SPECIAL ARTICLE Aesthetic and Reconstructive Surgery in the Aging Patient Daniel B. Allen, MD efore discussing the many ways in which plastic surgeons interface with elderly pa- tients, a preliminary question should be addressed: who are the elderly? Life expec- tancy continues to increase toward the maximum theoretical age of 120 years in hu- mans. A life expectancy of only 21 years could be expected in the Bronze Age and 47 Byears in 1900.1 In 1998, the mean life expectancy was 72 years for men and 79 years for women. The number of centenarians in the United States is projected to increase from 60000 in 1998 to 200000 in 2020 and then to an incredible 5 million in 2046.2 Most recent studies arbitrarily des- ignate “over 65” years as elderly, although it is clear that biological aging, which for so long eluded any attempt to quantify it, dwarfs chronological age in its overall reflection of an individual’s health. Women aged 65 years can expect to have well over a fifth as many years remaining, and their ob- jection to the designation of elderly is understandable. When interacting with patients of ad- tenuation of facial ligaments and the loss vanced age and their families, health care of dermal elastin. Zygomatic ligaments sus- professionals should alleviate their con- pend malar soft tissue over the zygo- cerns about ageism, that is, discrimina- matic eminence. Attenuation of these liga- tion against elderly persons. Most elderly ments with aging leads to inferior persons are in reasonably good health and displacement of this soft tissue, which ac- are able to function independently. Only centuates the nasolabial fold and creates 5% of the elderly population are institu- the illusion of its deepening. Jowls accu- tionalized; demographically, most of these mulate behind tethering mandibular liga- patients are very old, female, and white.1 ments anteriorly and masseteric cutane- Because of their greater longevity, women ous ligaments posteriorly (Figure 2).3 are more likely to lose their spouse and live Facial aging occurs not only in skin alone and, thus, directly face the difficul- but also in underlying fat and connective ties of aging. tissue. Dermal elastosis of the skin, lipo- Older persons as a group have a lower dystrophy of the neck, and laxity of the fa- socioeconomic status than other adults. cial ligaments all contribute to the stig- About a fifth of the elderly population have mata of the aging face. incomes approaching the poverty level. So- In the neck, the anterior fibers of the cioeconomic status directly affects health platysma descend and appear as platys- and the types of medical problems that will mal bands. The muscle hypertrophies but lead the aging patient to seek a plastic sur- also bowstrings and becomes tethered in geon (Figure 1). this position. Retaining ligaments that for- merly held the platysma down against the ANATOMICAL CHANGES IN AGING: deep cervical fascia weaken, causing the THE BASIS OF AESTHETIC SURGERY muscle to descend (Figure 3 and Figure 4).3,4 Two biological phenomena contribute to Body fat distribution varies with both the changes seen in the aging face: the at- sex and age. Age-related accumulation of From the Division of Plastic and Reconstructive Surgery, Department of Surgery, body fat can be difficult to counter. A study Alameda County Medical Center, Oakland, Calif. of fit male long-distance runners showed (REPRINTED) ARCH SURG/ VOL 138, OCT 2003 WWW.ARCHSURG.COM 1099 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 that the average 6-ft (1.82-m) tall man gained 3 lb 3 oz cades of life. There is less subcutaneous fat, but more intra- (about 1.37 kg) and added three fourths of an inch (about abdominal fat and infiltration of fat into and between 2 cm) to his waistline for every decade of life after the muscles. Lean body mass declines. Objective indexes of age of 20 years. To compensate for these metabolic these changes include triceps skinfold thickness, waist- changes and to maintain his proportions over a 30-year hip measurement ratios, and body fat plethysmogra- period, the man at age 50 years would have to run an ad- phy. Subcutaneous fat is more metabolically active than ditional 32 miles per week. Age-related changes in tes- visceral fat but both correlate independently with medi- tosterone and growth hormone production are sus- cal morbidity.5 pected to account for these differences.5 Weight loss that is surgically induced with gas- After menopause, women begin to acquire the male trointestinal bypass procedures decreases the medical mor- pattern of weight gain in the abdomen, possibly owing bidity of obesity. Although liposuction can perma- to decreasing levels of estrogen. They complain about the nently remove regional fat, the fat removed is small in loss of waistline definition. comparison to total body fat. Liposuction can provide cos- Both sexes experience changing fat patterns as they metic improvements to patients