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Abstract and Figures

An increasing number of injectable filler materials for facial wrinkles and folds points to the need for objective measurements of their effectiveness. Patient satisfaction is the goal, but proof of the value of a particular product requires objective measurement. A wrinkle assessment scale was developed as a simple tool for use by plastic surgeons, dermatologists, and aesthetic surgeons who want to assess the changes resulting from injecting filler materials in their patients. By correlating the grade of the wrinkle in the reference photographs with the wrinkle in a patient's face, a classification of 0 to 5 is assigned. Reliability of the scale was assessed by "live" judgment of 76 wrinkles by nine observers. The same rating was given to 92.7 percent of all wrinkles. In a second trial, photographs from 130 wrinkles were presented to eight observers who rated 89.4 percent of all wrinkles equally. A significant correlation of 87 percent was found between subjective ratings and objective wrinkle depth measured by profilometry on 40 silicone impressions. Manufacturers, monitors of clinical trials, health authorities, and most important, patients will benefit from objective data on current and new injectable materials.
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A Classification of Facial Wrinkles
Gottfried Lemperle, M.D., Ph.D., Ralph E. Holmes, M.D., Steven R. Cohen, M.D., and
Stefan M. Lemperle, M.D.
San Diego, Calif.
An increasing number of injectable filler materials for
facial wrinkles and folds points to the need for objective
measurements of their effectiveness. Patient satisfaction is
the goal, but proof of the value of a particular product
requires objective measurement. A wrinkle assessment
scale was developed as a simple tool for use by plastic
surgeons, dermatologists, and aesthetic surgeons who
want to assess the changes resulting from injecting filler
materials in their patients. By correlating the grade of the
wrinkle in the reference photographs with the wrinkle in
a patient’s face, a classification of 0 to 5 is assigned. Re-
liability of the scale was assessed by “live” judgment of 76
wrinkles by nine observers. The same rating was given to
92.7 percent of all wrinkles. In a second trial, photographs
from 130 wrinkles were presented to eight observers who
rated 89.4 percent of all wrinkles equally. A significant
correlation of 87 percent was found between subjective
ratings and objective wrinkle depth measured by profilom-
etry on 40 silicone impressions. Manufacturers, monitors
of clinical trials, health authorities, and most important,
patients will benefit from objective data on current and
new injectable materials. (Plast. Reconstr. Surg. 108: 1735,
The treatment of facial wrinkles, furrows,
and folds has become a major issue in many
offices of plastic surgeons, dermatologists, and
aesthetic surgeons. The judgment of its suc-
cess, however, still depends on the subjective
feelings of the physician and on the positive or
negative perceptions of the patient. Little has
been published on objective measurements of
wrinkles, furrows, and folds, and physicians are
overly dependent on the manufacturers’ infor-
mation and reliability.
New filler substances are developed every
year. Based purely on patient and physician
satisfaction, some manufacturers claim a last-
ing effect of their injectables
without objective
assessment before and after injection. Other
companies are convincing physicians and pa-
tients with preinjection and postinjection pho-
tographs without information on the time in-
terval between pictures.
Furthermore, there is
a difference in long-term quality and persis-
tence of a filler substance in animal experi-
ments and in humans: whether it is implanted
as a bulge under the skin of a rat’s forehead
injected intradermally into a dynamic facial
wrinkle. The onus is on all serious physicians to
objectively evaluate these products before they
become extensively implemented.
A discussion of wrinkles, furrows, and folds is
difficult because there is no commonly ac-
cepted classification or body of terminology
that is based on anatomic, dimensional, or eti-
ologic criteria. Words such as wrinkles, lines,
furrows, and folds are used with heavy reliance
on the intuitive grasp of such terms (Fig. 1).
Superficial wrinkles are associated with tex-
tural changes of the skin surface caused by
intrinsic aging and photoaging of topographi-
cally defined areas. The fine lines of wrinkling
may be discrete at first and then, over time,
become grouped and multidirectional as
noted by Stegman.
Apart from cutis rhomboi-
dalis caused by elastosis, they occur as wrin-
kling in the face or as regional static wrinkles
over the whole body. Wrinkle lines are usually
limited to superficial dermal creasing; thus,
they are amenable to treatments such as chem-
ical peeling, dermabrasion, and laser
Mimetic wrinkles, commonly referred to as
lines (partial thickness) or furrows (full thick-
ness), are the visible effects of deep dermal
creasing caused by repeated facial movement
and expression combined with dermal elasto-
sis. They are therefore perpendicular to the
From the Division of Plastic Surgery, University of California, and FACESplus, Inc. Received for publication September 15, 2000; revised January
5, 2001.
direction of the underlying facial muscles.
They occur with aging as forehead and glabel-
lar lines, nasolabial folds, radial lip lines, mar-
ionette lines, and lines in the corners of the
Glabellar lines result from frequent frown-
ing, and periorbital lines and nasolabial folds
result from smiling. Radial lip and marionette
lines, however, are caused by concomitant
movement of mimetic muscles during chew-
ing. Therapeutically, mimetic wrinkles or fur-
rows do not respond well to resurfacing proce-
dures, but react preferentially to muscle
resection (musculus frontalis, musculus corru-
gator palpebrae), botulinum toxin, or inject-
able skin filler materials.
Folds are the result of overlapping skin
caused by genetic laxity, intrinsic aging, loss of
tone, bony atrophy, gravity, and consequent
sagging. They occur as upper and lower lid
folds in blepharoptosis, as nasolabial folds in
midface sagging, and as horizontal neck folds
in lax skin. The correction of folds requires
tightening procedures such as blepharoplasty,
face lift, or direct skin excision.
tion of the bony skeleton by implants, bone
grafts, or skeletal osteotomies may also be nec-
essary to treat folds in properly selected cases.
