Facial Aging Process by Dr. Kenneth Dickie
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Dr. Kenneth Dickie from Royal Centre of Plastic Surgery in Barrie, Ontario explained the process of Facial Aging from when one was a baby to elderly. If you have any questions, please contact Dr. Kenneth Dickie at http://royalcentreofplasticsurgery.com/
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Facial Aging Process by Dr. Kenneth Dickie
- 1. Facial Aging Dr. Kenneth Dickie Royal Centre of Plastic Surgery
- 2. Aging of the Face © 2002 www.comstock.com
- 3. “Inflated Beach Ball” “Deflated Beach Ball” Aging and Facial Changes
- 4. ChildInfant Aging and Facial Changes
- 5. Young AdultsAdolescents Aging and Facial Changes
- 6. Middle Age Aging and Facial Changes
- 7. The ElderlySenior Citizen Aging and Facial Changes
- 8. Facial Movement and Anatomy
- 9. Facial Muscular Anatomy Fodor, PB, Nicanor GI, Hengst TC, eds. Endoscopically Assisted Aesthetic Plastic Surgery. St. Louis, MO; Mosby-Year Book, 1996.
- 10. Facial Muscles (Facial Wrinkles/Lines and Contributory Muscles) Copyright 2002, Icon Learning Systems, LLC. A Subsidary of MediMedia, USA, Inc. All rights reserved.
- 11. Upper Face
- 12. The FrontalisThe Frontalis © 2002 J. Carruthers, MD
- 13. The Frontalis (cont) Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Boston, MA: Blackwell Science; 2001.
- 14. Glabella: The Glabellar Complex © 2002 T. Flynn, MD
- 15. Muscles of the Glabellar Complex Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Boston, MA: Blackwell Science; 2001.
- 16. Glabellar Complex Muscles: Other Considerations • There is significant individual variation in the strength and size of the glabellar complex muscles • Men have a larger glabellar complex than women • Glabellar complex muscles are used almost solely for facial expression © 2002 Carruthers
- 17. Orbicularis Oculi Revisited © 2002 S.E. Cox, MD & C. Finn, MD Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Boston, MA: Blackwell Science; 2001.
- 18. Lower Face and Neck
- 19. Nasalis © 2002 T. Flynn, MD Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Boston, MA: Blackwell Science; 2001.
- 20. Orbicularis Oris © 2002 Carruthers Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Boston, MA: Blackwell Science; 2001.
- 21. Mentalis © 2002 T. Flynn, MD Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Boston, MA: Blackwell Science; 2001.
- 22. Depressor Anguli Oris © 2002 Carruthers Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Boston, MA: Blackwell Science; 2001.
- 23. Platysma © 2002 N. Lowe, MD Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Boston, MA: Blackwell Science; 2001.
- 24. Facial Vasculature Copyright 2002, Icon Learning Systems, LLC. A Subsidary of MediMedia, USA, Inc. All rights reserved
- 25. Facial Neuroanatomy Fodor, PB, Nicanor GI, Hengst TC, eds. Endoscopically Assisted Aesthetic Plastic Surgery. St. Louis, MO; Mosby-Year Book, 1996 Copyright 2002, Icon Learning Systems, LLC. A Subsidary of MediMedia, USA, Inc. All rights reserved
- 26. If you have any questions, feel free to contact Dr. Kenneth Dickie at royalcentreofplasticsurgery.com Stay In Touch Twitter: @RCPSurgery Twitter Personal: @DrKennethDickie Google+: plus.google.com/ +RoyalcentreofplasticsurgeryinBarrie/ Google+ Personal: plus.google.com/ +DrKennethDickieBarrie or Call Us at 705-726-2800
Notes de l'éditeur
- Aging of the Face An attractive face is a balanced blend of mature and immature features in a symmetrical arrangement. Age and the effects of sunlight and various lifestyle choices produce predictable changes in the skin and cause atrophy of subcutaneous tissues of the forehead and middle part of the face.
- Aging and Facial Changes: “Inflated Beach Ball” and “Deflated Beach Ball” The process of aging of the human face follows predictable changes allowing us to gauge a person’s age based on their facial appearance. A baby’s full, round face has a shape similar to an inflated beach ball. Over the aging process, muscular atrophy, photodamage and fat atrophy lead to the appearance of a wrinkled, deflated beach ball suspended on an inner orbital support.
