Advances in cutaneous aesthetic surgery.

THE PHYSICAL APPEARANCE of aged skin derives from a combination of intrinsic and extrinsic factors. Intrinsic changes are largely genetically determined and include the effects of gravity (sagging), expression lines, and atrophy of the dermis and subcutaneous tissue. Extrinsic aging is related to environmental influences with sunlight being the most important, followed by smokingandchemicalexposure.Theeffectsof long-term sun exposure on skin (photoaging) are characterized by a recognizable progression of textural, vascular, and pigmentary changes. Dyschromia, lentigines (brown macules), and telangiectasias appear gradually, and the skin loses its tautness and smoothness and develops fine and coarse rhytides (wrinkles), keratoses, and, possibly, skin cancers. The aesthetic relationships of the aged face are also altered by a decrease in the volume of the facial skeleton, loss of suspension of overlying structures, and reconforming of the skin in folds and creases, especially around the orifices. Eyelid skin redundancy and herniation of orbital fat pads create eyelid “bags” that are accentuated by brow ptosis. In addition, sagging of the chin and neck occur and are enhanced by buccal fat pad atrophy and downward angulation of the oral commissures. Medical and surgical treatments are available to help reverse these changes by improving irregularities of the skin surface, relaxing expression lines, filling cutaneous defects, and removing excess fat or skin.