Combinations of mimetic wrinkles and folds
are commonly present. For example, a sagging
nasolabial fold may be temporarily eliminated
by manual elevation, exposing a crease or fur-
row in its center.
proposed a classification of peri-
oral and periorbital wrinkling for use in estab-
lishing the effect of laser resurfacing of the
skin (Table I). Fitzpatricks classification was
. 1. Textural changes of the facial skin: (above) wrin-
kling, (center) mimetic wrinkles, and (below) folds.
Fitzpatricks Classification of Facial Wrinkling (Perioral
and Periorbital)
Class Score Wrinkling Degree of Elastosis
I13 Fine wrinkles Mild (fine textural changes
with subtly accentuated skin
II 46 Fine to moderate
depth wrinkles,
moderate number
of lines
Moderate (distinct papular
elastosis, individual papules
with yellow translucency,
III 79 Fine to deep
numerous lines,
with or without
redundant skin
Severe (multipapular and
confluent elastosis,
thickened yellow and pallid
cutis rhomboidalis)
,November 2001
directed toward generalized wrinkling and
elastosis rather than specific wrinkle depth.
Wrinkle depth analysis, which is not accounted
for by the Fitzpatrick scale, is a more important
measurement when considering wrinkle aug-
mentation with injectable fillers. Glogau
proposed a classification consisting of type I
(no wrinkles), type II (wrinkles in motion),
type III (wrinkles at rest), and type IV (only
wrinkles). These classifications are confined to
generalized wrinkles and do not address spe-
cific mimetic wrinkles or folds.
The only classification to include facial wrin-
kles, furrows, and folds was published by Ham-
A choice of appropriate therapy results
simply from categorizing the patients prob-
lems with this comprehensive and easily under-
standable chart (Table II). However, this clas-
sification, oriented toward treatment selection,
provides no scale to objectively measure the
outcome of treatment.
The first attempts to use quantitative meth-
ods have been described only recently
developed for the assessment of facial skin re-
juvenation after laser treatment of wrinkles.
Negative silicone rubber replicas of facial wrin-
kles were measured directly by use of a simple
light microscope, a technique confirmed by
electron microscopy.
Replicas have also been
converted into hard, positive epoxy resin im-
A mechanical or optical profilome-
was then used along with an image-
analyzing computer to measure wrinkle
These measurements were confined
to superficial wrinkles only, not facial furrows
or folds.
To develop a scale for the assessment of skin
fillers used in the treatment of facial mimetic
wrinkles or furrows, our goal was to determine
whether a photographically based classification
of mimetic wrinkles could be used reliably and
consistently by clinicians and to determine
whether this classification correlated with mea-
surement of wrinkle depth as determined by
profilometry on negative silicone replicas of
facial wrinkles.
A review of the literature
and current
practice revealed that there is not an appropri-
ate classification system for deep facial wrinkles
. 2. Anatomic reference points for assessment and
measurement of wrinkle depth. If the deepest point of the
wrinkle is outside of this point, it can be marked or described
separately. HF, horizontal forehead lines; GF, glabellar frown
lines; PO, periorbital lines; PA, preauricular lines; CL, cheek
lines; NL, nasolabial folds; UL, upper radial lip lines; LL, lower
radial lip lines; CM, corner of the mouth lines; ML, mario-
nette lines; LM, labiomental crease; NF, horizontal neck folds.
Hamiltons Classification of Contour Changes of Facial Skin
Morphology Tissue Location Clinical Location Etiology Optimal Treatment
A Folds Muscular Nasolabial folds,
neck, eyelids
Loss of tone, gravity Rhytidectomy, blepharoplasty
B Furrows Musculocutaneous Forehead, smile lines Repeated facial expressions Filler substances, injectables, implants
C Wrinkles Cutaneous Cheeks, crows feet,
Intrinsic aging, photoaging Resurfacing, laser, chemical peel
D Combination Combined approach
Vol. 108, No. 6 /
and folds. Objective measurements, however,
are necessary to rate the effect of treatments
with injectable materials. In daily practice, a
simple look at a reliable reference scale would
enable clinicians to classify the deep mimetic
wrinkles and folds on a patients face.
Wrinkle Assessment Scale
From hundreds of pictures taken from ran-
domized patients in the first authors practice
(G. Lemperle), one reference photograph was
selected for each class (0 to 5) of facial wrinkles
from 11 different regions (Fig. 2). As a result,
reference picture sheets were created (Figs. 3
through 13) for use in validating the reliability
of photographic classification.
For this study,
four of the regions were selected: right-side
and left-side glabellar lines, right-side and left-
side radial upper lip lines, right-side and left-
side nasolabial folds, and right-side and left-
side marionette lines.
The photographs of the Wrinkle Assessment
Scale were used livein direct comparison
with the corresponding wrinkle or fold in the
. 3. Wrinkle Assessment Scale of horizontal forehead lines.
,November 2001
patients face or indirectlyby comparing a
patients photograph with the pictures of the
scale. The assessment was always made at
the same location by use of anatomic land-
marks (Fig. 2). Horizontal forehead lines were
measured at their intersection with the vertical
pupillary line. Glabellar frown lines were mea-
sured at the level of the upper border of the
eyebrows. Periorbital lines were measured 1.5
cm lateral to the lateral canthus. Preauricular
lines were measured at the level of the lower
groove of the tragus. Nasolabial folds were
measured midway between the alar rim and
corner of the mouth (upper nasolabial) and at
the level of the corner of the mouth (lower
nasolabial). Cheek lines were also measured at
the level of the corner of the mouth. The
corner of the mouth lines were measured 5
mm below the commissure. Radial lip lines
were measured 2 mm above or below the ver-
milion border. Marionette lines were mea-
sured midway between the corner of the
mouth and the border of the lower jaw. The
labiomental crease and the neck folds were
measured in the midline.
