Anatomy and Physiology

Anatomy and Physiology 

Previous courses and training manuals offer an exhaustive description of the head and neck anatomy. When moving into advanced procedures, it is important to expand on this knowledge and study the functional aspect of facial anatomy. A special emphasis on practical details covering the important and more simple and complex structures involved in facial expressions. The static and dynamic subtle structures control the facial mimetic and define the way we look at other people. It is vital that you have a thorough knowledge of anatomical structures before treating a client that involves altering the facial shape.

Skin and Subcutaneous Tissue 

The face and neck are divided into two major regions according to the texture, thickness and quality of the skin and its underlying subcutaneous fat tissue.

The periorificial craniofacial region

This composes of the support for the dynamics of the face. The thinnest skin on the face can be found around the eyes, nose and mouth and has an extremely poor subcutaneous fat layer overlying the muscles in these areas.

The tight adhesions between the superficial muscles and the dermis appear as fine periorificial wrinkles called ‘expression lines’.

The skin of the eyelids is covered by thin skin, almost devoid of any subcutaneous fat. When present, this fatty tissue should not be confused with the retro-orbital or periorbital fat pockets.

The cervicofacial region

This is indicated by an abundance of subcutaneous fat tissue and thicker skin. The underlying layer is musculoaponeurotic, that comp

rises of the superficial musculoaponeurotic system (SMAS)–platysma sheath. It is less vulnerable to wrinkle formation as it is a rather static segment.

This homogeneous thick sheath of subcutaneous fat spreads all over the cheek area and neck, except in the malar area, where it benefits from a further volume that forms the malar fat pads.

Subcutaneous fat has an important role in facial aesthetics. It helps soften bony edges, fills facial contours and improves the quality of the skin.

Platysma muscles and musculoaponeurotic structures

Periorificial and centro-facial region

The muscular region of the face comprises of the perioral, peri-nasal, and peri-orbital muscles that provide two essential functions:

  • a primary protective function covering the eye globes and the oral cavity
  • a secondary dynamic function of facial mimics that reflect facial expression.

The periorbital region

The eyebrow is a mobile structure subject to two antagonist groups of muscles: an eyebrow elevator group, mainly made up of the frontalis muscle, and a depressor group made up of the orbicularis oculi muscle, the procerus muscle, and the corrugator supercilii muscle.

The musculoaponeurotic elevator group of muscles comprises the frontalis muscle, the galea aponeurotica and the occipitalis muscle. The frontalis is a 6-7 cm quadrilateral-shaped muscle. Its medial fibres connect at the glabella level, where they intersect with fibres of the procerus muscle. Its central and lateral fibres sit on top of the corrugator supercilii muscle and intersect with the outer fibres of the pars orbitalis component of the orbicularis oculi muscle. Its located between the galea and the skin, closely adherent to the latter. From the lower insertions on the supraorbital margin, the frontalis fibres cover the forehead and connect with the galea aponeurotica to join posteriorly, in the occipital region, the occipitalis muscle. Repeated contractions of this muscle are what leads to the formation of horizontal forehead wrinkles.

The galea aponeurotica or epi-cranial aponeurosis is a broad musculoaponeurotic layer that covers the calvaria. Posteriorly, it is firmly attached to the occipital protuberance and the superior nuchal line. It is separated from the outer table of the cranium by the loose connective tissue layer. This area is called Merkel’s space and allows for the smooth sliding of the scalp over the cranium.

Laterally, over the temporal crest, the epi-cranial aponeurosis is continuous with the superficial temporal fascia. The superficial temporal vessels and the facial nerve’s temporal and frontal branches are also found at this level.

The eyebrow depressor muscles are formed by the co-operation of three different muscles: the corrugator supercilii muscle, the pyramidal or procerus muscle, and the orbicularis oculi muscle. The corrugator supercilii muscle is a deep facial muscle. It is narrow and strong and has deep medial insertions on the glabellar periosteum and another more superficial lateral trans-orbicular insertion on the eyebrow’s medial portion. It depresses and brings the inner parts of the eyebrows together. This repeated contraction results in the development of vertical glabellar wrinkles.

