Comprehensive Treatment of the Aging Face-Cutaneous and Structural Rejuvenation

DAVID A. SHERRIS, M.D., CLARK C. OTLEY, M.D., AND GEORGE B. BARTLEY, M.D.

As people age, characteristic changes occur in the skin, the soft tissue envelope, and the bony skeleton of the face and result in the aging face syndrome. An understanding of the pertinent biomechanical and histologic changes is necessary for developing an appropriate treatment plan. The advent of many new techniques, including cosmetic exfo­liation, laser skin resurfacing, open rhinoplasty, and endoscopic, multiplane plastic surgical procedures, has the layers of the face are the skin, the soft tissue enve­lope (subcutaneous fat, muscle, and fascial layers), and the structural support (bone, cartilage, and teeth). The aging face syndrome refers to the dynamic, cumulative, and degenerative effects of aging on both the superficial and the structural integrity of the face. Factors such as geographic location, occupational and recreational preferences, genetic background, and overall health determine which facial features are most affected over time. For some patients, the soft tissue envelope and structural framework of the face remain well preserved; aging manifests superfi­cially as weathered skin, a condition termed "aging skin." For other patients, the cutaneous surface remains youthful, while aging of the bone and soft tissue elements of the face results in loss of structural landmarks and cutaneous laxity, an outcome termed "the sagging face." More common, however, is simultaneous aging of both the superficial and the deep structural elements of the face, resulting in the aging face syndrome. Although the treatment of any one component of the aging face necessitates specialized knowledge and expertise, a collaborative, multidisciplinary approach can lead to optimal results and enhanced patient satisfaction.

Changes Associated With Aging Skin
The changes that occur in the skin from infancy to old age are a result of both intrinsic and extrinsic aging pro-enhanced therapy for the aging face syndrome. Treatment protocols should be individualized for each patient's needs and desires. Several of these recent treatments for facial rejuvenation are reviewed herein.

SMAS = submusculoaponeurotic system

Intrinsic aging refers to the effects of chronologic aging, whereas extrinsic aging refers to changes caused by environmental factors such as exposure to sunlight, grav­ity, and cigarette smoke. In general, the changes associated with intrinsic aging of the skin include atrophy and loss of structural dermal and epidermal components, whereas those associated with extrinsic aging include dysplasia and structural alteration.' Histologically, the cumulative ef­fects of intrinsic aging on the skin include epidermal thin­ning due to retraction of the rete pegs, decrease in the number of Langerhans' cells and melanocytes, and changes in the morphology of the keratinocytes. Extrinsic aging of the skin results in keratinocytic dysplasia and accumula­tion of solar elastosis and can result in cutaneous carcinogenesis.' Because all patients experience intrinsic and extrinsic aging simultaneously, the separation of these aging processes is artificial. Clinically, as intrinsic and extrinsic aging of the skin progresses, pigmentary abnor­malities, rhytids (wrinkles), and textural irregularities re­sult in a weathered appearance that many patients find displeasing.

Facial Structure

Normally, structural changes of the face occur as people age. The skull thins and becomes smaller with a resultant increased laxity in the overlying skin and soft tissue enve­lope. Beginning in the third decade of life, the eyebrows slowly and steadily descend from a position above the superior orbital rim.45 Brow ptosis combined with redun­dancy of skin of the upper eyelids (dermatochalasis), weak­ening of the underlying orbital septum, and dehiscence of the levator palpebrae superioris aponeurosis results in an aging eye appearance. Baggy lower eyelids are caused by stretching of the orbital septum and orbicularis oculi, pro­trusion of orbital fat, and excess overlying skin.

