Periorbital changes with aging 의학강좌 Figure 1. Photograph of a 74-year-old woman with high placement of multiple creases and hollow superior sulcus. 1.

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1 Continuing Education Column pissn: eissn: 정호경 * 서울대학교의과대학보라매병원안과 Periorbital changes with aging Ho-Kyung Choung, MD* Department of Ophthalmology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea *Corresponding author: Ho-Kyung Choung, hokyung214@gmail.com Received July 8, 2013 Accepted July 22, 2013 As we face a rapidly aging population in the Republic of Korea, the number of patients with the need to prevent or alleviate periorbital changes due to aging will grow. The periorbital changes that occur with aging comprise a dynamic process involving the aging of facial tissue and bony structures. Epidermal thinning and decreases in collagen cause the skin to lose its elasticity. Loss of fat, coupled with gravity and muscle pull, leads to wrinkling and the formation of dynamic lines. The aging process has also been shown to affect the facial bones. Multiple studies suggest that aging of the orbit and midface bones occurs primarily due to contraction and morphologic changes. This loss of bony volume and projection may contribute to an aged appearance. The effort to understand each patient s individual involutional changes, which differ by age and gender, is mandatory. Identifying the patient s personal needs and selecting the appropriate treatment accordingly is crucial for achieving the best outcome both for the clinician and the patient. Keywords: Periorbital changes; Eyelids; Midface; Aging 서 론 얼굴중에서도사람의인상을가장크게좌우하는것으로알려져있는눈주변의구조와나이가들면서생기는이의변화에대해파악하는것은앞으로점점늘어날고령환자들의증상과요구를이해하는데도움이될것이다. 눈꺼풀은외부로부터안구를보호하고눈깜박임을통해눈물층을눈표면에고르게분포하게하며펌프기능을통한눈물배출등안구유지에중요한역할을한다. 미용적으로도눈꺼풀은매우중요하여안와지방이나눈둘레근뿐아니라눈썹, 얼 굴중간부위등주변조직과연결되어있으면서눈의모양과함께눈꺼풀틈새의크기, 쌍꺼풀의크기나모양, 안와지방의양이나위치, 피부주름의정도등여러가지요소가그사람의얼굴모양과인상에중요한영향을미친다. 따라서를이해하는데있어서눈꺼풀의해부학적특징뿐아니라안와지방이나눈둘레근등의주변조직과의관계눈썹, 얼굴중간부등주변구조물과의관계를이해하는것이중요하다. 본논문에서는나이가들어가면서생기는눈꺼풀및눈주변조직의퇴행성변화에대해중점적으로알아보고자한다. c Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 1012

Periorbital changes with aging 의학강좌 Figure 1. Photograph of a 74-year-old woman with high placement of multiple creases and hollow superior sulcus. 1. 윗눈꺼풀의변화 눈꺼풀의변화 나이가들어감에따라눈썹이내려오고눈꺼풀피부가늘 어지며늘어진피부가눈을가려시야가줄어들게되며눈꺼풀이무거워보이게된다 [1].

나이가들어감에따라안와지방이불거져나와서윗눈꺼풀고랑이불룩해지는경우와반대로안와지방이위축되어윗눈꺼풀고랑이깊어지는경우가있다.

