Download Perioral Wrinkles: Histologic Differences Between Men and Women

Facial Surgery
ERN
INT ATI
IBUTION
TR
AL CON
ON
Perioral Wrinkles:
Histologic Differences
Between Men and Women
Emma C. Paes, MD; Hans J. L. J. M. Teepen, MD, PhD; Willemijn A. Koop, MD; and
Moshe Kon, MD, PhD
Background: Women tend to develop more and deeper wrinkles in the perioral region than men. Although
much is known about the complex mechanisms involved in skin aging, previous studies have described histologic differences between men and women with respect to skin aging only incidentally and have not investigated the perioral region.
Objective: The purpose of this study was to investigate gender-specific differences in the perioral skin.
Methods: To determine wrinkle severity, skin surface replicas of the upper lip region in 10 male and 10 female
fresh cadavers were analyzed by using the dermaTOP blue three-dimensional digitizing system (Breuckmann,
Meersburg, Germany). In 30 fresh male and female cadavers, three full-thickness lip resections were investigated in a blinded fashion for specific histologic features. All results were statistically analyzed in a linear regression model with SPSS software (version 15.0; SPSS, Chicago, IL).
Results: The female replicas showed more and deeper wrinkles than the male replicas (P < .01). Histologic
analysis revealed that the perioral skin of men displayed a significantly higher number of sebaceous glands
(P = .000; 95% confidence interval [CI] 23.6–53.2), sweat glands (P = .002; 95% CI 2.1–8.1), and a higher ratio
between vessel area and connective tissue area in the dermis (P = .009; 95% CI 0.003–0.021). The amount of
hair follicles did not significantly differ between men and women, although the average number of sebaceous
glands per hair follicle was greater in men (P = .002; 95% CI 0.33–1.28).
Conclusions: Women exhibit more and deeper wrinkles in the perioral region and their skin contains a significantly smaller number of appendages than men, which could be a feasible explanation for why women are
more susceptible to development of perioral wrinkles. (Aesthet Surg J; 29:467-472.)
rinkle formation of the skin is a consequence
of aging that is influenced by both intrinsic
(biologic) and extrinsic (environmental) factors.1-4 The number and depth of wrinkles are linearly
related to a person’s age.5 Intrinsic aging is a largely
genetically determined process that mimics the aging of
all organs in the human body and results in cutaneous
alterations. Those alterations include a flattening of the
dermoepidermal junctions, atrophy of dermis and epidermis, and a reduction in the amount of collagen and
reticuline, as well as the number of fibroblasts.1,2
W
Dr. Paes and Dr. Kon are from the Department of Plastic,
Reconstructive and Hand Surgery, University Medical Center, Utrecht,
The Netherlands. Dr. Teepen is from the Department of Pathology, St.
Elisabeth Hospital, Tilburg, The Netherlands. Dr. Koop is from the
Department of Plastic, Reconstructive, and Hand Surgery, University
Medical Center, Leeuwarden, The Netherlands. Dr. Kon is a member
of the Dutch Society for Aesthetic Plastic Surgery.
Aesthetic Surgery Journal
Skin that has been exposed to the sun, like the skin of
the face and hands, develops permanent wrinkles, a
process that is known as photoaging.2,4,6 This process is
the main contributor to extrinsic aging; as much as 80%
of facial aging is caused by solar radiation.1,4,6 The damaging effects of ultraviolet (UV) radiation lead to dermal
elastosis, a reduction of collagen, and an initial thickening of the epidermis.1,2 Clinical signs of photoaging
include dryness, hyperpigmentation, telangectesia, and
deep wrinkles.3 These wrinkles do not disappear when
the skin is stretched; this is in contrast to temporary
wrinkles that arise during aging even on sun-protected
skin.7 Other environmental factors that contribute to the
extrinsic aging process are smoking,1,3,8 diet,1 and hormone replacement therapy (HRT).9,10
We can distinguish between several types of permanent facial wrinkles, one of which is linear wrinkles.
Linear wrinkles arise at the site of expression lines on
the face, such as frown lines on the forehead, crow’s
Volume 29 • Number 6 • November/December 2009 • 467
Figure 2. Measuring the skin surface replica. Orientation of the
replica during the measurement using a high-resolution camera. In
this figure, site C is seen. Three-dimensional topography was then
extracted from each 12-mm ⫻ 20-mm site.
kles in that region? In this study, the perioral skin of
men and women was investigated in an effort to resolve
this issue, in the hope that our results might contribute
to the understanding of facial skin aging and ultimately
lead to the development of better strategies for the prevention and treatment of perioral wrinkles.
