Indian Journal of Plastic Surgery
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Year : 2007  |  Volume : 40  |  Issue : 2  |  Page : 178-180

Facial aging: A clinical classification

Chair, Section of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302, USA

Correspondence Address:
Melvin A Shiffman
Chair, Section of Surgery, Tustin Hospital and Medical Center, 17501 Chatham Drive, Tustin, CA 92780-2302
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-0358.37763

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 » Abstract 

The purpose of this classification of facial aging is to have a simple clinical method to determine the severity of the aging process in the face. This allows a quick estimate as to the types of procedures that the patient would need to have the best results. Procedures that are presently used for facial rejuvenation include laser, chemical peels, suture lifts, fillers, modified facelift and full facelift. The physician is already using his best judgment to determine which procedure would be best for any particular patient. This classification may help to refine these decisions.

Keywords: Tear trough, classification of facial aging, facial aging

How to cite this article:
Shiffman MA. Facial aging: A clinical classification. Indian J Plast Surg 2007;40:178-80

How to cite this URL:
Shiffman MA. Facial aging: A clinical classification. Indian J Plast Surg [serial online] 2007 [cited 2019 Jul 22];40:178-80. Available from:

 » Clinical Classification Top

The classification utilizes four different areas of the face that are affected by the aging process [Table - 1]. The appearance of a tear trough depression is one of the first manifestations of facial aging. This is followed by loss of cheek fat, prominence of the jowls and then deepening of the various facial folds. The most prominent fold is the nasolabial followed in time by the marionette lines.

The use of neck manifestations such as loose skin, platysmal bands and transverse folds would be too variable since a heavy neck would hide these changes and a thin neck would show the changes earlier. Rhytids (wrinkles) generally are a result of heredity, skin aging from sun damage, overuse of facial expression muscles, sleep pressure and skin laxity. Laxity of eyelid skin and appearance of eyelid fat pads occur with aging but the skin laxity may be associated with heredity and sun damage.

 » Use of the Classification Top

The first change of aging from Stage 0 (no changes noted) to Stage 1 is the appearance of a deepening in the tear trough and a very slight appearance of the nasolabial fold depth [Figure - 1],[Figure - 2]. This is followed by extension of the tear trough with slight loss of cheek fat medially, mild nasolabial fold deepening and the appearance of the jowl prominence in Stage 2 [Figure - 3]. Stage 3 [Figure - 4] has a slightly more prominent tear trough depth than in Stage 2, moderate loss of total cheek fat, moderate depth of the nasolabial fold and mild to moderate prominence of the jowls. Stage 4 has severe changes in all of the areas being examined [Figure - 5]. Not every patient presents with these changes at the same time or in the same order. The most prominent category of change is in the extent of the tear trough and loss of cheek fat. Classification should take this into account when deciding the type of procedure for any particular patient.

 » Treatment Top

Stage 0 ordinarily needs no treatment whereas Stage 1 would improve with a filler such as autologous fat to the tear trough. Stage 2 would be improved with fillers to the tear trough and cheeks while suture lifts can be attempted to improve the jowl prominence (possibly with minimal liposuction) and nasolabial fold. Stage 3 would be treated with fillers in the defect areas, liposuction of the prominent jowls, as well as possibly a modified facelift if there were sufficient skin laxity. Stage 4 would benefit by fillers and possibly a full facelift.

As the skin gets more sun damage and more rhytids appear, consideration should be given to the use of chemical peels and laser. Suture lift of the neck for mild loose skin does not work very well. Neck lift surgery should be considered for moderate laxity of the neck skin.


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

  [Table - 1]


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