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‫ד"ר פרידמן טל‬
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
 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 +
•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
:Overall collagen content , III/I ,
Tensile strength of collagen fibril 
 Collagen
Skin appendages
•Sebaceous glands  in size but sebum
production 
•Pacinian and Meissner’s corpuscles -  in
•Apocrine glands -  in secretion
•Eccrine glands - 
•Terminal hair follicles - 
Effects of Age on Skin
 Shearing forces
 Elasticity
 Immunologic changes
 Increased susceptibility to UV light and
cutaneous malignancies.
Actinic Damage
Pathognomonic: Dermal elastosis and epidermal
Increase in thickness
Nuclear atypia of keratinocytes and
Thickened degraded elastic fibers:
“Basophilic degeneration”, “elastosis”:
Degraded collagen and elastin.
Increase of ground substance.
Decrease of mature collagen (type I).
Inherited Skin Disorders
Rare skin conditions that may present as
premature skin laxity, or aging.
Ehlers-Danlos Syndrom (Cutis
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
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
•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 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
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
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
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
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
– Fascial insertions of cutaneous muscles that
create surface grooves on surface animation.
Classification of facial wrinkles,
Furrows and Folds
Wrinkles- Intrinsic aging and photoaging.
 Clinical location: Cheeks, crow’s feet,
 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,
Furrows/ Lines: Repeated
facial expressions.
Clinical location: Forehead,
Glabellar, smile lines.
Tissue location:
Treatment: Muscle
resection, Botulinum
toxin, injectable skin
filler materials.
Combination Combined approach.
Face lifting only addresses the
effects of gravity
It is not a treatment for fine wrinkles!!!
Stigmata of the aging face
Skin: Intrinsic and extrinsic aging.
Subcutaneous: Descent of facial fatskin 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
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
Midface: Cutaneous descent superficial to the
Lower cheek, and neck:
Downward migration of the
skin-fat-platysma layer.
Mid face
Yousif- Analized changes in facial soft-tissues
occuring with age :
1994,5- Historical photographs and
NLF- Deepening due to descent
and anterior projection of the
subcutaneous cheek mass.
Marionette line- a fold extending from the labial
commissure to the parasymphyseal area
Jowls- descents of soft tissue below the
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
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
 The vector of the orbicularis oculi is
Criteria for a youthful neck
Inferior mandibular
Thyroid cartilage
SM-SM angle- 90
The Neck
Excess skin.
 Excess submental fat.
 Excess supraplatysmal or subplatysmal fat.
 Platysmal bands.
 Large submaxillary gland.
 Micrognatia.
Padgett and Stevenson, 1948- Platysmal
– 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.