Wrinkles of the face and neck: methods of their elimination

In second place after patients with nasal deformities in terms of frequency of seeking help from cosmetologists are people complaining of disfigurement of the face and neck due to wrinkles.

First of all, people whose profession requires speaking in front of an audience or serving the public (teachers, artists, musicians, salespeople, etc.) need such treatment.

What causes wrinkles on the face and neck?

The causes of premature aging of the human body, including facial skin, have not yet been sufficiently studied, but it is already undoubtedly clear that a decrease in the intensity of metabolism, in particular the self-renewal of proteins, dysfunction of the nervous system, stress, weight loss, endocrine disorders leading to insufficient blood supply (hypoxia) of the skin, are the main cause of the appearance of wrinkles.

It has been noted that facial skin aging occurs unevenly in its various areas; therefore, the following main clinical forms of manifestations of premature facial aging are distinguished:

1. wrinkles and folds of the skin of the forehead;
2. drooping eyebrows;
3. wrinkles and folds of the skin of the upper eyelids (with or without fatty hernias);
4. the same in the area of the lower eyelids;
5. fatty hernias of the lower eyelids:
6. wrinkles and folds of skin on the temples;
7. wrinkles and folds of the skin of the neck;
8. combined forms.

The appearance of early wrinkles can be caused by the habit of wrinkling the forehead, squinting, laughing often, grimacing. In some cases, the appearance of wrinkles is due to the profession (working in the wind or under the sun without protective glasses, acting on stage, etc.).

The habit of wrinkling the forehead in women is sometimes associated with the desire to “enlarge” their eyes by constantly raising their eyebrows; as a result, the skin of the forehead acquires an accordion-like relief.

The cause of premature wrinkles can be rapid weight loss, as well as premature loss of teeth, due to which the distance from the nose to the chin decreases and the mouth takes on a typical old-age, toothless appearance: sunken, with deep nasolabial folds.

Facial wrinkles are usually located perpendicular to the lines of force of the facial muscles: on the forehead - horizontally, on the cheeks and lips - almost vertically, on the eyelids - horizontally, at the corners of the eyes - fan-shaped. The skin in the eyelid area in humans is especially thin and elastic; therefore, with age, it stretches here under the influence of excessive fat deposits and impaired lymph drainage. This is largely due to the impaired excretion of water from the body by the kidneys.

Patients are particularly distressed by the appearance of wrinkles on the cheeks, at the corners of the eyes, as well as baggy or accordion-like sagging skin in the chin area.

In some cases, along with large wrinkles-furrows on the skin, there are many randomly located small furrows-folds, especially in the neck area in people with asthenic build (with rapid weight loss).

The appearance of premature wrinkles on the face causes severe psycho-emotional experiences in patients, especially women, a decrease or loss of appetite, which leads to further deterioration of the skin condition. In some cases, the patient is forced to change profession.

Pathological anatomy of wrinkles of the face and neck

Age-related changes in the skin of the face and neck include a gradual deterioration in lymph circulation, thinning and flattening of the epidermis, loss of papillae, fragmentation and even hyaline degeneration of elastic fibers.

The skin's sebaceous glands gradually atrophy. Their total number decreases, as a result of which the skin does not receive the necessary fatty lubrication.

Subcutaneous fat tissue and facial muscles also decrease in volume with age, but due to decreased elasticity, the skin does not have time to shrink following the fading and shrinking underlying “foundation”.

Elimination of wrinkles of the face and neck

Treatment of premature wrinkling of the face should be general and local. General treatment consists of improving nutrition of the whole organism, and facial skin in particular, normalizing the work, rest and sleep regime. For dry skin, the use of nourishing creams and masks is indicated according to the rules of cosmetology and dermatology.

Indications for surgical intervention should be based on the degree of clinical manifestations of facial aging, the patient's age, the nature of his profession, and general condition.

It is advisable to distinguish 3 degrees of manifestations of facial aging: at degree 1 (weakening of skin turgor and subcutaneous tissue, minor folds and furrows of the skin) the indications for surgery are relative, it should be performed with a small detachment of the skin.

In cases of II and III degrees of aging (pronounced skin folds, downward displacement of subcutaneous tissue, deep furrows, eyebrows hanging over the eyes, etc.), the indications for surgery are absolute; it requires the detachment of large areas of skin, strengthening of subcutaneous formations, excision of excess skin areas and stretching of widely separated adjacent areas to close the resulting wound surfaces. In all cases, one should strive to ensure that the scars are located in inconspicuous places.