METHODS
Figure 1. Marked silicone skin surface replica of the perioral region
indicating the location of three set sites (G, C, and D) that were used
for the measurements.
feet at the lateral canthus of the eye, the nasolabial
crease, and wrinkles at the skin of the perioral site.7
This last type seems to be observed more often in
women.11,12 Most requests for the correction of perioral
wrinkles are made by women. While this may be
explained in part by a greater concern among women
about their appearance, it also appears that distinctive
vertical wrinkles at the perioral region develop more
frequently in women than in men.
The growing demand for correction of these wrinkles has led to an expansion of treatment choices.
While dermabrasion and peeling13 were previously the
most commonly used methods, laser treatment, botulinum injections, and injectable or implantable wrinkle fillers are the latest options.12,14 Nevertheless, the
treatment of wrinkles at the perioral region still
remains a difficult matter.
Although some papers have described the complex
mechanism of aging of facial skin2,5,7,13-15 and the associated histologic changes,3,5,11,15 little is known about specific differences in facial skin aging between men and
women, particularly with respect to the perioral region.
Could there be a histologic explanation for why women
are more susceptible than men to development of wrin468 • Volume 29 • Number 6 • November/December 2009
To define wrinkle severity (amount and depth), a skin
surface replica was made of the perioral region in 10
white male and 10 white female fresh cadavers (age
range 75–93 years). With the exceptions of date of birth
and exterior appearance, nothing was known about their
medical history. Subsequently, three full-thickness lip
resections were taken for histologic analysis. To provide
additional histologic data, lip resections were also taken
from another five white male and five white female fresh
cadavers with the same characteristics.
Skin Surface Replica
The perioral skin was replicated by imprinting it on a
silicone elastomer. The elastomer was prepared by mixing a monomer (Xantopren L blue; Heraeus Kulzer,
South Bend, IN) with a catalyst (Optosol-Xantopren;
Heraeus Kulzer). This suspension was applied with
light pressure to the skin of the upper perioral region.
The low viscosity and hydrophobic properties of the
suspension promoted its penetration into all the irregularities of the skin. After several minutes, the catalyst
converted the silicone monomer into a harder polymer,
producing a high-resolution, permanent negative replica
of the skin surface (Figure 1). The replicas were analyzed at three set sites, using the dermaTOP blue
three-dimensional (3-D) digitizing system (Breuckmann,
Meersburg, Germany). The replicas were oriented so
that the fine perioral wrinkles were horizontal and the
region of interest was centered in the field of view of
the 3-D sensor (Figure 2). Three-dimensional topoAesthetic Surgery Journal
A
B
Figure 3. Three-dimensional wrinkle topography and visualization at a fixed scale of the upper perioral region. A, Three-dimensional topographic
image of male perioral skin. The colors indicate the height difference measured, with red being the highest measured point and green being the
lowest. B, Three-dimensional topographic image of female perioral skin. Note the deepness of the wrinkles, recognizable by the red lines.
A
B
Figure 4. Wrinkle depth set out in measurable two-dimensional (2-D) parameters. A, Wrinkle depth was scanned in all the topographies,
which resulted in 50 single profiles. B, Calculation of the roughness parameters Ra, Rz, and Lr for each single profile using the Gaussian 2-D
filtering standard method.
graphic images measuring 12 mm ⫻ 20 mm were
extracted (Optocat 5.0.14 and dermaTOP blue 2.0) and
an image from the topography at fixed Z-scale was
recorded. The fixed Z-scale allowed comparison of the
replicas and performance of a qualitative analysis
(Figure 3, A and B). Three-dimensional surface roughness parameters (Sa, Sq, St, and Sr) were calculated
out of the topographies. Subsequently, the topographies
were loaded and 50 profiles were extracted in a direction perpendicular to the wrinkles. Three roughness
parameters (Ra, Rz, and Lr) were calculated for each
two-dimensional (2-D) profile, using the Gaussian filtering standard method (Figure 4, A and B). The analysis of the parameters led to an interpretation of wrinkle
depth and the number of wrinkles. These were used as
a quantifiable measurement for wrinkle severity. The
Perioral Wrinkles: Histologic Differences Between Men and Women
roughness parameters were statistically analyzed in a
linear regression model using SPSS software (version
15.0; SPSS, Chicago, IL).