- Aging and Facial Changes: Infant and Child Babies and children have round, full faces with smooth convex contours. The faces of older children take on a leaner appearance, but still retain child-like features, such as a relatively small nose in relationship to the overall size of their face.
- Aging and Facial Changes: Adolescents and Young Adults During puberty, adolescents develop secondary sexual characteristics. Furthermore, they experience an accelerated phase of growth, which is responsible for distinguishable facial changes. The growth rates of bones, cartilage, muscles and fat are unequal, causing the sometimes awkward appearance of teenagers. Young adults retain much of the overall fullness of their face with minimal wrinkles.
- Aging and Facial Changes: Middle Age Muscles of facial expression can hypertrophy in adults. This leads to development of predictable wrinkles seen in the glabellar, lateral orbital and nasolabial fold areas. Predictable changes in facial appearance generally begin to appear in the third decade of life. Commonly, these include: Crow’s feet Lowering of eyebrows Trapezoidal configuration of the glabellar area Increased prominence of the nasolabial fold Progressive loss of skin and muscle tone Drooping in the lower cheek region Wrinkles in the glabellar and nasolabial areas
- Aging and Facial Changes: Senior Citizen and The Elderly Atrophy of subcutaneous fat leads to sagging or “hanging” of the skin in the aged, and photo-injury initiates skin wrinkling. In old age, muscular atrophy, extensive photodamage and atrophy of subcutaneous and deeper fat compound the situation.
- Facial Muscular Anatomy Facial musculature comprises three groups, each with a specific function: Muscles of upper facial expression Muscles of lower facial expression Muscles of mastication A continuous fibromuscular layer, the subcutaneous musculoaponeurotic system (SMAS), interconnects the muscles of facial expression. SMAS stabilizes, coordinates and distributes the contractions of the facial muscles to the skin. The muscles of facial expression are superficial muscles and are responsible for controlling facial movement. They give expressivity to the face. Fodor, PB, Nicanor GI, Hengst TC, eds. Endoscopically Assisted Aesthetic Plastic Surgery. St. Louis, MO; Mosby-Year Book, 1996.
- Facial Muscles Modern anatomists now correctly depict the muscles of facial expression as overlapping intertwined sets of skeletal muscles. Wrinkles (rhytides) of the skin occur perpendicular to the underlying muscles of facial expression, as depicted by the wrinkles on the individual on the right. Certain muscles are known to contribute to overlying skin wrinkles; these muscles are often grouped together as contributors to specific facial wrinkles.
- The Frontalis Transverse wrinkles of the forehead may result from underlying facial musculature hypertrophy, photoaging, intrinsic aging or other causes, such as smoking. However, early wrinkles of the forehead (appearing in the late 20s to early 40s) are usually produced by over-activity of the frontalis musculature. Contraction of the frontalis produces a series of primarily horizontal forehead wrinkles.
- The Frontalis (cont) The frontalis is a large quadrilateral muscle that originates from the galea aponeurotica and inserts inferiorly into the eyebrow region intertwining with the procerus, orbicularis oculi, corrugator supercilii and depressor supercilii muscles. It has no bony attachments and is adherent to the superficial fascia. The frontalis raises the eyebrows and the skin over the root of the nose and draws the scalp forward. While many anatomy textbooks depict the frontalis with two muscle bellies, in many individuals it spans across the forehead from one temporal fusion line of the skull to the other. This muscle may be thicker in certain portions of the forehead and thinner in other portions, with the thicker musculature contributing to increased overlying cutaneous rhytides. Reduction of forehead rhytides may be achieved by weakening the frontalis muscle with botulinum toxin. The goal is to decrease forehead wrinkles without producing brow ptosis. It is important to recognize that the lower two centimeters of the frontalis is largely responsible for elevation of the eyebrows. Therefore, one should avoid energetic treatment of the lower portion of the frontalis to avoid risk of brow ptosis.
