Aging Face Evaluation

Question 1

Examples of trigger events that may cause a person to seek consultation for aesthetic facial rejuvenation

Answer 1

• Observation of a friend who has undergone facial rejuvenative surgery with good results
• Self-criticism and realization of signs of aging in the face, eyes, and neck.
• Realization of a need for self-enhancement that may pave the way for career advancement.
• Realization of the need for self-enhancement to keep competitive in the work environment.
• Realization that a social relationship with a younger person would be enhanced by a more youthful appearance.

Question 2

Elements of the initial aesthetic facial surgery consultation

Answer 2

• Evaluation and discussion of the patient’s desires as well as current and past medical history.
• Thorough physical examination, which is best done with the patient comfortably seated in front of a large mirror with appropriate lighting. In addition, a reversing mirror can be used to demonstrate to the patient his/her actual appearance rather than the image that he/she sees in a standard mirror.
• Appropriate laboratory and radiographic tests to determine general health status. If a specific medical problem becomes apparent, consultation with the patient’s physician should be done.
• Visual examination, including acuity, Schirmer test (if indicated), and visual fields (if indicated).
• Photographic documentation of preoperative status.
• Patient education:
  • Videotapes
  • Instructional brochures
  • Discussion of arrangements for surgery with office staff (patient coordinator, nurse, secretary)

Question 3

Factors that contribute to the aged appearance of the face

Answer 3

• Atrophy and loss of skin tone due to sun damage
• Genetic inheritance
• Chronic smoking of cigarettes
• Chronic abuse of alcohol
• Large gains or losses in weight
• Morphologic changes of the facial bones
• Health-related problems
• Emotional stress
• History of trauma
• Chronic facial muscular contractions
• Environmental damage due to excessive sun exposure and pollution

Question 4

Intrinsic changes of the skin that may be seen in the aging face

Answer 4

• Loss of elasticity
• Keratoses, epitheliomas, other hyperpigmented lesions
• Fine lines and wrinkles
• Decreased amount of subcutaneous adipose tissue due to atrophy
• Abnormal pigmentation
• Environmental damage

Question 5

Signs of Aging in Face and Neck (Decade of the 30s)

Answer 5

• Upper eyelid skin becomes redundant

- Crow’s feet form lateral to the canthi

Question 6

Signs of Aging in Face and Neck (Decade of the 40s)

Answer 6

• Nasolabial folds become more prominent
• Transverse forehead furrows develop
• Vertical glabellar frown lines develop

Question 7

Signs of Aging in Face and Neck (Decade of the 50s)

Answer 7

• Rhytids develop in the neck
• Jawline becomes less distinct
• Jowls form
• Tip of nose droops

Question 8

Signs of Aging in Face and Neck (Decades of the 60s, 70s, and 80s)

Answer 8

Cutaneous and subcutaneous tissues atrophy, contributing to formation of increased wrinkles and sagging of skin

Question 9

Changes in the facial skeleton that occur with aging

Answer 9

• Decreased height of mid and lower portions of face
• Increased prominence of frontal sinus
• Increased prominence of zygomatic arch
• Slight increase in facial width
• Increased prominence of chin
• Increased facial depth

Question 10

Vital anatomic structures of the face to know when planning facial rejuvenation surgery

Answer 10

• It is extremely important to know the osteocutaneous and musculocutaneous ligaments that provide support to the soft tissue and skin of the face.
• It is essential that these be released or modified during facial rejuvenation surgery (i.e., face lift) to achieve optimal results.

