SUMMARY

THE ANATOMY OF AGING

Congratulations on completing course 'The anatomy of aging'
This course summary will cover the anatomical changes in the face that occur with age and result in the
appearance of lines, wrinkles and folds, as well as hollows and volume loss.

The aging process

As we age, the proportions of the face gradually alter. For example, the cheeks lose their volume and the face
becomes broader at the bottom.
A young face has been described as having a ‘V’ shape and with aging this ‘V’ becomes inverted.

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Factors affecting the aging process:

Intrinsic structural changes occur as a natural consequence of aging, are genetically determined and nor-
mally begin in our mid-twenties.1 The intrinsic rate of skin aging is influenced by extrinsic factors, such as
lifestyle and environmental exposures.1,2

Intrinsic factors Extrinsic factors

 Genetics – sex, race  un exposure
S
 Aging  Gravity
 Hormonal and biochemical changes  Smoking
 Atrophy of dermis and subcutaneous tissue  Repetitive facial expressions

 Bone resorption and remodelling

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Effects of intrinsic aging alone
Skin appearance:3
 Relatively unblemished and remains smooth
 Accumulation of some expression lines
Under the microscope:3,4
 Flattening of the epidermal/dermal boundary2
 Some breakdown of dermal tissue
Effects of extrinsic aging in
combination with intrinsic aging
Skin appearance:3
 Wrinkled
 Areas of hypo- and hyperpigmentation
 Reduced tone and elasticity, increased fragility
 Areas of purpura
Under the microscope:3,4
  ollagen and elastin become fragmented and
C
thick; this is a sign of crosslinking, which is
associated with wrinkle formation
 Disruption of the 3D collagen matrix
 Progressive degeneration of elastin fibres
(elastosis), as well as slower production of elastin

The aging face

The visible signs of aging in the face are a result of changes to the facial skeleton, muscles, ligaments, adipose
tissue and skin.

Changes to the facial… Effects

Skeleton5  Flattening of forehead
 Extension of orbit
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 Receding nasal bone
 Flattening and drooping of cheekbones
 Atrophy of maxilla
2
 Atrophy of mandible
    Loss of skeletal support
   

Muscles6,7   he facial mimetic muscles gradually straighten and shorten

T
© MERZ INSTITUTE  Muscles of the face may change their tension in response to
modification of the underlying bone
 A compensatory increase in muscle tone may occur in response
to skin laxity
    Laxity and atrophy
   
   
  An increase in facial muscle tone

Ligaments8  ollows develop where the ligament joins to bone (the osseous
H
origins)
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 Bulges form in areas of ligamentous attenuation, where the fat
compartment between the ligaments becomes displaced due to
a lack of support
    Downward and medial movement of soft tissue
   

Adipose tissue9–11  Redistribution of fat

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 Accumulation or atrophy/deflation of fat in certain areast
    Loss of volume
   
    Increased prominence of creases and folds
   

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 Changes to the facial… Effects
Skin3,12  Loss of connective tissue
 Slower rate of cellular renewal
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 Reduced vascular and glandular network
 Hyaluronic acid content reduces
 Collagen becomes disorganised
 Loss of organised elastin network
 Reduced sebum production
    Epidermal thinning, impaired barrier function,
   
reduced cellular hydration
   
   Increased vulnerability to insult
   Decreased nutrient transfer between the layers
   
   Loss of structural integrity and skin laxity
   
   Loss of volume
   

Differences in aging patterns based on sex and race/ethnicity

No comprehensive systematic studies comparing age-related anatomical changes based on sex or race have
been published.
Hormone levels, skin pigmentation and exposure to sunlight influence rates of photodamage, bone
remodelling, redistribution of soft tissue and fat atrophy.
For women, the decline in oestrogen levels during menopause is accompanied by skin atrophy, reduced
collagen synthesis and a decrease in hyaluronic acid levels, contributing to loss of elasticity and the
appearance of wrinkles.13
3
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Clinically, increased pigmentation confers greater intrinsic photoprotection. Darker skin also tends to be
thicker, more sebaceous and have more abundant collagen than fairer skin. Consequently, signs of photoaging
such as wrinkles, skin laxity and dyschromia tend to be delayed in individuals with darker skin compared with
fair-skinned individuals. Those with Fitzpatrick skin types IV–VI have an increased risk of dyschromia and keloid
formation following epidermal and dermal injury.14

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Aging in the mid-face is reported to be more prominent in African Americans than Caucasians. An expert
consensus panel noted that African American aesthetic patients present with a significant loss of volume in
the mid-face with age, heavier cheeks, a prominent tear trough, and fewer fine lines and wrinkles than
Caucasians.15

Remember: age-related anatomical changes are unique to every individual and influenced by sex, race and
skin type. Treatment goals and the approach to aesthetic procedures must be tailored to each individual.