The pyramidal or procerus muscle appears as a medial extension of the frontalis muscle. It overlaps the nasal bones in which it inserts distally along with the upper lateral cartilages. It depresses the medial portion of the eyebrows. The repetitive contractions lead to the formation of horizontal glabellar wrinkles.

The orbicularis oculi muscle is one of the largest muscles responsible for facial expression. It is wide, circular, and diaphragmatic. It appears as a flat and narrow muscle sheath that is closely adherent to the skin. Its fibres sweep in concentric circles around the orbital margins and in the eyelids and consists of three parts:

  1. The orbital part or pars orbicularis is external and devoid of deep attachments. It forms a ring and inserts medially on the medial palpebral ligament. The repeated contractions result in the onset of ‘crow’s feet’ and oblique glabellar lines. The lines are caused due to the contraction of the internal superior fibres of the pars orbicularis.
  2. The palpebral part, or pars palpebralis, is internal, adherent to the tarsal plates and inserted deeply within the palpebral ligament. A strip of muscle known as the ‘Horner’s muscle’ detaches from the palpebral muscle and runs towards the posterior lacrimal crest. This muscle encourages the emptying of the lacrimal sac and helps with lymphatic drainage in the orbital region.
  3. The orbitomalar crease corresponds to the inferior border of the orbicularis oculi muscle. It stands out as the limit between the orbital region and the cheek. It also delineates the superior border of the malar fad pad.

Beneath the orbicularis oculi muscle, there is a thin layer of fat continuous with the jugal fat called the sub-orbicularis oculi fat (SOOF). This layer provides a natural division.

The levator palpebrae superioris muscle in its retro-septal position causes the upper eyelid to be raised. It starts from its superior periosteal insertions in the orbital roof to its tight skin and tarsal insertions in the upper eyelid. The posterior head, also known as the Muller’s muscle, inserts inside superior border of the upper tarsal plate.

The fibroelastic layer is a continuous structure formed by the tarsus, the medial and lateral palpebral ligaments, and the orbital septum.

The nasal and perioral region

The nasal muscles of expression are:

  • the nasalis muscle consists of a transverse bundle (pars transversa) that depresses the nostrils and an alar bundle (pars alaris) that causes the nostrils to dilate.
  • The procerus muscle, a naso-glabellar muscle, the depressor septi or myrtiform muscle, which depresses the nasal septum
  • The levator labii superioris alaeque nasi muscle elevates the lip and the nose.

The Oromental Region 

Muscles appear in layers or strata as described by Freilinger:

  • A superficial layer made of the zygomaticus minor muscle, the depressor anguli oris muscle, and the orbicularis oculi muscle
  • A second layer comprises of the zygomaticus major muscle, the risorius muscle, the platysma muscle, and the depressor anguli oris muscle
  • A third layer is devised of the orbicularis labii muscle and the levator labii superioris muscle
  • A deep layer comprising of the mentalis muscle, the levator anguli oris muscle, and the buccinator muscle.

The platysma is an extensive sheet of wide and shallow vertical muscle fibres that coverer part of the inferior third  of the face and most of the anterolateral region of the neck. It extends from the lower cheeks and the perioral region down towards the clavicular region. The right and left platysma muscles draw as they diverge, an inverted ‘V’ with the apex pointing towards the mandibular symphysis. The platysma is part of the SMAS–platysma sheath. The cervical component of this sheath is purely muscular (platysma muscle per se), whereas it’s parotid region component is mainly aponeurotic (fibrous platysma). This musculoaponeurotic sheath adheres to the underlying structures through the so-called ‘facia.

Vessels of the face

Arteries of the face

The face is supplied mainly by two distinct networks:

  • a major superficial network derived from the external carotid artery
  • a deep network derived from the internal carotid artery.

These two systems connect freely, which explains the vitality of the facial skin.

