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. 1 י"ג/טבת/תש"ע 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 2 י"ג/טבת/תש"ע Aging A process of atrophy Epidermis No change in epidermis thickness Melanocytes Langerhans cells Dermal-epidermal junction 3 י"ג/טבת/תש"ע 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 4 י"ג/טבת/תש"ע 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. 5 י"ג/טבת/תש"ע Actinic Damage Pathognomonic: Dermal elastosis and epidermal dysplasia. Epidermis Increase in thickness Nuclear atypia of keratinocytes and monocytes 6 י"ג/טבת/תש"ע 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. 7 י"ג/טבת/תש"ע 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. 8 י"ג/טבת/תש"ע 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. 9 י"ג/טבת/תש"ע 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. 10 י"ג/טבת/תש"ע 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. 11 י"ג/טבת/תש"ע 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. 12 י"ג/טבת/תש"ע 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. 13 י"ג/טבת/תש"ע 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. 14 י"ג/טבת/תש"ע 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. 15 י"ג/טבת/תש"ע Mid face Yousif- Analized changes in facial soft-tissues occuring with age : 1994,5- Historical photographs and photogrammetry: 16 י"ג/טבת/תש"ע 17 י"ג/טבת/תש"ע 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 18 י"ג/טבת/תש"ע 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. 19 י"ג/טבת/תש"ע 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 20 י"ג/טבת/תש"ע 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. 21 י"ג/טבת/תש"ע 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. 22.