Histology
Full-thickness lip resections were taken at three different sites in the perioral region (Figure 5). The tissue
was excised within 24 hours postmortem in fresh
cadavers to prevent distortion of the morphology of
the skin. After fixation in formalin 4% solution and
dehydration, paraffin slides were made. After the
slides were stained (hematoxylin–eosin, Elastica—van
Gieson, and Masson trichrome stains) and marked
with CD31 and an estrogen receptor marker, a histologic
pilot study was performed. The slides were reviewed
in a blinded fashion for characteristics of the epiderVolume 29 • Number 6 • November/December 2009 • 469
Figure 5. Full-thickness lip resection. The resections were taken at
three different sites of the perioral region, marked in this figure.
mis, dermis, and appendages. The collected data were
analyzed and set out in a linear regression model
using SPSS software (version 15.0).
RESULTS
Skin Surface Replica
Women seemed to express more severe wrinkles in the
perioral region than did men. In general, more and
deeper wrinkles were seen on the 3-D topographies
(Figure 3). In addition, two of the four 3-D surface
roughness parameters calculated from the topographies
showed significant differences between men and
women (Table 1). All extracted average 2-D roughness
parameters showed significantly more and deeper wrinkling in women than in men (Table 1).
Histology
There were several significant differences encountered
between men and women. The perioral skin of men
displayed a significantly higher number of sebaceous
glands (P = .000; 95% CI 23.6–53.2) and sweat glands
(P = .002; 95% CI 2.1–8.1). Moreover, the average number of sebaceous glands per hair follicle was larger in
men than in women (P = .002; 95% CI 0.33–1.28),
although the number of hair follicles did not significantly
differ. There was also a higher ratio between the vessel
area and connective tissue area in the dermis in men
compared to women (P = .009; 95% CI 0.003–0.021).
Finally, the distance between the dermis and the orbicularis oris muscle was significantly larger in men
(P = .004; 95% CI 1199.4–5736.8; Table 2).
DISCUSSION
Five out of seven calculated parameters of the replicas
expressed significant differences between men and
women (P < .01). Women exhibited significantly more
and deeper wrinkles in the perioral region than men. The
skin in this region also contained a significantly smaller
number of appendages in women than in men. Many
470 • Volume 29 • Number 6 • November/December 2009
studies have described the complex mechanism of wrinkle formation and the factors that influence this process.
However, gender differences were not addressed in these
previous studies, although such differences could play an
important role in the etiology of perioral wrinkles
because perioral wrinkles seem to develop more in
women than in men. This might be caused by greater
exposure to extrinsic factors, of which solar radiation is
the most important. However, it might be assumed that
men and women are exposed to the same amount of UV
radiation, as members of both genders do not readily
cover up their face and hence solar exposition is approximately similar in both genders. Intrinsic factors are, of
course, very variable; they were not considered in this
study because they are not gender-specific.
The results of this study clarify the differences
between men and women with respect to several histologic issues, in addition to intrinsic and extrinsic factors. Similar results are described only incidentally in
the literature, do not address the perioral region specifically,6 and state that sebum levels tend to drop more
than 40% in postmenopausal women, whereas no
major changes appear in men.16 These studies discuss
differences between men and women in the number of
perioral wrinkles; their conclusions are pertinent to the
results of this study because male facial skin contains a
significantly higher number of sebaceous glands than
does female facial skin (Table 2). The postmenopausal
decrease in sebum levels among women might be a
feasible explanation for why perioral wrinkles generally
develop in women with age, while they do not develop
at all in a large percentage of men. Although the number of hair follicles in the perioral skin of men and
women did not differ significantly, male follicles contained a significantly higher average number of sebaceous glands per hair. Comparable results are not
found elsewhere in the literature.
Epidermal thickness has been found to be greater in
men than in women10,17,18; it was also observed in this
study, although the differences were not significant
(Table 2). In addition, Contet-Audonneau et al2 reported
that, during aging, the stratum corneum is thickened in
wrinkles and the incidence of dyselastosis is greater.
