Skeletal alterations as a basis for facial rejuvenation.

A slight decrease in overall facial bone bulk coupled with the increased soft-tissue expansion associated with aging produce effects that should be reversed in both the bone and soft tissue where possible. The changes are best done at the ledge areas: the supraorbital-temporal ridge areas, malar-midface, and chin mandible. However, the overall bone bulk may be increased in addition in the temporal fossae, in the infraorbital rim, at the lateral canthus, in the paranasal area, and at the alveolar ridges and dental areas. A combination of autogenous and synthetic materials is currently best, with synthetic materials most useful in the malar-midface, posterior mandibular, infraorbital, and paranasal areas. In the supraorbital ridge-temporal areas, it is a near equal choice between autogenous and synthetic materials. In the chin, the preferred method is by osteotomy using autogenous augmentation. The concept of increasing bone mass and decreasing expanded soft-tissue mass has application within the judgment of the surgeon coupled with the patient's desires. Subtle increases of bone mass to compensate for soft-tissue thinning as well as bone shrinkage, at the same time taking up lax soft tissue, can be done in conjunction with one another, effectively producing a three-layer face lift. The subperiosteal face lift is in reality an extended brow lift and can be used to enhance the brow-forehead area and the temporal, zygomatic, and paranasal areas. At the same time, the perioral, jowl, and submandibular regions must be treated by a combination of standard face lifting procedures and augmentation of the bone structures of the face.