On the other hand, photoaged epidermis is characterized by striking variability: in its thickness, with alternating areas of atrophy and hyperplasia; in pigmentation, with alternating lentigenes and depigmented areas; in the degree of nuclear atypia; and in orderliness of keratinocytes maturation (7). In the past, sun-damaged epidermis was thought to be characterized by a reduction in structural elements, leading to skin wrinkling. In fact, the most striking feature of photodamaged skin is the presence of large quantities of thickened, poorly organized degraded elastic fibers which degenerate into an amorphous mass (8). The result is aged skin which does not retain moisture and which loosens and hangs. The ground substance component of the dermal connective tissue matrix is greatly increased. In the dermal cell population, photodamaged skin shows numerous, hyperplastic fibroblasts and abundant, partially degranulated mast cells which result in a chronic low grade inflammation termed heliodermatitis. Finally, photodamaged skin shows extensive changes in the microcirculation which can affect flap viability.
Overall the aging face can be viewed as a coupling of redistributed ptotic underlying soft tissue with overlying skin changes. Together, these changes combine to contribute to the overall impression of the aging face. For most aging face patients, this means that facial rejuvenation will necessitate the surgeon concentrating on five points of interest: 1. the jowl 2. the deepened melolabial folds 3. the neck 4. the malar region, and 5. the skin itself.
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