The focus is on facial wrinkling. Comparable treatment algorithms do not apply for wrinkles in other areas of the body. The main reason is the unique anatomy of the muscles of facial expression.
In order to be able to mold the skin into complex three dimensional patterns expressing emotions and to facilitate nonverbal communication the mimetic muscles have to be connected to the skin like the strings of the puppet player are connected to different parts of the puppet to make them move as desired.
This gives rise to a fairly unique type of wrinkle in the face – the so called dynamic wrinkle arising during facial expressions as a surface correlate of hyperactivity of the facial musculature, particularly around the eyes, eyeborws and in the forehead area. Dynamic facial wrinkles disappear once the mimetic muscles relax. The ideal treatment is Botox or Dysport, blocking hyperactivity of the mimetic muscles in those areas.
The static facial wrinkles are located in the same spots as dynamic facial wrinkles. However, even with the mimetic muscles completely relaxed they do not completely disappear. They are more difficult to treat, but can be improved with fillers, fat grafting, laser resurfacing, chemical peeling and certain types of forehead, midface and face lifting procedures.
Fine wrinkles such as those seen after long standing sun exposure but particularly smokers around the lips and eyes are signs of intrinsic skin damage (originating in the skin itself). They are generally not improved by any lifting procedures. The “toxin” sun or smoking must be avoided (sun protection, smoking cessation). They can – very tediously as I may add – be improved by intradermal fillers. My choice is rather chemical peeling or laser resurfacing which I consider the most effective modalities for improvement of intrinsic skin damage.
The final entity to be considered is not that much a wrinkle as it is a fold at the transition of aesthetic units in the face e. g. cheek-lip – nose (nasolabial folds) or eyelid – nose – cheek (nasojugal groove or fold), cheek – neck (jowls). Descent of one unit in excess of the other combined with relative volume loss due to aging result in “shelving” forming peaks and valleys which can be looked at as folds. In mild cases improvement is possible by fillers or fat grafting. Some nonsurgical practioners, whose cosmetic practice is severely limited by not being able to perform the standard surgical procedures, encouraged by the manufacturers of certain medical devices advocate non surgical treatment modalities based more on wishful thinking than anatomical principles. Surgery is incomparably more effective for a defined mechanical problem – laxity of anchoring structures and descent of aesthetic units in the face with subsequent shelving and fold formation. The only rational treatment is lifting – midface lift, neck lift, face lift, depending on where the problem is exactly located. This is no different than in other areas of the body, where all wrinkles are in fact folds resulting from laxity of anchoring and descent. Only rational treatment are “plasties” e. g. abdominoplasty (tummy tuck), mammaplasty (breast lift, breast reduction) and so forth.
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