Research

JAMA Facial Plastic Surgery | Original Investigation

Patterns of Change in Facial Skeletal Aging

Boris Paskhover, MD; David Durand, MD; Emily Kamen, MD; Neil A. Gordon, MD

Supplemental content
IMPORTANCE Research in facial aging has focused on soft-tissue changes rather than bony
changes despite evidence of the importance of underlying bony structural changes. Research
has also been limited by comparing different patients in separate age groups rather than the
same patients over time.

OBJECTIVE To longitudinally document patterns of change in the facial skeleton and

determine a consistent methodology for measuring these changes.

DESIGN, SETTING, AND PARTICIPANTS Case series study of university hospital system records
using facial computed tomographic (CT) images timed at least 8 years apart in adults initially
aged 40 to 55 years with no history of facial surgery who required repeated facial imaging
that included the entire midface and cranium.

MAIN OUTCOMES AND MEASURES Face CTs were analyzed for 3-dimensional constructions
and 2-dimensional measurements to document changes in glabellar, piriform, and maxillary
angles and piriform height and width.

RESULTS Fourteen patients (5 men, 9 women; mean [SD] age, 51.1 [5.8] years) with mean
(SD) follow-up of 9.7 (1.4) years were eligible for 2-dimensional analysis, which revealed
statistically significant decreases in mean (SD) glabellar angles (from 68.8 [7.6] to 66.5
[8.6]) and maxillary angles on both the right (from 82.5 [6.3] to 81.0 [7.1]) and left (from
83.0 [5.8] to 81.0 [7.0]), as well as increases in mean (SD) piriform width (from 24.5 [1.6]
mm to 25.5 [1.3] mm). Nine patients (3 men, 6 women; mean [SD] age, 51.4 [6.3] years) with
mean (SD) follow-up imaging at 9.6 (1.5) years were eligible for 3-dimensional analysis, which
revealed statistically significant decreases in mean (SD) maxillary angles (from 56.5 [6.6] to
51.6 [7.6]) and piriform angles (from 50.8 [3.4] to 49.1 [3.4]). Statistically significant
differences between the sexes were also noted: Initial mean (SD) glabellar angle for men was
61.7 (5.7) vs 72.7 (5.4) for women, with final values of 57.9 (4.9) vs 71.2 (6.0). Mean
(SD) maxillary angle initial values were 87.8 (6.1) (right) and 87.1 (4.9) (left) for men, with
79.6 (4.3) and 80.6 (5.0) for women, respectively. Final values were 87.0 (4.4) and 86.9
(4.1) for men and 77.7 (6.1) and 77.7 (6.2) for women, respectively. Mean (SD) piriform
height for men was 35.0 (2.0) mm initially and 35.5 (2.1) mm finally, vs 31.3 (2.8) and 31.6 (3.0)
mm for women, respectively.

CONCLUSIONS AND RELEVANCE Our pilot study of repeated CT images of patients over several
years supports previous studies of bony facial aging and further characterizes these changes.
This study is the first, to our knowledge, to document bony changes of the face in the same
group of patients at different time points to better characterize facial aging. We also detail an
improved methodology to study bony aging to contribute to additional research in the field.

Author Affiliations: New York

LEVEL OF EVIDENCE NA.
University School of Medicine, New
York (Paskhover, Kamen); Rutgers
New Jersey Medical School, Newark,
New Jersey (Paskhover); Yale School
of Medicine, New Haven, Connecticut
(Durand, Gordon).
Corresponding Author: Boris
Paskhover, Department of
OtolaryngologyHead and Neck
Surgery, Rutgers New Jersey Medical
School, 90 Bergen St, Suite 8100,
JAMA Facial Plast Surg. 2017;19(5):413-417. doi:10.1001/jamafacial.2017.0743 Newark, NJ 07103 (boris.paskhover
Published online August 10, 2017. @njms.rutgers.edu).