However, they did not investigate gender-specific differences. In this study, we confirmed that women have a
thicker stratum corneum and a significantly higher incidence of dyselastosis than men (Table 2). Capillary
blood flow velocity has been shown to decrease in
postmenopausal women.2,16,19 This result is in line with
our findings; an almost three–times–higher ratio
between the area containing blood vessels and the area
of the connective tissue measured in a set surface in
the dermis of the perioral skin was found in men (Table
2). The perioral skin of men therefore contains more
blood vessels than perioral skin in women. Better vascularization might have a decelerating effect on the
development of wrinkles in the perioral skin. Nothing
was previously described concerning the relationship
Aesthetic Surgery Journal
Table 1. Roughness statistics of the skin surface replicas of the perioral region in 10 male and 10 female fresh cadavers
Mean (SD)
Variable
Male
Female
Difference (95% CI)
P*
.03938 (.00904)
.06704 (.01513)
⫺0.028 (⫺0.039 – ⫺0.016)
.000
Sq (mm)
.05574 (.01197)
.08444 (.01906)
⫺0.029 (⫺0.044 – ⫺0.014)
.001
St (mm)
1.05768 (.78157)
.98319 (.29030)
0.074 (⫺0.479 – ⫺0.628)
.781
Sr
1.10946 (.02935)
1.11671 (.02795)
⫺0.007 (⫺0.034 – ⫺0.020)
.578
Ra (mm)
.01954 (.00484)
.04221 (.00731)
⫺0.023 (⫺0.028 – ⫺0.017)
.000
Rz (mm)
.10782 (.01817)
.13671 (.02610)
⫺0.029 (⫺0.050 – ⫺0.008)
.010
1.03472 (.01265)
1.05258 (.01086)
⫺0.018 (⫺0.029 – ⫺0.007)
.003
Three-dimensional surface roughness parameters
Sa (mm)
Average two-dimensional roughness parameters
Lr
CI, confidence interval; LR, ratio of developed line to the profile length; Ra, arithmetic average of absolute values of roughness profile ordinates (Z), where Z is
the sum of the heights of the highest peaks and the lowest valley depth within a sampling length; Rz, arithmetic mean value of the single roughness depths
of consecutive sampling lengths; Sa, linear average surface roughness; SD, standard deviation; Sq, quadratic average surface roughness; Sr, ratio of developed
area to target area; St, maximum surface height difference (peak to peak value).
*P < .05 was considered statistically significant.
Table 2. Average statistical results of the histologic analysis of 90 biopsies taken from the perioral region in 15 male and
15 female fresh cadavers
Mean (SD)
Variable
Male
Female
Difference (95% CI)
P*
Maximum epidermal thickness (μm)
271 (164)
205 (60)
66 (⫺27 – 158)
.158
Maximum corneum thickness (μm)
19 (9)
21 (15)
28 (⫺3 – 59)
.075
1.93 (.59)
3.0 (.66)
⫺0.92 (⫺1.5 – ⫺0.38)
.002
Dyselastosis dermis
Ratio distribution of collagen to reticulin
1.05 (.40)
.99 (.70)
⫺0.05 (⫺0.54 – ⫺0.044)
.835
No. of hair follicles in coupe
42.0 (14.5)
36.0 (12.5)
4.1 (⫺6.3 – 14.5)
.426
.93 (.23)
1.03 (.29)
⫺0.044 (⫺0.25 – 0.16)
.661
84.5 (25.1)
45.9 (21.4)
38.4 (23.6 – 53.2)
.000
No. of (interspace) hair follicles/mm
No. of (interspace) sebaceous glands in coupe
No. of sebaceous glands/hair (interspace) follicle
2.08 (.45)
1.29 (.67)
0.80 (0.33 – 1.28)
.002
Percent of sebaceous glands with estrogen receptors
59.5 (28.8)
52.7 (30.7)
9.7 (⫺9.9 – 29.3)
.318
No. of sweat glands
13.1 (3.7)
8.4 (4.0)
5.0 (2.1 – 8.1)
.002
.0346 (.0290)
.0117 (.0095)
.0120 (0.003 – 0.021)
.009
11597.9 (3144.6)
8197.2 (2200.3)
3467.6 (1199.4 – 5736.8)
.004
Ratio of vessel area to connective tissue area (μm)
Maximum distance from orbicularis oris
to the epidermis (μm)
CI, confidence interval; SD, standard deviation.
*P < .05 was considered statistically significant.
between gender and the presence of sweat glands in
the perioral skin. Our study shows that the perioral
skin of men contains significantly more sweat glands
than that of women (Table 2).