The facial artery derives from the external carotid artery and lies superficially as it hooks around the inferior border of the mandible. In its course over the face, it runs alongside the nasolabial fold and follows a sinuous course between the muscle layers and runs deep into the platysma and the zygomatic muscles. Near the edges of the mouth, it sends the labial and alar branches that branch on the midline with the contralateral arteries. Near the upper section of the nasolabial fold, it then runs along with the nose to the inner angle of the eye as the angular artery and branches off inconstantly, with the ophthalmic artery.

The superficial temporal artery starts in the parotid region, where the external carotid artery splits into two branches, the superficial temporal artery and the internal maxillary artery. It ascends through the superficial temporal fascia, lateral to the temporal branch of the facial nerve. Along its ascending course, it gives off three collateral branches, the transverse facial artery, the zygomaticomalar artery, and the deep medial temporal artery. It ends in the scalp by splitting into two branches, an anterior frontal branch that contributes to the periorbital network of vessels and a posterior parietal branch that connects with the contralateral arteries.

The internal maxillary artery contributes to the deep supply of blood to the face. Among its collateral branches, we mention the buccal artery supplying the soft tissues of the cheek and the infraorbital artery emerging from the infraorbital foremen and supplying the lower eyelid and the cheek.

The ophthalmic artery branches from the internal carotid artery and contributes to the vascular supply of the face through its terminal branching from the nasal artery, the angular artery. It has two facial branches:

The supraorbital or external frontal artery, and the supratrochlear or internal frontal artery that runs upward and connects with the frontal branch of the superficial temporal artery.

Veins of the face

The venous system of the face can be superposed to the arterial one. A superficial network that is made up mainly of the facial vein that arises from the union of the supratrochlear and the supraorbital veins. The

facial vein lies inferiorly through the face and finishes by draining into the internal jugular vein.

The superficial temporal vein drains the forehead and scalp and unites with the maxillary vein, posterior to the neck of the mandible, to form the retromandibular vein. The retromandibular vein splits into an anterior branch that unites with the facial vein and a posterior branch that joins the posterior auricular vein to form the external jugular vein. The external jugular vein drains into the subclavian vein.

There is a deep venous network linked to the superficial one through the angular vein that connects the cavernous sinus to the facial vein.

Nerves of the face

Motor nerves of the face include the Cranial nerve (CN) VII, the facial nerve, supplies the muscles of facial expression. Posteriorly, over the cheek, the extracranial section of the facial nerve is protected by the parotid gland and then by the parotid masseteric fascia. The facial nerve emerges from the skull through the stylomastoid opening and runs within the parotid gland giving rise to a cervicofacial branch and a temporofacial branch. These subdivide into five major branches. All branches of the nerves run superficially within the substance of the parotid gland before they supply the muscles of expression and mimetic muscles.

The cervical nerve branch of the face is the most posterior and inferior of the five nerve branches. It runs behind and below the mandibular angle and supplies the platysma muscle.

The mandibular nerve branch of the face can be unique or divided into two sections. The inferior branch is always more significant. This runs superficially over the facial artery before supplying several motor branches to the inner surface of the mentalis muscle, the depressor labii inferioris, and the depressor anguli oris.

The buccal branch of the facial nerve divides early into two branches running over the masseter muscle just beneath the parotid masseteric fascia:

  • A superior ramus which follows an

anterior and inferior oblique path and crosses above the Stensen’s duct before supplying the outer surface of the buccinator muscle

  • An inferior ramus supplies the inner surface of the orbicularis oris.

The zygomatic branch of the facial nerve passes transversely over the zygomatic bone before dividing into

three major branches:

  • The superior palpebral branch which supplies the orbicularis oculi muscle and the corrugator muscle
  • The inferior palpebral branch which again supplies the orbicularis oculi muscle
  • The infraorbital branch supplies the zygomatic muscles and muscles of the upper lip and nose.

There are many connections between the buccal and zygomatic branches of the facial nerve.

