Aging of the FaceAging of the Face

ד"ר פרידמן טל

כירורגיה פלסטית

בי"ח אסף- הרופא

Aging of the FaceAging of the Face

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

GravityGravity

Affects all tissue layersResults in: Brow ptosis, Hallow infraorbital

region, Nasolabial folds, Jowls, Submental skin excess.

Pathogenesis of wrinklesPathogenesis of wrinkles

AgingAgingActinic damageActinic damageGenetic disordersGenetic disorders

AgingAging

A process of atrophyA process of atrophy

EpidermisEpidermis

No change in epidermis thicknessNo change in epidermis thickness

Melanocytes Melanocytes

Langerhans cells Langerhans cells

Dermal-epidermal junctionDermal-epidermal junction

DermisDermis

Components of the dermal connective tissue layer:

•Ground substance (Glycosaminoglycan gel + proteoglycans)

•Elastic fibers (elastin + microfibrillar components(

•Collagen ) Type I:III(

Ground substance (GAG)

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

•Elastic fibers number and diameter

General: 6% for a decade, Connective tissue matrix disorganized, avascular and acellular.

Skin appendagesSkin appendages•Sebaceous glands Sebaceous glands in size but sebum in size but sebum production production •Pacinian and Meissner’s corpuscles - Pacinian and Meissner’s corpuscles - in in numbernumber•Apocrine glands - Apocrine glands - in secretion in secretion

•Eccrine glands - Eccrine glands - •Terminal hair follicles - Terminal hair follicles -

Effects of Age on SkinEffects of Age on Skin

ThinningShearing forcesElasticityImmunologic changesIncreased susceptibility to UV light and

cutaneous malignancies.

Actinic DamageActinic Damage

Pathognomonic: Dermal elastosis and epidermal Pathognomonic: Dermal elastosis and epidermal dysplasiadysplasia..

EpidermisEpidermis

Increase in thicknessIncrease in thickness

Nuclear atypia of keratinocytes and Nuclear atypia of keratinocytes and monocytesmonocytes

DermisDermis

Thickened degraded elastic fibers:Thickened degraded elastic fibers:

““Basophilic degeneration”, “elastosis”:Basophilic degeneration”, “elastosis”: Degraded collagen and elastin.Degraded collagen and elastin.

Increase of ground substance.Increase of ground substance.

Decrease of mature collagen (type I).Decrease of mature collagen (type I).

Inherited Skin DisordersInherited Skin Disorders

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

Ehlers-Danlos Syndrom (Cutis Ehlers-Danlos Syndrom (Cutis Hyperelastica)Hyperelastica)

• HistologyHistology:: Abnormal collagen maturation and Abnormal collagen maturation and tissue fragility, increased capillary fragility.tissue fragility, increased capillary fragility.

• Genetic defect:Genetic defect: Lysyl oxidase Lysyl oxidase Clinical presentation:Clinical presentation: Hypermobile joints; Thin, Hypermobile joints; Thin,

friable, and hyperextensile skin; Subcutaneous friable, and hyperextensile skin; Subcutaneous hemorrhages; Ability to strech the skin- > Shrink hemorrhages; Ability to strech the skin- > Shrink back without wrinkling. Atrophic scars.back without wrinkling. Atrophic scars.

Rhytidectomy is not recommendedRhytidectomy is not recommended

Cutis LaxaCutis 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.

Rhytidectomy is beneficial in the absence of cardiorespiratory dis.

Pseudoxanthoma ElasticumPseudoxanthoma Elasticum

Mechanically stressed skin ( face and sides Mechanically stressed skin ( face and sides of neck and axilla) takes on the texture of of neck and axilla) takes on the texture of plucked chicken skin.plucked chicken skin.

Widespread artheriosclerosis- third decade.Widespread artheriosclerosis- third decade.

Plastic surgery can be beneficial Plastic surgery can be beneficial in the in the absence of vascular disease.absence of vascular disease.

Progeria (Hutchinson-Gilford Progeria (Hutchinson-Gilford Syndrome)Syndrome)

Inheritance: ARInheritance: ARSystemic dis.: Growth retardation, Systemic dis.: Growth retardation,

Craniofacial disproportion, Baldness, Craniofacial disproportion, Baldness, Pinched nose, Protruding ears, Pinched nose, Protruding ears, Micrognathia, Artheriosclerosis, Shortened Micrognathia, Artheriosclerosis, Shortened life span.life span.

No role for aesthetic surgeryNo role for aesthetic surgery

Werner’s syndrome (Adult Werner’s syndrome (Adult progeria)progeria)

Inheritance: ARInheritance: AR Scleroderma-like indurated patches of skin,Scleroderma-like indurated patches of skin,

Baldness, Aged facies, hypo-hyper-pigmentationBaldness, Aged facies, hypo-hyper-pigmentation

Short suture, high-pitched voice, cataract, mild Short suture, high-pitched voice, cataract, mild diabetes mellitus, muscle atrophy, osteoporosis, diabetes mellitus, muscle atrophy, osteoporosis, premature arteriosclerosis, neoplasms.premature arteriosclerosis, neoplasms.

Elective surgical procedures are Elective surgical procedures are contraindicated.contraindicated.

