#PRSJournalClub Wrap-Up: Three-Dimensional Facial Averaging: A Tool for Understanding Facial Aging

by Daniel M Balkin, MD, PhD (@DannyBalkin)

The December edition of the #PRSJournalClub featured a landmark study by Lambros & Gideon, entitled, “Three-Dimensional Facial Averaging: A Tool for Understanding Facial Aging.” In an effort to objectively evaluate the progression of facial shape with aging, the authors leveraged the power of three-dimensional imaging together with sophisticated computer modeling to average the faces of a large number of human subjects. In viewing the facial averages over time, one can objectively appreciate the intricate and complex dynamic changes that occur in facial aging. The authors demonstrate how eyelid apertures diminish (vertically and transversely) and lower lids rise. In addition, the upper and lower lips thin, while the horizontal labial fissure and oral commissures move inferioposteriorly impacting the nasolabial fold. Lastly, the authors reveal how the columellar base moves posteriorly, while the splaying and elevation of the alar base and ptosis of the nasal tip parallels the thinning of the lip. In a sophisticated manner, this innovative approach not only furthers our basic understanding of the aging face, but it also provides tremendous insight into innovative approaches and tailored therapies to restore facial fate for both reconstructive and aesthetic purposes.


This article was featured in Part 3 of the December 2016 PRS Journal Club Discussion Podcast. Participants included our previous Resident Ambassadors to the PRS Editorial Board, Sammy Sinno, MD (@sammysinnoMD), Amanda Silva, MD (@AmandaKSilvaMD), and Raj Sawh-Martinez, MD (@docrfsm) together with special guest moderator Rod J Rohrich, MD (@DrRodRohrich), Editor in Chief of PRS. Listen to this lively and meaningful discussion:

This Podcast was Sammy, Amanda and Raj’s final Podcast as Resident Ambassadors. On behalf of the entire PRS readership, we cannot thank them enough for their tireless leadership and meaningful contributions to the Journal.

#PRSJournalClub – Live Chat on Twitter:

On December 18-19, a rich and lively #PRSJournalClub discussion took place with author Val Lambros (@ValLambros). For those who might have missed it, or for others who would like to revisit the discussion, please find a summary below:

Tweets to get discussion started:



















Best Tweeted Conversations:

@JordanFreyMD: What surprised you most about these findings?
@Vallambros: The big picture. I saw all these changes in matched pictures. The averages show the gestalt.

@pallabc: The GIF did not miss the temporal hollowing also. Very impressive!!
@Vallambros: The more you look the more you see. Some of traditional views are wrong or incomplete.
@pallabc: Great suggestion to look at GIF for some time.

@shujashafqatmd: How does this change your approach to deeper augmentation strategies?
@Vallambros: It gives a more total understanding of how the face has changed. This influences rx.

@JordanFreyMD: Should all patients have baseline imaging to guide future interventions?
@Vallambros: Everyone should get a grid tattooed on their faces.

@pallabc: Do you reckon that you have made a strong case for deflation theory [rather] then gravitational one for facial aging?
@Vallambros: Aging is complex not pure. Face stretches, changes color, deflates inflates, these are powerful changes.

@JordanFreyMD: Any plans to perform and compare in select subsets of patients?
@Vallambros: Thin and fat faces any other suggestions?
@ shujashafqatmd: Twins with different comorbidities/lifestyles (sun exposure, smoking).

@JordanFreyMD: What interventions should this “averaged” aged patient be offered?
@Vallambros: The face tells you what to do. Listen.

@sammysinnoMD: For correction of tear trough and blended lid-cheek jxn, what are your thoughts on filler vs fat vs surg?
@Vallambros: HA fillers are more reliable than fat and won’t grow. 2-4 yrs life. You can remove them, safer. In OR I use fat, otherwise fillers. Safer and long[er] duration. Upper lids fillers.

@sammysinnoMD: What are future studies with this technology?
@Vallambros: Averaging thin and heavy faces. Accepting suggestions.
@sammysinnoMD: Would be interested in how those who had facelift age vs those without.

@JuhaKil: Could you briefly summarize the factors causing these aging changes?
@Vallambros: Decay, stretch, loss of recoil, demarcation of color, shape change, weight.

@ChadPurnellMD: Vertical palpebral loss from senile ptosis, transverse loss from canthal tendon weakness?
@Vallambros: Probably. Elevation of lower lid either from lct stretch or enophthalmos.

@sammysinnoMD: Does NL angle or collumelar-labial angle actually change with age or is it an optical illusion?
@Vallambros: The collumelar lip junction rounds out from curved to angle, looks like the angle becomes more acute
@JordanFreyMD: Great observation!



Three-Dimensional Facial Averaging: A Tool for Understanding Facial Aging
Lambros, Val; Amos, Gideon. Plastic & Reconstructive Surgery . 138(6):980e-982e, December 2016


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