The temporal branch of the facial nerve is the most vulnerable to injury during facial treatments. This path can be outlined by drawing a line passing through a point of 0.5 cm beneath the tragus and another 1.5 cm above the lateral border of the eyebrow. The different nerve branches connect each other, crossing the zygomatic arch approximately 2 cm anterior to the tragus, and reaches the superficial temporal fascia where it runs beneath the superficial temporal artery. The nerve ends by supplying the inner surface of the frontal muscle.

Sensory nerves of the face: the trigeminal and the great auricular nerves

Knowledge of these is essential for the practice of local anaesthesia of the face.

 

The trigeminal nerve provides sensory innervation of the face through these three branches:

  1. The ophthalmic nerve is the superior division of the trigeminal nerve. It splits into three branches: The lacrimal, the frontal, and the nasociliary branches. The  acrimal nerve supplies the lacrimal gland, the upper eyelid, the conjunctiva, and the lateral angle of the eye. The frontal nerve splits into two separate branches: supratrochlear and supraorbital. The supratrochlear nerve supplies the medial angle of the eye, the upper eyelid, the nasion, and part of the glabella. The supraorbital nerve emerges from the superior orbital margin through an opening or a small canal before it supplies the lateral canthus, the upper eyelid, and the temporal and frontoparietal regions of the head. The nasociliary nerve splits into two further branches, one internal and one external, that supply the nasal dorsum and the nasal tip.
  2. The maxillary nerve is the intermediate division of the trigeminal nerve. In the infratemporal region, it gives off an orbital branch before it divides into a lacrimopalpebral branch supplying the lateral part of the upper eyelid and a temporomaxillary branch supplying the anterior temporal region. It emerges then below the inferior orbital margin, through the infraorbital opening as a large terminal branch, the infraorbital nerve that supplies the lower eyelid, the lateral aspect of the nose, the cheek, and the upper lip. The mandibular nerve is the inferior section of the trigeminal nerve. It has cutaneous sensory branches, called the inferior alveolar nerve. After it passes through the inferior alveolar canal, the nerve emerges from the mental opening supplying the mental nerve that provides sensation to the chin and lower lip. Medial to the neck of the mandible, the mandibular nerve splits off into the auriculotemporal nerve that supplies the tragus, the ear lobe, and the skin within the temporal region. These nerves arise from the posterior division of the mandibular nerve. The anterior division provides the buccal nerve that supplies the skin over the cheek area.
  3. The great auricular nerve belongs to the superficial cervical plexus. It runs in the superficial cervical aponeurosis above the external surface of the sternocleidomastoid muscle, lateral to the external jugular vein. Beneath the ear, it becomes strictly subcutaneous before it supplies the lobe of the ear, the retro auricular region, and part of the cheek close to the tragus.

Ageing of the face and neck

In the course of ageing, the face and neck change their morphology and appearance dramatically. Ageing concerns all tissue layers composing the face and neck: the skin primarily but also the fatty tissue, the musculoaponeurotic system, and the bony scaffolding beneath. All levels of the face are affected by the ageing process. According to the skin type, morphotype, and exposure to certain predisposing factors, the different constituents and elements of the face will not age uniformly. Treatment of the consequences of ageing has become an important part of aesthetic treatments within the beauty industry.

Mechanisms of facial ageing

There are two main types of mechanisms that play a role in facial ageing: tissue modification, involving all components of the face, and a global drop of the facial tissues.

Impairment of the skin begins with the onset of fine lines, wrinkles, and grooves and cutaneous slackening. The two main reasons for this impairment are a reduction in skins elasticity and repeated contraction of the fine muscles. The effects of solar elastosis, which concerns the dermis and the epidermis, become visible from the mid-20s, especially in cases of genetic predisposition (fairer skin types). The face and neck are the area’s most severely affected first, owing to sun exposure.

