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Stephen R. Tan, Richard G. Glogau

'Wrinkles should merely indicate where smiles have been'
Mark Twain, 1897

Introduction

Over the past few years, the art and science of cosmetic surgery have evolved to enable physicians to treat the signs of facial aging more precisely. In a broad sense, wrinkles may develop as either hyper-dynamic lines caused by the repetitive movement of underlying facial musculature over the years, or as redundant skin which develops as the skin progressively loses its elasticity and submits to the relentless pull of gravity. For many years, the face lift and the brow lift have been the sine qua non of treating the wrinkles associated with inelastic and redundant skin; however, hyper dynamic wrinkles remained difficult to treat.

With the selective chemical denervation of facial musculature possible with botulinum toxin, physicians have expanded their therapeutic armamentarium to be able to treat the underlying cause of hyper dynamic lines effectively. In 1987, Drs Jean and Alastair Carruthers noticed the smoothing effect of botulinum toxin on the glabellar brow furrow when treating a patient for blepharospasm. They pursued their observations on the cosmetic effectiveness of botulinum toxin, and in 1992 published the first manuscript on the cosmetic use of botulinum toxin A (BTX-A) for treating glabellar frown lines. This observation began a new era in minimally invasive cosmetic surgery, and in 2003 they published a textbook on the subject.

To achieve maximal cosmetic improvement using botulinum toxin while minimizing the risk of complications, the physician must have a thorough understanding of facial esthetics. The word aesthetic is derived from the Greek word aisthesis, which means having a sense or love of that which is beautiful. In a modern sense, esthetics is a scientific attempt to explain a subjective concept by assigning proportions to various components of the face. The idealized face tends to exhibit several general characteristics, with slightly different proportions and shapes between women and men. Although these proportions may be used to define the 'ideal', 'attractive', or 'perfect' face, the real value in studying these principles lies in clarifying the range of normal relationships that exist between facial units. Harmony and balance of the face exist through a wide range of sizes, shapes, and configurations of the individual parts. The cosmetic surgeon must appreciate this in order to understand the changes that affect the face over time.

Etiology of the Aging Face

The face ages in response to a number of factors, which may appear to varying degrees between individuals. Sun exposure and smoking tend to accelerate these changes.

Chronic ultraviolet light damage to the skin

Photoaging adds to the inevitable changes seen with intrinsic chronologic aging; indeed, cumulative sun exposure is the single largest factor involved in our clinical perception of aging skin, and is responsible for a large portion of the unwanted esthetic effects. Glogau has developed a systematic classification of patient photoaging types (see Box 1.1 and Fig. 1.1).

Glogau photoaging classification

Box 1.1 Glogau photoaging classification

Glogau Wrinkle Scale

© R. Glogau, MD , 2000.

Fig. 1.1 Glogau photoaging classification. In type I patients, note the absence of wrinkles and pigmentary alterations. Type Il patients do not have wrinkles while the face is at rest, but wrinkles appear with facial movement. Type III patients have wrinkles present while the face is at rest. In type IV patients, the skin is entirely wrinkled, with no normal skin remaining on the face. Also note the yellow-gray, sallow color of the skin

Gravitational changes from loss of elasticity of the tissue

With aging, the facial soft tissues lose their inherent resiliency and ability to resist stretching; inevitably, they begin to sag under the effects of gravity.

Remodeling of the underlying bony and cartilaginous structures

Over time, bony resorption may result in a decrease in apparent facial volume, and gravitational stretch of cartilaginous structures may result in the drooping of structures such as the nasal tip. Facial asymmetry due to underlying bony or cartilaginous structural changes is difficult to correct, and pointing out these differences at the initial consultation is important in setting realistic patient expectations.

Anatomic Approach to the Aging Face

Physicians should approach a patient seeking cosmetic improvement of the signs of aging from an anatomic standpoint. The determination of what is wrong must precede how it should be corrected. All too often, physicians develop a preference for one or a few cosmetic techniques, and then attempt to apply these to all situations. Inappropriately using a therapeutic technique that does not address the underlying anatomic basis for a cosmetic problem leads to mediocre results at best, and disasters at worst. For example, patients with deep glabellar furrows treated with filler substances may experience transient improvement; however, unless the underlying muscles causing these hyperdynamic lines are paralyzed with botulinum toxin, the wrinkles will rapidly recur. Thus, an anatomic approach to the aging face is essential, and will allow the physician to rationally select the optimal therapeutic tool from a wide variety of therapeutic options.

Upper third of the aging face

Changes in the upper third of the face are primarily related to chronic ultraviolet light damage, to the intrinsic muscles of facial expression and their influence on the skin, and to gravitational changes from the loss of elasticity of the tissue. The widespread use of botulinum toxin for selective chemical denervation of facial musculature has emphasized the influence that these underlying muscles have on the skin. The forehead is undergoing constant dynamic stress from the frontalis, corrugator, and procerus muscles. These muscles are constantly active in facial expression, and convey frowning, scowling, surprise, and numerous other emotional states (see Box 1.2). Medial and lateral brow function independently in this regard, and surgeons must be aware of the strong impact that brow position can have on appearance.

Box 1.2 Relationship of emotional states with brow position

Fig. 1.3 Horizontally oriented hyperdynamic wrinkles on the forehead develop from frontalis muscle contraction		Fig. 1.4 Resting forehead wrinkles. Note that the horizontally oriented wrinkles are hyperdynamic lines resulting from frontalis muscle contraction, whereas the vertically oriented wrinkles are 'sleep creases' resulting from external compression of actinically damaged skin

Fibers of the vertically oriented procerus muscle attach from the glabella to the nasal root, and contraction produces the horizontally oriented 'scrunch' lines (see Fig. 1.5). Loss of cutaneous elasticity with age leads to glabellar ptosis, resulting in an accentuation and deepening of these wrinkles.

