Facial Aging
Facial aesthetics begin with the marriage of hard and soft tissue integration. However, the changing balance of these elements is the hallmark of the aging process. The major forces responsible for the facial aging include gravity, soft tissue maturation, skeletal remodeling, muscular facial activity and solar changes. It is the balance of skeletal structure, soft tissue, and skin that is responsible for appearance. These observations reveal a major characteristic of facial aging, in that the primary changes in a person’s three-dimensional skeletal contour can lead to secondary changes in the overlying soft tissue and skin.

Photoaging
When the effects of aging on the face are addressed, what is really being discussed is that wrinkles originate from:

• Chronologic skin aging
  
• Environmental factors
  
• Photoaging
  
• Hyperdynamic facial expressions
  
• Skin folding - Secondary to loss of underlying skeletal and soft tissue support

Skeletal structure
(the figure to the right is an artistic rendering;
not an actual patient)

Reduction in facial height

• Most marked in the maxilla and mandible
  
• The orbits increase in size
  
• The maxilla decrease in size - this process creates less available space for the overlying tissue resulting in the inferior displacement of the cheek fat pad and skin, with deepenning of the melolabial fold.

Skin

Many of the changes on the face secondary the aging are the result of gravity’s acting on skin that is becoming progressively thinner, drier and less elastic.

• Influence location and shape of facial wrinkles

One must differentiate. Changes occur as a result of:

• Intrinsic aging
• Photoanging - chronic solar exposure

GOLGAU 1994-clinical photoaged skin

Type 1

• No wrinkles
  
• Evidence of photdamage in the pigmentary system

Type 2

• Wrinkles in motion
  
• Lentigines

Type 3

• Wrinkles at rest
  
• Keratoses

Type 4

• Wrinkles - have no unlined skin on their face

Fitzpatrick Skin Classification
(the photos below are of models, not actual patients)

Histological changes associated with chronologically aged skin begin with a thinning of the viable epidermis, with flattening of the dermal-epidermal junction. The physiologic consequence of this flattening is the increased susceptibility to shearing forces, the epidermis can be easily torn from the dermis.

The most profound differences between chronological Y and photoaged skin can be seen in the dermis:

(the photos below are of a model, not an actual patient)

On all the dermal structural elements, elastic fibers most prominently display the sequelae of both chronologic and photodamaged skin.

CAS

• Elastic fibers can be slightly increased in thickness

PHDS

• Presence of massive quantities of thickened bundles of degraded elastic fibers or dermal elastosis

The elastotic material is postulated to result from UV- mediated damage to the extracellular matrix. UV damage to dermal fibroblasts produces abnormal elastin and chronic enzymatic degradation of the extracellular matrix.

(the photos below are of a model, not an actual patient)

In contrast to the hypertrophy of elastin the amount of mature collagen decreases in photodamaged skin. The microvasculature also is profoundly altered by chronic sun exposure. As water binding capacity and sebaceous gland activity decrease with age, the skin becomes drier.

(the photos below are of a model, not an actual patient)

The result of these various histologic rear-rangements is aged skin that is less stretchable and less resilient. The loss of inherent elasticity results in skin that is more lax, with dependent draping that is prone to wrinkling from gravitational effects. The combination of gravity, loss of tissue elasticity, decreased subcutaneous tissue, and progressive bony resorption leads to the inevitable inferior displacement of the brow.

(the figure below is an artistic rendering; not an actual patient)

MIDFACE
The skin represent only the covering for the deeper anatomic elements that project the topography of the aging midface. In the aging midface, these elements have shifted but will always maintain their intimate relationship to one another.

The periorbital soft tissue of youth is a shallow and narrow orbit, described as being an unbroken convex line from the lower eyelid to cheek. With progressive aging, those dimensions become wider and deeper as skeletinization of the orbit normally occurs, beginning in the fourth decade.

Ptotic cheek fat descends to become the melolabial fold, leaving behind a cheek depression that can be accentuated by buccal fat attenuation. As the orbicularis muscle becomes ptotic with aging, its inferior border becomes clinically apparent. This creates the malar crescent over the zygomatic emninence laterally, resulting medially in creation of the nasojugal fold.