Wrinkles begin to appear on a woman’s face around the mid-30s, at the same time that oestrogen levels begin to diminish. Changes start in the epidermis and occur due to the accumulation of dead keratinocytes in the stratum corneum. The amount of collagen and elastin in the dermis begin to decrease, particularly in women with excessive exposure to the sun and from smoking. From the age of 40, the rate of renewal of keratinocytes starts to diminish (the life of a keratinocyte changes from 100 to 48 days).

The epidermis becomes thinner with a reduction of cell turnover, and in the number of melanocytes (10–20% per decade) and fine, superficial wrinkles, deep wrinkles, and expression wrinkles appear. With the rapid decline of oestrogen levels during the menopause, the epidermis becomes irregular; thinning of the dermis becomes more marked, and the hypodermal fat layer atrophies. When the skin loses elasticity and becomes thinner, its capacity to renew itself diminishes, as does the vascularisation of the dermo-hypodermis.

The dermo-epidermal junction atrophies and becomes progressively flatter. The superficial dermis atrophies introducing a disorder of the collagen support, comprising degeneration with progressive reduction of elastin fibres and increased mucoid ground substance. A further degenerative process appears that is characterised by the accumulation in the dermis of colloid masses, giving a yellowish colour to the skin: senile elastosis. Damage caused by sun exposure can be separated into four stages.

Stage 1 (20–30 years), or the start of photo-ageing, is defined by the presence of mimic wrinkles and the beginning of impairment of pigmentation.

Stage 2 (35–50 years), expression wrinkles start to appear at the corners of the mouth and the eyes, and there is some keratosis.

Stage 3 (from 50 years) is characterised by persistent wrinkles at rest, obvious discolouration’s, and marked keratosis.

Stage 4 is defined by deep and widespread wrinkles, a yellow tone to the skin, and an increased frequency of skin malignancies. Hirsuteness is augmented by an increase in androgen production. The loss of elasticity is further aggravated by skin dryness and as a secondary reduction of sweat and sebaceous secretions. Under the effects of tissue impairment and gravity, prolapse of the skin becomes progressively established. It affects the surface skin, fatty structures, and platysma muscles of the face, causing creases (skin folds) and loss of the oval shape. To these cutaneous impairments is added the ageing of deep structures. The basal metabolism diminishes by about 5% per decade on average from age 40, which can favour fat accumulation at the level of the abdomen, the waist, the hips, and the thighs, but also to a lesser extent the face, especially under the chin, at the level of the cheeks, and around the eyes. Facial fat is supported by septa or fasciae, which become lax. Fat settles in the deep zones under the fasciae while it becomes thinner subcutaneously, which causes thinning and skin fragility. Slackening and atrophy of glandular tissue of the face, which accelerates after the menopause, also contribute to the loss of suppleness and firmness of the skin.

Cutaneous ageing: 

wrinkles 

The superficial skin starts to become thinner, more dehydrated, and progressively loses its elasticity. Subcutaneous adipose tissue becomes reduced. Muscular hypotony joins fatty hypotrophy in contributing to skin impairment.

According to the depth of wrinkles, they can be differentiated into fine lines (wrinkles) and grooves (furrows).

Fine wrinkles are initially isolated and discrete, then converge and become multidirectional. They are sometimes associated with repeated contraction of the muscles of the face and neck; they then become deeper and are called expression wrinkles (mimic lines), such as ‘crow’s feet’ in the orbit temporal region. When expression wrinkles extend to the dermis, they are called grooves (skin furrows) or glabellar wrinkles (frown lines). When the skin starts to slacken, it can be redundant in the form of excessive creases appearing on the upper eyelid. Main reasons for this is due to loss of elasticity of the dermis (dermal elastosis), which depends on genetic makeup and sun exposure, and repeated contraction of the muscles of the face and neck. You will need to learn to distinguish between fine wrinkles, expression wrinkles, and grooves, as well as creases, in terms of treatment. Fine wrinkles can be treated by laser resurfacing and expression wrinkles and grooves by filler products or botulinum toxin, but creases usually require surgical intervention.

