Skin Wrinkles – Full Treatment Guide

Skin Wrinkles – Full Treatment Guide

Skin wrinkles are the result of the following mechanisms: skin aging, actinic lesions and oxygen free radicals from the skin.

Aging of the skin is a process of atrophy, in epiderm, the thickness of stratum corneum changes very little, but there is a epidermal papillae loss process, a reduction in the melanocytes (the cells responsible for skin pigmentation) and a decrease in Langerhans cells (cells involved in the skin immunity process).
As a result of skin skin ageing, the most important changes occur in the dermis, especially in its upper third. The total thickness of dermis decreases with age, an average of 6% per decade of life, both in women and men. Much of the dermis is lost, so that its total amount is reduced to 20% of that of a young adult. Thus there is a destruction of elastic fibers and the amount of collagen in the dermis is reduced.

Skin Wrinkles

Actinic lesions are represented mainly by the degradation and thinning of elastic fibers and decreasing in the amount of collagen.

Oxygen free radicals are the major factors involved in ultrastructural damage to skin by ultraviolet rays. Application of skin protective agencies with antioxidant effect, will reduce the skin damage induced by high doses of ultraviolet rays.

Skin Structure

The morphology of skin wrinkles:

Visible morphological changes associated with aging of the face are:

• Decrease of bone structures;
• Decrease of skin thickness and elasticity;
• Decreased adhesion of the skin on underlying layers;
• Gravitational fall of soft tissue;
• Wrinkle formation in the areas of adhesion with deep structures and areas of the muscle insertion.

Facial, around the age of 30 years appear a surplus of upper eyelid skin, fine wrinkles in the sides of the orbits and the deepening of nasal-labial grooves.

Around the age of 40 years forehead wrinkles appear and the wrinkles around the orbit and nasal-labial grooves are accentuated.

At the age of 50 years wrinkles appear on the neck and tip of the nose falls.

At the age of 60 years facial skin is much thinner and can be seen traces of decreasing in the amount of fat tissue in the temporal and buccal region. These changes continue to accumulate until death.

There are basically three types of human skin wrinkles of aging:

• Wrinkles of animation, resulting from the contraction of mimic muscles;
• Fine wrinkles caused by the breakdown of fibrin network;
• Pronounced wrinkles, deep, produced by the degradation and thinning of elastic fibers by the ultraviolet solar rays.

Therapeutic principles of correction of the wrinkles:

Basically, there are six items available in facial rejuvenation action:

1. Correction of dynamic wrinkles by controlled and temporary paralysis of the muscles by injecting botulinum toxin (Botox);
2. Improving local metabolism and revitalize the dermal structures by mesotherapy, which will reduce the wrinkles;
3. Microscopic polishing action of the skin with improving its quality and wrinkles reduction;
4. The chemical peeling and laser peeling;
5. Removing excess skin and repositioning of the deeper structures by surgical lifting, which will reduce the wrinkles;
6. Restoring volumes required in the cheeks, cheekbones or lips by fat transplantation is another therapy for correction of the wrinkels.

Wrinkles Types

Non-surgical procedures in the treatment of wrinkles :

Chemical peeling and laser peeling:

Fine wrinkles will be removed through a chemical peeling technique, which involves the application of acid on the skin surface, singly or in combination (glycolic acid, mandelic acid, trichloroacetic acid or phenolic acid), producing a well-controlled deep burn, whose healing result will be a skin rejuvenation, through action at microscopic level. For similar effects can be appealed at the thermal effect of the CO2 laser (laser peeling).

Immediately after a medium peeling will appear brown scabs, which are starting to fall spontaneously after 2-3 days. After the fall of scabs, often there is a slight pink discoloration that can persist up to 2 or 3 weeks. Although, it is not a pure surgical intervention, it can be accompanied by some discomfort for several days, especially when the entire face is treated. Reintegration in social life is usually done after 3 to 4 weeks after treatment when the swelling is decreased and the red spots of the face will disappear.

Is not recommended sun exposure earlier than 8 weeks after surgery, because hyperpigmentation may occur in treated areas, which may become permanent.

Chemical Peeling

Botulinum toxin:

Botulinum toxin is used as a cosmetic treatment of facial wrinkles under the name of Botox in the U.S.A  and in Europe under the name of Dysport.

The principle of action of botulinum toxin is directed to the terminal neuromuscular junction, blocking chemical synaptic mediators and causing temporary paralysis of involved muscle groups.

Therefore, the target muscle groups lose the ability to shrink and the muscle relaxation will produce the stretching of the skin, which will be without wrinkles. Both relaxed muscles and relaxed skin will benefit from a local vasodilation with a rich oxygenation of the skin, which will have a brighter color and will be without wrinkles.

