High Frequency Ultrasound to Assess Facial Skin Thickness with Gender, Age and BMI in Healthy Adults

doi:10.21203/rs.3.rs-1387962/v1

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High Frequency Ultrasound to Assess Facial Skin Thickness with Gender, Age and BMI in Healthy Adults

https://doi.org/10.21203/rs.3.rs-1387962/v1

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Background

With the high frequency of ultrasonic instruments, high frequency ultrasound plays a more and more important role in normal skin measurement, skin disease diagnosis and cosmetic medicine. The study aimed to estimate the skin epidermis and dermis thickness on eight different sites of the face in healthy adults with high frequency ultrasound, and evaluate the correlation with age and BMI.

Methods

In this study, we performed a facial skin ultrasound on 118 volunteers using high frequency ultrasound. Their epidermis and dermis thickness of forehead, glabella, temple, eyelid, nasal dorsum, zygoma, submaxilla and neck were measured. The correlation of the epidermis and dermis thickness with age and BMI was analyzed by linear correlation analysis.

Results

The epidermis and dermis thickness in males were statistically significantly higher than female (P༜0.05), except the thickness of zygomatic epidermis and neck dermis. The dermis thickness on zygoma and submaxilla of female in young age group was statistically higher than middle age and old group respectively (P༜0.05). Overall, with the increase of age, the thickness of female facial skin decreased, mainly in the forehead, glabella, zygoma and submaxill dermis thickness. In females, the epidermis and the dermis thickness of neck were correlated with BMI (r = 0.392, 0.241, P༜0.05, respectively). However, in males, the epidermis and dermis thickness was correlated with age only in zygoma dermis (r=-0.327, P༜0.05), while there was no correlation between the epidermis and dermis thickness and BMI.

Conclusions

Gender, age and BMI had significant effect on the epidermis and dermis thickness on different sites of the face.

Ultrasonography

Age

Skin thickness

Epidermis

Dermis

Skin provides human body with barrier protection, which is of great significance to maintain the homeostasis of human environment. Long term exposure of facial skin is the most direct manifestation of human aging. With the gradual improvement of living standards and the development of medical beauty technology, the public has higher and higher requirements for youth[1]. Facial skin, as one of the important indicators of "beauty", has attracted more and more attention especially from cosmetic surgeons and dermatologists [2]. Skin thickness is one of the important indexes of facial aging research [3]. More accurate quantitative evaluation of skin rather than simple subjective evaluation has also become a common concern.

In recent years, with the increasing frequency of ultrasonic probe, especially the probe ≥ 20 MHz, different layers of skin can be clearly distinguished, it is more and more widely used in dermatology [4]. At present, the most commonly used probe frequency in clinic is 20 ~ 25 MHz, which can clearly show the epidermis, dermis, subcutaneous soft tissue and the junction between them.

In this study, we measured the epidermis and dermis thickness on eight different facial regions using ultrasound scanning with 24 MHz ultrasonic probes and to assess their variations considering age, gender, BMI and site.

Study design and population

This study enrolled 118 healthy adults (at Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, China). These volunteers underwent a high frequency ultrasound scan. Clinical investigations were performed according to the Declaration of Helsinki. Furthermore, each participant signed the informed consent form for this study. This study protocol was approved by the medical ethics committee of Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences (2019-B-15). The subjects were asked to avoid using any skincare products or make-up within 1 days before testing.

Inclusion Criteria

Inclusion criteria were as follows: ①Subjects were aged 18 years and above; ② Subjects were voluntarily participated in this study, and signed informed consent; ③ There were no systemic diseases and / or other diseases that may cause changes in skin thickness; ④ The facial regions of the subjects were not treated by other methods before included in this study.

Exclusion Criteria

The exclusion criteria includeds: ① Subjects with a history of any facial skin disorders, or application of corticosteroid drugs; ② Subjects with dermal lesions and / or crusts or marked keratinization on measuring sites. ③ Subjects were instant strong sun exposure in previous 3 months, or jobs which needed instant strong sun exposure and/or hard physical activity. ④ Subjects were unable to cooperate to complete measurement.

Ultrasound Examinations

Eight sites were considered for ultrasonic assessment (forehead, glabella, temple, eyelid, nasal dorsum, zygoma, submaxilla, neck) (Fig. 1). These locations were identified for measurement by the anatomical landmarks. The thickness of epidermis and dermis of eight sites were measured respectively.