2 Periorbital changes with aging 의학강좌 Figure 1. Photograph of a 74-year-old woman with high placement of multiple creases and hollow superior sulcus. 1. 윗눈꺼풀의변화 눈꺼풀의변화 나이가들어감에따라눈썹이내려오고눈꺼풀피부가늘 어지며늘어진피부가눈을가려시야가줄어들게되며눈꺼풀이무거워보이게된다 [1]. 또한가쪽눈구석에서는늘어진피부가접히면서눈꼬리피부가짓무르는증상이나타나기도한다. 또한눈꺼풀주변조직특히안와사이막의탄력성이감소하며안와지방이탈출되어눈꺼풀이불룩하게보이게된다. 1) 윗눈꺼풀고랑젊을때에는안와의골격이도드라지게보이지않으며특징적으로위, 아래눈꺼풀에불룩하게보이거나움푹들어가보이는부분없이대개평평하다 [2]. 나이가들어감에따라안와지방이불거져나와서윗눈꺼풀고랑이불룩해지는경우와반대로안와지방이위축되어윗눈꺼풀고랑이깊어지는경우가있다. 눈꺼풀올림근널힘줄이눈꺼풀판에서떨어져눈꺼풀처짐이생기면이를보상하기위해과도하게눈꺼풀올림근을사용하게되고이로인해눈꺼풀테와쌍꺼풀선사이의눈꺼풀판앞피부와눈둘레근에추가적인견인이발생하고널힘줄앞지방의심한후퇴를일으켜결과적으로높은쌍꺼풀선과깊은윗눈꺼풀고랑을만들게된다 (Figure 1) [3,4]. 나이가들면눈물샘의탈출이생길수있는데, 이로인해눈꺼풀가쪽이불룩해지는경우가있으며수술중눈물샘을절제하지않도록주의하고눈물샘을제위치에위치시켜놓는것이좋다. 2) 눈주위주름눈사이에는눈살근에의한수평방향주름과눈썹주름근 Figure 2. Photograph showing upper lid ptosis (asterisk) with elevated eyebrow and forehead creases (arrow). 에의한수직방향의주름이생기고, 가쪽눈구석에는눈둘레근에의한눈꼬리주름이나타난다. 3) 윗눈꺼풀피부늘어짐윗눈꺼풀의피부와근육이늘어져눈꺼풀틈새의크기가작아지고안와사이막의탄력성이감소하여안와지방이탈출되어젊을때에비해눈꺼풀이불룩하게된다. 특히가쪽에서눈꺼풀처짐이심하게생기는경우가많은데이는윗눈꺼풀의여분의피부가눈꺼풀판에고정되지못하여가쪽으로덮혀져서내려오게되거나눈물샘이돌출되기때문이다. 가쪽눈꺼풀피부늘어짐이생기면슬프고무거워보이는표정이생기며, 종종가쪽시야에도영향을주기도하고 [5], 휘트날인대내측부가약해져눈꺼풀판이가쪽으로이동하기도한다 [6]. 눈꺼풀처짐을호소하는환자들의대부분은피부나근육이늘어진경우에해당되며눈꺼풀의피부가쳐져눈거풀테가보이지않는경우처진피부를들어올려눈꺼풀테의위치가정상인단순눈꺼풀피부늘어짐인지눈꺼풀테가내려온눈꺼풀처짐인지를확인하여야눈꺼풀성형술만필요한지눈꺼풀처짐교정수술이동시에필요한지를판단할수있다. 4) 눈꺼풀처짐윗눈꺼풀의피부와근육의처짐으로눈꺼풀피부가늘어지게될뿐아니라눈꺼풀올림근의부착부파열이나퇴행성변화등으로인한기능약화로눈꺼풀의높이가실제로낮아지는윗눈꺼풀처짐 (ptosis) 이발생하게되는데심해지면눈꺼풀이동공을가려시야가좁아져일상생활에불편을겪기도한다. 한국인을대상으로한연구에서는 50세이상한국인의눈꺼풀처짐은매우높은빈도 (54.9%) 를보였으며연령이증가할수록그빈도가증가하였다 [7]. 노인성눈꺼풀처짐은후천적으로발생하는눈꺼풀처짐의가장흔한형태로나이가들어감 대한의사협회지 1013

Choung HK 에따라눈꺼풀올림근널힘줄을이루는콜라겐다발의미세허혈과눈꺼풀부종, 지속적인눈깜박임등의기계적스트레스에의한늘어짐, 그리고콜라겐섬유의생성과파괴에관여하는호르몬및사이토카인의불균형등이널힘줄을약화시키고나이가들면서조금식진행하는것으로알려져있다 [8-10].