In the case of multiple wrinkles as in an
upper lip, only the deepest wrinkle was as-
sessed and marked on the photograph or a
. 4. Wrinkle Assessment Scale of glabellar frown lines.
Vol. 108, No. 6 /
chart for later reference. In cases of asymme-
try, the wrinkles of the right and left upper lip
were assessed separately. The depth of the
wrinkle at its reference point (Fig. 2) was con-
sidered and compared, not its length or over-
lapping skin fold. Some elderly patients have a
pronounced skin fold or redundancy of skin
rather than a wrinkle or crease in the dermis.
In such cases, only the wrinkle was classified. If
it was not evident whether to rate a wrinkle as
a class 3 or class 4, for example, it was rated as
a class 3.5. All ratings were noted on a special
classification sheet (Fig. 14).
Silicone Impressions
A Kerr gun with silicone double cartridges
and mixing tips (Kerr Extrude Wash No.
28418, Kerr Corp., Romulus, Mich.) was used
for making the impression molds. The double
cartridges containing blue silicone fluid and a
hardener were fixed to the gun, the mixing tip
was applied, and the silicone was mixed with
the hardener filled up to the tip. The patients
face was fixed in a horizontal position and all
makeup was removed from the wrinkles.
The low viscosity of the elastomer coupled
. 5. Wrinkle Assessment Scale of periorbital lines.
,November 2001
with its hydrophobic properties promotes its
penetration into all irregularities of the skin.
The crease was filled with blue silicone in its
full length with one stroke from the gun to
prevent air bubbles. A landmark of the face
such as inner eye brow, alar base of the nose, or
corner of the mouth was included in the im-
pression mold.
An ordinary tissue cassette for histologic
preparations or a perforated Aquaplast splint,
a21 inch section cut from a
sheet (A 962-50, Smith and Nephew, German-
town, Wis.), was pressed gently into the still soft
silicone impression until half of its holes were
filled with blue silicone. The silicone polymer
hardens within 1 minute. Therefore, a new
mixing tip was used for each patient.
After 1 minute of polymerization, the im-
pression was removed together with the adher-
ent splint without touching the ridge of the
furrow. A transparent tape was pressed to the
back of the splint and the patient’s initials,
date, side, and wrinkle abbreviation (see Table
III) were recorded with a permanent marker. A
. 6. Wrinkle Assessment Scale of preauricular lines.
Vol. 108, No. 6 /
black line was drawn to indicate the highest
point for profilometry, and this point was
also marked on the patients photographic
Wrinkle Metrology
Measurements of wrinkle impressions were
made using a stylus profiler (Surfanalyzer 5000
Surface Analysis System, Federal Products Co.,
Providence, R.I.). This instrument uses a dia-
mond ball-tipped stylus mounted to a linear
variable differential transducer with a counter-
balanced downward force of 200 mg. The sty-
lus/transducer assembly is mounted to a pre-
cision reference bar that is straight to within
25 nm over a traverse of 25 mm. The vertical
resolution of the transducer is 25 nm. Thus,
the sample surface being traversed by the
stylus is compared with the reference bar
surface. The peaks and valleys of the sample
surface are displayed as distance versus
height (Fig. 15).
On the drawing of the wrinkles profile on a
graph paper, the deepest points of the skin
. 7. Wrinkle Assessment Scale of cheek folds.
,November 2001
surface on both sides of the wrinkle were lo-
cated and connected, and the depth of the
wrinkle was measured perpendicular to this
line (Fig. 14).
Live Ratings
The first test of the Wrinkle Assessment Scale
was made by nine observers (three plastic sur-
geons, three aesthetic surgeons, and three der-
matologists) who were asked to judge the
depth of 76 mimetic wrinkles on the faces of 32
colleagues during a plastic surgery meeting in
Cyprus in 1999. Using the reference photo-
graphs depicting the Wrinkle Assessment Scale
(Figs. 4 and 8 through 10), 689 individual rat-
ings of wrinkle depth were made on the faces
of these 32 colleagues (Table IV).
Interobserver variation occurred in 50 of 689
wrinkles; 92.7 percent of the wrinkles got the
same ratings (Table IV). The variations in the
ratings of three plastic surgeons, three aes-
thetic surgeons, and three dermatologists
showed no significant differences: 6.5 percent,
. 8. Wrinkle Assessment Scale of nasolabial folds.
Vol. 108, No. 6 /
6.9 percent, and 8.8 percent of the wrinkles
were rated differently from the majority of the
observers. A difference of two classes was rated
in only three of the 50 ratings in which observ-
ers differed.
Photographic Ratings
The next test of the wrinkle scale was per-
formed on 130 different mimetic wrinkles by
eight independent observers (four plastic sur-
geons, four lay persons). The wrinkles were
marked with an arrow at their deepest point.
With the aid of the photographic Wrinkle As-
sessment Scale (Figs. 4 and 8 through 10), the
eight observers were asked to score the depth
of each of the 130 wrinkles. There was an 89.4
percent agreement among the eight observers
in their classification of wrinkle depth using
the Wrinkle Assessment Scale (Table V).
To determine whether the Wrinkle Assess-
ment Scale correlates with the measurement of
wrinkle depth as determined by profilometry,
40 negative silicone impression replicas were
measured (Figs. 16 and 17) and compared with
. 9. Wrinkle Assessment Scale of upper lip lines.
,November 2001
the photographic ratings by the eight indepen-
dent observers (four plastic surgeons, four lay
persons) of the same wrinkles. There was an
87.0 percent agreement between the impres-
sion mold measurements and the observer rat-
ings with the use of the Wrinkle Assessment
Scale (Table VI).
