Aging of the Face

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Aging of the Face

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Aging of the Face
The process of facial aging represents a
combination of gravitational effects and the
aging of tissues.
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Gravity

• Affects all tissue layers
• Results in Brow ptosis, Hallow infraorbital
  region, Nasolabial folds, Jowls, Submental skin
  excess.

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Pathogenesis of wrinkles

• Aging
• Actinic damage
• Genetic disorders

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Aging
A process of atrophy
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Epidermis

• No change in epidermis thickness
• Melanocytes ?
• Langerhans cells ?
• Dermal-epidermal junction

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Dermis
Components of the dermal connective tissue layer

• Ground substance (Glycosaminoglycan gel
  proteoglycans)
• Elastic fibers (elastin microfibrillar
  components(
• Collagen ) Type IIII(

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? General 6? for a decade, Connective tissue
matrix disorganized, avascular and acellular.
? Ground substance (GAG)?

• Elastic fibers ? number and diameter

? Collagen Overall collagen content ?, III/I ?,
Tensile strength of collagen fibril ?

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Skin appendages

• Sebaceous glands ? in size but sebum production ?

• Pacinian and Meissners corpuscles - ? in number

• Apocrine glands - ? in secretion
• Eccrine glands - ?

• Terminal hair follicles - ?

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Effects of Age on Skin

• Thinning
• Shearing forces
• Elasticity
• Immunologic changes
• Increased susceptibility to UV light and
  cutaneous malignancies.

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Actinic Damage

• Pathognomonic Dermal elastosis and epidermal
  dysplasia.

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Epidermis

• Increase in thickness
• Nuclear atypia of keratinocytes and monocytes

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Dermis

• Thickened degraded elastic fibers
• Basophilic degeneration, elastosis
  Degraded collagen and elastin.
• Increase of ground substance.
• Decrease of mature collagen (type I).

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Inherited Skin Disorders

• Rare skin conditions that may present as
  premature skin laxity, or aging.

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Ehlers-Danlos Syndrom (Cutis Hyperelastica)

• Histology Abnormal collagen maturation and
  tissue fragility, increased capillary fragility.
• Genetic defect Lysyl oxidase
• Clinical presentation Hypermobile joints Thin,
  friable, and hyperextensile skin Subcutaneous
  hemorrhages Ability to strech the skin- gt Shrink
  back without wrinkling. Atrophic scars.
• Rhytidectomy is not recommended

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Cutis Laxa

• AD, AR, X-Linked

• Inadequacy of elastic fibers through-out the
  body, especially in the skin, lungs and aorta.
• 1' presenting symptom extreme laxity?
  prematurely aged.
• AD Involve only the dermis.
• AR Generalized abnoralities Emphysema,
  pulmonary infection, cor pulmonale, and hernias.

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• Rhytidectomy is beneficial in the absence of
  cardiorespiratory dis.

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Pseudoxanthoma Elasticum

• Mechanically stressed skin ( face and sides of
  neck and axilla) takes on the texture of plucked
  chicken skin.
• Widespread artheriosclerosis- third decade.
• Plastic surgery can be beneficial in the absence
  of vascular disease.

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Progeria (Hutchinson-Gilford Syndrome)

• Inheritance AR
• Systemic dis. Growth retardation, Craniofacial
  disproportion, Baldness, Pinched nose, Protruding
  ears, Micrognathia, Artheriosclerosis, Shortened
  life span.
• No role for aesthetic surgery

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Werners syndrome (Adult progeria)

• Inheritance AR
• Scleroderma-like indurated patches of skin,
• Baldness, Aged facies, hypo-hyper-pigmentation
  
• Short suture, high-pitched voice, cataract,
  mild diabetes mellitus, muscle atrophy,
  osteoporosis, premature arteriosclerosis,
  neoplasms.
• Elective surgical procedures are contraindicated.

