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The Relationship between Bone Remodeling and the Clockwise Rotation of the Facial Skeleton

A Computed Tomographic Imaging–Based Evaluation

Cotofana, Sebastian, M.D., Ph.D.; Gotkin, Robert H., M.D.; Morozov, Sergey P., M.D., Ph.D.; Kim, Stanislav Y., M.D., Ph.D.; Gombolevskiy, Victor A., M.D., Ph.D.; Laipan, Albina S., M.D.; Pyatnitskiy, Ilya A., M.D.; Movsisyan, Tigran V., M.D.; Frank, Konstantin, M.D.

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 1447–1454
doi: 10.1097/PRS.0000000000004976
Cosmetic: Original Articles

Background: Information on the onset and gender differences of midfacial skeletal changes, including the complete understanding of the theory behind the clockwise rotational theory, remains elusive.

Methods: One hundred fifty-seven Caucasian individuals (10 men and 10 women aged 20 to 29 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, 60 to 69 years, 70 to 79 years, and 80 to 89 years, and eight men and nine women aged 90 to 98 years) were investigated. Multiplanar computed tomographic scans with standardized angle and distance measurements in all three anatomical axes and in alignment to the sella-nasion (horizontal) line were conducted.

Results: Both men and women displayed an increase in orbital floor angle (p < 0.001, maximum at 60 to 69 years), decrease in maxillary angle (p = 0.035, 40 to 49 years), increase in palate angle (p < 0.001, 50 to 59 years), increase in vomer angle (p = 0.022, 30 to 39 years), but a decrease in the pterygoid angle (p = 0.002, 80 to 89 years). Orbital width decreased (p < 0.001, 60 to 69 years), pyriform aperture width increased (p = 0.015, 60 to 69 years), and midfacial height decreased with aging (p < 0.001, 60 to 69 years).

Conclusions: Age-related changes of the midfacial skeleton occurred independently of gender, but at various time points in different locations. The observed changes seem to be driven by a bone resorption center located in the posterior maxilla, rather than by a rotational movement of the facial skeleton.

Albany and New York, N.Y.; Salzburg, Austria; Moscow, Russia; and Munich, Germany

From the Department of Medical Education, Albany Medical College; private practice; the Department of Radiology, Paracelsus Medical University Salzburg; the Research and Practical Center of Medical Radiology, Department of Health Care of Moscow; and the Department for Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich.

Received for publication December 6, 2017; accepted May 18, 2018.

Disclosure: None of the authors listed has any commercial associations or financial disclosures that might pose or create a conflict of interest with the methods applied or the results presented in this article.

Sebastian Cotofana, M.D., Ph.D., Albany Medical College, 47 New Scotland Avenue, MC-135, Albany, N.Y. 12208,

©2018American Society of Plastic Surgeons