Keywords
Facial agingSkin changesBone changesVolume lossDynamic linesWrinklesMandible changesJowlsSkin laxitySkin foldsVolume lossCheek augmentationPhotoaging/hyperpigmentation3.1 Photoaging
A significant effect from sun exposure during the lifetime is the breakdown of components of the skin from ultraviolet radiation. This breakdown includes cellular changes that eventually lead to the development of skin cancers along with the formation of ephelides (freckles), lentigines, seborrheic and actinic keratosis , fine lines, and wrinkles (Nicol 2016; Habif 2016).
3.1.1 Lentigines
Lentigines are frequently referred to as “liver spots” and can occur on sun exposed areas such as the face, hands, scalp, arms, and back. Lentigo vary in size from 0.02 to 2.0 cm and becomes more numerous in adults as sun exposure increases. Ephelides , also called freckles, are small light brown or reddish macules that become more apparent with sun exposure and are usually found on the face, arms, and back (Habif 2016).
Lentigo Photo: B. Haney, DNP, FNP-C, FAANP
3.1.2 Seborrheic Keratosis
Seborrheic keratosis (SK) lesions are non-cancerous, nor do they become cancerous. SKs do not contain the human papilloma virus (HPV), therefore, they are not warty lesions although they are characteristically referred to as warts by patients (Habif 2016). SKs occur on hair bearing areas of the body including the scalp, face, arms, trunk, legs, and genitals; they do not appear on the lips, palms of the hands, or soles of the feet (Habif 2016).
Seborrheic keratosis. Photo: James Heilman, MD (Heilman n.d.)
3.1.3 Actinic Keratosis
Actinic keratosis (AK) is a squamous cell carcinoma lesion that is confined to the epidermis; however, when the cells extend deeper into the papillary or reticular dermis , it is termed squamous cell carcinoma (SCC) (Habif 2016). These superficial lesions need to be closely monitored by a qualified practitioner to ensure they do not progress into SCC. Most patients would likely become alarmed when the word cancer is mentioned, therefore, AK is the preferred term to use when educating patients. It is also important to inform them of the decreased possibility these lesions can transform into cancers (Habif 2016). Lighter-skinned people are more susceptible to form AKs. Sun exposure is a requisite to the development of these lesions and the judicious use of sunscreen is strongly recommended. Interestingly, organ transplant recipients are 65 times more susceptible to developing AKs so immunosuppression has been determined as a risk factor (Habif 2016).
Treatment for AK varies depending on the severity of the condition and lesions. Regimens include topical treatment of specific lesions using 0.05% tretinoin for several months, laser treatment with or without photodynamic therapy (PDT), or chemotherapy agents such as 5-fluoroucil or imiquimod (Habif 2016; Le Pillouer-Prost and Cartier 2016).
3.1.4 Lines and Wrinkles
The aging process begins in the third and fourth decade of life but then progresses quickly throughout the sixth decade (Binder and Azizzadeh 2008). However, fine lines and wrinkles can begin to appear on the skin as early as the second decade of life. Certain factors such as the amount of sun exposure and other lifestyle habits such as smoking, hydration, stress, environmental exposures, chemical exposures, and other factors initiate and accelerate aged appearance. Static lines are visible at rest or without facial muscle motion, and contribute to the appearance of aging (Baumann et al. 2016). These lines are a source of distress for many aesthetic patients and are a frequent cause for aesthetic consultation.
Many patients also complain of fine, crêpey skin under the eyes. The thinness of the skin in the suborbital area lends itself to fine lines, even when the remainder of the facial skin may have few, if any wrinkles. Non-ablative carbon dioxide laser resurfacing treatments have been successful in treating fine lines in the thin skin of the upper and lower eyelids (Tierney et al. 2011). In addition to laser treatments, lower eyelid skin has been shown to respond favorably to topical tretinoin (Hoenig and Hoenig 2013; Manaloto and Alster 1999).
Deeper wrinkles and folds are the result of one or more of the following: (1) sun exposure with subsequent collagen breakdown, (2) gravity in association with volume loss from aging or weight loss, (3) facial muscle contraction, (4) genetic influence, (5) bone changes (Hellman 1927; Whitaker and Bartlett 1991; Carruthers et al. 2008; Carruthers and Carruthers 1992; Carruthers et al. 1996). Some of these causes can be prevented or controlled, while some are the result of a natural process or genetic tendencies. Facial changes become more apparent between 35 and 50 years of age (see Figs. 3.1 and 3.2). This age group is the largest portion of the population who seeks aesthetic enhancement (Cosmetic Surgery National Data Bank STATISTICS 2017).
Static lines, increased skin laxity, discoloration, changes in bone structure, and softening of tissues that support the face all intensify the appearance of aging (Bitter 2000). Prevention of damage from ultraviolet (UV) radiation from sun exposure is an important aspect in the prevention of pre-mature aging. Protection from the UV rays of the sun can be achieved by using physical block, such as clothing, or chemical block from sunscreens. This is an important strategy recommended for young and old alike.
Dermal fillers, botulinumtoxin type A (BoNT/A), laser treatments, topical medications such as tretinoin, intense pulsed light (IPL) treatment, or surgery can be reasonable options to address the appearance of aging. The specific issue and condition of the skin will determine which options are appropriate for the patient (Walgrave et al. 2012; Beer 2006; Dreher et al. 2013; Rivas and Pandya 2013; Kotlus 2010). Understanding the aging process and elements that contribute to it, in conjunction with utilizing appropriate treatment options, will guide the practitioner in providing appropriate options for the best outcome.
3.2 Facial Volume Loss
Facial volume changes are due in part to depletion of fat in some areas but deposition of fat in other areas of the face (Coleman and Grover 2006). The reorganization of tissues in the face is a natural progression of aging and contributes to older appearance with advancing age. Patients might complain about deepening naso-labial folds (NLF), flattening cheeks, sunken temples, hollowing eyes, and/or the formation of jowls. While the human face generally loses fat as aging progresses, some facial compartments age differently and accumulate fat. For example, the mid-face tends to lose volume, while the submental and/or suborbital areas may accumulate fat (Hellman 1927; Coleman and Grover 2006; Rohrich et al. 2009). This redistribution of fat leads to many changes, puffiness under the eyes, flattening of the cheeks, hollowing of the eyes and temples, increased fullness of the submental area, formation of jowls, and development of melomental folds.
Variations of facial bones during the aging process add to the changes in facial structure (see Fig. 3.5) (Hellman 1927; Rohrich et al. 2009; Pessa et al. 2008; Zadoo and Pessa 2000). Simultaneous fat redistribution and bone resorption occur in the jaw, temporal, and malar areas adding to the aged appearance (Hellman 1927; Coleman and Grover 2006; Rohrich et al. 2009). Soft tissues of the face become more lax as the support from the underlying bone decreases.
The overall changes in the aging face are somewhat insidious and occur over time. Patients often present complaining about looking tired or sunken, stating these changes seem to have occurred overnight. Familial tendencies also contribute to the appearance of the face and patients often report they are starting to “look like my mother/father.”
Knowledge of naturally occurring changes that affect facial structures is essential for practitioners to understand when working with aesthetic patients. This allows the practitioner to provide the patient with appropriate and effective treatment options. Assessment of the patient’s skin and facial structures will guide the practitioner in creating the most suitable treatment plan.
3.2.1 Mandible
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