By listing the average impression depth for
each wrinkle score, a proposed range of wrin-
kle depth was defined for each wrinkle score
(Table VII).
Statistical Analysis
The intraclass correlation,
which applies to
the case in which more than two wrinkle types
(eight in this instance) are correlated, was sig-
nificant with a p0.001 in each case. The
magnitude of intraclass correlations ranged
above 0.80; the correlation is considered highly
significant when greater than 0.70 to 0.80.
The Wrinkle Assessment Scale was an easy,
consistent, and reliable tool for the assessment
of deep facial wrinkles. The scale correlated
well with an objective profilometry measure-
ment of the wrinkle depth.
The most accurate description of the photo-
graphed lines and creases in our wrinkle scale
. 10. Wrinkle Assessment Scale of corner of the mouth lines.
Vol. 108, No. 6 /
is probably furrows, not folds or wrinkles. How-
ever, furrows is not a commonly used and un-
derstood term, hence our rationale behind the
selection of mimetic wrinkles to differentiate
these deeper wrinkles, furrows, or creases from
generalized elastosis or folds. The etiology of
mimetic wrinkles or furrows is rather simple
and does not differ from that of the wrinkles or
creases in the fabric of ones gloves or shoes.
Smooth when new, the fabric develops grooves
at sites of long-sustained stress. There is no
chemical or architectural alteration, purely a
conformational change.
Wrinkles occur with
relaxation of the skin caused by receding pa-
pillae and degeneration of elastic and collagen
fibers at the dermal-epidermal junction. This
degeneration starts as early as age 30 and in-
creases with time, regardless of care and
The thickness of the living dermis can be
determined by either ultrasound
or xerora-
diographic technique. Skin thickness increases
linearly up to the age of 20 years and decreases
linearly with age subsequently. Depending on
race, genetics, and location of measurement,
the thickness of the dermis will vary. For exam-
. 11. Wrinkle Assessment Scale of marionette lines.
,November 2001
ple, dermal thickness in the medial forearm
varies from 0.6 to 1.0 mm in women and from
0.8 mm to 1.2 mm in men. In the lateral arms
or legs, Tan et al.
found a mean dermal thick-
ness of 1.32 mm, on the chest of 1.62 mm, and
on the back of 2.50 mm.
In the face, the dermal thickness increases
from lids (~ 0.2 mm), to corners of the mouth
(~0.4 mm), to nasolabial folds (~ 0.6 mm), to
forehead and glabellar dermis (~0.8 mm).
For comparison, a 30-gauge needle has an
outer diameter of 0.3 mm, and a 26-gauge
needle has a diameter of 0.45 mm.
The Wrinkle Assessment Scale is intended to
bring objective and comparable measurements
into the field of aesthetic medicine. Aside from
the standard of collagen injections, new injec-
tion or filler alternatives arrive on the market
every 6 months. Other resorbable filler mate-
rials such as hyaluronic acids (Restylane,
), autologous collagen (Autologen
allogeneic collagen matrix (Dermalogen,
. 12. Wrinkle Assessment Scale of the labiomental crease.
Vol. 108, No. 6 /
), dextran microspheres (Revi-
derm), polymethylacrylate particles (Der-
malive), and others have gained increased pop-
ularity. All claim to last longer than collagen,
but none have shown any statistically convinc-
ing proof. On the other hand, long-term per-
sistence of artificial products (Artecoll,
form) may also cause problems after poor
placement and subsequent dislocation.
The Wrinkle Assessment Scale should be an
excellent tool in the hands of every aesthetic
surgeon or dermatologist to objectively assess
the short-term and long-term effects of an in-
jected product and to establish a real price-
value relationship for patients.
Gottfried Lemperle, M.D., Ph.D.
302 Prospect Street
La Jolla, Calif. 92037
We are indebted to Paul Clopton, M.S., Research Service,
VA Medical Center, San Diego, Calif., for his invaluable sta-
tistical work. Joe de Lellis, Senior Engineer at San Diego
Magnetics, San Diego, Calif., performed the measurements of
the impression molds.
. 13. Wrinkle Assessment Scale of horizontal neck folds.
,November 2001
. 15. The Surfanalyzer provides a profile of each im-
pression mold. The depth is measured from a baseline con-
necting the adjacent skin surface.
. 16. Silicone impressions of a glabellar fold before second
treatment and 6 weeks and 3 months after a second treatment.
. 17. The depth of three impressions molds after three
treatments of the same glabellar fold measured by CEREC
computer imaging.
Classification of Facial Wrinkles
Facial Wrinkle Class Description
Horizontal forehead lines
Glabellar frown lines
Periorbital lines
Preauricular lines 0 No wrinkles
Cheek lines 1 Just perceptible wrinkle
Nasolabial folds 2 Shallow wrinkles
Radial upper lip lines 3 Moderately deep wrinkle
Radial lower lip lines 4 Deep wrinkle, well-defined edges
Corner of the mouth lines
5 Very deep wrinkle, redundant fold
Marionette lines
Labiomental crease
Horizontal neck folds
Significance of the LiveStudy of 689 Ratings of 76
Wrinkles by Nine Observers
Wrinkles Different Ratings Percentage Significance
Glabellar frowns 11 out of 191 5.8 p0.001
Nasolabial folds 14 out of 192 7.3 p0.001
Radial lip lines 5 out of 114 4.4 p0.001
Marionette lines 20 out of 192 10.4 p0.001
TOTAL 50 out of 689 7.3 p0.001
No lip lines grade 0 were excluded.
