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ד"ר פרידמן טל כירורגיה פלסטית בי"ח אסף- הרופא

Aging of the

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 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 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 , 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 and axilla) takes on the texture of plucked chicken skin.

 Widespread artheriosclerosis- third decade.

 Plastic 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 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,  .

 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 .  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 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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