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only — in the authors’ opinion — to plastic surgeons for the surgical undermining and repositioning of the soft tissue. This distinction between what is fixed and what is mobile also explains the morphological changes associated with ageing. A large part of the superficial malar fat pad sags,

sliding inward and downward, until it reaches the nasolabial fold. This sagging cannot go further, because at this level the skin–orbicularis labii pairing is attached and does not allow further sliding on the upper lip, but sometimes passes over the nasolabial fold. In addition to this concept of mid-face ageing, some authors prefer to describe the process as a redistribution of volume and shape4–6

. This facial transition and loss of youth can be

Figure 4 How to avoid the facial artery and vein Suborbital nerve and zygomatic nerve

Knowledge of the location of the suborbital and zygomatic nerves is essential (Figure 1). For those who inject very deeply with bony contact, one must use extreme caution not to approach their emergence, either with a needle or a cannula.

Facial artery and facial vein A branch of the external carotid, the facial artery runs above the submaxillary gland, contours the mandible just in front of the lower and anterior angle of the masseter, and continues up close to the posterior border of the depressor anguli oris (Figure 4). It continues along the nasolabial fold, then laterally to the nose, before ending at the angular artery at the inner corner of the eye. A very sinuous structure, it runs superficially over the buccinator, the levator of the lip corner, and the levator labii superioris. It is deeper than the platysma, the depressor anguli oris, and the zygomaticus major and minor. The facial vein has a route roughly parallel, but a few millimetres laterally to the artery, before joining the jugular vein.

Functional and physiological aspects of the ageing face The face is not static, but moves and expresses. In the mid-face, the main moving force is the orbicularis oculi muscle, which can move and elevate the skin–superficial malar fat pairing. It is important to remember, however, that the deep malar fat pad lies fixed to the underlying bony support, and does not move. This distinction therefore describes what is fixed and what is mobile, giving relatively less importance physiologically to the retaining ligaments3

34 ❚ . These ligaments have relevance

expressed by considering the concept of the ‘triangle of youth’. In a youthful appearance, the cheekbones appear high and well defined, the jaw line is also well defined, and this can be represented by an upside down triangle. However, as we age this triangle is inverted as a result of volume loss and sagging; the triangle of youth is lost and the appearance of ageing becomes more visually apparent. However, as aesthetic practitioners we have a selection of tools, such as volumising and/or lifting, that we can offer patients to restore the ratio of this triangle. As with the breasts, the analogy of an apple which

transforms into a pear is perfect to illustrate the movement of the sliding and sagging that comes with ageing, particularly when considering the superficial malar fat pad and skin moving toward the nasolabial fold. This morphological transformation with ageing influences the three main grooves of the face — the palpebromalar groove, mid-cheek groove, and nasolabial groove (Figure 5): ■ The full portion of the pear represents the bulge above the nasolabial groove

■ The mid-cheek groove separates the thin, higher portion and the full, lower portion of the pear. This groove is obliquely upward and inward owing to the downward and inward sliding vector

The face is

not static, but moves and expresses. In the mid-face, the main moving force is the orbicularis oculi muscle, which can move and elevate the skin–superficial malar fat pairing.

January/February 2012 |

■ The palpebromalar groove marks the upper end of superficial malar fat pad, namely the high end of the thin portion of the pear

■ The thin portion of the pear, located between the palpebromalar groove and the mid-cheek groove, is emptied, having lost its fullness owing to the loss of volume associated with sagging of the superficial malar fat pad.

The skin loses some of its elastic properties With ageing, the skin relaxes and sags, accompanied by the superficial malar fat, reaching the nasolabial groove, and sometimes passing over it. Parallel to this chronological ageing, is heliodermic ageing7

, which

arises as a result of exposure to the sun and other extrinsic factors (e.g. smoking, improper skin care, lack of sleep, poor nutrition), causing fine wrinkles and other clinical superficial skin damage. There are four main types of wrinkles:

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