ABSTRACT
While skeletal support of the human face changes little from early adulthood through middle
age, facial shape changes greatly. The morphology noted in the aging face results primarily
from volumetric soft tissue deflation and facial fat descent in relation to the underlying skeletal
pillars of the midface. The skeletal pillars that support the soft tissues of the midface are located
superolaterally and include the zygomatic eminence, the lateral and infraorbital rim, the
zygomatic arch, and the ramus of the mandible. In youth this skeletal support system forms a
foundation, which fixates facial fat through the retaining ligament system that is situated
overlying the parotid, anterior border of the masseter and malar eminence. As this ligamentous
support becomes attenuated with age, fat descends, and in conjunction with deflation, facial
shape changes. The youthful face tends to appear angular in contour, while in middle age facial
fat becomes situated anteriorly and inferiorly in the face, and facial configuration becomes
squarer, with little differentiation between the malar eminence and submalar fat. The
underlying skeletal support not only influences the appearance of the face in youth but also
affects facial shape in middle age, and is greatly affected by the loss of volumetric highlights
overlying the midfacial skeletal pillars. Skeletal support therefore affects the surgeon’s ability to
restore facial shape, and is one of the key elements to consider in aesthetic treatment planning
for facial rejuvenation.