Intraclass Correlations in the Wrinkle Assessment Scale
According to the Ratings of Eight Observers of 130 Facial
Wrinkles on 80 Photographs*
Wrinkles nMean SD Intraclass Correlation
Glabellar frowns 20 2.872 1.538 0.828
Nasolabial folds 40 2.451 1.293 0.921
Radial lip lines 30 1.762 1.281 0.904
Marionette lines 40 2.098 1.211 0.923
TOTAL 130 2.250 1.342 0.894
* There is 89.4 percent agreement among the eight observers.
. 14. Masked observers classification sheet of the four
most bothering lines.
Vol. 108, No. 6 /
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Validation of the Wrinkle Scale in Comparison with the
Measurements from Silicone Impressions of Facial
Wrinkle Score I
Mean Depth of
Proposed Margins
1 0.115 0.20
2 0.225 0.210.30
3 0.320 0.310.40
4 0.460 0.410.50
5 0.565 0.51
1 0.060 0.20
2 0.290 0.210.40
3 0.485 0.510.60
4 0.650 0.610.80
5 0.940 0.81
1 0.140 0.20
2 0.300 0.210.40
3 0.450 0.410.60
4 0.575 0.610.80
5 0.840 0.81
Radial lip
1 0.100 0.10
2 0.150 0.110.20
3 0.295 0.210.30
4 0.350 0.310.40
5 0.415 0.41
Intraclass Correlations between Wrinkle Measurement on
40 Impression Molds and Judgments from Photographs of
the Same Wrinkles
Molds nMean Ratings SD
Glabellar frown 10 2.337 1.264 0.828
Nasolabial folds 10 2.637 1.314 0.872
Radial lip lines 10 2.097 1.278 0.884
Marionette lines 10 2.423 1.541 0.828
TOTAL 40 2.380 1.309 0.870
,November 2001
... The outcome considered was the classification of the Lemperle Wrinkle Assessment Scale (WAS). [29] In the study by Sylvie Boisnic, [30] the authors observed that the Lemperle score decreased in both groups after 12 weeks of treatment with a reduction of 1 (±0.7) point in the experimental group and 0.34 (±0.5) point in the placebo group and a statistically significant (P < .0002) ...
... The evaluation of wrinkles will be carried out in a standardized way using the WAS. [29] This scale was developed and validated to quantify facial wrinkles based on predefined photographic models. To take photographs of the face, the participants will sign the image authorization term for use in the research and must be without any type of makeup. ...
... The images obtained will be edited and standardized to be evaluated by the specialists according to the WAS. [29] All images will be stored on a virtual disk which only the researcher will have access using a password. The images will be distributed later to the 3 plastic surgeons who will classify them according to the scale of wrinkles and photographic models pre-defined. ...
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Introduction: Skin aging is an irreversible, slow and progressive process, mainly influenced by age, but also by external factors such as ultraviolet radiation, smoking, and alcohol, among others. It is increasingly common to look for procedures that slow down skin aging by limiting or hiding its effects on appearance. Studies have shown the benefits of photobiomodulation (PBM) for the skin, especially with the use of red light-emitting diodes. However, there is a high level of variability in the treatment parameters and frequency of application. Methods and analysis: The objective of this study is to compare the effects of PBM with a light-emitting diode mask (660 nm, 6.4 mW/ cm², 8,02 J/ cm², 5.02 mW, 21 minutes) on facial rejuvenation using 2 frequency applications for 4 weeks: one group will receive PBM application on the face, twice a week and another group will receive PBM application 3 times a week. A group with simulated PBM applied twice a week for 4 weeks will be used as a control. The treatment will be performed on female participants aged between 45 and 60 years. After 4 weeks, evaluations of photographic images by specialists (Wrinkle Assessment Scale) as well as the quantitative analysis of the wrinkle size by the Image J software, the depth and width of wrinkles (assessment of face impressions by optical coherence tomography) and the level of Satisfaction with Facial Appearance Overall will be compared with data collected before the start of the study. All data will be analyzed statistically according to their distribution, seeking a level of statistical significance of 0.05. Ethics and dissemination: This protocol was approved by the Research Ethics Committee of the Nove de Julho University (acceptance number: 4.365.565). This trial has been registered in (ID: NCT04911140). This study is recruiting.
... Since, age estimation and age-invariant face recognition are conventionally handled as learning tasks, this factor therefore affects them as well. As much as research in psychology, face anthropometry and plastic surgery (George and Hole, 1995;Lemperle et al., 2001;Ramanathan and Chellappa, 2006b; M. G. Rhodes, 2009) has identified certain parts of the face from which useful age and identity cues could be extracted and several local and global face descriptors have also been proposed for this purpose (Ahonen et al., 2006;, there is no certainty of the exact type or amount of information available from such facial parts. Thus, the amount and type of features that are relevant to and sufficient for learning ageing and identity remains a question. ...
... Thus, a wide range of research efforts have been directed towards obtaining these kind of information from the face. Some of the research areas which have investigated these include Psychology (Fölster et al., 2014), Psychophysics (Pittenger and Shaw, 1975;Todd et al., 1980), Plastic Surgery (Lemperle et al., 2001) and Computer Vision (Kwon and Lobo, 1999). While most of the aforementioned research areas investigate the ability of humans to effectively obtain these 17 biometrics (age, gender, race, expression, identity and so on) from the face, Computer Vision research is concerned with automating these processes that is enabling the computer determine these biometrics with optimal accuracy based on input face. ...
... Twelve (12) facial wrinkle regions were identified in Lemperle et al., (2001) and in Choi et al., (2011), nine (9) of these were selected for use along with three (3) other regions characterized by their extent of exposure to Ultraviolet (UV) rays from the sun. The periocular region of the face that is the upper part of the face containing the eyes and nose region, have also been shown to give significant performance improvement over the whole face (Juefei- Xu et al., 2011;Lanitis, 2002). ...