(Reprinted) 413
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 Research Original Investigation
F
or more than half a century, the medical literature has
shown that all 4 structural tissue typesskin, fat, muscle,
and bonecontribute to facial aging.1 However, the ex-
tent to which each of these tissues contributes to the facial ag-
ing process continues to be debated.
During this time, it has been clear that the majority of fa-
cial aging is due to gravitational effects on the facial soft tis-
sues, validating the surgical model in which lifting, reposi-
tioning, and excising excess soft tissue is the optimal solution
to restore the face to its prior form. There are, however, inad-
equacies in the aesthetic outcomes, especially when tech-
niques that require skin tension are applied. Limitations are
also apparent in the extremes of age and in specific anatomic
locations such as the periorbital and nasolabial regions.
Volume restoration has also been advocated as a tech-
nique for facial rejuvenation during this period,2,3 but it was
the apparent inability of the surgical model to consistently
address certain facial aging patterns that led to a new empha-
sis on understanding the contribution of volume loss and the
recent popularity of the volume model. This model empha-
sizes deflation and touts the resultant folds and hollows
as evidence of facial fat loss causing the majority of aging
changes. Advances in soft-tissue fillers and fat transfer tech-
niques, as well as the ease, cost, and consumer demand for
the volume model, have fueled increased use of this
approach despite similar evidence of limitations and inad-
equacies in aesthetic outcomes. In addition, to our knowl-
edge there has been no study documenting the loss of facial
fat during the aging process.
Starting with studies from Pessa and Lambros, research in
the early 2000s documented the neglected contribution of the
facial skeleton in elucidating the aging process.1 Of interest,
skeletal changes occur in the exact regions where volume en-
hancements have their greatest success: the medial cheek and
periorbital region. In addition, bone loss also explains certain
limitations to the surgical model approach to the aging face,
especially in the extremes of age.
In his work, Pessa1 discussed Lambross theory of bony fa-
cial aging and verified it with the use of 3-dimensional (3-D)
stereolithography in 12 male participants separated into 2
groups by age. The study supported the theory that midface
changes can be thought of as a clockwise rotation in the sag-
ittal plane, relative to the skull base, with maxillary retrac-
tion and increasing prominence of the glabellar angle. Mea-
surements were performed on 3-D stereolithographs with a
1-mm variability during the printing process, and the axial
computed topography (CT) data that were used for the rapid
prototyping were noted to be up to 3-mm thickness. The com-
bination of the variability during the printing process and the
rather large gaps between axial data brings to light the diffi-
culty in accurately measuring the changes involved.
Nearly a decade later, Shaw and Kahn2 published work on
the aging face and its aesthetic implications with the use of CT
and 3-D volume rendering. Using 1-mm slice thickness, digi-
tal measurements were performed on the Volume Viewer (Vox-
tool 3.0.64q; GE Healthcare) platform. Using 3 separate pa-
tient groups of young, middle-aged, and old, they were able
to once again denote the various bony morphologic changes
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Patterns of Change in Facial Skeletal Aging
Key Points
Question What are the patterns of bony changes in the aging face
when patients are observed longitudinally?
Findings In this case series study of 14 adults, a significant
decrease in both maxillary and piriform angles was found on
3-dimensional analysis of computed tomographic scans repeated
at least 8 years apart. Two-dimensional analysis revealed
significant decreases in glabellar and maxillary angles and
significant increase in piriform width, as well as differences
between sexes.
Meaning A longitudinal design to study facial aging as well as
a 2-dimensional method of analysis can improve on previous
methods of characterizing the bony changes that occur in the
aging face.
including increases in orbital aperture width, orbital area, and
piriform aperture area. They also noted a significant reduc-
tion in glabellar and maxillary angles. Although the study clari-
fied the changes that occur to the bony skeleton, it was inher-
ently limited by the use of separate patient groups.
Our goal in this pilot study was to identify methodology
to accomplish a longitudinal study to characterize the timing
and pattern of these bony changes to define the contribution
of facial skeletal bone loss and remodeling to benefit our gen-
eral understanding of the aging face. Methodology to study pa-
tients longitudinally is necessary to investigate any interven-
tions aimed at treating, slowing, or preventing these bony
changes. Our present study is the first to identify these mor-
phological changes using improved methodologies while fol-
lowing individual patients longitudinally.
Methods
A retrospective query of our institutions radiology report da-
tabase (Montage Healthcare Solutions) was performed to iden-
tify adult patients initially aged 40 to 55 years with repeated
CT studies at least 8 years apart that included the entire mid-
face and cranium. This study was approved by the Yale School
of Medicine institutional review board, and a waiver for in-
formed consent was granted due to its retrospective nature and
use of deidentified patient information. A total of 14 patients
meeting criteria were selected for further review, with the ma-
jority having undergone CT angiography surveillance for in-
tracranial aneurysm growth. Patients were excluded from study
participation for evidence of prior significant calvarial or fa-
cial surgery, noted current or previous facial trauma, abnormal-
appearing soft-tissue or bony structures consistent with patho-
logic disease processes, or complete lack of maxillary dentition.
Slice thickness ranged from 0.63 to 1.25 mm.
Three-dimensional reconstructions were performed on a
dedicated GE Workstation. The skull was positioned so that the
sella-nasion line was oriented parallel to the axial plane. An-
thropometric measurements obtained were glabellar angle,
piriform angle, and maxillary angle according to previous au-
thors (Figure 1).1,2 Piriform distance, anterior lacrimal crest dis-
tance, and orbital and zygoma distance were measured from
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 Patterns of Change in Facial Skeletal Aging Original Investigation Research

Figure 1. Example 2-Dimensional Angle Measurements Figure 2. Distances Measured From a Line Drawn Inferiorly From
the Nasofrontal Suture, With Measurements Made With a Parallel Line
72.1 to the Nasion-Sella Line

12.2 mm
A
49.7

16.6 mm
B A
C
B

C 29.4 mm
47.3
D
11.6 mm
52.9 mm
A indicates glabellar; B, piriform; and C, maxillary angle.

A indicates anterior lacrimal crest; B, orbital; C, zygoma; D, piriform. All

a line drawn inferiorly from the nasofrontal suture, with mea-
measurements are 2-dimensional.
surements parallel to the nasion-sella line similar to previous
authors (Figure 2).3 Using the GE 3-D volume-rendering soft-
ware, we were able to 3-D reconstruct 9 of the 14 patients ini- Figure 3. Left and Right Maxillary Angles Obtained on Parasagittal Slices
tial images. Due to limitations with software compatibility and at the Level of the Infraorbital Foramen and Mid-Orbits
the images raw data, we were not able to reconstruct 5 of our
patients images using the 3-D software. This led us to estab- 84.3
lishing a methodology for 2-dimensional (2-D) analysis of the
aging face.
Two-dimensional multiplanar reformatted images were re-
constructed using Vitrea software (Vital Images) on all 14 pa-
tients. The following measurements were obtained on the mid-
sagittal slice: glabellar angle (eFigure 1 in the Supplement) (apex
anterior at the glabella with one side through the nasofrontal
suture and the other side parallel to the sella-nasion line) and
piriform height (measured from rhinion to nasal crest). The piri-
form width was obtained on coronal reformatted images and
defined as the maximal transverse width of the piriform ap-
erture (eFigure 2 in the Supplement). The left and right max-
illary angles were obtained on parasagittal slices at the level
of the infraorbital foramen and mid-orbits (apex anterior at the
superior maxilla with one side through the mid-sella and the follow-up of 9.6 (1.5) years. We noted a statistically signifi-
other side to the inferior maxillaalveolar crest junction) cant decrease in the mean (SD) maxillary angles from 56.5
(Figure 3). Of note, the superior line universally was parallel (6.6) to 51.6 (7.6) (P = .001) and a decrease in piriform angle
and approximated the orbital floor, similar to previous au- from 50.8 (3.7) to 49.1 (3.4) (P = .02). Piriform distance,
thors methods.4 anterior lacrimal crest distance, and orbital and zygoma dis-
Statistical analysis was performed using Microsoft Excel, tance results noted no statistically significant difference be-
version 14.4.7. Absolute change in anthropometric para- tween the initial and final images (Table 1).
meters and mean values between time points were calcu-
lated for each patient. Paired and unpaired t tests were per- Two-Dimensional Analysis
formed when appropriate. The correlation coefficient between Fourteen patients (5 men and 9 women) were included in
3-D and 2-D measurements was obtained as well when appro- our 2-D analysis of facial aging. The mean (SD) age was 51.1
priate. P .05 was considered statistically significant. (5.8) years at initial imaging, with changes of the initial and
final images documented over a mean (SD) 9.7 (1.4)-year
time frame (Table 1). We noted statistically significant differ-
ences in the mean glabellar angle (from 68.8 [7.6] to 66.5
Results [8.6]), both right and left maxillary angles (from 82.5 [6.3]
Three-Dimensional Analysis to 81.0 [7.1] and from 83.0 [5.8] to 81.0 [7.0], respec-
Our 3-D analysis of facial aging included 9 patients (3 men and tively), and piriform width (from 24.5 [1.6] mm to 25.5 [1.3]
6 women), with a mean (SD) starting age of 51.4 (6.3) years and mm). No significant difference was noted in mean piriform

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 Research Original Investigation Patterns of Change in Facial Skeletal Aging

Table 1. Three-Dimensional and Two-Dimensional Analysis Values Table 2. Two-Dimensional Analysis of Male vs Female Initial
and Final Values
Mean (SD)
Measurement Initial Final Difference P Value Mean (SD)
Three-Dimensional Measurement Male Female P Value
Angle, degrees Initial

Glabellar 69.9 (5.4) 71.5 (6.4) 1.6 .12 Angle, degrees

Piriform 50.8 (3.7) 49.1 (3.4) 1.7 .02 Glabellar 61.7 (5.8) 72.7 (5.4) .004

Maxillary 56.5 (6.6) 51.6 (7.6) 4.9 .001 Right maxillary 87.8 (6.1) 79.6 (4.3) .01

Distance, mm Left maxillary 87.1 (4.9) 80.6 (5.0) .04

To anterior lacrimal 11.3 (2.0) 10.8 (2.4) 0.5 .31 Piriform, mm

To orbit 16.6 (3.0) 16.8 (3.0) 0.2 .75 Width 24.9 (1.8) 24.2 (1.5) .42

To piriform 11.4 (2.5) 11.3 (2.6) 0.1 .56 Height 35.0 (2.0) 31.3 (2.8) .02

To zygoma 28.6 (4.2) 30.1 (4.5) 1.5 .11 Final

Two-Dimensional Angle, degrees

Angle, degrees Glabellar 57.9 (4.9) 71.2 (6.0) .001

Glabellar 68.8 (7.6) 66.5 (8.6) 2.3 .03 Right maxillary 87.0 (4.4) 77.7 (6.1) .01