Since facial wrinkle surgeries are performed mainly on elderly people, they should be carefully examined before the procedure. It is recommended to avoid surgeries on people with an unstable psycho-emotional status who do not adequately assess the degree of their cosmetic defects. Each patient should be informed about the nature and plan of the upcoming surgery, possible complications, the duration of the surgery effect, and the location of the scars. It is advisable to obtain the consent of the spouse of the person undergoing the surgery to prevent the possibility of various claims. It is necessary to tell the patient that he or she must take unpaid leave for the duration of the treatment.

For wrinkles of the entire face and neck, various surgical methods are possible. Let's consider one of them. On the eve of the surgery, the contours of a zigzag skin strip to be excised in the temporal region, in front of and behind the auricle are outlined with methylene blue.

The upper-posterior border of this tape (abcd) corresponds to the line of the first incision, which is applied with paint, starting from the border of the temporal and frontal areas, then along the border of the scalp in the area of the temple and auricle. Having rounded it, the line is continued to the longitudinal midline of the mastoid process. From here, the line of the future incision is led backwards and downwards (at an angle of 90°) by 2.5-3 cm. In front of the upper-posterior incision line, the anterior-lower line (aezhzd) is applied with paint, the length of which should be equal to the length of the first line. The length of both lines is determined by applying a silk thread to them. If one of them is longer, appropriate adjustments are made to the planned plan of incisions only by changing the distance between the lines. It is determined by gathering the skin with the fingers, depends on the degree of stretchability of the skin and is equal (in the middle part) to 2-3 cm.

A transparent X-ray or thick cellophane film is applied to the two marked incision lines that converge at the ends, on which the contours of the skin strip to be removed are drawn. The film is cut off above and below it. A template is obtained, according to which it is possible to perform a completely symmetrical excision of excess skin.

When marking the incision lines in front of the hair in the temple and auricle area, it is necessary to strive to ensure that as a result of the operation the greatest tension of the skin is created only in two areas: above the auricle and behind it - at the middle level. Due to this, the upper tension zone provides smoothing of the nasolabial fold, folds in the temple area and on the cheeks, and the lower zone - smoothing of the folds of the chin and upper neck.

In all other areas, the tension in the sutures should be minimal; otherwise, the auricle may shift forward and downward, the earlobe may be pulled back, or a noticeable wide postoperative scar may form in front and behind the auricle.

With a significant decrease in the turgor of the subcutaneous tissue in the cheek and neck area, the most effective is its subcutaneous strengthening, which contributes to a longer postoperative cosmetic result, which is confirmed by both clinical data and measurements of the elasticity of the cheeks before and after surgery using the vacuum diagnostics method.

In the postoperative period, the patient is prescribed general and local rest (smiling and turning the head to the sides are prohibited); multivitamins are administered orally, and a complex of antibiotics is administered intramuscularly to prevent suppuration in the wound area.

The stitches are removed on the 10th-12th day to avoid stretching the weak and fragile scar.

After this, the scars should be irradiated with Bucca rays, head movements and contractions of facial muscles should be limited for 1.5-2 months.

Treatment of forehead and nose wrinkles

In the case of forehead and bridge of nose wrinkles, simple excision of a spindle-shaped area of skin along the edge of the scalp or in the area of the bridge of the nose folds gives only a short-term effect. After some time, the folds reappear in most of those operated on.

In this case, two types of surgery are used: with an incision above the hairline on the forehead and in the area of the hairline of the scalp.

Before the operation, a strip of skin connecting both temporal areas is shaved on the scalp, 1.5-2 cm away from its border with the forehead skin. The shaved area should have the shape of an elongated oval; its width depends on the degree of mobility of the forehead skin (from 2 to 4 cm), and its length is 20-25 cm. The hair remaining in front of the shaved area is braided into pigtails. Later, they will cover the postoperative scars.

During the operation, the patient's chin is brought to the chest; the surgeon should be behind - at the head of the patient.

The incision is made along the upper edge of the shaved strip from temple to temple through the entire thickness of the skin. Bleeding from the wound is stopped by pressing on the skin above the eyebrows.

The lower edge of the wound is captured with symmetrically positioned clamps.

Using blunt curved Cooper scissors or a curved raspatory, peel off the skin of the forehead from the tendon helmet and the frontal belly of the occipitofrontal muscle to the eyebrows and bridge of the nose, without damaging the vascular-nerve bundles emerging from the supraorbital openings.

