fasil-scale-measurement-of-facial-skin-and-softtissue-laxity (1)

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Chapter
Fasil Scale: Measurement of Facial Skin 
and Soft-Tissue Laxity
Hector Leal-Silva
� 
4.1 
Introduction 
Human history is as recent or as ancient as 13,000 years 
[1] and for almost half that period evidence exists about 
efforts in widely diverse groups and times to enhance or 
modify physical attributes [2].
When efforts are made to enhance physical beauty, 
the attention frequently focuses on facial attributes. Fa-
cial skin, subcutaneous tissues and including bone expe-
rience constant structural modifications as time passes, 
modifications that together consist of growing and de-
velopment in the earlier stages and later evidence the 
characteristic signs of aging and facial deterioration.
Several systems have been presented by some authors 
as an attempt to understand and explain the dynamics 
of the facial aging process. 
Facial aging has been analyzed from the viewpoint of 
the presence or absence of wrinkles and photodamage 
[3], the persistency of wrinkles when manually pulling 
the skin [4], dynamic lines related to gestures and the 
effects of gravity and mechanical forces [5] or, further-
more, taking into account the degree of dermatoheliosis, 
considering pigmentary and textural changes [6].
The distinctive characteristics between a chronologi-
cally aged skin and a skin with actinic aging (photoag-
ing), considering the various structures that define a 
young, healthy skin free from deterioration, have been 
described by Obagi [7].
Others, like Donofrio [8], have given profound rel-
evance to the importance of facial volumetric distribu-
tion to reflect age and finding “antiaging” treatments for 
the correction or redistribution of the volume of spe-
cific “packs of soft tissue.” 
Recently Alam et al. [9] developed a numerical rat-
ing scale to assess the quality of cosmetic surgery pro-
cedures pertaining to clinical efficacy and patient satis-
faction.
4.2 
Justification 
With the recent technological and procedural develop-
ments in cosmetic dermatology, like the several nonsur-
gical lifting techniques with autoanchorage threads or 
nonablative radiofrequency for skin and subdermal tis-
sue contraction, or the diverse methods for volumetric 
redistribution of the face using fillers, the need for new 
methods to evaluate posttreatment outcomes became 
evident (Fig. 4.1).
The physical examination and photographic assess-
ments of these cases reveled that there was no accurate 
method available to evaluate results with regard to fa-
cial skin and subdermal laxity/firmness (Fig. 4.2).
Not one of the classification systems presented be-
fore was accurate to evaluate the spectrum between lax-
ity and firmness, and the only issue one was able to ex-
press in terms of results was whether the patient looked 
better, the same or worse on physical examination and 
in some cases on photographic evaluation before and 
after the procedure .
The approaches that have employed measurements 
and lines added by computer have failed, mainly due 
to the slightest degree of change in positioning the pa-
tient for photography also changes the measurement so 
greatly that they becomes useless for evaluation of facial 
laxity change as a result of treatments, time or events.
In my opinion the typical method for evaluating the 
percentage of improvement lacks precision in many 
ways. The most relevant reasons are the percentage of 
improvement in relation to what the appearance was 
before, other cases, personal experience or the degree of 
change that in the mind of the evaluator could constitute 
a 100% change. Even when evaluating half-face results, 
presented as the percentage of change when one com-
pares the degree of change in the untreated half with the 
degree of change in the half treated, 100% change can-
not be observed or determined by any method, and one 
can only guess from the data, becoming fully subjective 
again.
With the aim of giving some objectivity where sub-
jectivity prevails, a method to measure facial laxity was 
developed by the author.
4.3 
Laxity Classification System
The following describes a quantitative method of accu-
rate measurement of facial skin and deep tissue laxity. 
To classify a patient’s laxity, two separate steps must be 
 4
4 Fasil Scale: Measurement of Facial Skin and Soft-Tissue Laxity�2
Fig. 4.2 Thermage™ patient. a Before and b 
6 months after nonablative radiofrequency 
treatment
Fig. 4.3 Physical examination: pinch test Fig. 4.4 Superficial laxity
Fig. 4.1 Dermatologic cosmetic combined 
procedures
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performed: physical examination and photographic as-
sessment.
4.3.1 
Physical Examination
In the physical examination, the pinch test (Fig. 4.3) is 
critical to establish superficial (Fig. 4.4), deep (Fig. 4.5) 
or mixed (Fig. 4.6) laxity of facial skin and deep facial 
tissue (Table 4.1). The relevance of this differentiation 
resides in the fact that the physical expression of these 
variations in tissue laxity is structurally different and re-
quires a specific approach.
Superficial laxity alone can be determined by posi-
tive slide displacement sign (skin easily performs 
shallow lateral movement). Since the expression of 
superficial laxity is mainly wrinkles, and since for the 
classification of rhytids, outstanding classification sys-
tems have already been developed as mentioned before, 
no attempt has been made by the author to classify this 
type of laxity. 