It has been reported that women who receive HRT
have lower facial wrinkle scores than women who are
not treated with this therapy.9,10 In addition, mean levels
of epidermal skin moisture, elasticity, and skin thickness
are improved with HRT,10 although this has never been
shown with respect to the perioral region and the results
of this study showed no difference between men and
women regarding the presence of estrogen-positive sebaceous glands in this area. This suggests that other facPerioral Wrinkles: Histologic Differences Between Men and Women
tors may have a greater influence on the development of
perioral wrinkles.
As described, the perioral skin of men contains more
appendages than that of women, which could influence,
in some way, the natural filling of the dermis. Because
the dermis of the perioral skin in men includes considerably more sebaceous glands, sweat glands, and blood
vessels, one could imagine that the formation of wrinkles in that region is more difficult in men.
Another interesting observation was that the orbicularis oris muscle, which surrounds the lips, is anchored
1.5 times closer to the dermis in women than in men
(Table 2). This difference has not been previously reported
Volume 29 • Number 6 • November/December 2009 • 471
in the literature. It might play a role in wrinkle formation
because fibrous connections between the muscle and the
dermis can cause an inward traction, thereby creating
deeper wrinkles.
It should be noted that during data collection, the
assumption was made that the cadavers had a roughly
equal exposure to UV radiation during their lives. We
also cannot exclude the possibility that other external
factors that influence the aging process—such as smoking, hormones, and diet—may have been operative to
varying extents in the cadavers.
CONCLUSIONS
The treatment of perioral wrinkles remains a difficult
matter. To our knowledge, ours is the first study to investigate skin surface and specific histologic differences
between the perioral skin of men and women and their
possible relationship to wrinkle formation. We found
that, in comparison to men, women exhibit more and
deeper wrinkles in the perioral region and that women’s
perioral skin contains significantly fewer appendages.
These findings provide a feasible explanation for why
women are more susceptible to development of perioral
wrinkles and contribute to our current understanding of
wrinkle formation. ◗
11. Wojnarowska F. Clinical aspects of ageing skin. In: Fry L, editor. Skin
problems in the elderly, 2nd ed. Edinburgh: Churchill Livingstone;
1985, pp 28-46.
12. Monhian N. Injectable implantable materials for facial wrinkles.
Aesthetic Facial Surgery ed. 2008, pp 247-248.
13. Holmkvist KA, Rogers GS. Treatment of perioral rhytides: a comparison
of dermabrasion and superpulsed carbon dioxide laser. Arch Dermatol
2000;136:725–731.
14. Semchyshyn N, Sengelmann RD. Botulinum toxin A treatment of perioral rhytides. Dermatol Surg 2003;29:490–495.
15. Piérard GE, Uhoda I, Piérard-Franchimont C. Update on the histological
presentation of facial wrinkles. Eur J Dermatol 2002;12:XIII–XXIV.
16. Sandby-Moller J, Poulsen T, Wulf HC. Epidermal thickness at different
body sites: relationship to age, gender, pigmentation, blood content,
skin type and smoking habits. Acta Derm Venereol 2003;83:410–413.
17. Castelo-Branco C, Duran M, Gonzalez-Merlo J. Skin collagen changes
related to age and hormone replacement therapy. Maturitas
1992;15:113–119.
18. Vaillant L, Callens A. Hormone replacement treatment and skin aging.
Therapie 1996;51:67–70.
19. Raine-Fenning NJ, Brincat MP, Muscat-Baron Y. Skin aging and
menopause: implications for treatment. Am J Clin Dermatol
2003;4:371–378.
Accepted for publication May 22, 2009.
Presented at the 20th Annual Meeting of the European Association of Plastic
Surgeons, May 28–30, 2009, Barcelona, Spain.
Reprint requests: Moshe Kon, MD, PhD, University Medical Center Utrecht,
Department of Plastic, Reconstructive and Hand Surgery, PO Box 85500,
3508 GA Utrecht, the Netherlands. E-mail: [email protected].
Copyright © 2009 by The American Society for Aesthetic Plastic Surgery, Inc.
ACKNOWLEDGMENTS
The authors thank Mr. Simon Plomp and Mr. Willem van Wolferen
from the anatomy department of the University Medical Centre
Utrecht for their assistance in collecting the biopsies from the
cadavers.
1090-820X/$36.00
doi:10.1016/j.asj.2009.08.018
DISCLOSURES
The authors have no financial interest in and received no compensation from manufacturers of products mentioned in this article.
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