The volunteers underwent the examination in a supine position and breathed calmly. The volunteers underwent high frequency ultrasound scans by the ultrasound device (Canon, Aplio i800, Japan) equipped with a 24 MHz linear probe. The test site were coated with thick gel layer to fill the space between the probe and the skin surface to enhance test sensitivity and focuse at the most superficial cutaneous layers. Furthermore, the probe was placed on the skin surface vertically and gently to avoid compression of the anatomical structures. All images were obtained using the same setting and were captured until a clear epidermal and dermal layer was obtained, then we measured the thickness of epidermis and dermis of each site three times, and took the average value of thickness.

The distance between the thin strip and strong echo at the entrance of the epidermis was recorded as the epidermis thickness. The dermis thickness was the wide medium echo area between the back of the epidermis and the hypoechogenic subcutaneous fat layer.

Two observers were allocated for interobserver variability. One observer was designated for all 118 patients (observer A, with 20 years of experience in diagnostic ultrasound), while the other independent observer (observers B, with 10 years of experience in diagnostic ultrasound) measured the thickness of epidermis and dermis for the assigned 18 volunteers, respectively to assess interobserver variability. Both observers were experienced sonographers and were unaware of each patient’s clinical information or status.

Baseline Measurements

Individual results of a comprehensive health and lifestyle questionnaire for study participants were collected with their consent. Information about age, sex, history of facial allergy and facial exfoliation, smoking condition and alcohol consumption was obtained using a self-administered questionnaire. Weight and height were measured by nurses following standardized protocols, and body mass index (BMI) calculated as weight / height² (kg/m²).

Statistical analysis

Data analysis was performed using SPSS 23.0 (IBM, Armonk, NY, USA) statistical analysis software. The data were expressed as numbers and percentages by category for qualitative variables and as mean ± standard deviation, or as median and interquartile range if the distribution did not appear to follow a normal distribution, for quantitative variables. One way ANOVA test or independent t-test was applied to compare intergroup differences in epidermis and dermis thickness values in volunteers. Interobserver variability were examined by intraclass correlation coefficient (ICC).

Baseline characteristics

A total of 118 subjects were investigated in this study. The baseline characteristics of the subjects are shown in Table 1. There were 49 males (41.53%), with an average age of 46.45 ± 12.80 years; There were 69 females (58.47%), with an average age of 44.06 ± 11.10 years. According to WHO classification of age, the age of subjects was divided into three levels: 20 ~ 44 years, 45 ~ 59 years, ≥ 60 years. In this study, 62 cases (52.54%) aged years, 42 cases (35.59%) aged 45–59 years, and 14 cases (11.86%) aged 60 and over.

Table 1

Baseline characteristics of the three groups
Variables	18–44 years (n = 62)	45–59 years (n = 42)	≥ 60 years (n = 14)	F	P值
Gender, n(%)				3.608	0.165
Male	25 (40.32%)	15 (35.71%)	9 (64.29%)
Female	37 (59.68%)	27 (64.29%)	5 (35.71%)
Smoking	15 (24.19%)	9 (21.43%)	4 (28.57%)	0.312	0.856
Alcohol use (%)	33 (53.23%)	16 (38.10%)	4 (28.57%)	4.032	0.133
Allergy (%)	9 (14.52%)	11 (26.19%)	1 (7.14%)	3.565	0.168
Height (cm)	164.37 ± 7.28	161.17 ± 7.41^*	165.71 ± 7.21^#	3.201	0.044
Weight (Kg)	63.10 ± 11.17	60.29 ± 10.64	66.21 ± 10.21	1.782	0.173
BMI (kg/m²)	23.23 ± 2.89	23.10 ± 2.92	24.03 ± 2.74	0.563	0.571
Data are means ± SD or n[%]. BMI, body mass index, SD, standard deviation.
Compared with the group 18–44 years old, ^*P<0.05; Compared with the group 45–59 years old, ^#P<0.05

Interobserver Agreement

As measured by the two observers, the mean values of epidermis thickness of the whole face were 0.18 mm and 0.18 mm, respectively, while the mean values of dermis thickness of the whole face were 0.98 mm and 0.97 mm respectively. The preconsensus measurements had a good ICC of 0.81 for epidermis thickness [95% confidence interval (CI): 0.56, 0.92] and an excellent ICC of 0.83 for dermis thickness (95% CI: 0.60, 0.93).

