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Aging of the Face . ד"ר פרידמן טל כירורגיה פלסטית בי"ח אסף- הרופא. Aging of the Face. The process of facial aging represents a combination of gravitational effects and the aging of tissues. Gravity. Affects all tissue layers

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Aging of the face l.jpg

Aging of the Face

ד"ר פרידמן טל

כירורגיה פלסטית

בי"ח אסף- הרופא

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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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  • 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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A process of atrophy

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  • No change in epidermis thickness

  • Melanocytes 

  • Langerhans cells 

  • Dermal-epidermal junction

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Components of the dermal connective tissue layer:

  • Ground substance (Glycosaminoglycan gel + proteoglycans)

  • Elastic fibers (elastin + microfibrillar components(

  • Collagen ) Type I:III(

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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 Meissner’s 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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  • Increase in thickness

  • Nuclear atypia of keratinocytes and monocytes

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  • 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- > 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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Werner’s 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, crow’s 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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  • 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

  • Inferior mandibular border

  • Subhyoid

  • Thyroid cartilage

  • SCM

  • 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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