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Wrinkle scales: To use or not to use?

Article-Wrinkle scales: To use or not to use?

When it comes to using wrinkle classification systems, like Glogau, Merz or Fitzpatrick, some aesthetic physicians swear by them. Others would rather look at wrinkles as “mild,” “moderate” or “severe.”

American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) President Fred G. Fedok, M.D., says he uses specific wrinkle scales in his aesthetic practice to ascertain which treatments would be effective and safe in a given patient.

“I use two scales commonly when considering patients for resurfacing procedures — the Glogau and the Fitzpatrick scales,” he says. “I use the Glogau to characterize the patient to help guide the type of treatment and the aggressiveness of treatment. For instance, in patients with a lesser Glogau rating, I expect them to display less photoaging changes compared to those with a higher rating. In those former patients I may consider it most appropriate to do a lighter peel or use a less aggressive laser setting.”

Dr. Fedok says the Fitzpatrick scale tells him about skin type, the amount of melanin in a patient’s skin and the patient’s propensity for pigmentation complications, secondary to resurfacing.

“Those with a lessor Fitzpatrick type, will do well with many types and depths of resurfacing. Those with a higher Fitzpatrick designator will have to be treated quite cautiously,” Dr. Fedok says.

Princeton, N.J. plastic surgeon Adam Hamawy, M.D., says his scale of choice is the Glogau Wrinkle Scale, because it offers a good global assessment of the face.

“When I need to get more specific, I use the Merz scale for the specific region of the face,” Dr. Hamawy says.

But like many doctors who do aesthetic procedures, Dr. Hamawy thinks wrinkle scales are not used much in clinical practice.

“Scales are usually used to provide objective quantification of improvement in facial wrinkles after injection of a neurotoxin like Botox or a filler. They are most useful in research when assessing how effective an injectable treatment is. They are not typically used in routine, everyday clinical evaluations or treatments,” Dr. Hamawy says.

NEXT: Let the Scale Guide You


Let the Scale Guide You

For example, the Glogau scale is a great objective measure, mostly used in clinical research to evaluate the efficacy of different devices and creams, according to New York City dermatologist, Margarita Lolis, M.D.

“In clinical practice this scale is less commonly used, I believe mostly because treatments are tailored to individual patients and not based on the scale or, for that matter, on a protocol derived from the scale. I do however think the scale is a quick and easy way of determining one's degree of photoaging and can guide rather than dictate your treatment plan,” Dr. Lolis says.

Among the issues with clinical practice use: there are lots of scales.

“There are over a dozen validated wrinkle scales that have been published and used in the literature. In all of them, assessment of the wrinkles are always made from standardized photographs and require accurate positioning and consistent lighting,” Dr. Hamawy says.

Anesthesiologist Alex Roher, M.D., of San Diego Botox, says the scientific literature is severely lacking a standardized tool for the measurement of aging.

“Most of the published scales have not undergone any formal validation process, and many are subjective in their assessment of wrinkle severity. With this said, after extensive personal research, I use these three scales in my practice to present a baseline to the patient before treatment: the marionette lines grading scale, forehead lines grading scale and crow’s feet grading scale [all based on Merz scales],” Dr. Roher says. “We also rely on extensive before and after photography that we maintain in each client's electronic file.”

Wrinkle scales, according to South Florida plastic surgeon Jacob Freiman, M.D., are an attempt simplify a very complex problem.

“The purpose of all scales in medicine is take a disorder, in this case wrinkles, use a measurement, in this case location and depth, and then decide on a treatment,” Dr. Freiman says. “Plastic surgeons prefer to look at patients on a case by case basis and not shoehorn everyone into a category.”

NEXT: Mild, Moderate and Severe


Mild, Moderate and Severe

Aesthetic dermatologist S. Manjula Jegasothy, M.D., founder of Miami Skin Institute, Miami, Fla., says wrinkle classification systems lack specificity.

“There can be someone who, let’s say is in her mid-20s, who comes to me with a moderate-to-severe glabellar wrinkle that would be mild in someone who is 50,” she says. If a micrometer or some sort of measurement were put to it, those patients might have the same depth but would be considered very differently in different age groups,” Dr. Jegasothy says. “Wrinkle severity scores are pretty much used to standardize results for studies. In practice, I think most of us are mild, moderate and severe.”

Mild, moderate and severe is precisely how Joe Niamtu, III, D.M.D., an oral and maxillofacial surgeon with a practice limited to cosmetic facial surgery in Richmond, Va., does wrinkle assessments.

“There are two types of people. There are the dogmatic people who embrace numeric quantification and try and apply that to clinical practice. And there are those that are more clinically oriented and pay less attention to dogma in quantification,” Dr. