Composite Volumization of the Aging Face: Supra-Periosteal Space as the Foundation for Optimal Facial Rejuvenation

September 2016 | Volume 15 | Issue 9 | Case Reports | 1136 | Copyright © September 2016

Z. Paul Lorenc MDa and Johnson C. Lee MDb

aLorenc Aesthetic Plastic Surgery Center, New York, NY; Lenox Hill Hospital, New York, NY
bPrivate Practice, Beverly Hills, CA

Current concepts of facial aging propose that volume losses of bone and fat in specific compartmentalized areas are the primary and the most important causes of the characteristic changes seen in the aging face. The authors propose that the use of Radiesse in the supra-periosteal space of the temple, zygomatic arch, anterior cheek, pyriform aperture, and pre-jowl sulcus most effectively and most efficiently corrects these volume losses, and therefore best helps to restore a youthful appearance. Placement of filler directly on bone produces a lifting effect on all of the overlying tissues as a single unit which the authors term “composite volumization”.

J Drugs Dermatol. 2016;15(9):1136-1141.


The primary causes of facial aging have in common loss of volume: loss of bony support of overlying soft tissues due to resorption (particularly the dental-bearing areas of the maxilla and mandible and the superomedial and inferolateral orbit) and loss of fat volume from the various facial compartments (especially the deep medial cheek fat) via atrophy and caudal descent.1-3 This volume loss and the resulting loss of overlying soft tissue support leads to deflation, flattening and pseudoptosis of the soft tissues. These changes result in the characteristic signs of the aging face. This is a distinct and specific conceptual change from earlier theories of simple skin and superficial musculoaponeurotic system (SMAS) sagging due to gravitational effects. Consistent with this conceptual change in how the face ages, has been the change in how non-surgical correction of facial aging is best achieved.
Initial paradigms of non-surgical correction of facial aging focused simply on eliminating wrinkles. Injectable materials, silicone initially and then in the 1970s collagen, were injected in the dermis or immediate subdermal layers to “plump up” facial wrinkles and creases. This approach to non-surgical facial rejuvenation persisted through the development of subsequent filler products. Indeed, the original FDA approval for calcium hydroxylapatite (Radiesse, Merz Aesthetics, Inc) in 2006 (originally marketed as Radiance) was for the alleviation of deeper wrinkles and creases such as the nasolabial crease. This approval was for injection into the immediate sub-dermal and deep subcutaneous tissue. These paradigms were modified somewhat by the development of various neuromodulators, but the basic tenets remained the same.
Along with the evolution of the modern concept of volume loss leading to deflation, flattening and pseudoptosis of soft tissues, treatment algorithms have also evolved. The focus has shifted from simply “filling wrinkles” to revolumization of the face.1,2,4,5 Specifically, the areas of greatest volume loss (temple, anterior cheek/zygoma, pyriform aperture, mandibular angle, and pre-jowl sulcus) should be “revolumized”. Once restoration of volume has been achieved, once the foundation has been laid, then the finer details of elimination of remaining wrinkles and creases can be addressed. But how is this first step in facial rejuvenation best achieved? We maintain that off-label placement of Radiesse into the immediate supra-periosteal space in these particular areas provides the revolumization necessary to correct these characteristic changes of facial aging in a safe, reliable, and efficient manner.
In 1992, Dr. Sam Hamra published his technique of the composite rhytidectomy.6 Rather than dissecting and lifting the facial tissue layers as separate entities, he proposed that these tissues are best transposed as a single, composite (“made of many parts”) unit. Since placement of Radiesse directly on bone lifts and supports all of the overlying tissues (skin, superficial and deep fat compartments, and muscle) as a single unit, we term this technique “composite revolumization”. This report describes our experience with this technique

Patient Assessment and Treatment

Patients are assessed primarily from the frontal view. The primary areas to be evaluated were the temple, zygomatic arch and malar eminence/anterior cheek, pyriform aperture, and pre-jowl sulcus. These are the areas most affected by the loss of soft tissue support that is secondary to bony resorption and fat atrophy/caudal descent and that is seen predictably in the aging face.