다른한편으로는이마근처짐과동반하여눈썹처짐이생기는경우가있는데이마와함께눈썹, 눈꺼풀전체가아래쪽으로내려와눈꺼풀처짐이실제보다더심하게진단될수있다. 특히가쪽눈썹처짐이더많이발생하며이로인해눈꼬리쪽피부처짐이심하게보일수있으며눈꺼풀성형술과동시에눈썹올림술이필요할지살펴보는것이좋다. 눈썹처짐이의심되는경우이전의안면마비의병력을확인하는것이필요하다 (Figure 3).

3 Choung HK 에따라눈꺼풀올림근널힘줄을이루는콜라겐다발의미세허혈과눈꺼풀부종, 지속적인눈깜박임등의기계적스트레스에의한늘어짐, 그리고콜라겐섬유의생성과파괴에관여하는호르몬및사이토카인의불균형등이널힘줄을약화시키고나이가들면서조금식진행하는것으로알려져있다 [8-10]. 5) 눈썹의위치이상처진윗눈꺼풀피부에의해시야가가려져서이마근을이용하여눈을뜨게되므로눈썹이정상위치보다이마쪽으로올라가고이마에굵은이마주름이생기게된다 (Figure 2). 최근발표된한연구에서는나이가들면오히려다른신체부위와는달리눈썹은전반적으로이전에비해올라가는것으로알려졌으며특히내측과중앙부위가더많이올라간다고하였다 [11]. 다른한편으로는이마근처짐과동반하여눈썹처짐이생기는경우가있는데이마와함께눈썹, 눈꺼풀전체가아래쪽으로내려와눈꺼풀처짐이실제보다더심하게진단될수있다. 특히가쪽눈썹처짐이더많이발생하며이로인해눈꼬리쪽피부처짐이심하게보일수있으며눈꺼풀성형술과동시에눈썹올림술이필요할지살펴보는것이좋다. 눈썹처짐이의심되는경우이전의안면마비의병력을확인하는것이필요하다 (Figure 3). 한국인을대상으로시행한연구에서여성은 50대부터, 남성은 60대부터눈썹처짐과가쪽눈꺼풀의이완이유의하게진행하며, 중등도이상의눈꺼풀지방돌출은 40대부터나타나기시작한다고보고하였다 [12]. 2. 아래눈꺼풀의변화나이가들면서아래눈꺼풀에는윗눈꺼풀과는다른형태의 A Figure 3. Photographs showing asymmetric eyebrow (arrow) in patients with history of facial nerve palsy. (A) Photograph of right brow ptosis with history of right facial nerve palsy. (B) Photograph of left brow ptosis with history of left facial nerve palsy. 변화가생기는데아래눈꺼풀과뺨에아래안와뼈의골격이드러나보이고윤곽이고르지못하게된다. 젊었을때에는아래눈꺼풀과뺨이하나의볼록한선 (simple convex line) 을형성하고피부와근육그리고안와지방이마치한 B 개의구조물을이룬것처럼보인다. 하지만, 나이가들면서안와사이막이늘어나고지지력이약해지면서눈밑지방이탈출하게되며뺨은쳐지고안와아래뼈의골격이드러나게되어아래눈꺼풀과뺨이별개의볼록한모습을보이면서그림자가지는부위가생긴다 (Figure 4). 아래눈꺼풀당김기의약화로인해아래눈꺼풀의위치가변하는경우도있다. 눈꺼풀테가아래로내려가는눈꺼풀뒤당김 (retraction) 이생겨아래쪽의공막이보이게되기도하고, 가쪽안와인대가늘어나아래눈꺼풀수평이완이동반된경우에는눈꺼풀겉말림이나속말림이생기기도한다 (Figure 5). 아래눈꺼풀수평이완이있는경우수술중많은양의피부절제를하게되면수술후눈꺼풀뒤당김이나겉말림이생길수있으므로주의하여야한다. 또아래눈꺼풀의두드러진혈관이나햇빛에의한손상, 돌출된안와지방에의한그림자, 눈물고랑등으로아래눈꺼풀에다크써클이생기게된다 [13]. 얼굴중간부의변화 얼굴중간부는아래안와가장자리부터광대뼈, 코입술주름부사이의부위로얼굴중간부의변화는크게세층으로나누어서이해하는것이도움이된다. 가장깊은층에서는근육의이완이나과도한수축, 지방층의이동, 뼈의재흡수가일어나는데이러한변화는외부환경에의한것보다는타고난유전인자에의해일어난다. 중간층에서는진피층의위축과피부의긴장감의소실등의변화가일어나며이러한변화는피부주름의원인이된다. 상피층의변화는주로광손상이나외부환경에의한영향과관련이있으며피부질감 1014

