When we practice, we will start with the Western medical perspective and this lecture we’ll discuss facial anatomy. And then also the morphological changes that occur. The face ages over time.

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Hi, my name is Dr. Shellie Goldstein. I’m an acupuncturist specializing in cosmetic facial acupuncture. And I would like to thank the American Acupuncture Council for allowing me to be here today. It’s always a pleasure. Today’s presentation is the anatomy of facial aging. This is actually very important, particularly for cosmetic facial acupuncturist, because although we are practicing traditional Chinese medicine we always need to take into account the anatomy of the face and the way that it changes over time.

So this is. Presentation is almost the foundation of our sense skills and being able to get great results. When we practice, we will start with the Western medical perspective and this lecture we’ll discuss facial anatomy. And then also the morphological changes that occur. The face ages over time.

And then we will touch on Eastern medicine, acupuncture strategies for treating the aging face. And throughout my series with the AAC, we will break these down into smaller formats and address them individually. But today is just an overall of what you need to do in order to, and know in order to understand other lectures.

When we think about facial aging, from the perspective of Western medicine, we’re really talking about this biological process that happens with the resulting of a gradual reduction and the structural component cell function and the Chinese medicine. We think more in terms of the G and the energy and the organ systems.

Whereas from a Western perspective, we’re really going to look at the anatomical features of the face. And then the morphological changes that we see as the face ages over time. And when we think about a young phase that has a normal volume, nice and full with very well-defined contours along the jaw line and the cheekbones, that type of thing.

And then as we age these regional facial aesthetics, these units that we’re talking about begin to change. And from a Western medical perspective, those changes are mainly due to a number of factors, a reception of the bone fat tissue changes. Muscle attenuation or the changes that occur with the muscles of the face.

And then the skin gets thinner. The skin gets flacid. It develops elastosis and then we have ligaments in our face that we’ll talk about. And as those shift, they also reposition the soft tissue that it attaches to. When we look at the facial planes, we look at them and two different systems.

We look at them horizontally, and then we look at them vertically. So horizontally, we talk about the upper face, which includes the hairline and the upper hairline to the inner campus area at the top of the eyebrow. And the mid face is referred to from the inner campus plane to right below the nose. The

And then the lower face is considered right below the nose to the jaw area. And then we look at them from a vertical center line as well. So we have the very center, the vertical center line, and then moving out to the center of the pupil is the next vertical line. And then the third vertical line is right in front of the ear lobe.

So we’d go from upper to middle to lower upper face, maybe. Lower phase. And then from the center line, moving out to the center of the pupil and then directly in front of me. And these are fairly standard. There are obviously some changes that occur with different types of faces. So say a Caucasian face may have a narrow or nasal base and a larger tip projection that intercampus area widens at when compared to other faces.

Whereas in Eastern Asian face is going to have a very somewhat weaker facial structure framework. It’s a little more. Delicate. It’s a little wider, a little rounder. The eyebrows are a little bit higher. The lips are a little fuller. The nasal, the bridge is a little bit lower. And then the flaring of the nasal Alia or exists more with an Eastern Asian face.

And then the Malheur prominence in the mid face. This Malheur area. Right along here is more prominent. Lips are more protuberant and then the chin is a little more pushback or receipted for a Latino or Hispanic face. Typically the bises a zygomatic distance right in here is a little wider. The maxillary protrusion is a little wider.

The nose is a little wider and then the chin is a little more receded. And then an African-American faces much has a much broader nasal. I decreased nasal projection. The Bilac by maxillary protrusion exists where the orbital is a little more pro per ptosis, a little bit lower. And then the tissue is a little plumper, a little bit softer.

The lips are a little more prominent and there’s an increase in facial convexity. So there are so much changes, although we’re still dividing them up and along the same trajectories, both horizontally and for. When the face ages it moves from when you think of a young face, it has a very wide, upper number, upper face and upper mid face, and a more narrow and pointed lower face.

And when we look at the younger face, what we see is our eye goes directly to the upper portion of the face. So we look at eyes, we’re looking at a very high cheap, but when we look at a nice wide area and the upper face and the upper mid face, and then as we age, it moves, the weight of the face actually moves.

It drops. LA drops and then turn becomes more medial. So that in this case, as with the aging face, the weight of the face actually moves down. We start to lose, you can see along here, we lose the definition along the dry area. And the weight of the face moves from say upper and outer. So it up and wide to more medially, and.

This creates a lot of changes in the face. Then what are going to look at that right now? We know we have bone and then above the bone, we have soft tissue and in order to really get effective treatment results, we really need to understand the relationship between Eastern medicine. And the biomedical anatomy with regard to the morphological or the psychodynamic facial changes that were time.