The author’s system focuses on deep or mixed tissue 
laxity assessed by photographic analysis. This initial 
physical examination is necessary mainly to avoid mis-
interpretation of data related to superficial expressions 
of age.
Table 4.1 Physical examination
Superficial Deep Superficial + deep
Table. 4.2 Signs
Class
0 1 2 3 4 5
Upper face
Eyelid Eyelid fold 
slightly 
noticeable 
(thin line 
or absent)
Eyelid fold 
well defined 
(thick line)
Slight folding Folding 
without 
reaching the 
eyelashes
Folding on 
the eyelashes
Eyelid fold 
interfering 
with the field 
of vision
Middle face
Cheekbone 
roundness 
Full The central 
upper part of 
the cheekbone 
roundness is 
interrupted by 
an indentation
Nasojugal fold 
extends across 
the mid point 
of the cheek-
bone tissue
Nasojugal 
fold crosses 
the cheek-
bone tissue
The fold extend 
to form a flat-
tened area
Completely 
flattened 
cheekbone tis-
sue stretching 
the lower eye-
lid downward
Melolabial fold Absent Slightly 
noticeable
Defined Prominent Deeply marked 
crease
Line hidden 
by skin folding
Lower face
Jowls Absent Slightly 
noticeable
Protruding 
forward
Protruding 
forward and 
downward
Forward 
protrusion 
with down-
ward sagging
Forward 
sagging and 
lateral loss 
of definition 
in the neck
Upper neck
Platysma bands Absent Absent Slightly 
noticeable
Prominent Sagging Sagging to 
the point 
where bands 
or folds are 
no longer dis-
tinguishable
Horizon-
tal folds
Absent Absent Absent Slightly 
noticeable
Prominent
4.3 Laxity Classification System
4 Fasil Scale: Measurement of Facial Skin and Soft-Tissue Laxity��
4.3.2 
Photographic Assessment
This part must be performed by observing the patient 
indirectly by using a set of five high-quality photo-
graphs (one frontal, two profiles and two intermediate) 
(Fig. 4.7).
In regards to the photographs we suggest a special 
area with indirect light, gray background, white lateral 
walls and a gray fabric on the chest. A static (on a tripod) 
digital camera with more than five megapixels should 
be used. The patient should be sitting and should only 
be rotated for positioning, using red dots in the lateral 
angles for sight standardization. 
The photographic assessment includes two compo-
nents: the division of the face into four regions and two 
sides (Figs. 4.8, 4.9); and classification of the observed 
laxity into one of six classes, each one with distinctive 
signs (Fig. 4.10) for each region and side (Figs. 4.11–
4.34, Table 4.2).
The before mentioned regions mentioned before 
coverthe area of study, including the zone around the 
sign that mainly or secondarily reflects the laxity of the 
whole region, like the eyelid fold in the upper region, 
the nasojugal and melolabial folds in the middle region, 
the jowls in the lower region and the platysma bands in 
the neck, this being the reason for not using the classic 
division by thirds in the anatomical approach to study 
the aging face [10].
Step 1: Divide the subject’s face into regions and 
sides as follows:
1. Upper face: This region covers the area that begins 
at the hairline and extends to the horizontal line that 
crosses the pupils.
2. Middle face: This region covers the area that begins 
at a horizontal line that crosses the pupils and ex-
tends to a horizontal curved line that crosses the 
commissures of the mouth and the lower insertion 
of the ear. 
3. Lower face: This region covers the area that begins 
at a horizontal curved line that crosses commissures 
of the mouth and the lower insertion of the ear, and 
extends downward up to the jaw line.
4. Upper neck: This region covers the area from the 
jaw line to the horizontal line that crosses the upper 
boundary of the thyroid cartilage.
Step 2: Classify the laxity in each region on each side of 
the face according to Table 4.2.
Step 3: Fill out the photographic assessment table 
(Table 4.3).
For statistical purposes, the mode can be observed 
and documented as ‘the general facial grade’; the me-
dia can be used for more precise measurements and, of 
course, analyzing by region and side provides an abun-
dance of data for specific purposes.
Some authors have used a half-grade (0.5) system 
in-between grades to express a degree of improvement 
that can be observed and recorded, but it does not meet 
the specified criteria to be considered as a ‘full’ change 
in grade (F. Mayoral 2005, personal communication). 
Fig. 4.6 Superficial plus deep laxityFig. 4.5 Deep laxity
Table 4.3 Photographic assessment
Region Left Right
Upper face
Middle face
Lower face
Upper neck
��
As a demonstration of the process of photographic 
assessment of patients, two cases have been classified by 
the author:
1. Case 1 (Fig. 4.35): The upper region corresponds 
to class 2 “eyelid slightly folding”. The middle re-
gion also corresponds to class 2 “nasojugal fold 
extends across the mid point of the cheekbone and 
the melolabial fold is defined.” The lower region of 
the face in this case presents an extensive laxity that 
corresponds to class 4 “forward protrusion with 
downward sagging.” The neck presents changes cor-
responding also to class 4 “platysma bands sagging” 
even without the presence of horizontal folds. There 
are no significant differences between sides, so the 
table must be filled out as in Table 4.4.