Question 11

Retaining ligaments that provide support to the soft tissues and skin of the face over the bony skeleton

Answer 11

• Zygomatic osteocutaneous ligaments (McGregor’s patch)
• Mandibular osteocutaneous ligaments
• Platysma-auricular ligaments
• Anterior platysma-cutaneous ligaments

Question 12

Signs of facial aging that are correctable by aesthetic rejuvenative surgery

Answer 12

• Sag and laxity of the skin of the cheeks and neck
• Prominence of the nasolabial folds
• Deepening of the nasolabial and perioral commissural creases
• Formation of jowls with laxity and sag of the facial skin over the border of the mandible, causing the jawline to
  become less distinct
• Formation of rhytids in various areas of the face
• Atrophy of the skin and subcutaneous adipose tissues
• Ptosis of the soft tissues of the anterior aspect of the chin

Question 13

Signs noted on physical examination of the forehead that can be corrected by aesthetic facial rejuvenative surgery

Answer 13

• Transverse furrows
• Vertical glabellar frown lines
• Ptosis of the brows
• Fullness and hooding of the upper eyelids
• Fullness in the glabellar region
• Transverse creases over the dorsum of the nose in the area of the radix
• Crow’s feet

Question 14

Normal or Ideal position for the female eyebrow

Answer 14

• The brow is located approximately 1 cm above the superior orbital rim (whereas it lies approximately at the level of the rim in men)
• The medial aspect of the brow is delineated by a vertical line drawn superiorly and perpendicular through the alar base
• The lateral aspect of the eyebrow is delineated by an oblique line drawn from the lateral aspect of the alar base through the lateral canthus
• The medial and lateral ends of the brow are at approximately the same horizontal level.
• The highest portion or apex of the brow is delineated by a vertical line extending superiorly from the lateral aspect of the corneal limbus

Question 15

Signs of aging in eyelids that are correctable by aesthetic rejuvenative surgery

Answer 15

• Increased amount and laxity of skin of the lids
• Increased protrusion of periorbital fat
• Ptosis of the brows, which along with upper eyelid skin redundancy, causes hooding
• Crow’s feet, or rhytids, in the lateral canthal region
• Ptosis of the lacrimal glands
• Formation of xanthelasma
• Hypotonicity and horizontal laxity of the lower lids

Question 16

Is an ophthalmologic consultation required for all patients before undergoing aesthetic rejuvenation of the eyelids?

Answer 16

No, unless the patient is found to have a previously unknown defect in visual acuity or tear production or physical examination reveals an anatomic deformity that may require further ophthalmologic testing or treatment. A baseline vision examination should be performed in your office preoperatively.

Question 17

Signs of aging in external ears that can be corrected by aesthetic rejuvenation

Answer 17

• Increased prominence due to an increase in the conchoscaphoid angle and/or unfurling of the antihelix
• Increased size of the earlobes
• Increased size of pierced earlobe holes due to chronic wearing of heavy earrings

Question 18

Signs of aging of the nose that are correctable by aesthetic rejuvenative surgery

Answer 18

• Drooping nasal tip or decrease in the nasolabial angle
• Thickening of the skin of the nose
• Enlargement and thickening of alar cartilages
• Elongation of the nose
• Widening of the nostrils

Question 19

Signs of aging in the perioral region that can be corrected by surgical rejuvenation

Answer 19

• Vertical rhytids extending from the vermilion borders of the upper and lower lips
• Increased vertical height of the white portion of the upper lip
• Flattening of the contour of the upper lip
• Thinning and decreased fullness of the vermilion of the upper and lower lips
• Downturning of the lateral oral commissures
• Appearance and deepening of “marionette” lines

Question 20

Signs of aging in the neck that can be corrected by aesthetic rejuvenation

Answer 20

• Wrinkling of the skin
• Formation of vertical bands in the platysma muscle
• Formation of a less acute and more obtuse cervicomental angle (due to laxity of the platysma and/or excessive deposition of subcutaneous and subplatysmal adipose tissue)
• Laxity and sag of the submental and anterior and lateral cervical skin
• Ptosis of the submandibular glands

Question 21

Why are preoperative photographs necessary?

Answer 21

• They assist in preoperative planning and patient discussion
• They are invaluable for reference during surgery.
• They are essential for postoperative counseling and review.
• They provide necessary medicolegal documentation.