- Glabella: The Glabellar Complex The glabella is a smooth elevation of the frontal bone just above the bridge of the nose. Glabellar lines or “frown lines” are vertical creases seen adjacent or in between the medial aspects of the eyebrows. These are often the first wrinkles of concern to the middle-aged patient. Glabellar wrinkles are multifactorial. They are often made worse by muscular hypertrophy of the underlying muscles. The muscles of facial expression that contribute to frown lines include the orbicularis oculi and corrugator muscles (which move the eyebrow medially) and the procerus and depressor supercilii (which move the eyebrows inferiorly). These muscles are termed the “glabellar complex.”
- Muscles of the Glabellar Complex The orbicularis oculi (highlighted red above) is the sphincter muscle of the eyelids. It contributes to skin folds radiating from the lateral angle of the eyelids, commonly referred to as “crow’s feet.” The palpebral portion of this muscle is thin and close to the skin. It rings around the palpebral opening and generally acts involuntarily. The orbital portion of the muscle is thicker. Its fibers are horizontal and oblique around the “frown lines” and it moves the eyebrow medially. The lachrymal part is quite small and thin. The procerus (highlighted blue above) and depressor supercilii (highlighted purple above) originate from the nasal bone and extend upward to insert into the skin of the brow intertwining with fibers of the orbicularis oculi and the frontalis. These two muscles are adjacent to one another and may be an extension of the frontalis. The procerus draws the medial angle of the eyebrows down and produces transverse wrinkles over the nasal bridge. Corrugator supercilii muscles (highlighted yellow above) arise from the medial end of the superciliary arch and run at an angle to insert along and above the skin of the eyebrow. They are deep to the frontalis, just above the level of the bone. Glabellar wrinkles can be improved by weakening the glabellar complex with botulinum toxin.
- Glabellar Complex Muscles: Other Considerations There is significant individual variation in the strength and size of the glabellar complex muscles. As a rule of thumb, men have a larger glabellar complex compared to women, and many individuals with deeper wrinkles have a hypertrophic glabellar complex when compared to those with fewer wrinkles. These muscles are used almost solely for facial expression, especially to express concern, anger, unhappiness and displeasure. Therefore, a significant weakening of these muscles is desirable in order to achieve improvement of the glabellar frown lines. Botulinum toxin is the treatment of choice for glabellar frown lines. While filler substances may be necessary to completely correct deep long-standing frown lines, injections of fillers into this area have been associated with cases of unilateral blindness. This is due to emboli formation aided by the communication of superficial vessels in this area with superior ones that communicate to the orbit.
- Orbicularis Oculi Revisited Lateral canthal rhytides or “crow’s feet” are accentuated by the contraction of the orbicularis oculi, whose fibers run vertically under the skin at the lateral angles of the eyelids. The goal for treatment of the lateral canthal rhytides with botulinum toxin is to weaken or to reduce the action of the orbicularis oculi without fully inactivating the muscle. Complete inactivation of the orbicularis oculi could interfere with the ability to completely close the eye. It is important to remember the very superficial course of the muscle and to inject botulinum toxin subdermally, just below the skin. Some rhytides inferior to the lower lid can also be treated by weakening the orbicularis oculi with small amounts of botulinum toxin. Correct assessment of lower lid anatomy and tone must be done before injecting in this area.
- Nasalis The nasalis muscle runs from the dorsum of the nose inferiorly. Frequent contraction of the nasalis contributes to the development of rhytides obliquely across the root of the nose. These lines are often referred to as “bunny lines.” Relaxation of the nasalis with botulinum toxin will soften these lines.
- Orbicularis Oris The orbicularis oris is a sphincter muscle that encircles the mouth. It lies between the skin and the mucous membranes of the lips, extending upward to the nose and down to the region between the lower lip and chin. It is sometimes called the kissing muscle because it causes the lips to close and pucker. An overactive orbicularis oris causes perioral “smoker’s lines” that radiate outward from the vermilion border. Small amounts of botulinum toxin may be used to weaken the orbicularis oris musculature. However, phonation changes and noticeable lip weakness can be seen with the use of botulinum toxin in the periocular area.
- Mentalis The mentalis musculature serves to raise and protrude the lower lip and, at the same time, wrinkles the skin of the chin producing horizontal or multiple dimple rhytides. A botulinum toxin injection in the mentalis muscle can serve to soften some of these chin rhytides.