The mobilized skin is pulled upward and dissected (between the clamps of each pair) until a motionless edge of the wound appears. A suture is placed between the central pair of clamps, and then between the lateral pairs. The excess skin between these main sutures is excised, the wound is sutured tightly and a pressure bandage is applied.

This technique allows not only to straighten transverse furrows, but also to smooth out vertical folds on the bridge of the nose, reduce folds of the eyelids and corners of the eyes.

The disadvantage of the method is the increase in the skin part of the forehead. Therefore, this method is not applicable to people with a high open forehead and bald spots. In them, the skin dissection line should be carried out in a wave-like manner along the border of the hairline, ending the incisions in the hairy part of the scalp.

In case of significant baldness of the forehead, it is recommended to use the Fomon-G. I. Pakovich operation, in which a continuous incision is made above the eyebrows, the skin is widely separated to the middle of the crown, the skin of the forehead is moved down, its excess is excised and blind sutures are applied to the skin edges of the wound.

In order to switch off the mechanism of forehead wrinkle formation, I. A. Frishberg (1971), modifying the operation according to Uchida (1965), cuts the skin of the forehead along the hairline or in the area of the scalp, peels off the skin above the frontal muscle and tendon helmet; then dissects them along the line of the skin incision and from its ends to the outer ends of the eyebrows lowers the muscle and tendon helmet to a new level. Due to this, the effect of the frontal belly of the occipitofrontal muscle on the skin of the forehead is switched off, the threat of recurrence of folds in the forehead area is eliminated, but at the same time the ability of the muscle to raise the eyebrows is preserved.

Correction of drooping eyebrows

When correcting drooping eyebrows using the I. A. Frishberg method (in contrast to the Barnes, Fomon, Clarkson methods, which involve excision of elliptical areas of skin above the eyebrows), all soft tissues of the superciliary region are excised down to the bone, the frontal belly of the occipitofrontal muscle is dissected, and the eyebrow tissues are sutured to the periosteum. This achieves more reliable fixation of the eyebrows,

This technique can be used when it is necessary to raise eyebrows that are too low; moreover, if there is no need to simultaneously eliminate the interbrow folds, it is not necessary to make an incision on the bridge of the nose.

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Elimination of wrinkles of the upper eyelids

Eyelid wrinkles are divided into two main types:

• folds of the eyelid skin only;
• swelling of the eyelids due to the displacement of the subcutaneous tissue of the orbit into the thickness of the eyelid, which can be observed even in young patients with a weak ligamentous-muscular apparatus of the eyelids.

Anatomical tweezers are used to grasp the fold of skin at the point of greatest sagging; marks are made with paint above and below the fold, corresponding to the greatest width of the excess skin. From these points, lines are drawn, converging at their ends at the outer and inner corners of the eyelids. This results in an irregularly shaped oval, the widest being closer to the outer edge of the eyelid.

A transparent X-ray film is applied to the eyelid with the drawn oval, the contours of the area of skin to be excised are applied, the edges of the film are trimmed and a template is obtained that is also suitable for applying contours (incisions) on the other eyelid.

If the folds on the upper eyelids are clearly asymmetrical, the operation plan is outlined for each eyelid separately, i.e. without using a plastic template (some authors do not resort to it even with symmetrical folds).

Excess skin is excised without ligating the vessels, since the catgut nodules, slowly dissolving, will be visible under the thin (750-800 µm) skin of the eyelids.

Bleeding is stopped by temporarily pressing the bleeding surface or by instilling 1-2 drops of adrenaline solution (1:1000) into the wound.

After a small separation of the edges of the wound, one continuous plastic suture is applied, which is removed after 3 days by pulling it by the outer end (the inner end of the thread should not be fixed with a knot during suturing of the edges of the wound).

When mixing the subcutaneous tissue after excision of excess skin, its upper edge is mobilized upward, the orbicularis oculi muscle (under the supraorbital edge) and thinned fascia are dissected, protruding fat lobules are detected and removed. The edges of the muscle and fascia are brought together with thin catgut sutures, and the edges of the skin are brought together with a continuous suture made of polypropylene fiber.

Elimination of lower eyelid wrinkles

The skin is cut 2-3 mm below the lash line from the inner to the outer corner of the eye. Then the cut is extended horizontally (along one of the natural grooves) by 5-8 mm, the lower edge of the skin is grasped with two holders and the skin of the eyelid is peeled off with blunt scissors without damaging the orbicularis oculi muscle.

