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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
Aging of the Face

ד"ר פרידמן טל

כירורגיה פלסטית

בי"ח אסף- הרופא

aging of the face1
Aging of the Face

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

  • Affects all tissue layers
  • Results in: Brow ptosis, Hallow infraorbital region, Nasolabial folds, Jowls, Submental skin excess.
pathogenesis of wrinkles
Pathogenesis of wrinkles
  • Aging
  • Actinic damage
  • Genetic disorders

A process of atrophy

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

Components of the dermal connective tissue layer:

  • Ground substance (Glycosaminoglycan gel + proteoglycans)
  • Elastic fibers (elastin + microfibrillar components(
  • Collagen ) Type I:III(

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 

skin appendages
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 - 
effects of age on skin
Effects of Age on Skin
  • Thinning
  • Shearing forces
  • Elasticity
  • Immunologic changes
  • Increased susceptibility to UV light and cutaneous malignancies.
actinic damage
Actinic Damage

Pathognomonic: Dermal elastosis and epidermal dysplasia.

  • Increase in thickness
  • Nuclear atypia of keratinocytes and monocytes
  • Thickened degraded elastic fibers:

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

  • Increase of ground substance.
  • Decrease of mature collagen (type I).
inherited skin disorders
Inherited Skin Disorders
  • Rare skin conditions that may present as premature skin laxity, or aging.
ehlers danlos syndrom cutis hyperelastica
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
cutis laxa
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.
pseudoxanthoma elasticum
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.
progeria hutchinson gilford syndrome
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
werner s syndrome adult progeria
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.
idiopathic skin laxity
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
histology of the aged skin
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.
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.
Lapiere- Microanatomy of human skin furrow:
    • Fascial insertions of cutaneous muscles that create surface grooves on surface animation.
classification of facial wrinkles furrows and folds
Classification of facial wrinkles, Furrows and Folds
  • Wrinkles- Intrinsic aging and photoaging.
  • Clinical location: Cheeks, crow’s feet, perioral.
  • Tissue location: Cutaneous.
  • Treatment: 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.

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

It is not a treatment for fine wrinkles!!!

stigmata of the aging face
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.

upper face
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)

middle and lower face
Middle and Lower face
  • Midface: Cutaneous descent superficial to the SMAS.
  • Lower cheek, and neck:

Downward migration of the

skin-fat-platysma layer.

mid face
Mid face
  • Yousif- Analized changes in facial soft-tissues occuring with age :

1994,5- Historical photographs and photogrammetry:

  • 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.

vectors of aging
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
criteria for a youthful neck
Criteria for a youthful neck
  • Inferior mandibular border
  • Subhyoid
  • Thyroid cartilage
  • SCM
  • SM-SM angle- 90 degrees.
the neck
The 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.