In the midface, the cartilaginous skeleton of the nasal tip weakens and broadens, an outcome that results in tip ptosis, lengthening of the nose, and, occasionally. airway obstruc­tion. With progressively increasing skin laxity, resorption of subcutaneous fat, and resorption of alveolar bone, a relative excess of the skin and soft tissue envelope of the lower part of the face develops. These events lead to the descent of the chin pad. the loss of delineation between the jawbone and the neck, and the development of the charac­teristic jowled "turkey gobble" neck. As aging progresses. the hyoid bone and the larynx descend, and thus the middle and lower aspects of the neck appear to be more promi­nent.' In some patients, prominent platysmal bands de­velop in the submental region, an occurrence that further accentuates the aging process. In other patients, a relative underprojection of the malar eminences or the chin devel­ops because of the redistribution of the overlying skin and soft tissue envelope. The degree to which various abnor­malities manifest differs for each patient. An expert assess­ment of patients with the aging face syndrome will result in the most effective therapeutic intervention for the predomi­nant abnormalities. Collaboration between physicians who have expertise in therapy for both the sagging face and the aging skin enhances patient satisfaction.

PREVENTION OF AGING SKIN

Patients interested in therapy for the manifestations of ag­ing skin and the aging face syndrome expend considerable time, anxiety, discomfort, and resources undergoing vari­ous treatment interventions. Education for patients with early stages of photodamage about protection from sun-light may eliminate the need for more aggressive therapeu­tic interventions later in life. Likewise, every patient should adhere to sunlight protection practices after facial rejuvenation procedures, most importantly during the first 6 months postoperatively. Conscientious protection from sunlight prevents photodamage as well as precancerous growths and skin cancer. Basic sunlight protection in­cludes regular application of sunscreens with a sun protec­tion factor of 15 or greater. use of protective clothing, and avoidance of prolonged exposure during the hours of peak solar intensity between 11 AM and 3 PM. Besides exposure to sunlight, smoking is the other major extrinsic factor that should be eliminated both to prevent skin aging and to prevent poor healing around therapeutic interventions.

REJUVENATION OF AGING SKIN
Medical Therapy

Medical therapy for aging skin can he satisfying for patients with early signs of aging and for those not inter­ested in more aggressive therapeutic interventions. If real­istic expectations about the limitations of medical therapy are fostered, many patients will find that these low-risk medications are effective. The efficacy of these agents is limited because of their primary focus of action on epider­mal cells. The most commonly prescribed medical therapy for aging skin, tretinoin cream (Retin-A), is a retinoid derivative capable of smoothing fine rhytids, reducing pig­mentary abnormalities. and reversing early keratinocytic dysplasia.6 Tretinoin applied nightly will produce clini­cally apparent but mild improvements in 6 to 12 months. and irritation is the only common side effect.' Applications of bleaching agents, such as 4 solution of hydroquinone or 20% azelaic acid cream, can fade lentigines gradually by inhibiting melanogenesis. As with tretinoin, the effects are mild and gradual but can be satisfying for patients with realistic expectations.

Mild and superficial chemexfoliation with low concen­trations of a-hydroxy acids, such as glycolic acid, has recently gained widespread acceptance. Forty to seventy percent glycolic acid chemical peels result in superficial epidermal exfoliation and can eventuate in a freshening effect on the skin.10 Low-concentration glycolic acid peels are superficial, cause mild to moderate irritation, and usu­ally allow patients to continue daily activities without inter­ruption. Patients must be informed that higher concentra­tion glycolic acid peels occasionally can cause epidermal necrosis. Maintenance therapy with daily application of low-concentration glycolic acid preparations can sustain beneficial effects. Therapy with various combinations of tretinoin, hydroquinone, and glycolic acid can enhance results if used in a regimen that minimizes irritation.

Cutaneous Resurfacing-Laser Techniques, Chemical Peel, and Dermabrasion

Cutaneous resurfacing refers to rejuvenating techniques that eradicate the entire aged epidermis and a variable portion of the dermis and thus allow regrowth from follicu­lar epithelium. By wounding the dermis to a controlled degree, resurfacing techniques cause connective tissue contraction that may result in tightening of the skin with elimination of fine and moderate rhytids and eradication of unsightly solar elastosis-a pebbly, yellow quality of aged skin. The attendant benefits, morbidity. and risks are greater than those associated with medical therapies. Ap­propriate patient selection is necessary to identify those who desire moderate to pronounced improvement in the surface manifestations of the aging face and to exclude those who are unable or unwilling to subject themselves to a substantial postoperative healing process and occasional adverse effects.