- Depressor Anguli Oris The depressor anguli oris originates from the mandible and inserts on the angles of the mouth to depress the corner of the mouth. The depressor anguli oris contributes to lateral oral commissure wrinkles, which are also called melomental folds. These wrinkles are treated best with soft tissue augmentation. Weakening the depressor anguli oris with botulinum toxin can be of assistance in treating this area of cosmetic concern. Care must be taken not to weaken the depressor anguli oris significantly because this will alter phonation and cause functional limitations of the mouth.
- Platysma The platysma is a large muscle arising from the upper parts of the pectoralis major and deltoideus stretching across the clavicle and proceeding upward in a slanting manner along the sides of the neck. Some fibers extend to the mandible while other fibers insert in the skin and subcutaneous tissue of the lower part of the face. Other fibers blend into the muscles of expression above the angle and lower part of the mouth. Two types of lines can be produced by the platysma. Horizontal “necklace” lines are transverse lines seen in the neck. These wrinkles are perpendicular to the contraction of the platysma. Small amounts of botulinum toxin may be placed directly into these lines in order to soften their effect. The platysma also produces vertical platysmal bands. This is a complex problem and botulinum toxin can be used to improve the appearance of the platysmal bands. This is an advanced procedure that is still undergoing investigation. Bartleby.com, Inc [Web site]. Available at: http://www.bartleby.com/107/illus378.html. Accessed January 2002.
- Facial Vasculature Those performing techniques for cosmetic improvement of the face should be familiar with the superficial vascular supply of the face. Arteries supplying the face include the supraorbital and supratrochlear arteries that emanate from the so named fossa in the skull coursing superficially to supply blood to the facial musculature and overlying skin. The infraorbital artery, also a branch of the external carotid artery, exits from the infraorbital foramen. The mental artery exits from the mental foramen and the mandible, supplying the mentalis muscle. Other branches of the external carotid artery include the facial artery which courses underneath the mandible, proceeding upward to supply blood to the perioral and nasal musculature. Veins of the Face: The facial veins are a wide anastomotic network. This network can easily be penetrated with small needles such as used in botulinum toxin therapy or filler substances. Care must be taken to avoid directly penetrating a small vein with the needle, which could lead to local ecchymosis. The facial venous network makes important connections with the cavernous sinus. Because the facial vein has no valves, blood may course retrograde entering the cavernous sinus (one of the venous sinuses of the dura mater) and result in meningitis. Injectable substances must be used cautiously in the triangular area of the face.
- Facial Neuroanatomy The sensory nerves of the face are supplied by the trigeminal nerve (cranial nerve V) . The first portion of the trigeminal nerve exits from the supratrochlear and supraorbital foramen. It innervates the area above the eye and eyebrow area and courses superiorly to innervate the frontal portion of the scalp. The second portion of the trigeminal nerve exits from the infraorbital foramen and innervates the middle portion of the face. The third portion of the trigeminal nerve exits from the mental foramen and courses posterior superiorly to innervate the mandible and the lateral portion of the scalp and upper ear. Motor nerve function to the face is supplied by the facial nerve (cranial nerve VII). The facial nerve exits from the stylomastoid foramen under the cover of the mastoid process. The nerve passes anterolaterally and travels under and through the parotid gland. The facial nerve branches into five branches: the temporal, zygomatic, buccal, marginal mandibular, and cervical branch. Cosmetic surgeons should be familiar with the two “danger zones” of the facial nerve. The marginal mandibular branch passes along the inferior border of the mandible and courses over the mandibular ridge to innervate muscles in the lower lip and chin. Since this portion of the facial nerve is superficial, care should be taken to avoid its damage when performing facial enhancement procedures. The superficial temporal branch of the facial nerve is close to the skin in an area approximately 1 x 2 cm lateral to the tail of the eyebrow. This portion of the facial nerve courses superiorly before it extends down to innervate the frontalis musculature. Again, care should be taken to avoid this nerve during facial cosmetic procedures. Fodor, PB, Nicanor GI, Hengst TC, eds. Endoscopically Assisted Aesthetic Plastic Surgery. St. Louis, MO; Mosby-Year Book, 1996.