Question 22

Visual records that are used to document preoperative appearance

Answer 22

• Preoperative photographs are an essential part of the patient’s permanent medical record. They serve two purposes:
  
  • Medicolegal documentation;
  • Documentation of present status to assess postoperative results.
• Historically, photographs were taken with a 35-mm camera with a high-grade portrait lens (105 mm). However, in the digital age, a digital SLR camera is preferred. Note that many existing lenses will work with digital SLR cameras; however, there is usually a 1.4 or 1.5 “multiplier” effect. The digital photographs can be archived along with the patient’s medical record.
• Several paperless systems that allow attachments to the photographs are available. Computer imaging
  programs can “morph” photographs in order to help predict postoperative results. Of note, this will also give the patient a “visual imprint,” which may otherwise be difficult to achieve.

Question 23

Standard views of the face and neck that are taken for photographic documentation

Answer 23

• Anteroposterior
• Right lateral
• Right oblique
• Left lateral
• Left oblique

Question 24

Additional views that may be taken to demonstrate deformities

Answer 24

• Close-up of the eyes to demonstrate fine lines and asymmetry of the lids
• Close-up of the eyes to demonstrate bulging of the periorbital fat in the lower lids
• Smiling profile to demonstrate change in position of the nasal tip
• “Worm’s eye” view to demonstrate the basilar orientation of the inferior aspect of the nose and its relationship to the cheeks and lip
• Flexed lateral view to demonstrate laxity and sag of the skin of the lower face and neck
• Posteroanterior view to demonstrate protrusion of the ears from the side of the head (conchoscaphoid angle)
• Close-up of the mouth at rest, smiling, and puckering to demonstrate muscular function, asymmetry, and rhytids

Question 25

Does the consultation for aesthetic facial rejuvenative surgery differ for men and women?

Answer 25

No. However, physical characteristics and psychological considerations may be greatly different and must be explored and adequately discussed

Question 26

Differences that are noted between men and women in evaluating patients for aesthetic facial surgical rejuvenation

Answer 26

• The position of the eyebrows is different. In women, the brow usually is located above the superior orbital rim, whereas in men it is located at or slightly below the rim.
• Different patterns of hair growth in the scalp. Men tend to have recession of the frontal forehead hairline with loss and thinning of hair much earlier in life than do women.
• The presence of a beard in men causes an increase not only in the thickness of the skin but also in the blood supply due to a richer subdermal plexus.
• Psychologic differences are evident. Active men like to be in control of all aspects of their situation and are less likely to follow postoperative instructions such as restriction of activity and taking medication. Men seem to be less demanding about the results of surgery and usually have more realistic goals.

Question 27

As people age, is it better to “start early” and undergo procedures when signs of facial aging begin or to wait and have “everything done at once”?

Answer 27

• As people age, the intrinsic changes in the skin and soft tissue and the changes in the facial skeleton require a corresponding increase in the complexity and number of procedures required to achieve improvement.
• Signs of facial aging should be addressed when they begin to appear. Early signs may be correctable with injectable products.
• As time progresses, particular areas, such as the eyes, chin, nose, cheeks, and forehead, can be addressed and treated to improve the patient’s overall appearance.

Question 28

What is the best age at which to undergo aesthetic facial rejuvenative surgery?

Answer 28

There is no one best age. The timing of surgery depends on

(1) the patient’s desires
(2) the patient’s general health status
(3) the patient’s mental health status
(4) the presence of signs of aging that the plastic surgeon believes can be surgically corrected
(5) the patient’s history of sun exposure and presence of environmental damage to the skin

Question 29

Is there an age at which the patient is “too old” to undergo facial rejuvenative surgery?

Answer 29

No, as long as the patient’s general mental and physical health status are deemed satisfactory

Question 30

How long do the results of facial rejuvenative surgery last?

Answer 30

• The answer depends not only on the general health status of the patient but also on the age at which the procedure is performed
• Usually foreheadplasties and eyelidplasties do not need to be repeated
• Facialplasties are considered to last for 8 to 10 years.

