Download Aging of the Face Rhytidectomy

‫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.