Idiopathic skin laxityIdiopathic skin laxity

Shelley, 1977, “ wrinkles due to idiopathic Shelley, 1977, “ wrinkles due to idiopathic loss of mid-dermal elastic tissue”loss of mid-dermal elastic tissue”

Patchy areas of mid-dermal elastosis Patchy areas of mid-dermal elastosis manifesting as localized fine wrinkling, manifesting as localized fine wrinkling, without systemic abnormalitieswithout systemic abnormalities

Histology of the aged skinHistology of the aged skin

Hashimoto, 1974- described 2 types of Hashimoto, 1974- described 2 types of wrinkles in the skin:wrinkles in the skin:– Shallow wrinkleShallow wrinkle- sun protected area, - sun protected area,

disappears when the skin is stretched.disappears when the skin is stretched.– Deep wrinkleDeep wrinkle- sun-exposed skin, that does not - sun-exposed skin, that does not

disappear on stretching.disappear on stretching.

Kligman- LM and EM:Kligman- LM and EM:– Cutaneous wrinkles are mechanically induced Cutaneous wrinkles are mechanically induced

grooves of the skin in areas of grooves of the skin in areas of frequent motionfrequent motion..

Tsuji- Histology of wrinkles:Tsuji- Histology of wrinkles:– Deep wrinkle- Greater amount of Deep wrinkle- Greater amount of elastotic elastotic

swelling swelling on either side of the wrinkle than in on either side of the wrinkle than in the linear depression.the linear depression.

Lapiere- Microanatomy of human skin Lapiere- Microanatomy of human skin furrowfurrow::

– Fascial insertions of Fascial insertions of cutaneous musclescutaneous muscles that that create surface grooves on surface animation.create surface grooves on surface animation.

Classification of facial wrinkles, Classification of facial wrinkles, Furrows and FoldsFurrows and Folds

WrinklesWrinkles- Intrinsic aging and photoaging.- Intrinsic aging and photoaging.Clinical locationClinical location: Cheeks, crow’s feet, : Cheeks, crow’s feet,

perioral.perioral.Tissue location:Tissue location: Cutaneous. Cutaneous.Treatment:Treatment: Resurfacing. Resurfacing.

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.

Furrows/ Lines: Repeated facial expressions.

Clinical location: Forehead, Glabellar, smile lines.

Tissue location: Musculocutaneous.

Treatment: Muscle resection, Botulinum toxin, injectable skin filler materials.

Combination Combined approach.

Face lifting only addresses the Face lifting only addresses the effects of gravityeffects of gravity

It is not a treatment for fine wrinkles!!!

Stigmata of the aging faceStigmata of the aging face Skin:Skin: Intrinsic and extrinsic aging. Intrinsic and extrinsic aging.

Subcutaneous:Subcutaneous: Descent of facial fat- Descent of facial fat-

skin layerskin layer

Fat:Fat: Gain or loss Gain or loss

Retaining ll.-Retaining ll.- Much of this change relates to a Much of this change relates to a

loss of support from the loss of support from the retaining llretaining ll., ., accompanied by dermal elastosis, and accompanied by dermal elastosis, and facial lipodystrophy.facial lipodystrophy.

Upper FaceUpper 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)

Middle and Lower faceMiddle and Lower face

Midface: Cutaneous descent superficial to the SMAS.

Lower cheek, and neck:

Downward migration of the

skin-fat-platysma layer.

Mid faceMid faceYousif- Analized changes in facial soft-tissues Yousif- Analized changes in facial soft-tissues

occuring with age : occuring with age :

1994,5- Historical photographs and 1994,5- Historical photographs and photogrammetry:photogrammetry:

NLF- Deepening due to descent NLF- Deepening due to descent and anterior projection of the and anterior projection of the subcutaneous cheek mass.subcutaneous cheek mass.

Marionette line- a fold extending from the labial Marionette line- a fold extending from the labial commissure to the parasymphyseal areacommissure to the parasymphyseal area

Jowls- descents of soft tissue below the Jowls- descents of soft tissue below the mandible.mandible.

SkullSkull

Bartlett, Grossman and Whitaker,1992:Bartlett, Grossman and Whitaker,1992:

Analysis of 160 skulls: Analysis of 160 skulls:

Reduction of facial height,Reduction of facial height,

Modest increase in facial width and depth and Modest increase in facial width and depth and generalized coarsening of bony prominences.generalized coarsening of bony prominences.

Vectors of agingVectors of aging

Alter the position and appearance of key Alter the position and appearance of key anatomic structures:anatomic structures:

The vector of aging of the chThe vector of aging of the cheek fat andeek fat and platysma muscle in the lower platysma muscle in the lower face isface is inferomedialinferomedial

The vector of the orbicularis The vector of the orbicularis oculi isoculi is inferolateralinferolateral

Criteria for a youthful neckCriteria for a youthful neck

1.1. Inferior mandibular Inferior mandibular borderborder

2.2. Subhyoid Subhyoid

3.3. Thyroid cartilage Thyroid cartilage

4.4. SCMSCM

5.5. SM-SM angle- 90 SM-SM angle- 90 degrees.degrees.

The NeckThe Neck

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

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.