얼굴중간부에노화가시작되면피부가늘어지고뺨지방덩이와위쪽으로이어져있는 SOOF (suborbicularis oculi fat) 가아래로내려오고이로인하여아래안와가장자리와광대융기를따라서연조직과안와지방의부피가줄어들어안와가넓어보이게된다.

4 Periorbital changes with aging 의학강좌 Figure 4. Photographs of a 57 year-old man showing both upper lid skin drooping (dermatochalasis, asterisk) and prolapsed fat on both lower eyelids (festoon, arrow). 의변화, 얼룩덜룩한색소침착등으로나타난다 [14]. 얼굴중간부에노화가시작되면피부가늘어지고뺨지방덩이와위쪽으로이어져있는 SOOF (suborbicularis oculi fat) 가아래로내려오고이로인하여아래안와가장자리와광대융기를따라서연조직과안와지방의부피가줄어들어안와가넓어보이게된다. 또한아래눈꺼풀과뺨사이의이행부에움푹들어간공간이보이게되며, 이의안쪽에서는깊어진비협주름이나눈물골변형이나타나고가쪽에서는뺨주름이보이며, 코입술주름이깊어지게된다 [15]. 그외에도아래눈꺼풀의아래측으로의만곡, 공막보임, 동그란눈, 가쪽눈구석의하방편위와같은변화가발생한다. 피부의변화 나이가들면서생기는피부의변화는개인마다차이가있으나주로환경이나햇빛에노출된정도에비례하여손상이진행한다 [16]. 상피층의변화로는질감과색깔의변화, 반점과같은색소침착, 윤기및수분량의감소가일어나고, 진피층의변화로는근육의움직임이줄어듦과동시에탄력성이없어지면서얼굴표정움직임에따른주름이만들어진다. 진피층의피부밑결체조직이얇아지면서지지조직으로서의기능이저하되며, 얼굴의지방층은아래쪽으로이동하면서동시에눈주변과뺨주변의지방층의위축이진행되는반면광대뼈부위, 코입술주름쪽에는늘어진조직들이처진다 (festoon). SMAS (superficial musculoaponeurotic system) 라고알려진부위는얇아지면서늘어지게되며이는광대뼈와위턱뼈의위축과안와아래쪽의꺼져보이는현상이얼굴의골격변화와관련이있다. Figure 5. Photograph of entropion in a 66-year-old woman showing inversion of the lower eyelid with cilia and eyelid skin touching the cornea. 결 론 고령화사회에접어들면서앞으로나이가들면서생기는눈주변의여러질환뿐아니라미용적개선을위한환자들의요구가증가할것이다. 연령과성별에따라각각다른형태를가진환자의퇴행성변화를이해하려는노력이필요하며이러한환자개개인의차이에따른환자의요구를파악하고이에맞는치료방법을선택하는것이좋겠다. 핵심용어 : 눈주변의변화 ; 눈꺼풀 ; 얼굴중앙부 ; 노화 REFERENCES 1. Lott P, Caldiera AM, Lucas A, Grigalek G. Envejecimiento facial. Papel de la orbita senil. Cir Plast Ibereo-Latinoamer 1996;22: Loeb R. Anatomical considerations. In: Loeb R, editor. Aesthetic surgery of the eyelids. New York: Springer-Verlag; p Matsuo K, Kondoh S, Kitazawa T, Ishigaki Y, Kikuchi N. Pathogenesis and surgical correction of dynamic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus. Br J Plast Surg 2005;58: Sultana R, Matsuo K, Yuzuriha S, Kushima H. Disinsertion of the levator aponeurosis from the tarsus in growing children. Plast Reconstr Surg 2000;106: Har-Shai Y, Hirshowitz B. Extended upper blepharoplasty for lateral hooding of the upper eyelid using a scalpel-shaped excision: a 13-year experience. Plast Reconstr Surg 2004;113: Shore JW, McCord CD Jr. Anatomic changes in involutional blepharoptosis. Am J Ophthalmol 1984;98: Park CY, Jeon SL, Woo KI, Chang HR. The frequency and aspects of ptosis in Korean old age. J Korean Ophthalmol Soc 2007;48: Sanke RF. Relationship of senile ptosis to age. Ann Ophthalmol 1984;16: 대한의사협회지 1015

