are of the lower lid, are the visible manifestation of aging
located several millimetres above the inferomedial orbital changes in and around the malar segment. The shape of
rim, held up by the unyielding character of the arcus margin- malar mounds, triangular with the apex medially, mirrors
alis reinforced lower edge of the septum orbitale in this loca- that of the underlying prezygomatic space, being defined
tion. Because of this and the deeper location of the septum, by the same ligamentous boundaries.1,4,41-43
medial fat bulges initially forward, not inferomedially, and The prezygomatic space overlies the body and maxil-
this tends to exaggerate the depth of the nasojugal groove.44 lary process of the zygoma1, and is separated from the pre-
• Lower lid bags are the result of herniated orbital fat, and septal space of the lower lid superiorly by the ORL.
ptosis of the orbicularis oculi. The roof of the prezygomatic space (layer three) is the
• The lower boundaries of lower lid bags are defined by SMAS investing the orbicularis oculi pars orbitale, deep to
the tethering effect of the orbicularis retaining ligament. which is a thin layer of adherent fat quite distinct from the
These well-defined boundaries are the nasojugal and preperiosteal fat by its fine lobulation and distinct yellow colour.
palpebromalar grooves. This is the sub-orbicularis oculi fat (SOOF) (Figure 61-9).1,4,43

Figure 61-11. The aged midcheek.

The cutaneous grooves and soft tis-
sue segments reflect the underlying
anatomy.
10 SECTION VIII - T H E F A C E – S U R G I C A L T R E A T M E N T

Figure 61-12. Anato-

my of the preseptal and
prezygomatic spaces.

Figure 61-13. Boundaries of the prezygomatic space. Orbicularis retaining ligament - ORL. Zygomatic cutaneous ligaments - ZL.
 CHAPTER 61 - T H E A G I N G F A C E 11

The floor of the prezygomatic space (layer five) overlies which also serves to elevate the lateral ala. The middle sec-
the origins of the three lip elevator muscles overlying the in- tion of the crease is deepened by the action of levator labii
ferior part of the bone. Adhering strongly to this area of bone superioris.49,50 The inferior extent of the nasolabial crease is
is the preperiosteal fat that not only covers the exposed bone, accentuated by the action of zygomaticus major.46,49,51
but it also extends inferiorly between the muscles and covers Flattening of the nasolabial fold in the setting of facial
the origins and bellies of the muscles for some distance. The nerve palsy51-53 indicates that the action of the above-men-
floor is lined by a thin transparent membrane adherent to the tioned muscles contributes not only to the nasolabial crease,
preperiosteal fat and the muscles. As a result, the floor of the but also to the shape and apparent volume of the nasolabial
prezygomatic space extends lower than expected.1,4,43 The fold. Levator labii superioris, zygomaticus minor, and zygo-
boundaries of the space are depicted in Figure 61-13. maticus major are all deep to the fold on their course from
The boundaries of malar mounds are defined by the the zygoma to the orbicularis oris. Zygomaticus major con-
tethering effect of the orbicularis retaining ligament superi- traction exaggerates the fold by pulling the nasolabial
orly - separating the mounds from the lower lid bags, and crease beneath the fold, resulting in a concertina effect.53
of the zygomatic ligaments inferiorly. The effect of SMAS traction to elevate the nasolabial
Malar mounds are the result of laxity and ptosis of the fold is to directly reposition the composite layer (layers
orbicularis oculi over the prezygomatic space. This ptosis one, two, and three) of the fold and so it reduces the con-
is largely the result of laxity of fixation above by the orbic- certina effect caused by the action of the lip elevators on
ularis retaining ligament. the crease. This dynamic further demonstrates the interplay
The nasolabial segment (Figure 61-6) is separated from between ptotic tissue and structures tethering the dermis.
the laterally-placed lid-cheek segment by the nasojugal Compounding the aging changes in the nasolabial fold
groove, and below that from the malar mounds by the mid- and crease, is the malar fat pad. Within the composite struc-
cheek furrow, a continuation of the nasojugal groove down- ture of the nasolabial segment, which in other regions of
ward and outward.4 Fullness of the nasolabial fold, the me- the face behaves as an en bloc structure with respect to pto-
dial side of the nasolabial segment, is part of a complex sis, the malar fat pad (layer two) independently descends
change developing in concert with the development of these with age on the plane superficial to the SMAS-invested
furrows.46 The nasolabial fold has an upper and lower part. mimetic muscles.47 As such, the ptosis leading to increased
The upper part is partially attached to the underlying maxil- volume and positional change of the nasolabial fold occurs
la where it overlies the origins of the levator labii superioris across two planes. Given the significant contribution by the
and levator labii superioris alaequae nasi. This attached up- malar fat pad, correction of this alone may obtain a major
per part continues to the level of the alar crease. The major degree of improvement. Dissection of the underside of lay-
part of the nasolabial fold overlies the vestibule of the oral er two (deep subcutaneous plane) off the thin SMAS here
cavity and the buccal space and is accordingly mobile. On- can be readily performed (Figure 61-2).
ly the most lateral part of this mobile segment has a direct • The nasolabial crease is defined by the dermal inser-
fixation. This is where the strong zygomatic ligaments (re- tions of the lip elevators, and these insertions have a
sponsible for the midcheek furrow), aided by the upper mas- tethering effect on the nasolabial fold.
seteric ligaments suspend it from the body of the zygoma. • The nasolabial fold and crease are accentuated with age
The lower part of the fold continues into the lower cheek be- by ptosis of tissue layers one, two and three over the
yond the oral commissure where it contributes to the full- maxilla and the vestibule of the oral cavity.
ness of the labiomandibular fold as the buccal fat pad dis- • The malar fat pad contributes substantial volume to the
tends the lower border of the buccal space with age.1,4,46 nasolabial fold.
The nasolabial fold is separated from the medially The jowl and labiomandibular fold appear with the onset
placed peri-oral region by the nasolabial crease, which, of facial aging. In this, they differ fundamentally from other
with aging, develops into the nasolabial furrow.4,46,47 facial landmarks, such as the nasolabial crease and the lid-
The subcutaneous fat (layer two) in the nasolabial fold cheek junction, the presence of which are integral to the shape
is both thicker and more mobile than the subcutaneous lay- of the youthful face, although they deepen with aging.54
er over the midcheek segments lateral to the midcheek fur- The jowl and labiomandibular fold are the result of ptosis
row.27 Because of its thickness and defined boundaries, the of the roof of the premasseter space. The mandibular ligament
subcutaneous fat of the fold appears as a distinct entity, tethers the dermis at the anteroinferior corner of the space. In
commonly referred to as the malar fat pad47, which is a mis- youth, the (weaker) masseter cutaneous ligaments at the ante-
leading term because the malar fat pad does not overlie the rior border of the space provide further fixation, but this fixa-
zygoma (malar segment) as its name suggests. It actually tion does not result in visible cutaneous tethering.
overlies the maxilla.4,43,48 The shape of the premasseter space reflects the shape of
The nasolabial crease is the result of two anatomical fac- the floor, which is based on the deep fascia investing the mas-
tors; the abrupt transition of subcutaneous thickness between seter muscle (layer five).7,54 The roof of the space is formed
the medial border of the malar fat pad and the lip, and the by the SMAS investing the platysma (layer three).1,7,28,54 The
mimetic muscle action via slips which insert into the dermis roof is lined by a membrane which reflects deeply at the
of the crease.49 At its superior extent, the crease is accentuat- boundaries of the space and lines the floor as well.54 The
ed by the action of the levator labii superioris alaeque nasi, boundaries of the space are shown in Figure 61-15.
12 SECTION VIII - T H E F A C E – S U R G I C A L T R E A T M E N T

