ד"ר פרידמן טל כירורגיה פלסטית 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 Results in: Brow ptosis, Hallow infraorbital region, Nasolabial folds, Jowls, Submental skin excess. Pathogenesis of wrinkles Aging Actinic damage Genetic disorders Aging A process of atrophy Epidermis No change in epidermis thickness Melanocytes Langerhans cells Dermal-epidermal junction Dermis 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 :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 number •Apocrine glands - in secretion •Eccrine glands - •Terminal hair follicles - Effects of Age on Skin Thinning Shearing forces Elasticity Immunologic changes Increased susceptibility to UV light and cutaneous malignancies. Actinic Damage Pathognomonic: Dermal elastosis and epidermal dysplasia. Epidermis Increase in thickness Nuclear atypia of keratinocytes and monocytes Dermis 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 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 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 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) 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) 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 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 furrow: – 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, 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. 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 SMAS. 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 photogrammetry: 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 mandible. Skull 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 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 1. 2. 3. 4. 5. Inferior mandibular border Subhyoid Thyroid cartilage SCM SM-SM angle- 90 degrees. 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.