JOWL AND NECK
The cervical appearance with aging is a combination of:

• Changes in skin
  
• Fat distribution
  
• Platysma muscle
  
• Underlying bony/cartilaginous framework
  

(the figure below;right is an artistic rendering; not an actual patient)

The down-ward pull of the platysma creates jowls, with lost of definition of chin and jawline. The jowl, or broken jawline, is created by ptosis of the facial portion of the platysma muscle. The skin of the neck can become lax over the platysma developing horizontal rhytides.

The vertical fibrous bands on the neck are caused by contraction and prominence of the platysma muscle. Anterior edges of the platysma separate and lose tone, thus creating the anterior banding or “turkey neck”, deformity. A large submental fat pad is situated deep to the platysma bands, whereas a smaller pad is situated more superficially.

The major forces responsible for facial aging include:

• Gravity
  
• Soft Tissue Maturation
  
• Skeletal Remodeling
  
• Muscular Facial Activity
  
• Solar Changes

SKELETON, MUSCLE, SOFT TISSUE AND SKIN ARE AFFECTED INDIVIDUALLY BY THE AGING PROCESS BUT ACT IN CONCERT TO RESULT IN FACIAL SENESCENCE.

Topical Treatments

• Retina A
  
• Furfuryladenine
  
• Vitamin C
  
• AHA’s
  
• Bleaching agents - Hydroquinone 4% + Glycolic 2%
  
• Moisturizers
  
• Sunscreens

Systemic Therapies

• Copper
  
• Vitamin E
  
• Immeden^®
  
• Reviface^®

FILLER SUBSTANCES

• Collagen - Zyderm^® and Zyplast^®
  
• Cosmoderm
  
• Autologen^®
  
• Isolagen^®
  
• Dermalogen^®
  
• Hyaluronic Ac. - Hylaform^® and Restylane^®
  
• BOTOX^®
  
• Aquamid^®
  
• Artecoll^®
  
• Goretex - Softform^® and Advanta^®
  
• Alloderm^®
  
• Fascian ^®
  
• New fill^®
  
• Dermalive^®
  
• Dermadeep^®
  
• Radiance ^®
  
• Silicone microdroplet
  
• Autologous fat Transplantation - Lipostructure and FAMI

Peelings

• AHA’s
  
• TCA
  
• Phenol
  
• Baker
  
• Exoderm

Others

• Microdermoabrasion
  
• Laser Resurfacing
  
• IPL plus Radiofrequency Aurora^®

CLASSIFICATION OF RESURFACING MODALITIES BY WOUNDING CAPACITY

Superficial - to stratum garnulosum, papillary dermis

Very light

• Resorcinol
  
• Jessner solution
  
• Carbon dioxide
  
• Tretinoin
  
• AHA’s
  
• TCA 10-20%

Light

• TCA 35%
  
• Microdermoabrasion
  
• Erbium :YAG laser

Medium Depth Wounding - upper reticular dermis

• Combination CO2 plus TCA 35%-50%
  
• Jessner plus TCA
  
• 70% Glycolic plus TCA
  
• TCA 50%
  
• Dermabrasion
  
• Er:Yag Laser
  
• Ultrapulse CO2
  
• Coblation

Deep Depth Wounding - to midreticular dermis

• Baker’s phenol
  
• Dermabrasion
  
• Ultrapulse CO2
  
• Coblation
  
• Er:YAG Laser

Threads

EUROPE
Different threads under wrinkles has been suggested

• Dexon
  
• Nylon
  
• Gold threads - Keith Type Needle

FACIAL LIFTING WITH GENTLELIFT

The indications for correction of the contours of the face and neck with Gentlelift threads:

• any-aetiology ptosis of tissues of the face and neck
  
• flabby, flat face
  
• poorly manifested aesthetic contours

MARKING SOFT TISSUE OF THE FACE AND NECK

(the figure below is an artistic rendering; not an actual patient)

SUCCESS OF THE GENTLELIFT PROCEDURE SINCE 1998

Over 500 patients.

Aged from 22 to 77 years.

Female - 91.3 %

59% - manipulation as an independent intervention

41% - manipulation as an addition to other interventions (peeling, undercutting wrinkles without external cuts, liposuction, lipoinjection,etc.).