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The desire to maintain or restore a youthful appearance has become a significant concern for many people in today’s world. Evidently, “wrinkles” are considered one of the major obstacles in this arena. In 2004, Botox Cosmetic™ injections were shown to be the most often performed cosmetic procedure in the United States.1 Cutaneous wrinkles, defined as furrows or ridges on the skin surface, appear to be multifactorial in etiology and a consequence of intrinsic and extrinsic aging (discussed in Chapter 6). While genetic predisposition is an important factor in developing wrinkles, engaging in particular life style behaviors such as excessive sun exposure and smoking are also known causes of cutaneous aging (see Chapter 6). This chapter will concentrate on wrinkles not caused by sun exposure but, rather, by intrinsic aging. Treatment approaches focus more on the condition itself, but also address behavioral elements pertaining to extrinsic aging.


Aging is a process that occurs in all organs, but is most visible in the skin. The skin may very well reflect or act as an outward sign of processes occurring in the internal organs. In fact, the amount of facial wrinkling has been shown to correlate with the extent of lung disease in COPD.2 The naturally-occurring functional decline of organs with age can be exacerbated by environmental factors, but there is certainly a genetic component that influences the aging process. Little is known at this point about the genetics of skin aging except for the genes that have been implicated in premature aging syndromes such as Werner’s syndrome3 (Table 19-1). Mammalian cells can undergo only a certain number of cell divisions before replicative senescence occurs and they are no longer able to divide.6 This may be nature’s way of preventing these cells from becoming cancerous; however, this process plays a role in aging as well.

TABLE 19-1Premature Aging Syndromesa

Pathology and Etiology

The histopathology of wrinkles is a combination of interesting findings. Epidermal thinning is an outstanding microscopic feature, where the atrophy is more prominent in the deepest area of the wrinkle (Fig. 6-8). Other changes include flattening of the dermal-epidermal junction, atrophy of the subcutaneous adipose tissue of the hypodermis, as well as the loss of collagen, glycosaminoglycans, and elastin tissue.

Collagen Loss

Abnormal and reduced collagen is a major finding in the pathology of wrinkles, both in sun-exposed and non-sun-exposed skin.7 Collagen modification in wrinkled skin can be explained with a combination ...

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