So let’s break these down and let’s look at them as they exist from bottom to top. So deep search deep to the surface. We have bone, the basic structure of our face that holds the shape of our. On top of bone, we have muscle on top of muscle. We have fat and then superficially, we have skin. So let’s look at them.

Let’s look at what happens with bone first as we age bone resorbs, which means that it starts to break down and it breaks down from the openings that exist. So for example, the eyes get a little bit wider. The eye socket gets wider. And we’re looking at this boat. This is a CT image of two females. This one on the left.

She’s between 20 and 40. This is someone who is over 65 on the right. And you can see, and the earlier one you can see a nice squared face, open eyes. Here’s the nasal bone and it’s nice and thick and foam. And look what happens over time. The openings start to open up and get white. The F as the face itself starts to get smaller.

So the openings get wider. The skull itself starts to shrink. So it gets smaller. You can actually see it starting to push down. When the skull starts to push down, what happens? You lose the form. So the mid area, the maxillary area get shorter. The mandibular bone, the mandibular area starts to break down too.

It starts to push forward to, you can actually see this rotation, this inward medial rotation of bone that you see changes in dentation. And so we see the height of the face starts to decrease the eye socket, start to expand. You get temporal hollowing. Here’s the temple there starts to break down and get hollow.

And the piriform, this is the nasal pyriform. This is the openings that we were talking about. The nasal pyriform gets wider and we get the resorbtion of the breakdown of the mandible read in here, along the base, the maxilla on the top. And then this causes changes in your teeth, changes of indentation.

It starts to push for. And then the entire face starts to rotate and protrude. And this is what it looks like. What we begin to see as eye sockets, start to increase the nasal pyriform starts to widen the mandible. And here starts to shorten the mandibular length starts to break, to lengthen and shorten as well.

The nose starts to change and the maxillary area right in here, this angle starts to get change. You start to see changes in the height of everything which pushes the teeth. When that happens, this is what so the darker areas is where the bone is starting to break down. What happens to all of the soft tissue on top.

All of that tissue starts to, it has it’s losing its support. It’s losing its underlying foundation. So in even in a healthy tissue, it’s going to start to stag. It doesn’t have the foundation anymore. So it starts to sag and drop and move medially. As we saw. On top of bone, we have muscles. Now the faces unique, the face has two site types of muscles.

It has superficial muscles and it has deeper. The deeper muscles generally attached, like on the body from bone to bone, our bone to muscle and the deeper muscles in the face are primarily located in the mid face, this mid area. And they’re designed to move bone and it’s attachment. So primarily what we’re talking about.

Is the mandible. The mandible is the only loose bone on the body. Everything else is connected. And so the main purpose of the deep muscle muscles of the face is actually to move bone. And it’s primarily for chewing for moving the mandible back and forth and for chewing. Now the muscles on the superficial muscles are a little different.

We call them the muscles of expression are medic muscles memetic, and these muscles are different than the rest of the muscles on the face and the deep muscle the deep muscles of the face and on the body, them a medic muscles are designed to move other muscles and move the skin. So rather than moving both.

Or bony attachments, they’re going to move muscles and they’re going to move school. They’re very flat and you can see them in this cadaver. There here’s a medic muscle right here. There’s one around the eyes. There’s one here in the cheek area. Here’s one right here and then around the mouth and then the participant muscle along the neck and with age rather than atrophy, they attenuate.

So what does that mean? We think of muscles atrophying over time. And it’s mainly from lack of use, but when you think about the muscles of their face, We use them all the time. We use them with our expressions. We use them when we talk, we are eyes they’re opening and closing all the time. We are constantly using the muscles of our face.

So they don’t they don’t really atrophy. They attenuate. And when we see a tango what that means is they get short. So they move, they reduce in their amplitude of movement and they get stiff and straight. And instead of being nice and flexible and moist and resilient, they start to straighten, they start to stiffen, they get stuck or they reduce an amplitude, so they don’t move as well.

And that limited amplitude of these mimetic muscles leads to a more permanent or more contrasting. Position. Whereas we, if you look in an aging person and it looks like their muscles are frozen, they aren’t moving, they aren’t moving back and forth or contracting and relaxing. They’re stuck in their position.

And when these muscles get thinner and tighter and stiffer or straighter the skin on top of them starts to crease our we start developing a facial asymmetry and when we get wrinkles. So a lot of this is combining the changes in structure and the bone plus the changes or the attenuation of the mimetic muscles of the face.

And then we see systemic changes in the integumentary system. The integumentary system is made up of three layers. It’s made up the subcutaneous or the fat layer it’s made up of the dermis, the mid layer. And it’s made up of the epidermis, which is the very surface area of our standards. What we see when we look in the mirror or when we’re looking at.