The esthetically ideal position of the eyebrows varies between the genders. The medial edge of the brow should have a slight club-like configuration, with a gradual taper towards the lateral end. In men, the eyebrows are ideally positioned at or just above the supraorbital rim and are almost horizontal in shape, with only the slightest hint of an arc (see Fig. 1.6). In women, the eyebrows should be posi­tioned above the supraorbital ridge; however, unlike the relatively horizontal eyebrows in a man, the female brow has a gentle gull-wing shape, with the lateral aspect being more elevated than the medial (see Fig. 1.7). The maximal brow elevation of the female eyebrow arch occurs at or just lateral to a line tangential and vertical to the lateral limbus. The lateral brow should end at an extension of a line beginning at the nasal ala and passing through the lateral canthus. The lateral eyebrow should frame the superolateral orbital rim, which is frequently accentuated with appropriate makeup. Obvious brow ptosis is noted when the eyebrows fall below the level of the supraorbital ridge, resulting in a fatigued appearance (see Fig. 1.8). Brow ptosis results from a combination of gravitational stretching of inelastic skin, atrophy of the brow fat pad, alterations in the underlying soft tissue support, and a decrease in underlying bony volume. Brow ptosis may be generalized, or may be isolated to the medial or lateral portions. The fascia under­ lying the brow has firm attachments over the medial one-half to two-thirds of the superior orbital rim and weaker connections laterally; thus, the weaker lateral connections allow for brow ptosis to typically be greater along the lateral aspects. Lateral brow ptosis is seen clinically as temporal hooding and, if there is concomitant upper lid ptosis, may interfere with vision. Patients may attempt to compensate by cocking the head back slightly and by contracting the frontalis muscles in an attempt to raise the drooping brow, adding to the forehead furrows. This is commonly seen in males and is typically perceived as a masculine characteristic, whereas in females it may be perceived with a negative connotation.

Fig. 1.5 Glabellar hyperdynamic wrinkles. Corrugator muscle contraction produces both vertically and obliquely oriented wrinkles, whereas procerus muscle contraction leads to horizontal 'squinch' lines		Fig. 1.6 Idealized male brow, positioned at the supraorbital rim with an almost horizontal shape		Fig. 1.7 Idealized female brow, with a gentle gull-wing shape

Fig. 1.8 Brow ptosis. Note brow position below the level of the supraorbital ridge, as well as early hooding as the upper eyelid skin droops towards the visual axis		Fig. 1.9 'Crow's feet' hyperdynamic wrinkles radiating outwards from the lateral canthus

On the lateral aspects of the face, wrinkles may develop as 'crow's feet' emanating radially from the lateral canthi (see Fig. 1.9). Analogous to the hyper-dynamic wrinkles in the forehead and glabella regions, crow's feet result from the accordion-like movement of the orbicularis oculi muscles. With progressive loss of cutaneous elasticity, the skin is less able to rebound from the continued pulling of the underlying muscles, and these wrinkles may eventually remain at rest.

Middle third of the aging face

Aging of the middle third of the face affects the lower eyelids and periorbital regions, the cheeks, and the nose. Changes in these areas primarily result from a combination of photoaging, loss of sub-cutaneous tissue, loss of cutaneous elasticity, and remodeling of underlying cartilaginous and bony structures. For a full description of the changes in this area, please see the chapter entitled 'Fillers esthetics' in this series.

Lower third of the aging face

The age-related changes seen in the lower third of the face affect the lips, the chin, the lower cheeks, and the neck. Changes result from a combination of chronic ultraviolet light damage to the skin, loss of subcutaneous fat, changes due to the muscles of facial expression, gravitational changes from a loss of elasticity of the tissue, and remodeling of the under­lying bony and cartilaginous structures.

Wrinkles form around the lips as a result of the constant pulling of the orbicularis oris muscle on progressively more inelastic upper- and lower-lip skin, creating angular, radial, and vertical wrinkles (see Fig. 1.10). The effects of gravity result in drooping of the oral commissures laterally and downward, which may lead to a tired and sad appearance. Fullness of the lips and a strong definition of the philtrum are seen in youth; however, with advancing age there is a thinning of the vermillion, loss of lip highlights, and an overall flattening of the lip.

Conclusion The introduction of botulinum toxin for selective chemical denervation has emphasized the impact of facial musculature on the appearance of facial aging. Complete or partial weakening of the glabellar corrugator/procerus muscle complex, the forehead frontalis, and the lateral orbicularis oculi muscles has revolutionized the management of the upper third of the aging face. Deep glabellar lines, which could only briefly be improved with injectablefillers, are now effectively treated with the place ment of botulinum toxin in the procerus and corru gator muscles and orbicularis oculi. Crow's feet lines, which routinely reappeared 2-3 months after deep resurfacing, now vanish after a few days. Even trouble­ some horizontal lines and creases of the lower eyelid that persist after blepharoplasty and/or resurfacing can be treated with botulinum toxin.

Fig. 1.10 Perioral wrinkles radiating outward from the upper and lower lips. 'Marionette lines' form as vertical wrinkles extending downwards from the oral commissures

An appreciation of the patient's baseline state is essential to attaining a successful cosmetic outcome. With a thorough working knowledge of facial esthetics, anatomy, and the changes seen with aging, the cosmetic surgeon can approach a patient with hyperdynamic wrinkles to effectively utilize botulinum toxin to achieve maximal cosmetic improvement.

Further Reading