Musculoaponeurotic ageing

The superficial fascia, a fine muscular insertion in all mammals and limited to the deep layer of the hypodermis, has evolved in man to the point of being only a fibrous small strip, often difficult to identify, at the level of the members of the trunk. Its phylogenetic related persistence in the human face allows for facial expression and is described by Mitz and Peyronie as the superficial musculoaponeurotic system (SMAS), composed of elements of muscular origin found in the same vicinity and forms a continuous structure. This group of discontinuous structures, including the fine muscles of the face, parotid aponeurosis, and fine muscles of the neck or platysma, are not in the same plane. Recent research distinguishes two types of SMAS: type 1, a network of fibrous septa enveloping lobules of fatty tissue, found in the posterior part of the face behind the nasolabial groove, at the level of the forehead, covering the parotid, zygoma, and infraorbital region; and type 2, a network of collagen and elastin fibres intermixed with muscular fibres, found at the front of the nasolabial groove around the levels of the upper and lower lips.

Muscular ageing is characterised by a reduction in muscle mass, modification to metabolism, and excess fat. A particularly visible slackening occurs at the level of the orbicularis muscle and also around the lips.

Ageing of the fatty masses 

The evolution of the fatty masses on the face can be either a decline or an increase. A reduction in fatty tissue affects the orbital, temporal, and submalar regions. However, the fat pad of the premalar region shows a progressive decline, with the sliding of the malar region into the canine fossa, this overhangs the nasolabial groove.

Ageing of the bony base

Recent research has contradicted the idea that craniofacial skeletal growth is completed at the end of adolescence. This growth continues and is associated with an enlargement of the sinus and an anticlockwise rotation of the bony structure, and a clockwise rotation of the mandible. Anthropometric measurements of the skulls of ageing subjects, and especially video study of the ageing of numerous subjects over several decades, showed notable modifications. A reduction of mandibular and maxillary height, and a related retrusion of the jaw, appear with age. In women, this is accompanied by an increase in depth of the upper two-thirds of the cranial arch. Each transverse dimension of the face is augmented, while the depth of the inferior third section of the face diminishes. The facial skeleton is not static but a dynamic structure that evolves with age. The upper part of the face widens and deepens, and its projection increases by 6%, the frontal sinus from 9 to 14%, and the mandible by 7%.

There is the further development of the prominence of the supraorbital arch, and the bony protuberances start to become more pronounced with prominent frontal bumps and, an increase of the nasofrontal angle can be seen in men. Finally, the projection and form of the chin change via mandibular rotation leading to an appearance of general concavity of the facial contour. There is no reduction of the facial bony volume but, on the contrary, expansion.

Demineralisation

In addition, demineralisation occurs. Bony structures, due to progressive demineralisation (accelerated by the menopause), undergo a reduction which can, especially in very old persons, change the appearance. This reduction affects the jaw in particular. Thinning of the alveolar bone leads to a loss of teeth and a thinning of the anterior part of the upper jaw aggravates cutaneous slackening and upper lip wrinkles.

Topographic ageing

The face can be separated into three regions: upper, mid-, and lower. The upper face comprises the forehead, the glabella, the eyebrows, temporal regions, and the upper eyelids. The mid-face comprises the lower eyelids, the cheeks, which are divided into the anterior, mid-, and posterior zones, as well as the upper lip. The lower face is consisting of the lower lip, the chin, and the vertical and horizontal sections of the anterior part of the neck.

Upper face 

The first signs of ageing appear in the upper third of the face. Wrinkles appear at the level of the forehead and glabella, with fine wrinkles around the temporo-orbital region (crow’s feet). Slackening and thinning of the frontalis muscle leads to the onset of horizontal forehead wrinkles, which, from simple expression wrinkles, can be transformed into deep grooves or even folds. Hypertrophy of the corrugator and procerus muscles is the origin of the frown lines, often wrinkles of very deep expression. The procerus is responsible for horizontal wrinkles, the corrugator for slanting wrinkles. As for the forehead, impairment can lead to simple expression wrinkles or deep grooves or folds implicating the reticular dermis. The tail of the eyebrow is subjected to prolapse due to the subsidence of the orbicularis.