Maxillary Left maxillary 86.9 (4.0) 77.7 (6.2) .01

Right 82.5 (6.3) 81.0 (7.1) 1.5 .03 Piriform, mm

Left 83.0 (5.8) 81.0 (7.0) 2.0 .01 Width 25.7 (0.8) 25.4 (1.6) .72

Piriform, mm Height 35.5 (2.1) 31.6 (3.0) .02

Width 24.5 (1.6) 25.5 (1.3) 1.0 .02

Height 32.7 (3.0) 32.9 (3.3) 0.2
height. We also noted a statistically significant difference
between the male and female patients regarding their mean
glabellar angle, maxillary angle, and piriform height at both
initial and final scans (Table 2). Initial mean (SD) glabellar
angle for men was 61.7 (5.7) compared with 72.7 (5.4) for
women, with final values of 57.9 (4.9) vs 71.2 (6.0). Mean
(SD) maxillary angle initial values were 87.8 (6.1) (right)
and 87.1 (4.9) (left) for men, with 79.6 (4.3) and 80.6
(5.0) for women, respectively. Final values were 87.0 (4.4)
and 86.9 (4.1) for men and 77.7 (6.1) and 77.7 (6.2) for
women, respectively. Mean (SD) piriform height for men was
found to be 35.0 (2.0) mm initially and 35.5 (2.1) mm finally,
compared with 31.3 (2.8) and 31.6 (3.0) mm for women,
respectively. No significant difference between sexes was
noted for piriform width.
Correlational statistics were performed comparing our 3-D
maxillary angle measurements and our 2-D maxillary angle
measurements for the patients for whom 3-D reformatting was
obtained. Correlation coefficients of 0.55 and 0.69 for the ini-
tial and final scans, respectively, were obtained. We also com-
pared the glabellar angle measurements between the 2-D and
3-D methods and noted a correlation coefficient of 0.90 and
0.91 for the pre- and postscans, respectively.
Discussion
Although the bony facial aging changes that we define in
our study have been previously documented by several
groups,1-5 previous skeletal studies have had limiting meth-
odologies, specifically involving CT technology, that
resulted in statistically invalid findings. In addition, they
were not longitudinal in design because none analyzed the
same patient over time. Our pilot study results have con-
.27
firmed previous findings, as well as documenting a method-
ology to longitudinally study skeletal changes. As imaging
technology continues to advance, we will add other data
points as markers to this methodology.
Specific to this study, our 3-D analysis strategy confirmed
the decrease in maxillary angle and piriform angle, represent-
ing the maxillary retrusion that occurs with age. Because the
underlying maxilla provides the essential projection around the
nose, these bony changes likely contribute to the appearance
of many common mid-face aging changes, such as prominent
nasolabial folds,5 facial hollowing, loss of dentition, and the se-
nile nose. These findings are consistent with the documenta-
tion by Pessa1 of loss of projection of the maxilla and the quan-
tified description by Mendelson et al4 of maxillary retrusion.
Our 2-D results also showed significant changes between
the initial and final scans. We noted a decrease in glabellar and
maxillary angles, along with a widening of the piriform aper-
ture. This is consistent with the documentation by Shaw and
Kahn2 of these changes in different age groups. We found that
the 2-D analysis allowed more precise data gathering than our
3-D analysis because the measuring techniques were more eas-
ily standardized. As expected from previous studies with sex
comparisons, we did also note a statistically significant dif-
ference between the male and female patients.2,4
Interestingly, the strong correlation between the 3-D and
2-D results for glabellar and maxillary angles supports the fu-
ture use of 2-D measurements as a general marker. Choosing
specific points on 3-D reconstructions inherently introduces
more variability, and therefore obtaining reliably reproduc-
ible measurements was substantially more difficult than on the
2-D films.
Limitations
Our study was limited by the small sample of patients avail-
able in the radiology report database whose records met cri-

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 Patterns of Change in Facial Skeletal Aging Original Investigation Research

teria. This is due to the scarcity of patients who require high-
fidelity CT imaging over several years without substantial
operative intervention or facial trauma. However, our ana-
lytical techniques highlight the possibilities that a multi-
institutional database of patients will offer. Our study
focused on differences within a patient spanning approxi-
mately a decade. Ideally, patients should be studied longitu-
dinally to document changes in the individual. Because
aging changes occur over decades, defining methodology
using 2-D measurements and adding a larger database would
allow a greater range of ages to be included in new studies
because older CT images could then meet criteria for inclu-
sion. The fact that our study confirms the results of previous
studies that have compared ages ranging from 20 to 70 years
is encouraging to further study of specific patterns and tim-
ing of facial skeletal changes. In addition, the influence of
sex and other demographic characteristics and hormonal
and disease states, as well as other variables, can be assessed
across individuals.
Conclusions
Ultimately, defining a methodology to longitudinally document
the 3-D patterns and timing of facial skeletal aging changes will
allow us to objectively test specific treatments aimed at slowing
or reversing these bony aging changes. The timing of when in-
tervention can be helpful can also be defined. Treatments already
in use for osteoporosis such as hormone modulators, bisphos-
phonates, or calcitonin may be effective for aging. Mechanical
devices used in orthopedics and orthodontics, as well as novel
pharmaceutical approaches, may allow us not only to treat but
also to prevent these facial skeletal changes from occurring,
opening up a whole new paradigm in facial aging prevention.

ARTICLE INFORMATION REFERENCES 5. Mendelson B, Wong CH. Changes in the facial

Accepted for Publication: March 29, 2017.
Published Online: August 10, 2017.
doi:10.1001/jamafacial.2017.0743
Author Contributions: Dr Paskhover had full
access to all of the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Paskhover, Durand,
Gordon.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Paskhover, Kamen,
Gordon.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Paskhover.
Administrative, technical, or material support: All
authors.
Supervision: Paskhover, Gordon.
Conflict of Interest Disclosures: None reported.
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