Ageing is an uncontrollable process of human life, which introduces noticeable changes in different parts of the body, including the face. Age-Invariant Face Recognition (AIFR) is the task of recognising an individual across different age-separated faces, while age estimation involves determining the age of an individual from the given face image. Research has shown that a major challenge has been the uncertainty of what constitutes the set of facial features that are sufficiently relevant to age and identity as well as low-dimensional features often difficult to represent. This has limited the discriminatory power and reproducibility of features used in age estimation and AIFR algorithms, consequently imparting negatively on their accuracy. Therefore, this study aimed at developing improved age estimation and AIFR models to capture and represent low-dimensional, discriminatory and reproducible facial features. The study was conducted on publicly-available standard datasets (FG-NET with 1002 images of 82 individuals and Lifespan with 1046 images of 575 individuals) and one local dataset (FAGE with 540 images of 363 individuals) collected purposively for this study. A Multi-Stage Post-Detection (MSPD) algorithm was developed for enhancing face detection and alignment of input images. Raw image pixels and Local Binary Patterns (LBP) features were extracted from face regions and compressed with a Features Compaction (FC) algorithm. Age-Group Ranking (AGR) model was used to establish the correlation of each image with each age group and to encode it. The similarity Scoring (SS) model facilitated the disparity of each face from each individual. Support Vector Regressor and Support Vector Classifier with radial basis function kernel were used as age and age-invariant identity learners, respectively. The developed age estimation and AIFR models were trained and tested with 5-fold and Leave-One-Person-Out cross validation protocols on FG-NET, Lifespan and FAGE datasets. Standard evaluation metrics such as Mean Absolute Error (MAE) and Recognition Accuracy (RA) were used to evaluate the performance of the age estimation and AIFR models. Equations were derived for the AGR and SS models to realize the features vectors, the age-group rank, the ranked features vector, and the deviation of feature values. On the basis of MAE, the best performances for MSPD, FC and AGR for age estimation were 8.41, 8.52 and 2.22 years, while the performance on the basis of RA for MSPD, FC and SS for AIFR were 98.4%, 96.1% and 98.3%, respectively. Overall, the best MAEs of 1.69, 1.72 and 3.25 years were obtained on FAGE, FG-NET and Lifespan, respectively. The best RA of 97.0% was obtained on FG-NET and 99.5% on FAGE. These MAEs indicated the ability of the AGR model to improve age estimation accuracy, while the RAs indicated improved disparity measurement of the SS model. The age estimation and age-invariant face recognition models provided low-dimensional and sufficient discriminatory features with reproducible effects, which enhanced effective age estimation and age-invariant face recognition accuracy.
... Glogau classification of photoaging menilai derajat penuaan yang disebabkan oleh photoaging. 12 Fitzpatrick wrinkle assessment scale menilai kerut wajah secara umum disertai elastosis. 12 Global aesthetic improvement scale (GAIS) membandingkan penampilan estetika secara global dibandingkan dengan sebelum perawatan. ...
... 12 Fitzpatrick wrinkle assessment scale menilai kerut wajah secara umum disertai elastosis. 12 Global aesthetic improvement scale (GAIS) membandingkan penampilan estetika secara global dibandingkan dengan sebelum perawatan. 13 Fitzpatrick mengajukan sistem yang dikenal sebagai MFWS untuk klasifikasi NLF yang terdiri dari beberapa kelas untuk menilai tingkat kerut. ...
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Latar Belakang: Penuaan merupakan kondisi yang tidak dapat dihindari yang terjadi sejak lahir dan terus berlangsung sepanjang hidup. Meningkatnya kebutuhan masyarakat dalam menjaga penampilan, bervariasinya kebutuhan dan kondisi tiap individu, serta beragamnya efek samping yang dapat ditimbulkan dari intervensi yang telah ada, menuntut upaya terus menerus dalam mengembangkan teknik peremajaan kulit. Berikut akan dipaparkan mengenai peran terapi akupunktur pada rejuvenasi wajah. Tujuan: Mengetahui peran terapi akupuntur pada rejuvenasi wajah. Pembahasan: Akupunktur menunjukkan efek positif pada rejuvenasi wajah dengan efek samping yang cukup dapat ditoleransi. Akupunktur berperan mencegah penuaan melalui mekanisme antiinflamasi, pencegahan degradasi kolagen dan peningkatan produksi kolagen. Kesimpulan: Akupunktur terbukti efektif dalam rejuvenasi wajah dengan modalitas yang paling banyak digunakan adalah akupunktur manual dan akupunktur tanam benang. Akupunktur dapat menjadi salah satu intervensi pilihan pada rejuvenasi wajah.
... Expert grading is carried out by a professional (dermatologist, make-up artist, hairdresser, etc.) on a variety of characteristics [26][27][28]. Digital pictures of the test area should be taken under standard and reproducible light conditions. ...
... Penilaian kerutan wajah dinilai dari 11 regio wajah yang berbeda. Tingkat keparahan kerutan terbagi menjadi enam dengan masing-masing foto referensi untuk setiap tingkat dan lembar klasifikasi penilaian yang dapat dilihat pada Tabel 4. Bila terdapat beberapa tingkat keparahan kerutan pada satu regio maka kerutan dengan lekukan terdalam yang diambil untuk penilaian.18 ...
