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PATHOGENESIS OF FACIAL AGING

Facelift surgery or rhytidectomy, brow lifts, and midface lifts are surgical treatment of the aging face performed in an effort to re-drape and suspend facial soft tissues to regain a more youthful appearance to the face. Facial aging has traditionally been attributed to the force of gravity causing soft-tissue ptosis descent of the face as the patient ages in conjunction with bony skeletal remodeling that occurs with age. New research on skeletal bony changes and soft-tissue fat descent has helped support our understanding of the aging process. In general, facial aging tends to occur in 3 dimensions and involves all tissue components of the face: skin, muscle and soft tissue, facial fat pads, and the bony facial skeleton. To appropriately treat the patient, the surgeon must be aware of all these facets of the aging face.

Facial aging can be thought of occurring from superficial to deep, and tends to begin during the ages of the late twenties and thirties in the skin. Photodamage is defined as the functional and structural damage that occurs to skin after chronic exposure to ultraviolet radiation from the sun. The structural changes involve gradual thinning of the epidermis, flattening of the epidermal-dermal border, loss of collagen and thickness in the dermis, decrease in collagen type I to type III ratio, and reduction in the skin cellular and protein components. Lax skin with decreased collagen manifests through sagging and increases the propensity to be wrinkled and furrowed.

Deeper into the facial soft tissues, muscle laxity and atrophy, as well as bony remodeling and resorption, can potentiate the loss of facial, mandibular, and neck definition. These anatomic changes manifest clinically as brow ptosis, deepening of the nasolabial fold, jowling, blunting of the cervicomental angle, and platysmal banding (Figure 76–1). These features of the aging face are particularly amenable to correction with a rhytidectomy, platysmaplasty, midface lift, and/or brow lift.

Figure 76–1

Characteristic features of facial aging: (A) brow ptosis, (B) descent of the midface, (C) nasolabial fold, (D) excessive jowling, (E) marionette line, (F) prejowl sulcus, and (G) platysmal banding.

Understanding the desires of the aging-face population is essential for the surgeon who wishes to participate in their treatment. They often desire the best treatment without any signs of having undergone treatment. They also often will say they do not want to look different, but they desire to look how they feel. This places additional pressure on the cosmetic surgeon who must balance the particular treatments and minimize any chance of complications.

However, there are limitations to these surgical procedures. The surgeon must know that there are options to deal with aspects of the aging face for which a facelift or a brow lift is not as effective. Although photodamage from the sun or tanning beds ...

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