vertical descent of the skin-soft tissue envelope of the face and neck. The platysma muscle also loses much of its tone. Repeated contraction, combined with volume loss in the anterior neck, can lead to prominent vertical platysmal bands.

59.2.3 Aging Facial Skeleton

The aging process also affects the skeletal foundation of the face. As the result of hormonal changes, there is an overall decrease in bone density. This decrease is not exclusive to weight-bearing bone, but may also be seen in the facial skeleton. Osteopenia of the zygoma and maxilla leads to a decrease in malar prominence, but also loss of support for the malar fat pads, SMAS, and facial musculature. Osteopenia of the mandible contributes to the formation of the anterior mandibular groove and may accentuate existing microgenia or just a hypoplastic mentum.

These qualitative visual criteria reflect physiologic changes occurring beneath the epidermis at the dermal level. Nicotine found in tobacco products leads to increased blood levels of vasopressin, causing peripheral vasoconstriction and a state of dermal ischemia [11–13]. As nicotine blood levels decline, leading to a decrease in vasoconstriction, postischemic reperfusion may lead to the generation of reactive oxygen species which are a major component of UV injury and photoaging [14]. Induction of matrix metalloproteinases within the skin may be yet another mechanism by which tobacco smoke leads to premature skin aging [15].

Other important factors which contribute to the aging of the skin include skin type, history of sun exposure, history of skin irradiation, hyper or hypothyroidism, diabetes, peripheral vascular disease, atherosclerosis, and liver failure. Not only do the aforementioned factors contribute to skin aging, but they may also influence the degree of surgical correction performed by affecting the viability of skin flaps. Ameliorating factors, such as retinoic acid use, routine skin care, and sun protection may serve to retard the aging process.

59.3 Other Factors

Individual patient factors also play an important role in aging. Perhaps the most important of these factors is tobacco use, which is still quite prevalent and is extremely detrimental to skin quality and blood supply. Model [10] originally coined the term “smoker’s face” and attributed to this term the following visual criteria:

1.Lines or wrinkles on the face, typically radiating at right angles from the upper and lower lips or corners of the eyes, deep lines on the cheeks, or numerous shallow lines on the cheeks and lower jaw.

2.A subtle gauntness of the facial features with prominence of the underlying bony contours. Fully developed this change gives the face an “atherosclerotic” look; lesser changes show as slight sinking of the cheeks. In some cases these changes are associated with a leathery, worn, or rugged appearance.

3.An atrophic, slightly pigmented grey appearance of the skin.

4.A plethoric, slightly orange, purple, and red complexion different from the purple blue color of cyanosis or the bloated appearance associated with the pseudo-Cushings’s changes of alcoholism.

59.4 Evaluation of the Aging Neck

59.4.1 Analysis and Classification

Previous authors have described visual criteria for the youthful neck which include [16]:

1.Distinct inferior mandibular border from mentum to angle without jowl overhang

2.Subhyoid depression

3.Visible thyroid cartilage bulge

4.Visible anterior border of the sternocleidomastoid muscle distinct in its entire course from the mastoid to sternum

5.Cervicomental angle between 105° and 120°

Another classification system in use is that proposed by Dedo [17]:

Class I: Minimal deformity: well-defined cervicomental angle, good platysmal tone, no fat accumulation.

Class II: Early cervical skin elastosis, no fat accumulation, no platysmal weakness.