22.1 Description

• Thin middle-aged woman with aged-related changes to the face

• Fitzpatrick skin type II and Glogau class III wrinkle scale (Table 22.1 and Table 22.2)

• Upper face: Static and dynamic transverse forehead and vertical glabellar rhytids, mild brow ptosis, and temporal hollowing

• Periorbital region: Crow’s feet, crepey lower eyelid skin, tear trough deformity, no upper eyelid ptosis, and moderate lower eyelid tone

• Midface: Malar volume loss with superficial and deep fat pad atrophy, mild descent, and grade II nasolabial fold wrinkle (see Table 22.3)

• Perioral: Vertical static and dynamic perioral rhytids, upper and lower lip fat pad atrophy with lengthening and flattening of lip contour

• Lower face: Marionette lines, mental strain and mental crease deepening, minimal jowling, and weakened mandibular angle

• Neck: Medial platysmal bands, minimal skin excess and lipoatrophy

  Table 22.1 Fitzpatrick classification for sun-reactive skin types

  Type	Skin color	Hair color	Eye color	Effect of sun exposure?
  I	Light	Red	Blue/green	Always burns, never tans
  II	Light	Blonde	Blue	Usually burns, tans with difficulty
  III	Medium	Brown	Brown	Sometimes mild burn, tans average
  IV	Medium/dark brown	Brown/black	Dark brown	Rarely burns, tans with ease
  V	Dark brown	Black	Dark brown	Very rarely burns, tans very easily
  VI	Black	Black	Dark brown	Never burns, tans very easily

  Table 22.2 Glogau photo aging classification

  Class	Wrinkle characteristics	Age range	Clinical findings
  I	No wrinkles	20s–30s	Mild pigmentary changes No keratoses Minimal to no makeup
  II	Wrinkles in motion	Late 30s–40s	Early senile lentigines Palpable keratoses Parallel smile lines Some makeup foundation
  III	Wrinkles at rest	50s or older	Obvious dyschromia Visible keratoses Telangiectasias Heavy makeup foundation
  IV	Only wrinkles	60s–70s	Yellow-gray color of skin Skin malignancies Makeup results in “cakes and cracks”

  Table 22.3 Wrinkle severity rating scale (WSRS)

  Grade	Wrinkle severity	NLF characteristics	Anticipated effect of filler
  I	Absent	Not visible Continuous skin line	None indicated
  II	Mild	Shallow visible fold Slight indentation	Slight improvement
  III	Moderate	Moderately deep fold Visible at rest, disappears on stretch	Excellent correction
  IV	Severe	Very long and deep fold Prominent facial feature <2mm fold visible on stretch	Significant improvement
  V	Extreme	Extremely long and deep fold Detrimental to facial appearance 2–4mm visible fold on stretch	Unlikely to have satisfactory correction
  Abbreviation: NLF, nasolabial fold.