י"ג/טבת/תש"ע
ד"ר פרידמן טל כירורגיה פלסטית בי"ח אסף- הרופא
Aging of the Face
The process of facial aging represents a combination of gravitational effects and the aging of tissues.
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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
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Aging
A process of atrophy
Epidermis
No change in epidermis thickness
Melanocytes
Langerhans cells
Dermal-epidermal junction
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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
Collagen :Overall collagen content , III/I , Tensile strength of collagen fibril
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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.
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Actinic Damage
Pathognomonic: Dermal elastosis and epidermal dysplasia.
Epidermis
Increase in thickness
Nuclear atypia of keratinocytes and monocytes
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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.
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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.
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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.
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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.
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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.
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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.
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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.
Combination Combined approach.
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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 fat- skin 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.
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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.
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Mid face
Yousif- Analized changes in facial soft-tissues occuring with age : 1994,5- Historical photographs and photogrammetry:
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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
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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.
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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
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Criteria for a youthful neck
1. Inferior mandibular border 2. Subhyoid 3. Thyroid cartilage 4. SCM 5. SM-SM angle- 90 degrees.
The Neck
Excess skin. Excess submental fat. Excess supraplatysmal or subplatysmal fat. Platysmal bands. Large submaxillary gland. Micrognatia.
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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.
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