In the interval between the anterior ear cartilage and the

posterior border of the premasseter space, the SMAS is firm-
ly adherent to the underlying structures, particularly the
parotid capsule.28,54 This dense attachment extends forward
of the tragus for approximately 25 to 30 mm, then terminates
abruptly over the lower part of the masseter. In this region
there is a major fusion of all the layers, which is named the
platysma auricular fascia (PAF). This broad area of ligament
is beneficial for surgeons as it supports fixation sutures from
the mobile SMAS anterior, to the fixed SMAS (PAF) poste-
rior. The lower posterior part of the PAF overlying the trunk
of the facial nerve immediately anterior to the lower part of
the tragus is the tympano-parotid fascia, and has been called
Lore’s fascia55. It is an excellent fixation point for platysma
fixation sutures. The posterior border of the premasseter
space begins where this dense attachment ends, just forward
of the anterior edge of the parotid and well beyond the pos-
terior border of the mandible.54 There is no visible aging
Figure 61-14. Labiomandibular fold and jowl. The yellow dot over- change here on account of the strong fixation and the small
lies the fixation provided by the mandibular ligament. This point is amount of movement over this part of the mandible. In con-
the anterior edge of the jowl and the inferior extent of the labio- trast, there are major aging changes of the anterior boundary
mandibular fold. of the premasseter space.

Figure 61-15. Premasseter

space anatomy in youth. Ante-
rior boundary: Masseter-cuta-
neous ligaments (MCL),
Mandibular ligament (ML).
Posterior boundary: Fusion of
the SMAS to the parotid cap-
sule. Inferior boundary: Mem-
branous reflection overlying
the mandible.
 CHAPTER 61 - T H E A G I N G F A C E 13

Figure 61-16. Anatomy of the

aged premasseter space. Note
the bulging of the anteroinferi-
or corner of the space produc-
ing the jowl.

