Creases and Coarse Rhytids

BACKGROUND

Creases and coarse rhytids are both manifestations of the aging process but have markedly different etiologies and treatment paradigms. Coarse rhytids are mostly secondary to solar elastosis, and repetitive muscular activity, whereas creases or folds are a complex end result of bony resorption and remodeling, volumetric changes in the facial fat compartments resulting in soft tissue repositioning and relative tissue excess. Although most patients display both signs in the aging face, creases and folds are more ubiquitous, as they generally occur secondary to intrinsic aging with or without sun exposure. Both entities will be discussed separately throughout this chapter.

PRESENTATION

Deep folds typically manifest in the nasolabial and melolabial regions starting in the third and fourth decades of life depending on the skin type. As aging progresses, and with muscular activity, deep creases may also present in the forehead, periorbital region, and the buccal areas.

DIAGNOSIS

Histopathology

In general, in aged skin, collagen bundles become thinner, widely separated, and haphazardly arrayed. The lateral cohesiveness between individual collagen fibrils inside a given bundle is also less compact. The dermal elastic fibers become disorganized, and proteoglycans may be decreased.²

Coarse Rhytids

Photoaging is present in coarse rhytids and characterized by dermal elastosis with loss of the regular network of collagen bundles. Also present is an accumulation of basophilic material in the upper reticular dermis corresponding to abnormally overgrown elastic fibers containing a combination of microfibrils embedded in a bulk of amorphous elastin. Immunohistochemistry reveals antibodies directed to fibrillin, decay-accelerating factor, serum amyloid proteins, recombinant tropoelastin, lysozyme, and immunoglobulins. Enlarged knotted elastotic masses and elastin breakdown are seen, accompanied by macrophages and dermal dendrocytes. The relative proportion of collagen types is altered.²

Coarse rhytids also demonstrate atrophy of the collagen bundles in the reticular dermis and in the connective tissue strands partitioning the hypodermis. They are associated with impaired mechanical properties, including increased extensibility and unfolding capacity and decreased elasticity.²

Permanent rhytids in photoaged skin show hypertrophic elastosis accompanied by collagen atrophy. Thick and compact solar elastotic material forms a cobblestone-like pattern. The accumulation of actinic elastosis is markedly increased below the permanent wrinkles compared with the reducible wrinkles.²

Creases and Folds

Dynamic expression lines’ anatomical support is in the hypodermal connective tissue strands harboring fascicles of muscle cells. In permanent dynamic rhytids or creases following repeated contractions exerted at these sites, collagen and vertically inserted elastic fibers detach underneath the dermoepidermal junction (DEJ) and papillary dermis (elastin-DEJ connection loss).³

Gravitational folds’ main structural changes consist of a loosely remodeled fibrous network in the hypodermis. The same phenomenon occurs in flexural lines created by body posture.²

Subtypes

Primary Classification

Coarse Rhytids. Coarse rhytids typically manifest as deep rhytids in areas where there is a major contribution from photodamage as well as repeated muscular activity. These tend to be distributed in the forehead and periorbital and buccal regions.

Creases and Folds. Creases and folds occur secondary to laxity and muscular movement. Areas affected include nasolabial and melolabial folds, jowls, and the lower cheek area.

Alternative Classification

Static Rhytids. Static rhytids are present at rest in the absence of muscular movement. Such rhytids are more responsive to laser or filler procedures.

Dynamic Rhytids. Dynamic rhytids are seen with muscular movement and are more amenable to botulinum toxin injections.

Grading Systems

The Fitzpatrick and Glogau scales (Tables 4.1.1 and 4.1.2) have been in use for decades whereby grades group the severity of rhytids together with other facets of photoaging such as elastosis; the Alexiades grading scale (Table 4.1.3) subdivides rhytids, laxity, and the various categories of photoaging into individual clinical findings so that each sign of aging may be scored independently.

TABLE 4.1.1 Fitzpatrick Scale²¹

Class	Wrinkling	Score	Elastosis
I	Fine wrinkles	1-3	Mild: fine textural changes with subtly accentuated skin lines
II	Fine to moderate-depth wrinkles, moderate number of lines	4-6	Moderate: distinct popular elastosis (individual papules with yellow translucency under direct lighting) and dyschromia
III	Fine to deep wrinkles, numerous lines with or without redundant skin folds	7-9	Severe: multipapular and confluent elastosis (thickened yellow and pallid) approaching or consistent with cutis rhomboidalis

TABLE 4.1.2 Glogau Scale²²

Group	Severity	Skin Characteristics
I	Mild	Little wrinkling or scarring and no keratoses
II	Moderate	Early wrinkling, mild scarring, and sallow color with early actinic sallow color with early actinic keratoses
III	Advanced	Persistent wrinkling, discoloration with telangectasias and actinic with telangectasias and actinic keratoses
IV	Severe	Wrinkling—superficial to deep actinic keratoses ± skin cancer

PATHOGENESIS

Coarse Rhytids

Facial aging is a complicated process in which both intrinsic and extrinsic factors lead to changes in physiologic function and loss of structural integrity. Decreased dermal thickness is the hallmark of extrinsic aging, with accompanying skin laxity and changes in both pigmentation and texture.⁴ Chronic ultraviolet exposure and resultant solar elastosis is responsible for 80% of skin aging.⁵ The effects of sun exposure are many, including a dramatic decrease in collagen and an alteration of the extracellular matrix (ECM). The ECM is made up of collagen, elastin, and hyaluronic acid (HA); proteoglycans, and glycosaminoglycans.⁶ Support of the ECM is lost with the formation of a disorganized elastic tissue network, and there is a reduction in the production of all components of the ECM.⁷,⁸ Matrix metalloproteinases are responsible for the continual breakdown of collagen but can be downregulated via a stretch receptor in the collagen-forming fibroblasts.⁴,⁶,⁷,⁹ All of these ultrastructural changes lead to physiological changes that result in the appearance of coarse rhytids especially in areas overlying the mimetic musculature. Repetitive facial movements, especially in areas of sun exposure, give rise to the hallmark deep aging lines in the glabella, forehead, and lateral canthal areas.

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