How Has Wrinkle Treatment Changed Over Time?
The treatment of wrinkles has changed as the theories behind their formation have evolved over time and with the development of more advanced less invasive treatments such as botulinum toxin, dermal fillers, chemical peels, and laser therapy.
In times gone by…
Previous theories behind facial ageing were based around increased amounts of spare skin and fatty tissue occurring as we get older. As a consequence surgeons concentrated on removing this excess skin and fat to tighten the skin over the underlying tissues and reduce the appearance of wrinkles. For example, it was thought that gravity stretched the eyelid skin over time as we age and that this allowed fat to protrude above the eyes so surgeons developed ways of removing this excess skin and fat whilst leaving minimal scarring. However, this technique led to an unsatisfactory outcome in some, leaving patients feeling gaunt with a reduced fullness to the facial features.
Current thoughts…
It is now thought that there are other processes involved in ageing that contribute to the formation of wrinkles in addition to the increased amounts if redundant skin, and these have had a bearing on current wrinkle treatment. The descent and deflation of facial features as we age plays a major role as does volume loss of all facial tissues including the skin, facial fat and bone.
Facial fat reduces with age and this results in areas of the face which appear hollowed out such as the cheek, temple, and around the eyes, with the bony features of the face becoming increasingly visible. The loss of bony volume can also accentuate the appearance of facial drooping, particularly of the eyelids, eyebrows and nasolabial folds, the skin folds that run from each side of the nose to the corners of the mouth.
How Does The Midface Change As We Age?
The midface is defined as the area between two hypothetical horizontal lines on the face; one passing between the upper and lower eyelids, and the other passing between the upper and lower lips. The midface is one of the first facial areas to show signs of ageing, and patients often choose to have wrinkle treatment to alleviate this.
There are four main ways by which this part of the face is affected by ageing; dropping of tissues, changes in facial skin, loss of facial fat and facial bone volume. It is important to understand how the face ages in order to determine which wrinkle treatment, or method of cheek augmentation, will best achieve a patient’s desired outcome.
Beneath the skin there is a layer of tissue called SMAS (superficial musculoaponeurotic system) that provides structural support for the muscles and skin of the midface. This layer is attached to the underlying bone by ligaments; these elongate with age and cause descent of the skin and underlying fat.
The descent of facial tissues causes many common aesthetic concerns for patients. Ageing results in a hollowed out appearance below the lower eyelids and this in turn exaggerates the appearance of protruding fat below the eyes, commonly known as ‘bags’ under the eyes. The folds of skin that run from either side of the nose to the corners of the mouth, the nasolabial folds, also become more prominent as the midfacial tissues descend.
The facial skin becomes thinner as we age and photoageing occurs. This is premature ageing of the skin, particularly that of the face, due to ultraviolet light exposure, often visible in the form of wrinkles and discolouration of the skin. The skin becomes less elastic and more amenable to wrinkle formation.
As we age there is a reduction in facial fat, leading to a hollowed out and gaunt appearance of the cheeks, temple, and around the eyes. The loss of volume is an important principle to consider when thinking about cheek augmentation. The areas of fat just below the lower eyelids have been found to maintain their fullness and may increase in size with ageing. In combination with surrounding areas of fat loss and tissue descent, this can lead to the appearance of ‘bags’ below the eyes.
Facial bones also undergo volume loss. Relevant to the midface is deflation of the cheekbones, resulting in a less full appearance, an increased hollowed out area beneath the eyes, and enhanced nasolabial folds.
Understanding the principles behind ageing of the midface empowers patients to choose, with guidance from their clinician, wrinkle treatments and methods of cheek augmentation which will best achieve their desired cosmetic outcome.
How does the lower face change as we age?
The lower face is defined as the area below a hypothetical horizontal line which passes through the corners of the mouth between the upper and lower lips. It is important to understand how the lower face ages when considering chin augmentation, wrinkle treatment, and the treatment of marionette lines. Ageing of the lower face involves the decent of tissues, changes in facial skin, the loss of fat from beneath the skin, and loss of bone volume.
Descent of tissues from the areas higher up on the face, such as the cheeks, leads to down turning of the angles of the mouth where the upper and lower lips meet. This also leads to the development of marionette lines, vertical lines running from the corners of the mouth and down either side of the chin, which cause people to appear dissatisfied, and are associated with frowning. Descent of the cheek tissue also leads to deepened nasolabial folds, the folds of skin running from either side of the nose to the corners of the mouth.
The facial skin becomes thinner as we age and photoageing occurs. This is premature ageing of the skin, particularly that of the face, due to ultraviolet light exposure, often visible in the form of wrinkles and discolouration of the skin. The skin becomes less elastic and more amenable to wrinkle formation.
The loss of volume is an important principle to consider when thinking about chin augmentation. Loss of fat volume and resorption of bone as we age leads to a loss of jawline definition. A hollowing either side of the chin can also develop, these are known as pre-jowl sulci, and have a detrimental impact on the appearance of a smooth youthful jawline.
The lower face is the most commonly treated area of the face. Understanding the principles behind ageing of the lower face empowers patients to choose, with guidance from their clinician, wrinkle treatments and methods of chin augmentation which will best achieve their desired cosmetic outcome.
How does the neckline change?
As we age the chin adopts an appearance that may be described as ‘dimpled’ caused by a combination of loss of superficial structures that support the skin, such as fat and collagen, and contraction of the mentalis muscle. The mentalis muscle, present on both sides of the face at the tip of the chin, acts to raise and push up the lower lip, and is sometimes referred to as the ‘pouting muscle’.
The platysma is a broad and thin superficial muscle which extends from the lower jaw to the collar bones. It acts to depress the lower jaw and draw down the lower lip and corners of the mouth. Contraction of the platysma may also result in horizontal or vertical wrinkle formation on the front of the neck extending onto the upper part of the chest (the décoletté region). These wrinkles are exacerbated by ageing and sun damage. Botulinum toxin can act to reduce the formation of these by partially paralysing this muscle and those with thin skin, good elasticity and minimal fat or sagging of the skin are ideal candidates for this treatment.
Mid-chest wrinkles and those in the décoletté region are formed due to position during sleep, sun damage, and the contraction of the platysma and pectoralis major muscle, which is largely responsible for movement of the shoulder. Botulinum toxin may be used if the muscles are contributing to the formation of imperfections.
Discuss with your clinician which areas would be best treated with botulinum toxin to achieve your desired cosmetic outcome.