In the hands of an experienced surgeon, cutaneous re-surfacing can be safely and effectively performed by car-bon dioxide laser, chemical peel. or dermabrasion.

Fig. I. Patient before (A) and after (B) full-face ultrapulse carbon dioxide laser resurfacing.

Each technique has certain advantages and disadvantages, de-pending on the specific clinical setting. The choice of resurfacing modality may be based on the site of treatment, the presence of preexisting scarring, the availability of equipment, and the physician and patient preference." Claims about the absolute superiority of one technique over another are unsubstantiated.

Dermabrasion involves the mechanical removal of lay­ers of skin with a rotating diamond wheel or brush. The level of skill and experience needed for safe and effective dermabrasion may be higher than that with the other tech­niques, but with training, dermabrasion can produce excel-lent results, especially in patients with associated scarring. Medium-depth chemical peels with trichloroacetic acid alone or in combination with Jessner's solution, gly­colic acid, or solid carbon dioxide are reliable and effective for achieving complete epidermal eradication and partial dermal necrosis. The choice of formula depends pri­marily on physician preference and experience; however, the subtle differences in indications may optimize the therapeutic decision. Deep chemical peels with Baker's formula phenol can produce more dramatic effects as a result of complete epidermal eradication and deep dermal necrosis." This type of chemical peel has an increased risk of scarring and a high probability of long-term hypopig­mentation that necessitates camouflage with makeup.

With the advent of ultrapulse and scanning technology, carbon dioxide laser resurfacing has emerged as the most sought after resurfacing modality. By delivering pulsed laser energy, the new carbon dioxide lasers limit collateral thermal damage and allow very precise removal of thin layers of tissue." Combined with computerized pattern generators, this laser is the most technologically advanced resurfacing modality and may offer a more predictable and reproducible level of tissue necrosis. Advanced technol­ogy is no replacement for sound surgical judgment and experience, however.

Indications for a cutaneous resurfacing procedure in­clude hyperpigmentation, textural abnormalities, and fine, moderate, or deep wrinkling. Although the results of cuta­neous resurfacing procedures can range from disappoint­ing, due to an underaggressive procedure, to disastrous, due to an overaggressive one, well-performed procedures are highly satisfying to patients and physicians alike. Rea­sonable expectations from a resurfacing procedure include substantial improvement in skin texture and color as well as the eradication of fine and moderate wrinkles (Fig. 1). Severe wrinkles may diminish but usually persist to some degree.

The wounds that are produced by cutaneous resurfacing procedures are substantial, and patients must be completely informed of the pronounced morbidity and lifestyle in­fringement that will occur postoperatively. Partial-thick­ness dermal wounds are more difficult to manage than are closed wounds associated with rhytidectomy. Postopera­tive wound care may involve application of full-face dress­ings or ointment and necessitates cleansing numerous times a day. Once reepithelialization occurs, the skin is fragile, pink, and photosensitive for weeks to months.

The risks of medium-depth wounding resulting from cutaneous resurfacing are considerably greater than those associated with medical therapies for aging skin; however, complications from well-planned and appropriately ex­ecuted resurfacing are uncommon. Scarring is uncommon if the depth of necrosis is mid-dermal or higher. Infections are rare, especially with prophylaxis against reactivation of herpes simplex virus. Although usually transient, hyper-pigmentation and hypopigmentation can be problematic in patients with deeply pigmented skin. Close postoperative follow-up facilitates early identification of incipient com­plications and allows timely therapeutic intervention.

Soft Tissue Augmentation

Soft tissue augmentation involves the injection or inser­tion of autologous, heterologous, or artificial substances to correct soft tissue deficits.' The most common indications for soft tissue augmentation are rhytids and furrows result­ing from facial expressions. Placement of soft tissue fillers is accomplished by means of injection, needle-guidance, or open insertion. Autologous transplantation of adipose tis­sue or dermis appeals to patients who wish to avoid foreign substances. The drawbacks of these substances, however, are the need for a separate harvesting procedure and prepa­ration for reinjection. The most commonly used substance for soft tissue augmentation is bovine collagen-Zyderm and Zyplast. Fibrel, another agent for soft tissue augmen­tation, incorporates a patient's serum into a gelatin matrix. Most autologous and heterologous substances have the disadvantage of lack of durability; typically, they re-sorb in 3 to 12 months, and periodic retreatment is neces­sary. Implantable polytetrafluoroethylene threads have re­cently been used for contour enhancement of the lips and nasolabial folds."

