36.4 Aging Changes in the Face

The dermal thickness of the skin decreases progressively and its elasticity begins to disappear. In course of time, telangiectasias, keratosis, and increase of melanosis are to be seen. The aging period differs from one person to the other and the face is especially affected by many factors from smoking habit to climate. Aging doesn’t form in a straight line, but in parts and pieces and these parts can vary. Emotional influences can increase the speed of aging. Other exterior impacts that increase the speed of aging process are sunlight, dry air, repeating movements of facial mimetic muscles, progressive loss of the fat tissues of the face, cellular degenerative changes, and attachments of retaining ligaments and muscles to the skin (Fig. 36.15) [1, 2, 4, 5, 10, 11, 16, 22, 31, 35–40].

Aging changes in the face can be histologically arranged as follows: flattening of dermoepidermal intersection, changes in the thickness of epidermis, changes in the cell amount and dimension, atypic changes in nucleus, decrease of melanosis, decrease of langerhans cells. In dermis, the changes are as follows: decrease of

Malar crescent

dermal volume and atrophy, decrease of fibroblasts, decrease of mast cells, shortening of capillary structures, abnormal nerve outcomes, increase of hydroxyproline, increase of nonfusible collagen, decrease of fusible collagen, increase of collagen resistance, decrease of elasticity, decrease of acid mucopolysaccharide and hexosamin. The changes on the skin are graying of hair, decline in hair amount, increase of vellus in thermal period, abnormal nailfolds, decrease of eccrine sweat glands, increase of apocrine glands, decrease of sebaceous glands [1, 2, 4, 5, 10, 22, 31, 36, 38].

The retaining ligaments of face support facial soft tissue in normal anatomic position, resisting gravitational change. As this ligamentous system attenuates, facial fat descends in the plane between superficial and deep facial fascia and the stigmata of facial age develop. A loss of zygomatic ligament support allows for the inferior descent of the malar pad, influencing nasolabial fold prominence, whereas a loss of masseteric ligament support allows for the inferior descent of facial fat to the mandibular border, leading to the formation of facial jowling. Repositioning of the descended fat pads culminates in a young face.

As a result of aging, the amount of the facial fat as well as its quality decreases. The anatomic location of the facial fat in youth determines the facial shape. Typically, the youthful face is full of well-supported fat, overlying the malar region, and overlying the parotid and masseter in the lateral cheek, secondary to the intact intrinsic support of the retaining ligament system.

The combination of fullness in the malar region and the lateral cheek and concavity overlying the buccal recess accounts for the angular appearance of the youthful face. As the human face ages, facial fat descends and facial shape changes. In the older face, fat situates anteriorly and inferiorly, producing a facial contour that is square in configuration, with little difference between malar highlight and midfacial fat on the frontal view. As facial fat situates inferiorly in the face, the face also appears longer [1–5, 8–12, 22, 26, 31, 33, 34, 36].

Cheek

depression

Ptotic fat

Ptotic platysma muscle

Fig. 36.15 Anatomical changes in the face with aging

36.5Facelift and Historical Development of Retaining Ligaments of the Face

Midface region has always been the facial part that is aesthetically first noticed. This part of the face has been recognized as a sign of health and beauty. If the

exterior view ages while the mind is still youthful, interference is needed. In the last quarter of this century, the operations for repositioning of the face have become very popular.