2. Case 2 (Fig. 4.36): The upper region exhibits side to 
side differences: the right side corresponds to class 
3 “eyelid folding without reaching the eyelashes,” 
whereas the left side presents changes that correspond 
to class 4 “eyelid folding on the eyelashes.” The mid-
dle region presents symmetrical changes that corre-
spond to class 2 “nasojugal fold extends across the 
mid point of the cheekbone and melolabial fold is 
defined”. The lower region is more or less symmetri-
cal and corresponds to class 3 “jowls protruding for-
ward and downward” (exhibits a mild asymmetry 
that fits within the same class). The neck presents 
changes in the horizontal folds (not in platysma 
bands) that correspond also to class 3 “slightly no-
ticeable.” The table must be filled out as in Table 4.5.
Fig. 4.7 Complete set of facial photo-
graphs
4.3 Laxity Classification System
4 Fasil Scale: Measurement of Facial Skin and Soft-Tissue Laxity��
Fig. 4.8 Sections of face
Fig. 4.9 Sections of face
Fig. 4.10 Distinctive signs
Fig. 4.11 Upper-face region, class 0. The 
eyelid fold slightly noticeable (thin line or 
absent)
Table 4.5 Photographic assessment of case 2
Region Left Right
Upper face 4 3
Middle face 2 2
Lower face 3 3
Upper neck 3 3
Table 4.4 Photographic assessment of case 1
Region Left Right
Upper face 2 2
Middle face 2 2
Lower face 4 4
Upper neck 4 4
��
Fig. 4.12 Middle-face region, class 0. The 
cheekbone roundness is full and a melola-
bial fold is absent
Fig. 4.13 Lower-face region, class 0. The 
jowls are absent
Fig. 4.14 Upper-neck region, class 0. 
Platysma bands and horizontal folds are 
absent
Fig. 4.15 Upper-face region, class 1. Eyelid 
fold is well defined (thick line)
Fig. 4.16 Middle-face region, class 1. The 
central upper part of the cheekbone round-
ness is interrupted by an indentation and a 
melolabial fold is slightly noticeable
4.3 Laxity Classification System
4 Fasil Scale: Measurement of Facial Skin and Soft-Tissue Laxity��
Fig. 4.17 Lower-face region, class 1. Jowls 
are slightly noticeable
Fig. 4.18 Upper-neck region, class 1. 
Platysma bands and horizontal folds are 
absent
Fig. 4.19 Upper-face region, class 2. 
The eyelid is slightly folding
Fig. 4.20 Middle-face region, class 2. The 
nasojugal fold extends across the mid point 
of the cheekbone and the melolabial fold 
is defined
��
Fig. 4.21 Lower-face region, class 2. 
The jowls are protruding forward
Fig. 4.22 Upper-neck region, class 2. The 
platysma bands are slightly noticeable and 
horizontal folds are absent
Fig. 4.24 Middle-face region, class 3. The 
nasojugal fold crosses the cheekbone and 
the melolabial fold is prominent
Fig. 4.23 Upper-face region, class 3. Eyelid 
folding without reaching the eyelashes
4.3 Laxity Classification System
4 Fasil Scale: Measurement of Facial Skin and Soft-Tissue Laxity�0
Fig. 4.26 Upper-neck region, class 3. 
The platysma bands are prominent and 
horizontal folds are slightly noticeable
Fig. 4.25 Lower-face region, class 3. 
The jowls are protruding forward and 
downward
Fig. 4.27 Upper-face region, class 4. 
The eyelid is folding on the eyelashes
Fig. 4.28 Middle-face region, class 4. The 
nasojugal fold extends to form a flattened 
area and the melolabial fold forms a deeply 
marked crease
�1
Fig. 4.29 Lower-face region, class 4. The 
jowls are protruding forward with down-
ward sagging
Fig. 4.30 Upper-neck region, class 4. The 
platysma bands are sagging and horizontal 
folds are prominent
Fig. 4.31 Upper-face region, class 5. The 
eyelid fold interferes with the field of vision
Fig. 4.32 Middle-face region, class 5. The 
completely flattened cheekbone stretches 
the lower eyelid downward and the line of 
melolabial fold is hidden by skin folding
4.3 Laxity Classification System
4 Fasil Scale: Measurement of Facial Skin and Soft-Tissue Laxity�2
Fig. 4.35 Case 1
Fig. 4.34 Upper-neck Region, class 5. The 
platysma bands and horizontal folds are 
sagging to the point where bands or folds 
are no longer noticeable
Fig. 4.33 Lower-face region, class 5. The 
jowls sag forward and there is lateral loss of 
definition in the neck
�3
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Fig. 4.36 Case 2
References