5 Choung HK 9. Goldberg B, Rabinovitch M. Connective tissue. In: Weiss L, Greep RO, editors. Histology. 4th ed. New York: McGraw-Hill; p Bailey AJ, Duance VC. Collagen in acquired connective tissue diseases: an active or passive role? Eur J Clin Invest 1980;10: Matros E, Garcia JA, Yaremchuk MJ. Changes in eyebrow position and shape with aging. Plast Reconstr Surg 2009; 124: Seo HR, Ahn HB. Morphological changes of the eyelid according to age. J Korean Ophthalmol Soc 2009;50: American Academy of Ophthalmology. Anatomy. In: American Academy of Ophthalmology, editor. Orbit, eyelids, and lacrimal system, San Francisco: American Academy of Ophthalmology; p Cantisano-Zilkha M. Patient home care regimens. Ophthalmol Clin North Am 2005;18: Mendelson BC, Hartley W, Scott M, McNab A, Granzow JW. Age-related changes of the orbit and midcheek and the implications for facial rejuvenation. Aesthetic Plast Surg 2007; 31: Benedetto AV. The environment and skin aging. Clin Dermatol 1. Clin Dermatol 1998;16: Peer Reviewers Commentary 본논문은노화와관련된눈주변의변화를눈꺼풀, 얼굴중간부의구조적인변화, 피부의조직학적변화를중심으로다각적으로기술한논문이다. 정상눈꺼풀의기능을서두로하여, 각세부변화를관련된해부학적기전과함께기술하고있으며교정방법및주의점까지체계적으로소개하였다. 또한세부변화를잘나타내는사진과도해로이해를도왔다. 노화와관련되어발생하는눈주변의변화는미용적으로보기좋지않을뿐아니라, 기능적인이상도초래할수있으며, 인구노령화와노인인구증가가중요한사회적이슈로부각되고있는현시점점에서큰의의를가진논문이라고판단된다. [ 정리 : 편집위원회 ] 1016

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< D31322D323128C0CCC1A4B1D42DB1E8C0E7C8C6292D E687770> 대한안과학회지 2009 년제 50 권제 8 호 J Korean Ophthalmol Soc 2009;50(8):1141-1145 DOI : 10.3341/jkos.2009.50.8.1141 = 증례보고 = 접수번호 : 50-08-12-21(5/21 교정 ok) 위눈꺼풀피부늘어짐환자에서위눈꺼풀성형술후눈썹의위치변화 김재훈 이정규 중앙대학교의과대학안과학교실 목적 :