Let’s start in the deeper layer in the subcutaneous or that fat layer. We have two layers on the body, the face we have the deeper layer and we have a more superficial layer and they look different. You hear in this cadaver, we can see on the on the surface of the the left side, this is the, it’s a little lighter yellow color, and it sits on the surface.

Whereas the deep fat is a little darker in color and it’s deeper underneath the surface of this. Regardless see that as we look at the phase and as we look at the fat in our face, the fat is what provides the structure or the plumping plumpness of. Some people have more than others, as you can see. I don’t have a lie.

But they’re all of these fat pads, we think of them as being all across the face in a uniform position. But in fact, that’s not the case. They are actually separated by ligand implements. So they’re partitioned in sex, sectioned off and held into place with ligaments. As we age changes occur.

And those, the fat we call it descent and deflate, which means that it moves as it breaks down. It starts to lose its form. It lose its integrity and then it moves. And oftentimes it moves under the eye socket. And in this fold between the nose and the corner of the mouth, it’s called the nasal labial fold.

And we see as people get older, This area begins to thick, and it’s not a wrinkle it’s actually partially due to the movement of the tissue and the muscles immediately towards the nasal labial fold. But it can also be due to fat right in here that is moving from the center of the face, into that area.

And it’s also due to just simple loss of fat in the mid-face area, so that we see a flattening or a deflating. In the mid-face area, but then we also have the illusion of being thicker in the nasal Lavia. Also what we see as changes in the upper area, the forehead, the periorbital area, the temporal area.

We start to see a breakdown of fat into this area. And then some of this also lands along the jaw. And that is partially what happens when we start to lose our jaw area are the cut that we see in our general area. We may think that it’s all skin that is starting to fall down. And in fact, some of that may be due to fat, build up along this jaw area that creates that asymmetry from side to side, but also that loss of definition in the jaw area.

On top of the fat layer or the adipose tissue of the deeper areas. We see the dermal layer. The dermal is right here in the middle. And then on top of that is the. And the dermal area is where the health of the cells develop cells begin their growth cycle at the base of the dermal area. And they begin to float up their base.

Then this nutrient of hyaluronic acid and fluid proteins, vitamins, everything that we need in order to create healthy cells occurs on the German. And floats up to the top, moves up to the dermal layer, the epidermal layer, and then spreads off. So not only do we have a number of nutrients and bathing solutions in this dermis, but we also have our our rector Pillai muscles, their muscles that we feel when we get the chills and our, and the hair starts to stand up on our.

I sweat glands, a number of sebaceous oil glands, a number of different vital substances are in the dermal area out of this. It’s composed of a papillary layer, which is a loose meshwork of thin connective tissue. And then the deeper area is the thicker layer of connective tissue. And if you look in this side image, this is connective tissue.

We’ll go into this a little more deeply, but it’s a very loose matrix, a loose structure, whereas the lower areas a little bit. And then on top of that area is the epidermis. The remembering the epidermis is that theory surface layer of the skin it’s made up of a number of different layers, seven different layers.

On the very top are dead cells. They’re filled with keratin. It’s what we slough off and we fully ate our skin. And then as we move deeper to the dermal layer, the cells are a little bit healthier. They’re a little bit plumper. They’re a little thicker. They have a little more, most moisture in them. And then as they move through the dermal cells, move through the dermal layer into the epidermis.

They start to thin out, they start to flatten. They lose their moisture. And then at the very surface is the dead keratin cells. As we age a number of things happen, one is the health of the cells that are floating up from the dermal layer up to the surface, the cell health and the dermal layer starts to change.

We start to lose the water content. They start to be a little thinner, a little drier. So they’re not as healthy as they move up to the surface. Also the structure of the dermis. Remember we spoke about that connective tissue starts to lose its integrity. Collagen and elastin are the main components that hold up the integrity of the dermal layer.

When that starts to become disorganized and break down, we actually lose the integrity of that entire dermal layer. Think of a mattress that’s thick, and as we lie on it over and over, it gets a little bit thinner and. Like we lose the integrity of our mattress. Over time, we lose the integrity of that dermal layer and then cells on the top are thinner.

They are dryer though, less subtle, they’re less plump and the entire area sinks. So here’s the mattress, here’s the sinking of the skin and the mattress. And it looks like their wrinkles been. In fact, it’s just loss of college and loss of integrity and skin aging on the surfaces. Remember that connect that.

In that connective tissue. So connective tissue is throughout fascia is a type of connective tissue and it is the most abundant form of collagen fibers in, in, in the tissue of the skin. There’s fascia on the face, which attaches to the bone, the lining of the one, the periosteum, and it encapsulates and protects the muscles and the deeper layers of.

Tissue. And then there’s a superficial and that superficial, it’s like a thin layer of say sticky film or saran wrap. So it’s a little sticky and it attaches to the muscles and then the muscles attached to the skin. And every time a muscle moves, it causes the skin to move. And that’s how we get our expressions.