Question 31

Where can facial rejuvenative surgery be performed?

Answer 31

• Facial rejuvenative surgery may be performed in a:
  
  • Hospital
  • Free-standing ambulatory outpatient surgical facility
  • Physician’s office
• Any of these options is acceptable as long as the appropriate equipment for performance of the surgery and resuscitation is available
• In addition, the necessary trained and certified medical personnel must be available.

Question 32

What type of anesthesia is most appropriate for facial rejuvenative surgery?

Answer 32

• The type of anesthesia depends on
  
  • The procedure
  • The patient’s general health status
  • The surgeon’s preference
• For some procedures, local anesthetics may be sufficient. However, for the great majority of procedures, local anesthetics must be combined with intravenous sedation and analgesics
• General anesthesia is used for procedures requiring
  complete relaxation (e.g., complete relaxation of the abdominal muscles during abdominoplasty).

Question 33

Who may not be considered candidates for facial rejuvenative surgery?

Answer 33

• Patients who have difficulty with describing or delineating the changes they desire
• Patients who feel that their deformities are greater than they actually are
• Patients with unrealistic expectations
• Patients with severe mental or physical health problems who are poor surgical risks
• Patients who are addicted to cigarettes, alcohol, and/or drugs
• Patients with non-supportive family members

Question 34

Who else may not be considered good candidates for aesthetic facial rejuvenative surgery?

Answer 34

• Patients who are overly concerned about minimal defects
• Patients who are too demanding or direct the physician about what to do and how to do it
• Patients who constantly interrupt when explanations are given by the physician
• Patients who have previously undergone surgery by another physician with less than desirable results and are antagonistic and defensive

Question 35

What are the five rare skin conditions that may present as premature aging with or without skin laxity?

Answer 35

• Ehlers-Danlos Syndrome
• Cutis Laxa
• Progeria
• Werner’s Syndrome (Adult progeria)
• Pseudoxanthoma Elasticum

Question 36

Ehlers-Danlos Syndrome

Presentation, Association(s), Defect(s), Surgical indication

Answer 36

• Characterized by thin, friable, and hyperextensible skin, hypermobile joints, and subcutaneous hemorrhages.
• It may be associated with posttraumatic bleeding and poor wound healing.
• It is caused by a genetic defect with inadequate production of the enzyme lysyl oxidase.
• Rhytidectomy is not indicated.

Question 37

Cutis Laxa

Presentation, Association(s), Defect(s), Surgical indication

Answer 37

• Degeneration of the elastic fibers in the dermis
• Associated with chronic obstructive pulmonary disease, pulmonary infections, cor pulmonale, gastrointestinal and genitourinary diverticula, and hernias.
• The genetic defect is a deficiency of lysyl oxidase. -
• Aesthetic facial rejuvenation is indicated and beneficial as long as the patient’s general health status is satisfactory.

Question 38

Progeria

Presentation, Association(s), Defect(s), Surgical indication

Answer 38

• Characterized by growth retardation, craniofacial disproportion, baldness, protruding ears, pinched nose, and micrognathia
• Atherosclerotic heart disease, and shortened life span.
• Unknown cause
• Plastic surgery is not indicated.

Question 39

Werner’s Syndrome (Adult’s Progeria)

Presentation, Association(s), Surgical indication

Answer 39

• Scleroderma-like skin changes, including patchy induration
• Associated with baldness, aged facies, hypo/hyperpigmentation, short stature, high-pitched voice, cataracts, diabetes, muscle atrophy, osteoporosis, various neoplasms, and premature atherosclerosis.
• Plastic surgery is not indicated because of the presence of diabetic microangiopathy.

Question 40

Pseudoxanthoma Elasticum
(Presentation, Surgical indication)

Answer 40

• Degenerative disorder of the elastic fibers with premature skin laxity.
• Aesthetic facial rejuvenative surgery is beneficial.