The lower masseteric cutaneous ligaments at the anteri- The jowl and labiomandibular fold are the end result of
or boundary of the space undergo considerable attrition, re- ptosis of the composite tissue layers one, two and three
sulting in more laxity of the boundary and weakened at- over the premasseter space.
tachment of the platysma roof. The nearby mandibular lig- The labiomandibular crease results from the tethering
ament remains strong and its tethering effect becomes more effect of the fascia of depressor anguli oris on the overlying
apparent. dermis.
When significant aging changes are present, the buccal Ptosis of the buccal fat pad contributes to the volume of
fat may extend down so low as to bulge into and distend the the labiomandibular fold, and if profound, can also con-
anterior boundary of the premasseter space (where it is an- tribute to the volume of the jowl.
gled obliquely forward above the jowl extension). Buccal Traditionally, it has been regarded that a subcutaneous
fat in this area contributes to the heaviness of the labio- plane for facelifting is the safest plane on account of it be-
mandibular fold and in cases of major descent may also ing remote from the facial nerve. However, the subcuta-
contribute to fullness of the jowl.54 neous plane is vascular, compared to dissecting within the
It is the laxity of the superficial fascia (platysma) ‘avascular’ soft tissue spaces, which are also safe spaces as
where it overlies the jowl extension of the premasseter there are no facial nerve branches within.
space immediately above the mandibular ligament that Recontouring the face, rather than tightness of the skin, is
allows fullness of the labiomandibular fold to develop. the objective of modern rejuvenation surgery. In fact, con-
This laxity contrasts with the labiomandibular crease, touring requires an avoidance of the flattening effect of ex-
which defines the medial extent of the fold and results cessive skin tension. Contouring of the lower face can be
from the tethering from the line of fibrous adhesion be- achieved in either of two ways. Indirectly, by re-draping the
tween the fascia on depressor anguli oris and the overly- en bloc composite flap following subSMAS dissection (layer
ing dermis.54 3) or by direct contouring of the subcutaneous layer using lo-
14 SECTION VIII - T H E F A C E – S U R G I C A L T R E A T M E N T

cal plication sutures following superficial subcutaneous dis- 14. Campiglio GL, Candiani P. Anatomical study on the temporal
section (layer 2). fascial layers and their relationships with the facial nerve. Aes-
Understanding the anatomy along the lower border of the thetic Plast Surg 1997; 21: 69-74.
15. Davidge KM, van Furth WR, Agur A, Cusimano M. Naming the
premasseter space is important for the surgeon. When the
soft tissue layers of the temporoparietal region: unifying anatom-
roof of the premasseter space is tightened, the benefit extends ic terminology across surgical disciplines. Neurosurgery 2010;
well inferior to the lower boundary of the space and beyond 67: 120-129; discussion 9-30.
the jowl into the upper neck, on account of the absence of lig- 16. Babakurban ST, Cakmak O, Kendir S, Elhan A, Quatela VC.
amentous fixation of the entire lower boundary, i.e., between Temporal branch of the facial nerve and its relationship to fascial
the PAF posteriorly and the mandibular ligament anteriorly. layers. Arch Facial Plast Surg 2010; 12: 16-23.
This is the reason why the limited dissection MACS lift56 and 17. Coscarella E, Vishteh AG, Spetzler RF, Seoane E, Zabramski JM.
SMASectomy57 procedures work well for lower face lifting. Subfascial and submuscular methods of temporal muscle dissec-
tion and their relationship to the frontal branch of the facial
The avoidance of the risk of mandibular branch injury is an nerve. Technical note. J Neurosurg 2000; 92: 877-880.
additional bonus. Below the mandible, the platysma can be 18. Ammirati M, Spallone A, Ma J, Cheatham M, Becker D. An
similarly re-draped without the need for preliminary dissec- anatomicosurgical study of the temporal branch of the facial
tion using an external plication through Layer 2 of the mobile nerve. Neurosurgery 1993; 33: 1038-1043; discussion 44.
platysma to the fixed Lore’s fascia (PAF).55 19. Ridgway JM, Larrabee WF. Anatomy for blepharoplasty and
brow-lift. Facial Plast Surg 2010; 26: 177-185.
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CONCLUSION
21. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of
An understanding of the concentric layered structure of the the frontal branch of the facial nerve: the significance of the tem-
facial soft tissues provides the basis for understanding the poral fat pad. Plast Reconstr Surg 1989; 83: 265-271.
effects of the aging process, and for a logical comparison of 22. Salas E, Ziyal IM, Bejjani GK, Sekhar LN. Anatomy of the fron-
the various planes used in facial rejuvenation procedures. totemporal branch of the facial nerve and indications for interfas-
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23. Hing DN, Buncke HJ, Alpert BS. Use of the temporoparietal free
fascial flap in the upper extremity. Plast Reconstr Surg 1988; 81:
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