The loss of projection of midface contour with age is due to the loss of volume and descent of soft tissues and not the result of diminished bone support, as suggested by Shaw and Kahn1 and Pessa.2 Shaw and Kahn’s research and that of Dr. Pessa arrive at the same false conclusions about midfacial aging because both suffer from the same error-prone methodology. Appropriate evaluation of facial aging requires longitudinal study of individual subjects over many years. To be clear, longitudinal studies, as in Behrents’3 and Broadbent and Bolton’s4 orthodontic analyses, assess facial growth using cephalometric measurements of individuals over their lifespan. Shaw and Kahn’s cross-sectional study is scientifically unsound. Unfortunately, as does Pessa, they entice the reader with the advanced technology of computed tomography or magnetic resonance imaging and stereolithography.5 Their comparison of different individuals reflects sampling rather than change in a single subject. To study different subjects at different ages is not the same as studying the same subject in the process of aging.
The correct conclusion based on longitudinal study is that “adults with horizontal maxillary deficiency present with an unmasking of their underlying skeletal contours by the loss of soft-tissue volume and position that create the characteristic changes that we associate with aging.”6 In other words, patients with shallow orbits, negative vector lower lid relationships, and tear trough deficiency had, in youth, adequate lid-cheek interface support and volume before lipoatrophy and attenuation of ligamental anchorage. This concept supports current strategies of rejuvenative surgery that are based on soft-tissue volume filling rather than skeletal repositioning by osteotomy.
Richard Allen Levine, M.D., D.D.S.
4499 Medical Drive
San Antonio, Texas 78229
1. Shaw, R. B., Jr., and Kahn, D. M. Aging of the midface bony elements: A three-dimensional computed tomographic study. Plast. Reconstr. Surg.
119: 675, 2007.
2. Pessa, J. E. Aging of the midface bony elements: A three-dimensional computed tomographic study (Discussion). Plast. Reconstr. Surg.
119: 682, 2007.
3. Behrents, R. An Atlas of Growth in the Aging Craniofacial Skeleton.
Ann Arbor, Mich.: Center for Human Growth, University of Michigan, 1985.
4. Broadbent, T., and Bolton, R. Standards of Dentofacial Developmental Growth.
St. Louis, Mo.: Mosby, 1975.
5. Pessa, J. An algorithm of facial aging verification of Lambros’ theory by three-dimensional stereolithography with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast. Reconstr. Surg.
106: 479–488, 2000.
6. Levine, R. A., Garza, J. R., Wang, P. T., Hurst, C. L., and Dev, V. R. Adult facial growth: Applications to aesthetic surgery. Aesthetic Plast. Surg.
27: 265, 2003.
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