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Seiring dengan bertambahnya usia seseorang, kulit sebagai jaringan terluar dari tubuh manusia akan memberikan gambaran paling terlihat dari proses penuaan. Penuaan kulit dipengaruhi oleh dua faktor yaitu faktor intrinsik dan faktor ekstrinsik. Faktor intrinsik terjadi secara alamiah dan berkaitan dengan proses degenerasi seluler. Faktor ekstrinsik berkaitan dengan pajanan sinar matahari, rokok, dan polusi udara. Penyebab utama penuaan kulit akibat faktor ekstrinsik berupa pajanan kronik sinar ultraviolet dikenal sebagai photoaging. Tanda klinis photoaging dapat bervariasi, namun yang sering ditemukan berupa perubahan pigmentasi dan keriput. Saat ini telah tersedia lebih dari 100 instrumen penilaian penuaan kulit menggunakan fotografi, dermoskopi, dan alat diagnostik multifungsi namun masih belum ada yang dianggap sebagai baku emas. Tinjauan pustaka ini bertujuan untuk membahas berbagai instrumen penilaian photoaging yang sering digunakan dalam praktik klinis sehari-hari dan karakteristik dari masing-masing instrumen tersebut.
Background: Wrinkling is the hallmark of skin aging. We previously reported that perioral wrinkling is more severe in females; however the molecular basis is unknown. Objective: This study assessed sex differences in the molecular expression of key aging regulators in perioral skin. Methods: 12 subjects (n=6 male/female) were enrolled in this cross-sectional study and biopsies were taken from the perioral and periocular region. RNA expression of collagen I, collagen III, cysteine-rich angiogenic inducer 61 (CYR61), and insulin like growth factor 1 (IGF-1) was assessed by qPCR. Results: There was no difference between females' and males' Griffith's grades (6.67 and 5.67 respectively, p=0.096) or periocular wrinkling grades (3.2 and 2.6, p=0.421), but females had more severe perioral wrinkling grades than males (6.2 and 2.8, p=.0.035). Females expressed significantly more CYR61 (p=0.018) than males, but also expressed more collagen III (p=0.016). There was no difference in collagen I (p=0.115) or IGF-1 (p=0.124) expression between sexes. In the periocular region, there were no significant differences between sexes in the expression of all four markers. Conclusion: The significant molecular differences in the perioral region between the sexes may contribute to the greater perioral skin wrinkling seen clinically in females.
Background: Hyaluronic acid presents a valuable cosmetic ingredient that occurs naturally. Its direct links to skin aging has led to its broad application. The aim of this study was to improve the cosmetic efficacy of high molecular weight hyaluronic acid (HMWHA) without chemical modifications and evaluate such improvements through clinical and in vitro studies. Methods: A novel formulation of HMWHA (SCAI-HA) was prepared and investigated to comparatively assess 6 clinical and 2 in vitro parameters concerning its dermatological cosmetic efficacy and biological properties. The dermatological and cellular parameters examined in this study include skin hydration, transepidermal water loss (TEWL), skin elasticity, wrinkles, facial sagging, dermal density, cytotoxicity, and collagen synthesis. Results: SCAI-HA exhibited the ability to improve the tested dermatological parameters (hydration, elasticity, wrinkles, and density) to magnitudes comparable to those of HMWHA. In addition, SCAI-HA showed notably improved capacities for attenuating facial sagging and TEWL and promoting cellular collagen synthesis in normal human dermal fibroblasts. Conclusion: SCAI-HA presents a novel conformation of HMWHA with improved cosmetic efficacy in mitigating (i) facial sagging, (ii) TEWL, and promoting, and (iii) collagen synthesis. These findings denote the enhancement of SCAI-HA as a cosmetic ingredient with potential anti-aging properties.
Purpose. To evaluate the aesthetic effect of the rehabilitation of edentulous patients, using prostheses on dental implants and injections of hyaluronic acid on perioral wrinkles. Material and methods. In total, we observed 56 patients (women aged 49 to 61 years) with edentulous implantation in the period of 2016–2021. Inclusion criteria: edentulous patients with mild to moderate perioral wrinkles on the Merz Aesthetic Scale (MAS on an approved 5-point scale, where 0 = no wrinkles, 1 – mild wrinkles, 2 – moderate wrinkles, 3 – severe wrinkles and 4 – very strong wrinkles). In order to vitalize (moisturize, increase the elasticity and firmness of the skin), the patients underwent a course of intradermal injections of 1 ml of the Bio Mial Vel preparation for vitalization. Vitalization (vita-s from Lat.: life, revitalization, vitality) means a course of 3-fold administration of SGC gel in order to correct superficial wrinkles. The immediate results were assessed 1 month after the course (M03), and the long-term results - at the 6th month of observation (M06). Results: The long-term X-ray examination of patients (for 1 year or more) revealed an increase in dense bone tissue of the implantation bed. At the same time, an intimate fit of the newly formed bone to the implant was noted, which determined the positive dynamics of the osseointegration process. Compared to the baseline, the average marginal bone loss (MBL) after 6 months of prosthetics is 0.57±0.28, at the end of 1 year – 0.91±0.32, at the end of 3 years –1.27±0.32, and at the end of the 5th year – 1.46±0.64, respectively. On average, over the observation period (58.6±16.4 months), the success rate of implantation was 96.8%. After analyzing the photographs taken before and after a complex and personal conversation with each patient, the following results were obtained: normal wrinkles on the face were smoothed out in 83% of the participants, the oval of the face was tightened in 62% of the participants, the study revealed a large number of positive cosmetic effects. Most patients also showed significant improvement at M12 visit. Conclusions. The results of the study show that the use of implant-rehabilitation and injection therapy with the use of fillers based on hyaluronidase acid increases the effectiveness of treatment, improves skin function, helps to rejuvenate, smoothing wrinkles and skin folds, the face acquires a well-groomed and rejuvenated appearance. The patients were satisfied with the aesthetic and functional result of the treatment.