The mean epidermis and dermis thickness of the whole face between two observers were comparable, and the ICC for the interobserver variability was over 0.8, suggesting good agreement between observers.

Ultrasound Measurements Of Epidermis And Dermis Thickness

Multivariate analysis of variance showed that gender had a significant effect on the thickness of facial dermis and epidermis of normal adults (P<0.05), while age had no significant effect on the thickness of facial dermis and epidermis of normal adults.

Except the thickness of zygomatic epidermis and neck dermis, the thickness of epidermis and dermis in other sites of the male face were significantly thicker than those in female, and the difference was statistically significant (P<0.05) (Table 2). Forehead had the highest epidermal and dermis thickness of the males, while the dermis thickness was the highest on neck in females.

Table 2

Comparison of epidermal and dermal thickness in different sites
Facial region	male (n = 49)	Female (n = 69)	t	P值
Epidermis (mm)
Forehead	0.22 ± 0.03	0.20 ± 0.03	3.356	0.001
Glabella	0.21 ± 0.03	0.19 ± 0.02	2.961	0.004
Temple	0.19 ± 0.02	0.18 ± 0.02	2.476	0.015
Eyelid	0.18 ± 0.03	0.17 ± 0.02	3.156	0.002
Nasal dorsum	0.20 ± 0.03	0.19 ± 0.02	2.356	0.020
Zygoma	0.19 ± 0.03	0.20 ± 0.18	-0.322	0.748
Submaxill	0.21 ± 0.09	0.18 ± 0.03	2.220	0.028
Neck	0.19 ± 0.03	0.17 ± 0.03	3.926	<0.001
Dermis (mm)
Forehead	1.17 ± 0.28	0.86 ± 0.16	7.515	<0.001
Glabella	1.14 ± 0.30	0.90 ± 0.23	4.972	<0.001
Temple	1.06 ± 0.20	0.80 ± 0.19	7.272	<0.001
Eyelid	0.67 ± 0.14	0.58 ± 0.11	4.192	<0.001
Nasal dorsum	1.03 ± 0.16	0.93 ± 0.25	2.604	0.010
Zygoma	1.14 ± 0.21	0.87 ± 0.35	4.938	<0.001
Submaxill	1.02 ± 0.24	0.91 ± 0.34	1.990	0.049
Neck	0.98 ± 0.22	0.99 ± 0.20	-0.117	0.907

Comparison of epidermal and dermal thickness in females between age groups(20 ~ 44 years, 45 ~ 59 years and over 60 years), showed that the dermis thickness was significantly thicker in zygoma and submaxill in the 20 ~ 44 years group (P<0.05) (Fig. 2). In males, the thickness of epidermal and dermis was lower in over 60 years age group in all sites (but reached statistical significance only in neck epidermis) (Table 3).

