Implications of Aging in Plastic Surgery

Abstract

Given the rapidly aging population, investigating the effect of age on plastic surgery outcomes is imperative. Despite this, the topic has received relatively little attention. Furthermore, there appears to be little integration between the basic scientists investigating the mechanisms of aging and the plastic surgeons providing the majority of "antiaging" therapies. This review first provides a description of the effects and mechanisms of aging in 5 types of tissue: skin, adipose tissue, muscles, bones and tendons, and nervous tissue followed by an overview of the basic mechanisms underlying aging, presenting the currently proposed cellular and molecular theories. Finally, the impact of aging, as well as frailty, on plastic surgery outcomes is explored by focusing on 5 different topics: general wound healing and repair of cutaneous tissue, reconstruction of soft tissue, healing of bones and tendons, healing of peripheral nerves, and microsurgical reconstruction. We find mixed reports on the effect of aging or frailty on outcomes in plastic surgery, which we hypothesize to be due to exclusion of aged and frail patients from surgery as well as due to outcomes that reported no postsurgical issues with aged patients. As plastic surgeons continue to interact more with the growing elderly population, a better appreciation of the underlying mechanisms and outcomes related to aging and a clear distinction between chronological age and frailty can promote better selection of patients, offering appropriate patients surgery to improve an aged appearance, and declining interventions in inappropriate patients.

Video Graphic 1.

See video, Supplemental Digital Content 1, which displays the aging experience. Patient perspective on the impact of aging on personal health and well-being. This video is available in the “Related Videos” section of the Full-Text article at PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A957.

Fig. 1.

Skin aging. Decreased cellular turnover and inefficient nutrient exchange between the different layers occurring with aging result in atrophy of both the epidermis and dermis. The decrease in collagen number and organization result from decreased production of collagen as well as increased breakdown by metalloproteinases. A reduction in the vasculature is also seen leading to inefficient cutaneous blood supply.

Fig. 2.

Adipose aging. The increased production of proinflammatory cytokines that occurs with aging inhibits preadipocyte differentiation leading to a decrease in adipocytes. Furthermore, there is a marked decrease in adipocyte size, an increase in senescent markers and cells and a shortening of the adipocyte telomeres. A decrease in insulin responsiveness promotes lipolysis and production of factors that inhibit adipogenesis.

Fig. 3.

Muscle aging. Aging causes the release of proinflammatory cytokines that lead muscle to become atrophic through decreased anabolism, as well as increased autophagy and catabolism. Stem cell exhaustion results in a decrease in satellite cells, leading to a decline in the reparative capacity of damaged muscle and increased fibrosis. Proteostasis and a deregulation in nutrient sensing result in a decrease in fiber size, and mitochondrial dysfunction may lead to decreased endurance. An accumulation of adipose tissue within muscle promotes inflammation and insulin resistance.

Fig. 4.

Mechanisms of aging. Aging occurs due to multiple intertwined mechanisms; dysregulation in proteostasis with subsequent accumulation of dysfunctional proteins, dysfunction of mitochondria and accumulation of reactive oxygen species, DNA and nuclear lamina damage, shortening of the telomeres, as well as dysregulation of intercellular signaling. All these mechanisms are believed to result in activation of cell senescence, inhibition of autophagy and apoptosis, and exhaustion of stem cells.

Fig. 5.

Skin aging treatment. In the preventative stage, there are numerous exogenous factors that are known to either promote or delay aging. Smoking, excessive sunlight exposure, stress, and pollution are all factors known to expedite aging. On the other hand, maintaining an active lifestyle, a low-calorie diet, as well as overall good health could help delay the aging process. Active treatment of aging skin is a multimodal approach, that can comprise medications, either topical or systemic, and invasive treatments that can be both nonsurgical and surgical.