The glabella starts to become more prominent owing to the fall of the frontal tissues and expansion of the sinus. The temporal pit begins to hollow, and the external orbital arch, owing to the resorption of superciliary fatty tissue and the prominent expansion of the bone.

The upper eyelid presents with excess skin, which can be so severe that it can interrupt the visual field. Fatty excess is often present, particularly at the level of the internal pocket, particularly in a case where weakening of the orbital septum occurs, which can cause a pseudo-hernia of the fatty pocket. There can also be a deficiency of fat.

Mid-face

The lower eyelid presents in variable manners, such as a fatty enlargement in the form of the nasal, middle, and the temporal pockets, as well as excess skin. The convexity of these ‘pockets’ is due to an excess of fatty tissue but also because of a slackening of the septum supporting them. The orbicularis muscle loosens, which favours the appearance of fatty pockets and herniated subocularis oculi fat pads (SOOF) known as ‘malar bags’, while the ligaments of the external canthus relaxes, sometimes leading to its fall. The slackening of fine muscles of the mid-third of the face accentuates the fall of fat under the skin, which seems to be accumulated in the lower, anterior region and diminished in the lateral, upper region. The nasolabial fold then becomes a deep groove.

The malar bone becomes flattened and diminished. The zygoma and malar and submalar regions lose fat, giving a skeletonised appearance of the cheekbones with submalar hollows, while ‘jowls’ appear from around age 30 and increase progressively. Diminishing fat is particularly notable at the level of the ball of ‘Bichat’, which aggravates the skeletonisation of the face. The cutaneous and muscular flaccidity appears on the cheeks and increases the nasolabial groove, which leads to the appearance of the labiomental groove. The orbicularis oris muscle atrophies and slackens, leading to thin and impaired skin of the upper lip and chronic muscular shrinkage, causing the progressive appearance of the characteristic vertical wrinkles of the ageing upper lip. Initially, the fine multidirectional lines appear, then wrinkles, which begin to converge, then the true grooves and vertical or slanting creases appear. The profile of the upper lip and vermilion starts to become flat. The loss of teeth and osteoporosis of the anterior part of the upper maxilla increases the cutaneous laxity of the upper lip. With the descent of the labial corners, the interlabial line becomes lower than the incisal line.

The nose is also subject to the effects of ageing but in an isolated manner. The quality of the skin is disrupted by solar elastosis and loss of elasticity, sometimes with skin excess, and in men and increase in density of the sebaceous glands, which thickens the skin and can lead to rhinophyma. The tip starts to lose its definition and falls (under a horizontal line that crosses the nasal ridge) via diminution of the alar cartilage secondary to the thinning and the division of the fibrocartilage between the different structures, and via the weakening of the suspensory ligament, the thinning of cartilage, cutaneous thickening, and the subsequent decrease of the columella secondary to maxillary detachment caused by alveolar bony lysis and reduction of the nasal ridge.

Lower face and neck

Ageing of the cervicomental angle is particularly marked by the fall of subcutaneous fat and accumulation in the lower part of the cheeks. The youthful oval shape of the face loses its definition with the appearance of cutaneous and muscular prolapse that creates ‘jowls’ from around age 30, which are further increased by fatty subsidence and can ‘overflow’ under the mandibular border. The apex of the chin drops and becomes lower than the mandibular line.

Hypotony and slackening of the orbicularis oris and the depressor anguli oris cause vertical wrinkles at the corners of the lower lip and on the chin and further increases the depth of the nasolabial groove. Atrophy of the skin favours the appearance of these wrinkles. With the extension of the nasolabial groove, a labiomental wrinkle starts to develop. Muscular hypotony is further increased by gingival retraction and resorption of the alveolar bone.

