Facial Aging

Autors: Dr. Abdul Hameed

Introduction
There is no specific age when the signs of aging begin to appear and there are many factors that enter into the gradual process of aging. Many people become aware of the changes over a short period. It seems as if things were “holding up” well until the aging suddenly began. No one can predict when an individual’s rapid ag­ing period begins or the rate at which aging continues through life because we each age differently.
The appearance of the face and neck typically changes with age. Facial aging process begins with surface and subsurface structural changes in multiple facial tissue layers, including skin, fat, muscle, bone and teeth. Facial tissue ages interdependently, contributing to the overall facial appearance of the face. Changes in one tissue layer have an effect on the other layers. As individual grow older, the skull decreases in size, some of our fat layer is absorbed, and degenerative changes in the skin causes it to lose much of its elasticity; resulting in the development of wrinkles. In addition, the muscles lose their tone and portions of the face “deflate” and lose volume. As the deterioration continues, the skin begins to sag and droop, and the lines of facial ex­pression become deeper and more apparent (forehead lines, grooves at the side of the mouth, etc.).

CAUSES
There are two types of factors related to facial aging: internal (age-related) and external (or environmental). Both factors cause visible and nonvisible effects.

Internal factors are those that happen over the period of time and are caused by genetic factors, breakdown of cellular structures and processes, reduced bone density and hormonal changes. These factors lead to visible effects,

External factors are the environmental factors that are purported to affect facial appearance include mental stress, diet, work habits, drug abuse, hormonal imbalance, chronic solar exposure, smoking, and disease.

Skin - With age, the dermis thins due to the breakdown of collagen, thus reducing its ability to retain elasticity (from elastin) and moisture (from hyaluronic acid). Elastin is a protein found in connective tissues that is elastic and helps skin maintain it shape and integrity.

Changes that are seen in skin as aging process are

• Reduction in collagen
• Thinning
• Drier skin
• Less elastic skin
• The skin around the eyes gets wrinkles, creating crow's feet; at the side of the eyes.
• The number and size of blotches and dark spots on the face increase.
• Eyebrows and eyelashes turn gray.

Collagen
Collagen loss is a key factor in the aging process. As skin ages, the middle layer of skin (dermis) thins due to collagen loss. This reduces the skin’s ability to retain elasticity (from elastin) and moisture (from hyaluronic acid). Due to this loss of elastin and hyaluronic acid, the skin becomes:

• Dryer
• Less elastic
• Less supple
• Thinner (volume loss)

Fat
There are two layers of fat superficial (between the dermis and fascia superficialis) and deep (under the muscles). A youthful look depends on having the right amount of facial fat distributed in the right places. Redistribution, accumulation, and atrophy of fat lead to facial volume loss:

• Areas that lose fat - periorbital, forehead, malar, temporal,mandibular, mental, glabellar, and perioral sites.
• Areas that gain fat or remain persistant - submental, lateral nasolabial fold and labiomental crease, jowls, infraorbital fat pouches, and malar fat pad.

Modification of the fat pads leads to contour deficiencies; the malar fat pad gradually slides forward and down to bulge against the nasolabial crease, giving rise to the prominence of the nasal fold in the aged face. This redistribution and demarcation of fat gives the senile face an unbalanced appearance

Muscle mass -
there is lengthening of facial muscles with age, numerous studies show that the actual muscle tone increases, with shortening of the amplitude of movement, muscle tone at rest staying close to maximum contracture tone, which is a reaction to the bony changes. Whatever is the reason, this tightening of the muscle results in shifting of fat, accentuation of skin creases resulting in permanent wrinkling of skin

Bone
There is a significant loss of facial bone with age. Aging of the craniofacial skeleton may be due to changes in the relative dynamics of bone expansion and bone resorption. Bone resorption leads to biometric volume loss. There is an appreciable reduction in facial height, which is mainly due to remodelling of maxilla and mandible, and a moderate increase in facial width and depth. Without the structural support of bone, there are noticeable changes in the other layers of overlying soft tissue and skin.

• Decrease in maxilla - Downward displacement of malar fat pad and accentuation of the nasolabial fold. Loss of support in the upper lip contributing to perioral wrinkling.
• Resorption in mandible –changes in projection and shape of chin.

Dentition -
Missing teeth and receding gums change the appearance of the mouth so your lips may look shrunken. Loss of bone mass in the jaw reduces the size of the lower face and makes your forehead, nose, and mouth more pronounced. Your nose may also lengthen slightly.

Approx age	Likely Bony Change	Probable Soft Tissue or Facial Appearance Effect
30	Slight craniofacial skeletal growth Slight anterior (mostly lower) face height increase Mandibular length increase	Upper eyelid drooping begins Eyes appear smaller Nasolabial lines begin to form Lateral orbital lines begin to form Upper lip retrusion begins in females
40	Dentoalveolar regression suggesting eruptive movement of teeth. Maxillary retrusion progressing, contributing to nasolabial folds Mandibular length increase	Circumoral striae begin to form Lines begin to form from lateral edges of nose to lateral edges of mouth. Upper lip thickness decreasing
50	Craniofacial skeletal remodeling progresses Dental alveolar regression and dental eruption progressing Maxillary and mandibular dental arch lengths decreasing	Facial lines and folds continue to increase in depth. Nose and chin positioning affected as dental arch lengths decrease Most profound morphological changes of the head, face, and neck are evident
60	Craniofacial remodeling continues Cranial thickness likely unchanging Alveolar bone remodeling Possible dental attrition affecting vertical face height	Facial lines and folds continue to increase in depth. Protuberance of nose and ears due to greater craniofacial convexity
70 and above	Decrease in craniofacial size Greater craniofacial convexity(excluding maxilla and mandible) Possible temporomandibular joint arthritis and joint flattening Alveolar bone remodeling continues	Protuberance of nose and earscontinues Concave appearance in cheek hollows due to alveolar bone remodeling Diminished jaws

Summary
Facial aging is a multifactorial, three-dimensional process that involves volume loss, volume descent, and skin alterations. Every anatomic component of the face is affected. This article we discussed about the morphologic consequences of facial aging and reviewed the salient literature relating to the numerous factors that contribute to an aged appearance.

Figure 1:- A) Youthful Face	Figure 1:- B) Youthful Face

Figure 2:- Various changes on facial appreance, tear trough deformity, hollowing of the cheek, nasolabial folds, melomental folds, and jowling

Figure 3:- Attributes of the youthful versus aged face