Table 3

Comparison of male and female epidermis thickness ultrasound measures among the three groups
	Male					Female
Facial region	18–44 years (n = 25)	45–59 years (n = 15)	≥ 60 years (n = 9)	F	P值	18–44 years (n = 37)	45–59 years (n = 27)	≥ 60 years (n = 5)	F	P值
Epidermis (mm)
Forehead	0.23 ± 0.03	0.22 ± 0.03	0.20 ± 0.04	1.555	0.222	0.20 ± 0.04	0.20 ± 0.02	0.19 ± 0.02	0.145	0.865
Glabella	0.21 ± .025	0.21 ± 0.04	0.19 ± 0.03	1.670	0.199	0.20 ± 0.02	0.19 ± 0.02	0.20 ± 0.01	0.894	0.414
Temple	0.19 ± 0.02	0.19 ± 0.02	0.18 ± 0.02	1.500	0.234	0.18 ± 0.02	0.18 ± 0.03	0.17 ± 0.01	0.566	0.571
Eyelid	0.19 ± 0.03	0.18 ± 0.02	0.16 ± 0.02	2.575	0.087	0.17 ± 0.02	0.16 ± 0.03	0.17 ± 0.02	0.937	0.397
Nasal dorsum	0.20 ± 0.03	0.21 ± 0.03	0.19 ± 0.02	1.809	0.175	0.19 ± 0.02	0.20 ± 0.02	0.18 ± 0.01	0.567	0.570
Zygoma	0.19 ± 0.03	0.19 ± 0.02	0.18 ± 0.02	0.912	0.409	0.18 ± 0.02	0.23 ± 0.28	0.18 ± 0.04	0.752	0.476
Submaxill	0.22 ± 0.12	0.20 ± 0.02	0.18 ± 0.02	0.927	0.403	0.18 ± 0.03	0.19 ± 0.02	0.18 ± 0.01	0.688	0.506
Neck	0.19 ± 0.03	0.20 ± 0.03	0.17 ± 0.02^#	3.650	0.034	0.17 ± 0.03	0.17 ± 0.03	0.18 ± 0.03	0.406	0.668
Dermis (mm)
Forehead	1.22 ± 0.30	1.12 ± 0.27	1.12 ± 0.23	0.753	0.477	0.90 ± 0.14	0.83 ± 0.17	0.77 ± 0.17	2.598	0.082
Glabella	1.16 ± 0.33	1.15 ± 0.29	1.05 ± 0.20	0.510	0.604	0.95 ± 0.24	0.85 ± 0.23	0.75 ± 0.06	2.548	0.086
Temple	1.07 ± 0.22	1.04 ± 0.20	1.07 ± 0.18	0.178	0.838	0.82 ± 0.18	0.78 ± 0.19	0.71 ± 0.27	1.007	0.371
Eyelid	0.68 ± 0.15	0.65 ± 0.11	0.69 ± 0.17	0.183	0.834	0.56 ± 0.10	0.59 ± 0.11	0.63 ± 0.16	0.869	0.424
Nasal dorsum	0.98 ± 0.17	1.08 ± 0.13	1.09 ± 0.17	2.431	0.099	0.93 ± 0.24	0.90 ± 0.27	1.01 ± 0.20	0.393	0.677
Zygoma	1.21 ± 0.21	1.08 ± 0.18	1.07 ± 0.19	2.790	0.072	0.97 ± 0.33	0.78 ± 0.36^*	0.63 ± 0.20^*	3.853	0.026
Submaxill	1.07 ± 0.23	0.98 ± 0.22	0.96 ± 0.31	1.117	0.336	1.00 ± 0.29	0.84 ± 0.39	0.60 ± 0.26^*	4.112	0.021
Neck	0.96 ± 0.19	1.04 ± 0.28	0.95 ± 0.19	0.730	0.488	0.96 ± 0.16	1.02 ± 0.24	1.03 ± 0.18	0.838	0.437

Correlation Of Epidermis And Dermis Thickness With Age And Bmi

In females, the dermis thickness of forehead, glabella, zygoma and submaxilla was correlated with age (r=-0.284, -0.361, -0.403, -0.342, P<0.05, respectively). The epidermis and dermis thickness of neck were correlated with BMI (r = 0.392, 0.241, P<0.05, respectively) (Table 4).

Table 4

Results of univariate the association of Female epidermis and dermis thickness with age and BMI
	Age	BMI
Epidermis
Forehead	-0.069	0.052
Glabella	-0.022	0.188
Temple	-0.072	0.097
Eyelid	-0.126	0.229
Nasal dorsum	-0.016	0.045
Zygoma	-0.012	0.070
Submaxill	0.170	0.122
Neck	0.128	0.392^**
Dermis
Forehead	-0.284*	0.037
Glabella	-0.361**	-0.255^*
Temple	-0.209	-0.081
Eyelid	0.147	0.087
Nasal dorsum	0.065	-0.056
Zygoma	-0.403**	-0.198
Submaxill	-0.342**	-0.110
Neck	0.199	0.241^*

In males, the epidermis and dermis thickness was correlated with age only in zygoma dermis (r=-0.327, P<0.05), while there was no correlation between the epidermis and dermis thickness and BMI.

The study is to evaluate the epidermis and dermis thickness on different facial regions using ultrasound scanning with 24 MHz ultrasonic probes to assess their variations considering age, gender, BMI and site. We observed there are differences in the epidermis and dermis thickness in different sexes and different sites on the face of adults. Gradual decrease in dermis thickness with age in forehead, glabella, zygoma and submaxilla dermis was more significant in women than in men. With the increase of BMI, the thickness of female facial skin changes, mainly in the glabella, neck dermis thickness and neck epidermis thickness.