The neck presents with cutaneous and muscular subsidence that can be particularly important and associated with diastasis of the internal edges of the platysma muscle, which also begin to show hypotrophy, slackening, and weakness, giving rise to the ‘turkey neck’ appearance and visible platysma bands. Weight gain that is often linked to ageing causes adipose infiltration under and in front of the platysma to varying degrees.

Fat underneath the platysma can become visible due to the separation of the platysma muscle and gives a thickened appearance of the neck. Fine, cervical wrinkles due to atrophy of the skin, solar elastosis, and a reduction of subcutaneous fat all contribute to semi-circular skin creases and loss of the cervicomental angle. Lastly, the cervical contour becomes convex with compaction and hyper lordosis of the cervical vertebrae that leads to a shortening of the neck, disappearance of the curve of the nape, lowering of the hyoid bone, and hypertrophy and protrusion of the trachea and thyroid cartilage and cricoids.

Ageing, according to Fitzpatrick grading.

Ethnicity and ageing

The thickness of the skin varies according to the ethnicity of the client. Dark skin has more melanin in the deeper layers of the epidermis and better resistance to sun exposure. Hence, solar elastosis appears earlier and is more severe in clients with pale skin, e.g. those with red or blonde hair. These clients must be very vigilant regarding the duration of sun exposure in relation to risk augmented by sunburn, especially for skin carcinomas: basocellular, spinocellular, and melanoma principally.

Certain ethnic groups have more prominent cheekbones (especially those of Asian origin) that delay the onset of cutaneous subsidence. When a prominent facial skeleton is associated with fine skin having a tendency to retraction more than prolapse. In Africans, Afro-Caribbean’s, and ‘mestizas’, with the greatest thickness of the skin, an aged and wrinkled aspect of the skin is less visible, and the indication for a cervicofacial facelift is reduced. In fact, the visible signs of ageing are delayed on average for at least a decade in most non-Caucasian populations:

Asian, African, and Afro-American.

Fine lines and expression wrinkles appear much later and are less pronounced than in clients with a Fitzpatrick of 1-3. In contrast, fat prolapse and muscular slackening are equally or more important than in Caucasians.

Morphotype and ageing

Ageing presents with important individual variations according to the predominance of skin prolapse, wrinkles, skin thickness, and exposure to environmental factors such as solar radiation or smoking.

The bony relief of the facial skeleton is particularly important, especially in the malar and mandibular regions.

Prominent cheekbones will delay the effect of prolapse, and a hyomandibular or ’long face’ syndrome will favour the early appearance of subsidence of the inferior third of the face and neck. A rounder face associated with excess weight is an advantage, but significant weight loss accentuates flaccidity and, therefore, cutaneous fall. Facial signs of ageing can have a global nature or can be isolated, with the appearance and emphasis of different signs seen in a discrete manner.

Factors favouring cutaneous ageing

Sun exposure, besides the obvious risks of the appearance of cutaneous cancerous lesions or transformation

of precancerous lesions favours cutaneous ageing via its negative effect on elastin fibres. ‘Age spots’ appear, and solar elastosis develops in the skin of the face and neck, highly exposed zones which are therefore affected most severely. These effects appear earlier for the same duration of exposure in people with a fair complexion. Smoking is associated with well-known risks of lung cancer or chronic lung disease, and cardiovascular disease, and it also contributes to cutaneous ageing. Repeated contraction of the orbicularis muscle while smoking a cigarette reveals early vertical wrinkles of the upper lip. It also causes a poor buccodental state, which, as a source of infection and lysis of the alveolar bone, can change the aspect of the mouth. It also accelerates the yellowing of teeth.

Lack of sleep and psychological stress also have a harmful effect on the appearance of the skin. A low-humidity atmosphere can dehydrate the skin, and climatic changes can act on its physiology.

Excessive blinking of the eyes can cause the appearance of periorbital wrinkling.

Large weight loss leads to a slackening of the skin, giving a prematurely aged appearance not only to the face but also to the rest of the body.

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