And then. All of these are in a horizontal plane and then running in a perpendicular plane are our retaining ligaments. There are a number of different retaining ligaments in the face. Remember they surround and encapsulate fat, but they also are like little plugs. They hold all of the loose tissue.

That’s running in a horizontal plane. They hold it all together. So what happens as they age? They start to attenuate as well. They start to dry out. They start to thicker, they lose their integrity. And as all of the horizontal tissue starts to shift, starts to dry out. Remember turn more immediately the these re retaining ligaments start to move as well.

So again, everything moves medially, and again, we start to lose our Mallory projection, and this is what we. If you look at this is on this end on the, to the left is aging as a young face from the frontal and then side view. As we age, we can start to see shortening in the far ahead, we start to lose or flattening in the mid phase and then loss of definition along the jawline, as you can see.

So let’s look at this. So here is a younger face. Nice to see the height up here. Eyes wide, open forehead. Nice and relaxed. Now look, this is what happens as we start to age, remember everything starts to drop down, move more, more immediately. We develop that nasal labial foam. We develop a long here, the repositioning of fat loss of structure.

Everything starts to fall and then loses it. Here we see this side is a younger face. B is the older face. Can you see how the mid face starts to flatten? We start to see a deeper nasal labial fold. We start to see loss of collagen and elastin, particularly in around the mouth and loss of definition along the job.

I hear it as a. Here’s a younger face. Hirsi is the older face deepening and the nasal labial fold loss of definition. The jaw line, the corners of the mouth start to turn down. This is another conversation about muscles and the effect that muscles have on the phase. Particularly the mimetic muscles.

And then in terms of treatment, how are we going to treat this? We see this changes starting to happen. We see the the changes that are starting to occur. Some that you can change. You can’t really change bone loss. These the, that have already lost some bone. It’s very hard to change, but we can make a.

And we can do that with our acupuncture treatments. So in the link shoe, there are a numerous discussions about needling guidelines specific to the layers of the face, the skin, the flesh between the areas between that flesh and the channels and around the muscles at the local level. In the link shoe, they talk about the skin, the flesh, the muscles, the tendons, and meridians all occupied different places in the body and that different diseases respond to different methods.

And when we talk about diseases in this case, what we’re talking about is. And if illness are aging is superficial, the different needling that we do, it will penetrate and injure the good flesh. If we do not treat it at the superficial layer or we miss it, then we’re not going to get the right results.

So when we treat what we’re treating, as we talk about the superficial layers, we’re talking about the epidermis and the dermis. So when we’re actually treating them, we have to angle the needle in a way that we’re actually treating the epidermis and the dermis. So we’re actually aligning that. Very flat.

When we talk about angle of insertion, what we’re talking about is relative to the skin surface. So we would lay that needle right at the surface of the skin, and we say five to 15 degrees and we can treat the superficial wrinkles. We can treat skin atrophy. Pain. There are a lot of pain receptors in the dermal layer of the skin.

And so we can actually help treat pain by laying that needle in a very superficial layer. We can use it with intradermals. A Japanese style of acupuncture is very good for addressing for our purposes. Introducing. Japanese acupuncture to treat the epidermal and dermal layer of the skin. If we want to move a little bit deeper into the hypodermis or the fat layer, we’re going to angle it a little bit deeper, not much because remembering if you actually place your hand on the surface of your skin, if you push a little bit, you’re already at the bone.

So it’s very superficial, very shallow. So we’re going to angle the needle at a 15 to 20 degree angle. We use it for skin atrophy for any type of fat atrophy or deflating. It’s really good for prevention. For aging on the deeper channels at the muscle. If we want to address the muscle layer, we’re going to name and go that needle on a 45 to 60 degree angle.

Really good for treating muscle attenuation trumps. Muscle trauma or prevention. And then for the bone, we’re going to go right or into treating the meridians. We’re going to go at the angle of the bone, which are the more 90 degree angle. So that’s also great for prevention, any Meridian problem or trauma to the face.

So here’s an example. This is a different protocol or a protocol. This is just an example of how we might use and to the muscles in the neck area at a 45 degree angle. If we’re going to treat the meridians, we might go right into the acupuncture points on the face, a shallow noodling into wrinkles and the, into the dermis and the epidermis treating the muscles, the corrugator muscle.

You can see this deep corgi. Fold, and then 90 degrees into the meridians. And this would be a before and after picture of what you can expect to see, say, and this is a 10 treatment series. So that’s it for today. There again, I have a number of different lectures for you where we take a deeper dive into the individual.

So thank you very much. Again, thank you to the AAC for allowing me to present today. Stay tuned next week for Sam Collins. He’ll be presenting next Wednesday. He’s always exciting. Very interesting to listen to. And see you again. Thank you.