Dermatological implications of skeletal aging: a focus on supraperiosteal volumization for perioral rejuvenation.

It is becoming widely accepted that volume changes in the skin and soft tissue contribute greatly to age-related facial reshaping. A significant contribution to these volume changes is the loss of craniofacial skeletal support to the overlying soft tissue. Gravity, once considered the major culprit in facial aging, is now recognized to determine the direction, rather than the extent, of tissue deflation. Although the sequence of events observed in aging is somewhat predictable, its pace among individuals is variable and may be influenced by both intrinsic (e.g., gender, genetics) and extrinsic (e.g., photoaging, smoking, stress) factors. Changes in different tissue layers within a single individual do not occur independently, but interdependently; changes in one tissue within an individual may influence subsequent changes in other tissues. Midfacial soft tissue descent has been observed in response to decreased craniofacial support in both congenital craniofacial hypoplasia and following trauma, leading to a hypothesis that the loss of underlying bony support for any reason, including aging, leads to soft tissue descent in the face. As craniofacial support (the "table") decreases, it leaves less surface area for the outer soft tissue envelope (the "tablecloth") causing it to fold or sag. Replacing this deep support with craniofacial implants has been shown to reposition the overlying soft tissue. Following a brief review of the current literature on aging changes in the skin, soft tissue, and bone; the authors describe their experience with the use of poly-L-lactic acid (PLLA), both as a soft tissue volumizer and as an injectable craniofacial implant in a supraperiosteal location to address both soft tissue volume loss and loss of craniofacial support. In the cases presented, the most striking result noted was the ability to restore a youthful proportion to the perioral area, which had not been achieved previously with soft tissue treatment alone.