Repositioning of aging face was first applied by Hollander in 1901 with the subcutaneous face-lift procedure. In 1916 Lexer developed this procedure; in 1921 Joseph also strived to popularize this procedure. In 1920 Bettman used the incision, which is used today as well. In the same year Bettman and in 1927 Bames applied the continuous incision and subcutaneous facelift procedures. In 1959 McGregor first defined the zygomatic cutaneous ligament. In 1960 Aufricht showed that subcutaneous face-lift border can reach to platysma branches in the submental region. In 1964 Adamson, Horton, and Crawford and in 1972 Pensini and Capozzi defined the submental defatting. In 1969 Baker and Gordon defined the plication of deep tissues in the lateral cheek region and founded the SMAS plication which is being used today. In 1974 Tipton published the postoperative views of 33 patients with deep tissue plications. In 1966, 1973, and 1981 Pitanguy published the anatomical variations of frontal branch and the results of the subcutaneous face-lift which he applied. In 1972 Webster and between 1968 and 1972 Millard defined the submandibular lipectomy. In 1973, 1978, and 1984 Rees described the deep plan plication, SMAS anatomy, and plication and published his clinical series. Between 1974 and 1976, Skoog defined for the first time the deep plane face-lift procedure adding the platysma and SMAS to the skin flap. In 1974 Mitz and Pyronie defined the anatomy of SMAS in the middle and lateral cheek regions. Owsley developed the sub-SMAS platysma face-lift technique in 1977, 1986, and 1993 and he defined the reposition of the malar fat pad. In 1977, 1979, and 1983 Baker studied the surgical anatomy of the face and the facial nerve anatomy with details and strived to obtain the repositioning of the face by applying chemical peeling and deep plane face-lift at the same time. In 1989 and 1995 Furnas studied the retaining ligaments of the face and determined their localizations and dimensions. He also emphasized the extended SMAS surgery and nasolobial fold surgery. In 1989, 1992, and 2000, Stuzin defined the surgical flatting of superficial and deep fascias, buccal fat pad anatomy, extended SMAS dicession, facial nerve frontal branch anatomy, vicryl mesh, increasing of SMAS support, and the fixation of facial forms. In 1990, 1992, 1995, 1998, and 2000 Hamra defined the blepheroplasty and face-lift combination

techniques and emphasized the midface plane. He also improved the deep plane composite face-lift technique. Between 1991 and 1996 Ramirez defined the subperiosteal face-lift and endoscopic subperiosteal face-lift techniques. Between 1992 and 1997 Barton published his works on SMAS and nasolabial fold anatomies. Between 1993 and 1996 Gosain studied the nasolabial fold and SMAS anatomies. In 1993, 1994, 1996, and 1998 Yousif studied the nasolabial fold and SMAS anatomy and described the changes in the midface region. In 1995 Hagerty applied and advocated the central suspension technique. In 1996 Robbins did the nasolabial fold restoration by using the SMAS plication technique. In 1996 Har and Shai described the skin and SMAS anatomy with details. In 1997 Whetzel and Mathes published their studies on the topic of face-lift flap becoming bloodstained. In 1997, 1999, and 2001 Mendelson published his study on SMAS plication vectors in retaining ligaments flatting. In 1998 De la Plaza defined the sub-SMAS subperiosteal face-lift technique. In 1999 Camarena defined multiple combined SMAS platysma plication technique [30, 41].

Face-lift surgery has developed progressively until today and a lot of researchers have shared their experiences about rejuvenation.

The development of SMAS surgery revealed the subperiosteal approach, allowing the repositioning of the ligaments of the middle cheek over the periosteum of the zygoma. However retaining ligaments can cause some interior difficulties; first, the mobilization of the vertical limb of the L is not possible because it is bound more to the masseter muscle fascia than the periost. Second, restricted repositioning of the medial cheek and nasolabial fold was encountered because of insufficient tension over the unblocked periosteum of the middle cheek region. While knotting each stur, the probable dimples on the skin are watched; if there is a dimple that probably appeared because the traction is too wide or vertical or the suture is placed too superficial, the suture is changed.

The fundamentals of facelift surgery should include the fixation parallel to the natural anatomic ligaments unrestricting the functional results. The SMAS indicates various properties throughout the regions of face and is strengthened with vertical retaining ligaments including the deep fibrils of the reticula cutis.

The description of the zygomatic and masseteric retaining ligaments of the cheek supports extended SMAS face-lift surgery with the function and the localization of the retaining ligaments taken into