Typical sites for injectable soft tissue fillers include the nasolabial folds, glabellar frown lines, perioral rhytids, forehead creases, and periorbital lines (Fig. 2). Bruising, swelling, superficial necrosis, infection, and surface irregu­larities are uncommon. The speculative association of con­nective tissue diseases with collagen implants is unsubstantiated by scientific evidence. Uncommon allergic reac­tions to heterologous collagen necessitate pretreatment testing.

Botulinum Toxin

Used as a very dilute preparation, the exotoxin derived from Clostridium botulinum produces a temporary and re­versible paralysis of striated muscles that can be used thera­peutically to counteract the formation of glabellar frown lines by overactive corrugator muscles. Forehead lines and periorbital rhytids are likewise responsive. As a result of the muscular paralysis and atrophy, the overlying fur-rows tend to diminish and cannot be activated by the pa­tient. As long as patients accept the temporary nature of the therapy, the effects can be gratifying. Complications such as transient brow ptosis, headache, numbness, infection, and bruising are uncommon. The development of antibod­ies against botulinum toxin (Botox) can render treatments ineffective.

Laser Surgical Treatment

In addition to the use of ultrapulsed carbon dioxide lasers for cutaneous resurfacing, as previously described, laser technology has expanded the options for treating the pigmentary and vascular manifestations of aging skin. Telangiectasias, dilated superficial blood vessels, can be a prominent manifestation of aged or photodamaged skin. The flashlamp-pumped pulsed dye laser selectively obliter­ates vascular channels and thus is ideal for the treatment of facial telangiectasias.'6 Postoperative swelling can be mild to moderate, but a dark purple purpura develops within minutes at the treatment sites; the purpuric lesions, which may limit a patient's ability to work or socialize, typically last for 7 to 14 days. With the exception of the prominent purpura, the pulsed dye laser is considered one of the safer and more effective lasers available. Scarring is extremely rare, and pigmentary abnormalities are usually transient.

Fig. 3. Patient before (A) and after (B) endoscopic brow-lift. septorhinoplasty. and submusculoaponeurotic system cervicofacial rhytidectomy with platysmal plication.

Although several technically simple therapies exist for the treatment of pigmentary abnormalities, lasers are avail-able for selective ablation of lentigines associated with aging skin. The Q-switched neodymium:yttrium-alumi­num-garnet laser, frequency doubled to a wavelength of 532 nm, selectively targets melanin in areas of increased pigmentation.' The Q-switched ruby and pulsed dye lasers work similarly to eradicate excess melanin deposits in lentigines.' The response of lentigines to laser therapy is usually gratifying. Because treatment with these lasers can be painful, topically applied or injected anesthesia may be desirable. Mild swelling, pinpoint bleeding, or bleaching of the affected tissue may be experienced postoperatively, and patients may need to perform daily wound care de-pending on the intensity of treatment. Postoperative pig­mentary abnormalities are a possible complication; skin may become excessively light or "rebound" to a darker shade. Scarring is uncommon. Strict photoprotection is necessary to prevent recurrence of lentigines.

REJUVENATION OF THE FACIAL STRUCTURE

Surgical therapies aimed at rejuvenating the effects of both skin and structural facial aging are varied. In the assess­ment of the patient's face for structural procedures to treat aging, a convenient method is to divide the face into thirds. The upper one-third includes the forehead and brows; the middle one-third includes the cheekbones, eyes, and nose; and the lower one-third includes the lower part of the cheeks, jawline, and neck. Recent innovations with endoscopes and various anatomic planes of dissection have substantially changed the surgical techniques.