This changes are installed differently from case to case, being modified by age and sex. Although, usually within 24 hours appear the first effects of injected botulinum toxin, correct evaluation is done after 7-14 days.

All these changes are temporary and therefore, it is always necessary the reinjection or returning to treatment in 4-6 months.

Contraindications of treatment with botulinum toxin are:

• In people allergic to one or more components of the botulinum toxin, such as albumin;
• In people with diseases that cause the overall decrease of muscle strength, such as myasthenia gravis;
• In people under treatment with antibiotics;
• In people under treatment with non-steroidal anti-inflammatory drugs;
• The presence of infections in the face region;
• Pregnancy and lactation;
• Minor patients who have not obtained parental consent.

Botulinum Toxin

Surgical procedures in the treatment of wrinkles:

Subperiosteal facial lifting:

This technique was applied initially to lift the the cheek and forehead fine tissue, the technique being later extended to the periorbital dissection and around the zygomatic body, to correct the cheek position.

Subperiosteal facial lifting can be done on the entire length of the upper jaw and on the nasal bones, to get a good effect of reducing wrinkles in the cheek and to get a good effect in reduction of  nasal-labial groove.

Subperiosteal facial lifting complications are:

• Injury to the branches of facial nerve (buccal, mandibular or temporal branch);
• Skin flap necrosis, especially common in smokers;
• Alopecia (hair loss) that may occur due to errors in temporal incision placement.

Nasal-labial contour:

Nasal-labial contour is harder to correct than the wrinkles in the chin or the wrinkles in the mandibular region. To solve the nasal-labial grooves have been proposed the following solutions:

• Subcutaneous procedures that are stretching the cheek skin;
• Direct excision of skin;
• Exogenous collagen injection;
• Autologous fat injections or dermo-adipose grafts.

Nasal-Labial Fold Correction

Zygomatic region:

In the ideal face, from the aesthetic point of view, zygomatic region is more prominent. The increasing of the region can be made by:

• Use of silicone implants, bioceramic implants or restyline implants;
• Autologous fat transplant.

Cervico facial liposuction:

When is combined with face lifting, liposuction can be applied percutaneously, before the lifting of the skin or under direct viewing through an open approach. Facial liposuction technique manage to remove the fat excess without detaching the skin and presents little risk of damage the facial nerve. Complications have been reported as the appearance of skin depressions and the appearance of fibrous streaks in the subcutaneous tissue.

Currently, liposuction is indicated for the removal of fat excess from the neck and removal the wrinkles from the neck.

Correction of lip aging:

As for lips, changes due to aging occurs as follows:

• A greater distance between the basis of nasal septum and upper lip vermilon (the red of the upper lip);
• Less exposed vermilion (thin lips);
• Relative loss of the  amount of vermilion.

These can be corrected by:

• Removing the excess skin from the basis of nose or from the vermilion;
• Correction of vermilion by injection with collagen, autologous fat or restyline.

Lip Correction

Frontal lifting:

Frontal muscles are extensions of the frontal cranial aponeurosis and are inserted into the supraorbital dermis.

Innervated by the frontal branches of the facial nerve, vertically fibers of the frontal muscle contract to raise eyebrows, producing transverse wrinkles along the forehead. Tonus and frontal muscle contraction help to maintain the eyebrow position.  Frontal muscle must resist to the gravitational forces and to the periorbital muscle action that pushes the eyebrow down.

Lower movement of the eyebrows is the combined result of the action of the procerus muscle, corrugator supercilli muscle and orbicularis oculi muscle.

Prolonged hyperreactivity of the upper facial muscles produces three types of wrinkles:

• The transverse raising of the forehead with the appearance of  transverse wrinkles of the forehead (frontal muscle);
• Eyebrows ptosis, with the appearance of wrinkles around the orbits (corrugator and orbicularis muscles);
• Vertical wrinkles at the root of the nose (procerus muscle).

Forehead Wrinkles

If the main objective is raising eyebrows, then in this case, the most effective technique involves the complete release of soft tissue adhesions from the orbital groove, in this way is kept intact the frontal muscle.

On the other hand, if the primary purpose is to reduce the transverse wrinkles of the forehead, the recommended procedure is the incision and excision of the frontal muscle, in this way,the release of soft tissue along the orbit groove no longer needed.

To achieve simultaneous eyebrows lifting and forehead wrinkle reduction, is required the release of soft tissue along the orbit groove and the incision and excision of the frontal muscle.

To reduce the transverse wrinkles of the forehead is also recommended the using of botulinum toxin injections.