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Idiopathic skin laxity

• Shelley, 1977, wrinkles due to idiopathic loss
  of mid-dermal elastic tissue
• Patchy areas of mid-dermal elastosis manifesting
  as localized fine wrinkling, without systemic
  abnormalities

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Histology of the aged skin

• Hashimoto, 1974- described 2 types of wrinkles in
  the skin
• Shallow wrinkle- sun protected area, disappears
  when the skin is stretched.
• Deep wrinkle- sun-exposed skin, that does not
  disappear on stretching.

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• Kligman- LM and EM
• Cutaneous wrinkles are mechanically induced
  grooves of the skin in areas of frequent motion.
• Tsuji- Histology of wrinkles
• Deep wrinkle- Greater amount of elastotic
  swelling on either side of the wrinkle than in
  the linear depression.

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• Lapiere- Microanatomy of human skin furrow
• Fascial insertions of cutaneous muscles that
  create surface grooves on surface animation.

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Classification of facial wrinkles, Furrows and
Folds

• Wrinkles- Intrinsic aging and photoaging.
• Clinical location Cheeks, crows feet, perioral.
• Tissue location Cutaneous.
• Treatment Resurfacing.

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• Folds- The result of overlapping skin caused by
  genetic laxity, intrinsic aging, loss of tone,
  bony atrophy, gravity, and consequent sagging.
• Clinical location Lids, nasolabial fold,
  horisontal neck folds.
• Tissue location Muscular.
• Treatment Rhytidectomy,
• Blepharoplasty.

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• Furrows/ Lines Repeated facial expressions.
• Clinical location Forehead, Glabellar, smile
  lines.
• Tissue location Musculocutaneous.
• Treatment Muscle resection, Botulinum toxin,
  injectable skin filler materials.

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• Combination??? Combined approach.

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Face lifting only addresses the effects of gravity

• It is not a treatment for fine wrinkles!!!

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Stigmata of the aging face

• Skin Intrinsic and extrinsic aging.
• Subcutaneous Descent of facial fat-
• skin layer
• Fat Gain or loss
• Retaining ll.-
• Much of this change relates to a
• loss of support from the retaining ll.,
  accompanied by dermal elastosis, and facial
  lipodystrophy.

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Upper Face

• Drooping of the eyebrows.
• Hooding of the upper eyelids.
• Forehead wrinkling.
• Glabellar frown lines.
• Prominent lines and laxity
• of the outer canthus ,onto the
• temple area.
• 40 of face- lifted patients
• have concomitant forehead
• lift (Owsley)

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Middle and Lower face

• Midface Cutaneous descent superficial to the
  SMAS.
• Lower cheek, and neck
• Downward migration of the
• skin-fat-platysma layer.

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Mid face

• Yousif- Analized changes in facial soft-tissues
  occuring with age
• 1994,5- Historical photographs and
  photogrammetry

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NLF- Deepening due to descent and anterior
projection of the subcutaneous cheek mass.
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Marionette line- a fold extending from the labial
commissure to the parasymphyseal area
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Jowls- descents of soft tissue below the mandible.
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Skull

• Bartlett, Grossman and Whitaker,1992

Analysis of 160 skulls Reduction of facial
height,
Modest increase in facial width and depth and
generalized coarsening of bony prominences.
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Vectors of aging

• Alter the position and appearance of key anatomic
  structures
• The vector of aging of the cheek fat and platysma
  muscle in the lower face is inferomedial
• The vector of the orbicularis oculi is
  inferolateral

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Criteria for a youthful neck

1. Inferior mandibular border
2. Subhyoid
3. Thyroid cartilage
4. SCM
5. SM-SM angle- 90 degrees.

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The Neck

• Excess skin.
• Excess submental fat.
• Excess supraplatysmal or subplatysmal fat.
• Platysmal bands.
• Large submaxillary gland.
• Micrognatia.

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• Padgett and Stevenson, 1948- Platysmal bands
• The medial borders of the platysma m. tend to
  become redundant ? Platysmal bands.
• McKinney, 1995
• The bands are not the medial edge of the muscle,
  but rather lateral pleats caused by laxity of the
  muscle .
• Pseudoherniation of the submental fat Turkey
  gobbler deformity.

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