Upper Third of Face-Brow-Lift and Blepharoplasty

In an analysis of the upper third of the face, the hairline, depth of central brow rhytids and glabellar frown lines, and brow position are located. Brow position is the main determinant in whether the patient needs a brow-lift proce­dure. In women, the eyebrow should rest at or just above the supraorbital rim with the peak of the brow between the lateral limbus and lateral canthus of the eye. In men, the brow usually is flatter and parallel with or slightly below the superior orbital rim. Brow ptosis can be mistaken for upper eyelid skin laxity, fat herniation, or true eyelid ptosis, and it is important which entity or entities are present. If the brows are low, a consideration is to elevate them with traditional coronal, pretrichial, mid-forehead, direct lifts or with newer endoscopic techniques. Although the tradi­tional procedures necessitate large incisions, an endoscopic brow-lift is done through multiple small incisions at or behind the hairline. Using an endoscope, the surgeon dissects deep to the soft tissues of the forehead in the sub­periosteal plane and resects overactive depressor muscles of the brow while simultaneously elevating the brow. Through the coronal, pretrichial, or endoscopic approach, the midface can also be elevated to some degree (Fig. 3 and 4). The advantages of endoscopic techniques include con­siderably less postoperative paresthesia of the scalp, less risk of scar alopecia, less blood loss, and a quicker healing time.

Fig. 4. Patient before (A) and after (B) endoscopic brow-lift, lower lid blepharoplasty, and deep plane cervicofacial rhytidectomy.

The disadvantages of endoscopic brow-lifting are longer surgical time and lack of information on long-term results. Complications with all brow-lifting procedures include possible hair loss at the site of scalp incision, long-term scalp anesthesia or paresthesia, facial or trigeminal nerve damage, hematoma, and infection.

Once any brow malposition has been addressed, upper and lower eyelid abnormalities should be assessed. Dermatochalasis (excess skin of the upper or lower eyelids or both) and orbital fat herniation are the most common complaints of people who want to undergo periocular cos­metic surgical treatment. Fine wrinkles without excessive skin redundancy can be treated adequately with laser skin resurfacing. Skin redundancy and anterior prolapse of orbital fat are treated with upper and lower blepharoplasty. The presence of true eyelid ptosis should be sought and repaired if present at the time of blepharoplasty (Fig. 5). Surgical treatment of the lower eyelids can be done through either an external (skin) incision or a conjunctival incision. The advantages of transconjunctival blepharoplasty are the avoidance of an external scar and less risk of postoperative ectropion or retraction. The limitation of this approach is that it is useful only for patients with fat herniation but minimal skin excess. The presence of lower eyelid laxity necessitates a concomitant lower lid tightening procedure. The potential complications of blepharoplasty are dry eye, lagophthalmos, sclera] show, ectropion, and visual loss." Although upper and lower blepharoplasty can be done concurrently with a brow-lift, many surgeons choose to delay upper blepharoplasty for 1 to 3 months after a brow-lift; with this approach, the appropriate amount of tissue to be excised can be determined after the brow malposition has been corrected and swelling has resolved.

Middle Third of Face - Midface Lift, Malar Augmentation, and Rhinoplasty

The midface can be approached through brow-lift inci­sions, eyelid incisions, or incisions in the maxillary gingivobuccal sulcus. The procedures commonly done in the midface include midfacelift with endoscopic tech­niques, placement of cheek implants for improved malar prominence, placement of submalar implants to improve deficiency in the submalar region, and full midface subperiosteal lift. These procedures are adjuncts to the other previously mentioned major procedures. As with other procedures, the risks include nerve damage (zygo­matic branch of the facial nerve as it traverses the zygo­matic arch), sensory nerve damage (infraorbital nerve), hematoma, implant infection or extrusion, and implant asymmetries.

