From the Department of Dermatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Dr Arndt is a member of the JAMA Editorial Board and Editor of Archives of Dermatology .
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 smoking and
chemical exposure. The effects of 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.
Stratigos AJ, Arndt KA, Dover JS. Advances in Cutaneous Aesthetic Surgery. JAMA. 1998;280(16):1397-1398. doi:10.1001/jama.280.16.1397