who retain areas of re- progress from the third to the seventh and eighth de- gional fat despite diet and exercise and can provide en- couragement to the lifestyle modification efforts of those trying to reduce their weight. Low-Income High-Income The objective of aesthetic surgery is to improve the Elderly Person Elderly Person patient’s psychological well-being by modifying their body image. This is accomplished by reshaping normal struc- tures. Aesthetic surgery has been shown to improve stan- Poorer Health Common to Both Groups dardized quality-of-life indexes and reduce depression Better Health (Figure 4).6 Because depression is common in the eld- Chronic Illness Debilitation Photoaging erly population, patients presenting for aesthetic sur- Skin Cancer More Likely to Seek gery should be screened for its symptoms. Those with Breast and Be Able to Afford Pressure Sores Reconstruction Aesthetic Surgery clear symptoms of depression should be referred for treat- ment before further discussion of surgery. Figure 1. Plastic surgery operations in elderly persons vary according to Aesthetic surgery is one component of the evolv- socioeconomic status. ing field of antiaging medicine. This has been defined as A B Masseteric Cutaneous Ligaments Mandibular Ligaments Figure 2. Attenuation of support from the masseter cutaneous ligaments allows the soft tissues of the medial cheek to descend inferiorly in the aging face, leading to the formation of the facial jowl. Reprinted with permission from Baker et al.3(p185) (REPRINTED) ARCH SURG/ VOL 138, OCT 2003 WWW.ARCHSURG.COM 1100 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 A B Subplatysmal Fat Retaining Ligaments Figure 3. A, The platysma in the neck is supported in its normal anatomical position against the deep cervical fascia by a series of retaining ligaments. Reprinted with permission from Baker et al.3(p185) B, Descent of the platysma muscle due to lax retaining ligaments. A B Figure 4. A, Correction of jowls, platysmal bands, and other stigmata of the aging face by rhytidectomy. Reprinted with permission from Grotting.4(p218) (REPRINTED) ARCH SURG/ VOL 138, OCT 2003 WWW.ARCHSURG.COM 1101 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 additional (but certainly much smaller) number were done Table 1. Differences Between Acute by American Society of Plastic Surgeons nonmembers, and Chronic Osteomyelitis it is small when compared with the number of mastec- tomies performed in this age group. Variable Acute Osteomyelitis Chronic Osteomyelitis Breast reduction and breast lift procedures make up Seeding Hematogenous Local the remainder of plastic surgery operations ordinarily Causative organism Staphylococcus aureus S aureus or gram- negative done in this population. The 65-years-and-over age Treatment Antibiotic agents alone Surgical debridement group constituted 3% of both breast reduction and 9,10 generally successful generally necessary breast lift procedures. This equates to about 2500 breast reductions and 1400 mastopexies done annually by American Society of Plastic Surgeons members in the United States. “the application of knowledge that delays the physical These data indicate that plastic surgery breast op- and mental deterioration associated with senescence to erations in the elderly population, although less fre- the absolute end of life.”2(p2140) The intent is more to maxi- quent, are not rare. Adherence to the guidelines in the mize the quality of life than to lengthen life. Antiaging phi- “Optimizing Perioperative Safety in Patients of Ad- losophy also incorporates diet and exercise, other lifestyle vanced Age” section will reduce unnecessary morbidity changes, and medical or hormonal manipulations.2 and mortality in this population. Chronic medical conditions are common in elderly AGE-RELATED PATHOLOGIC CONDITION THAT persons. The 3 leading causes of death in this popula- MAY NECESSITATE RECONSTRUCTIVE SURGERY tion are coronary artery disease, cancer, and cerebrovas- cular accident. In addition to causing 75% of the mor- Older individuals with sun-damaged skin are prone to tality in elderly persons, they also account for 50% of their develop actinic keratoses and basal cell carcinomas. These bedridden days.1 Hip fractures and other orthopedic in- patients should be examined every 6 months by a phy- juries are another major cause of immobilization and dis- sician with a special interest in the early detection of cu- ability. Primarily for these reasons, the elderly popula- taneous pathologic abnormalities. Serial photography may tion are most affected by pressure sores. be helpful. Unless promptly and effectively managed, pressure Dermabrasion and deep chemical peels have been sores profoundly affect quality of life, predispose to osteo- shown to clear the skin of actinic keratoses and small skin myelitis and septicemia, and are strongly associated with cancers and to reduce the number of degenerative le- mortality.