If fat lobules protrude into the wound, the skin is peeled off lower - further from the infraorbital edge. In the middle part of the wound, the infraorbital edge is felt with a finger, the muscle and fascia are separated with blunt-ended scissors, and lobules of subcutaneous tissue are found.

After additional light pressure on the eyeball from above, the protruding tissue is removed. The muscle and fascia are sutured with catgut. If the muscle is flabby and thin, it is sutured with several U-shaped catgut sutures in such a way as to invaginate part of the muscle in place of the removed fat and thus strengthen the muscular wall of the eyelid.

The exfoliated skin of the eyelid is moved upward and outward without tension, the excess skin is dissected towards the outer apex of the wound and the first knotted suture is applied here.

Excess skin is cut off, bringing the edges of the skin together without tension. A continuous suture with polypropylene fiber can be applied to the skin.

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One-stage removal of wrinkles of both eyelids

The simultaneous removal of wrinkles on both eyelids is best done using a technique that essentially combines the above-described methods of separate removal of folds and wrinkles on the upper and lower eyelids. In this case, a horned flap of skin from both eyelids is excised, connected in its lateral part by a bridge.

After eyelid surgery, a light aseptic dressing is applied, secured with narrow strips of adhesive tape.

In the first hours after the operation and in the following 2-3 days, cold is prescribed to the eyelid area. It is recommended to remove the stitches on the 4th day.

Removal of wrinkles of the neck and chin

Neck and chin wrinkles are effectively eliminated by independent surgery only in thin people with well-mobile skin, without significant deposits of subcutaneous tissue. In this case, the incision is made from the upper level of the tragus, around the lobe and continues behind the auricle to the border of the hair on the neck, then along this border.

Having separated the skin widely, it is pulled upward and backward until the folds on the neck disappear. The edge of the skin is cut towards the upper point of the wound and the area behind the ear, where the first suture is applied, capturing the tissue up to the periosteum of the mastoid process. Then the excess skin is cut off and knotted sutures are applied.

Elimination of wrinkles and sagging cheeks

Wrinkles and sagging cheeks often occur in relatively young people without signs of baldness or receding hairlines. Therefore, they should use the surgical technique with incisions above the hairline on the temples; in this case, the hair in the temple area is braided, a strip of skin 2-2.5 cm long is shaved, an incision is made along the upper edge of the shaved area, which continues downwards in front of the auricle.

The skin is peeled off within the entire parotid region and up to the middle of the neck, its edges are grasped with two clamps, pulling up and back.

Next, the skin is cut between the clamps, one knotted suture is applied, excess skin is excised and a continuous suture is applied with polyamide thread.

To eliminate pronounced persistent nasolabial grooves, L. L. Pavlyuk-Pavlyuchenko and V. E. Tapia (1989) recommend (along with excision of excess subcutaneous tissue and skin) using the temporal fascia, a transplant from which is introduced through a subcutaneous tunnel in the cheek area and sutured to the aponeurosis of the nasolabial groove area.

Sequence of operations for facial wrinkles

If the patient's entire face is covered with wrinkles and folds, a general operation is performed first - wrinkles on the entire face and neck are removed, then on the forehead. After this, there may be no need for an operation on the eyelids, since during the tightening of the skin of the forehead and cheeks, wrinkles in the area of the corners of the eyes and eyelids are simultaneously smoothed out to a certain extent. If an operation is necessary, the amount of skin removed can be reduced.

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Outcomes of facial wrinkle surgery

The duration of the effect of surgical intervention for facial wrinkles depends on the general condition of the patient, his psycho-emotional mood, living conditions, family relationships, nutrition, constancy of body weight, etc.

Some patients remain in good condition for 7-8 years or more, while others require repeat surgery after 2-3 years.

The more loose and mobile the skin on the face was before the operation, the better and longer the results of the operation. Since the process of reducing skin elasticity is still ongoing in young patients, the effect of the operation is less stable for them than for older patients.

When a keloid scar appears, the effect of the operation is reduced to zero. Its occurrence can be prevented by irradiation with soft X-rays (Bukki) in a dose of 10-15 Gy. The appearance of hypertrophic, atrophic and keloid scars is facilitated by trauma to the flap during the operation, over-tensioning of the displaced flaps, the use of coarse suture material and long-term leaving of sutures in the suture channels.