The skin consists of epidermis, dermis and subcutaneous tissue. Facial skin is affected by several external environmental factors for a long time such as sunlight, temperature and humidity, which is more obvious than that of other parts of the skin[5]. With the occurrence of skin aging, the three components of the skin have different degrees of degenerative changes, and the skin thickness also changes [6]. Delaying skin aging, especially the facial skin, has always been the focus of attention. Skin thickness is one of the important indicators of facial aging research.

Ultrasound as a non-invasive diagnostic method has been used since the 1970s of the 20 th century for determining the whole skin thickness in the field of dermatology [7]. At present, high frequency ultrasound with the characteristics of noninvasive, rapid and economic has gradually become an important development direction of dermatology [8].

The results of this study showed that the epidermal and dermis thickness in males was higher than females, which consistented with Seidenari et al [9]. In our study, the difference was statistically significant, except the thickness of zygomatic epidermis and neck dermis.

Overall, our results on skin thickness are essentially in accordance with the study of Escoffier et al. [10] and Shuster et al. [11], which demonstrates that the acoustical properties of skin vary both relative to age and to gender. In males, there was no significant correlation between the epidermis and dermis thickness of facial skin and age. However, in females, the dermis thickness of forehead, glabella, zygoma and submaxilla decreased gradually with age. Research showed that with the occurrence of skin aging, among the three components of the skin, the change of dermis was the most obvious [6], which was consistent with our research results. The differences between male and female may be caused by the particularity of female aging. The study found that the change of estrogen level can change the skin thickness by affecting the amount of collagen [12, 13]. Most women began to change their menstrual cycle from about 40 years old, so as to start skin aging from 40 years old. After 48 years old, the skin thickness decreased linearly with the increase of age, and the aging was significantly accelerated from 60 to 70 years old [14, 15].

The neck is also an important part of the facial appearance. With the growth of age, the aging of the neck can be manifested as skin relaxation, wrinkles or fat accumulation, especially in the inherent neck [16]. In this study, we found that in females the neck epidermis and dermis thickness were both correlated with BMI, however, in male that was not reach statistical significance. This also showed that there were differences in skin aging and skin thickness between male and female. Van Mulder et al[17]. showed that increasing BMI was associated with an increased skin thickness. However, only the neck epidermis and dermis thickness of females in our study are correlated with BMI, potentially due to different sites. Most findings agreed to a positive relation between skin thickness and BMI, but the impact of BMI is lower at the facial sites.

Limitations

This study has several limitations. First, in this study, we did not observe the epidermis and dermis thickness variations according to skin type, race and other external environmental factors, such as sun exposure. Second, we did not evaluate the skin density, echogenicity, elasticity and blood perfusion information of the epidermis and dermis layer, these are required to be further studied in the future.

In conclusion, evaluation of epidermis and dermis thickness using high frequency ultrasound scanning is convenient, and effective. These merits made high frequency ultrasound for use as noninvasive detection methods and curative effect evaluation for dermatologists and cosmetic medicine in broad clinical. The findings of our study suggest important differences in the thickness of skin epidermis and dermis in different anatomical parts of the face, different genders, BMI, and ages.

Ethics approval and consent to participate

These clinical investigations were performed according to the Declaration of Helsinki and each participant signed the informed consent form for this study. This study protocol was approved by the medical ethics committee of Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences(2019-B-15).

Consent for publication

Written informed consent was obtained from all the patients for publication of this manuscript and any accompanying images.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Competinginterests

The authors declare that there is no conflict of interest with any financial organization or corporation or individual that can inappropriately influence this work.

Funding

This research was funded by Shanghai Jiading District Natural Science Research Project(No. JDKW-2021-0015) and Jiading District Key Medical Specialty Project (No. 2020-jdyxzdzk-02).

Author contributions

YM and LF—carried outultrasound; JLS and ZXY—carried out statistical analysisandprepared figures; LJand LF—drafted themanuscript, which was critically reviewed by all authors.

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You are reading this latest preprint version

High Frequency Ultrasound to Assess Facial Skin Thickness with Gender, Age and BMI in Healthy Adults

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Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Study design and population

Inclusion Criteria

Exclusion Criteria

Ultrasound Examinations

Baseline Measurements

Statistical analysis

Results

Baseline characteristics

Interobserver Agreement

Ultrasound Measurements Of Epidermis And Dermis Thickness

Correlation Of Epidermis And Dermis Thickness With Age And Bmi

Discussion

Limitations

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1