How medical aesthetics can help combat the signs of aging

Medical aesthetics focuses on the treatment of lines, wrinkles and folds, as well as hollows and volume loss.16
The primary goal of any rejuvenation procedure is to restore the balanced distribution of facial fullness that
exemplifies the youthful face.

Five common non-surgical treatments used to achieve rejuvenation:

 Neurotoxins
 Resurfacing techniques – chemical peels, microdermabrasion, laser resurfacing
 Traditional hyaluronic acid fillers
 Collagen-stimulating fillers (injectables)
 Collagen-stimulating energy-based devices

Microfocused ultrasound, a type of collagen-stimulating energy-based device, is aimed at the mid-to-deep

reticular layer of the subdermis and dermis. It can be used for non-invasive skin lifting and tightening.

Aesthetic treatment
Vectors of aging Vectors of rejuvenation
options
Skin laxity Increase skin thickness
 TF, CS, EBD 4
Fat loss in upper and mid-face Volumise upper and mid-face TF, CS
Fat accumulation in lower face Reduced fat in jowls and chin *
Descent of fat and skin Lifting procedure N, TF, CS, EBD
Loss of skeletal support Localised volume placement TF, CS, EBD
Decreased muscle mass Localised volume placement TF, CS, EBD
Increased muscle tone Reduce muscle tone N
Skin quality (hyperpigmentation, Increase skin quality and even skin tone RT
surface irregularity)

*This is best treated with lipolysis

Abbreviations:
CS = collagen-stimulating fillers (injectables); EBD = collagen-stimulating energy-based
devices; TF = traditional hyaluronic acid fillers; N = neurotoxins; RT = resurfacing techniques

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References
1. Saville CR, Hardman MJ. Skin, Mucosa and Menopause: Management of Clinical Issues. Berlin
Heidelberg; Springer-Verlag: 2015.2. Farage et al. Int J Cos Sci. 2008;30;87–95.

2. Farage et al. Int J Cos Sci. 2008;30;87–95.

3. The International Dermal Institute. Structural Changes Associated with Aging Skin. Available at:
http://www.dermalinstitute.com/uk/assets/articles/11_pdf_53a0c066e6e63_Structural%20
Changes%20Associated%20with%20Aging%20Skin.pdf. Last accessed: 29 Jan 2015.

4. Farage MA, et al. Adv Wound Care 2013;2:5–10.

5. Shaw RB, et al. Plast Reconstr Surg 2007;119:675–81.

6. Liao D, et al. Standard Lower Lid Blepharoplasty: Current Concepts in Aesthetic and
Reconstructive Oculoplastic Surgery. Amsterdam, The Netherlands; Kugler Publications: 1999.

7. Nicolau P. Anatomy and the Aging Changes of the Face and Neck: Office-Based Cosmetic
Procedures and Techniques. Cambridge, UK; Cambridge University Press: 2010.

8. Wulc A, et al. Midfacial Rejuvenation. Chapter 2: The Anatomic Basis of Midfacial Aging. New
York, NY; Springer: 2012.

9. Prendergast P. Anatomy of the Face and Neck: Cosmetic Surgery. Eds. Shiffman M, Di Giuseppe
A. Berlin Heidelberg; Springer-Verlag: 2012.

10. Wan D, et al. Plast Reconstr Surg Glob Open 2013;1:e92–100.

11. Medscape. Mid Face Facelift. Available at: http://emedicine.medscape.com/article/1818907- 5

overview. Last accessed: 29 Jan 2015.

12. Yaar M, et al. Fitzpatrick’s Dermatology in General Medicine (5th edition). Eds. Freedberg IM,
Fitzpatrick TB. New York, NY; McGraw-Hill: 1999.

13. Verdier-Sévrain S, et al. Exp Dermatol 2006;15:83–94.

14. Grimes PE, et al. The Aging Face in Darker Racial Ethnic Groups: Aesthetics and Cosmetic
Surgery for Darker Skin Types. Philadelphia, PA; Lippincott Williams & Wilkins: 2006.

15. Carruthers JD, et al. Plast Reconstr Surg 2008;121(Suppl.):5S–30S.

16. Vleggaar D, Fitzgerald R. J Drugs Dermatol 2008;7:209–20. Fabi S. Clin Cosmet Investig
Dermatol 2015;8:47–52.

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