Objective: This study was undertaken to establish and validate a new wrinkle clinical assessment scale to measure Chinese Han women`s validated lacrimal groove. Methods: Three clinical investigators asked to rate lacrimal groove wrinkles severity one each side for 30 photographic images from 15 subjects. Five-grade rating scale has been used in this clinical assessment. Scale definitions was standardized by 6 researchers in visual and descriptive formats. Assessments were conducted independently and were repeated after 1 week. Results: For 30 photos from 15 subjects, test-retest of three investigators analyzed by Spearman's correlation were between 0.967 and 0.993 (p < 0.001), and by ICC Cronbach's α were between 0.989 and 0.997 (p < 0.001); intraobserver agreement of three investigators analyzed by Spearman's correlation were between 0.652 and 0.897 (p < 0.001), and by ICC Cronbach's α were between 0.840 and 0.959 (p < 0.001). Conclusion: This lacrimal groove wrinkles visual assessment scale is a valid and reliable instrument for quantitative assessment of China woman skin folds with inter- and intraobserver consistency. This assessment scale should prove a useful clinical tool by allowing objective and reproducible grading for assessing the effectiveness of lacrimal groove area.
A Statistical Model for ReliabilitySome Consequences of UnreliabilityThe Simple Replication Reliability StudyThe Control of Unreliability by ReplicationThe Interexaminer Reliability Study
A new tissue augmentation product, made from hyaluronic acid, was clinically evaluated at three clinics in accordance with the new directive, EN 540, for medical implants. One hundred patients were fully assessed following treatments in 285 locations. The treatment was completed when the skin was levelled following one to two injections. At 6 months follow-up of all patients and at 12 months follow-up of a randomized group of the patients all showed that close to 60% of the effect was still there. No serious or permanent adverse events were noted.
In facial aesthetic surgery, we perform operations that may at times have short-lived but positive aesthetic effects. When suboptimal results do occur in aesthetic surgery, for example, with laser skin resurfacing, they may relate less to inadequate execution and more to the failure to eliminate some or all causative factors such as exposure to the sun, poor nutrition, smoking, and hyperfunctional facial musculature. Lines typically occur from muscular contractions in facial expressions that involve a multitude of complex coordinated actions of various facial muscles. Hyperfunctional facial muscular contraction tends to be a long-standing, partially involuntary action. Pretreatment of target areas with botulinum toxin type A (Botox®; Allergan Inc., Irvine, CA) may not only temporarily eliminate the facial lines produced by increased muscular activity, but also may improve the effect of the surgical or laser resurfacing procedure. Pretreatment with Botox® before laser exfoliation may allow for smoother skin resurfacing by eliminating the hyperfunctional component during healing. We now better understand how to treat these facial lines with chemodenervation. In 1992 I reported on the use of botulinum toxin type A not only as a primary treatment for glabellar frown lines but also as a supplemental adjunct for autologous injectable collagen (Autologen®; Collagenesis Inc., Beverly, MA) for soft tissue augmentation in certain facial regions.1 Since then, I have found chemodenervation to be useful as a primary modality to temporarily eliminate facial lines and furrows caused by hyperfunctional muscles and as an adjunct and “fortifier” for a variety of facial aesthetic procedures, including laser skin resurfacing, canthoplasty, brow lifts, and soft tissue augmentation. After several years of experience in CO2 laser skin resurfacing, many of us have come to realize that in spite of excellent execution of skin resurfacing, rhytids tend to recur commonly in very …
Collagen from allogenic and xenogeneic sources has been made soluble by controlled proteolytic digestion. The monomeric, telopeptide-poor collagen so prepared forms a cohesive mass when warmed to body temperature (upon injection), creating a structural basis for new soft connective tissue. We have treated 28 patients with human and/or bovine collagen injections for the correction of soft tissue contour defects, and we have followed them for 3 to 18 months. In most instances, there has been lasting and substantial correction of the defects treated. The complications have been few and transient.
Quantitative techniques for assessing the effects of tretinoin on photo-aged skin mainly involve humans, although hairless mice were used in initial studies. Ideally techniques should be non-invasive but occasionally biopsies have to be taken, especially when studying the effects of tretinoin on different skin compartments. Characteristic features of photo-aged skin, including the development of fine and coarse wrinkles, skin discoloration, rosy cheeks and telangiectasis, have been assessed subjectively using a visual analogue scale. Effects of tretinoin on wrinkle depth have been measured non-invasively by quantifying contours of silicone rubber replicas using either a mechanical tracking device or an optical technique employing an image-analysing computer. Changes in skin colour have been measured using an erythema meter and the stimulatory effect of tretinoin on blood flow has been established by laser doppler flowmetry. Skin thickness has been measured non-invasively using pulsed A-scan ultrasound which showed that tropical tretinoin increased thickness. Biopsies have also been used but no changes in the thickness of the dermal repair zone have been noted in humans, in contrast to the situation in hairless mice. Epidermal dysplasia has been measured by a visual analogue scale or by objective image analysis.
Facial fine lines and wrinkles can be faithfully captured by silicone rubber impression materials. Computerized digital image processing of such specimens provides objective measurement of the skin's topography, which has a significant degree of correlation with clinical grading. Optical profilometry provides a dimension of objectivity that can complement clinical assessment in the study of agents that may be useful in the therapy of photodamaged skin.
This article describes how computer models of the skin can be used to obtain objective information about surface-altering events. Although alterations produced by various forms of therapy are being emphasized, more needs to be known about alterations produced by aging, environmental factors, and disease. The term "automated optical surfometry" has been applied to the method described in this chapter. (The term "optical profilometry" has also been used. Because this designation was applied at an earlier time to a method that is entirely different, the use of the word "optical surfometry" appears to be preferable as well as more accurate). Space limitations made it possible to allude only briefly to some of the other techniques that are being used to learn more about the configuration and dynamics of the surface of the skin. The development of imaging and modeling methods for topographic studies of the skin owe their origins in large measure to the advent of inexpensive computer technology.