Rhinoplasty and septorhinoplasty for the aging patient may be useful for functional nasal airway obstruction and the cosmetic deformities associated with laxity of the carti­lage, thinning of the nasal bone, and thinning and laxity of the nasal skin (Fig. 3 A). In many patients, pronounced nasal tip ptosis develops and results in nasal airway

Fig. 5. A. Patient with true ptosis of right upper eyelid (result of dehiscence of levator palpebrae superioris aponeurosis, as evidenced by high eyelid crease) and pseudoptosis of left upper eyelid (result of dermatochalasis). B, Same patient, 1 week after repair (advancement) of levator palpebrae superioris aponeurosis in right upper eyelid and functional blepharoplasty (excision of redundant skin and orbicularis oculi muscle) in left upper eyelid.

obstruction and may contribute to functional problems like sleep apnea. h1 addition, occasionally, the side walls of the nose collapse with age, an outcome that results in pro­nounced nasal valve collapse (Fig. 3 A). The surgeon may use nasal endoscopy, preoperative photographs, and rhino-manometry to define deformities in various regions. Many of these deformities are severe, and autologous cartilage grafts from the patient's nasal septum or ear are needed. With use of rhinoplasty techniques, the nose can be struc­turally reconstructed from the inside out and replaced in its more youthful position. Occasionally, skin excision must be done concurrently with rhinoplasty in order to treat discrepancies in the skin soft tissue envelope versus under-lying structure sizes. Complications are uncommon but include recurrent nasal or septal deviation, autologous graft resorption, epistaxis, or asymmetric healing.

Lower Third of Face-Nasolabial and Lip Augmentation and Rhytidectomy

Other facial areas amenable to treatment include the cheek and neck complex, the nasolabial and perioral creases, and the lips. The nasolabial creases and lips can be augmented with various materials including dermal fat grafts, fat injections, and expanded polytetrafluoroethylene (Gore-tex) implants. Augmentations of these regions work well to improve the contour by flattening the nasolabial creases, about 50 to 75% improvement can be expected, and by thickening the lips according to the patient's wishes. The biggest risk with autologous or alloplastic implants in these regions are resorption, infection, or extrusion. These procedures can be done concurrently with rhytidectomy.

The face-lift operation has undergone a revolution dur­ing the past 10 years. Previously, only the skin was el­evated. Surgeons then began to suspend the skin and underlying submusculoaponeurotic system (SMAS)'-' (Fig. 3). The contemporary operation may now involve dissec­tion of the skin and SMAS in continuity, beyond the nasolabial crease and into the neck') (Fig. 4). With platysmal muscle tightening procedures, the need for liposuction is much less. The underlying structural support of the cheeks and lower part of the face can be realigned with these procedures. The skin-only face-lift is rarely done except in cases of revision after a primary rhytidectomy with SMAS tightening. Although rare, hematoma formation and skin sloughing are possible com­plications. Because smoking increases the risk of this problem, all patients must abstain from smoking for at least 2 weeks before and 2 weeks after a face-lift. Hypertrophic scar formation can occur in patients who have a predisposi­tion to this disorder, but it can be minimized if extreme care is taken to avoid placing excessive tension on the skin flaps. Nerve injuries, including sensory injury of the great auricular nerve or motor injury of the zygomatic or mar­ginal mandibular branches of the facial nerve, are rare. Temporary sensory denervation of the face is expected, and 4 to 6 months are needed for recovery because of the large area of undermining. Permanent sequelae from any of these complications are rare.

The degree to which multiple facial cosmetic procedures can be performed concurrently is a matter of debate." Certainly, preoperative treatment of pigmentary changes and topical application of tretinoin are accepted prepara­tions before cutaneous resurfacing. When substantial pro­cedures such as cervicofacial rhytidectomy and full-face cutaneous resurfacing are done concomitantly, however, the attendant risks are higher than those with either proce­dure alone. In selected cases, concomitant surgical inter­ventions can be well tolerated and safe. The merits of combined modality therapy should be judged individually.

Therapies for superficial and deep manifestations of the aging face should be complementary (Table 1). Treatment of aging skin can optimize the effects of a well-performed surgical reconstruction. Likewise, surgical correction of underlying structural defects can provide the necessary foundation for performing cutaneous resurfacing proce­dures. Close and collegial collaboration among surgeons of various disciplines can result in optimal therapy, excep­tional results, and satisfied patients.

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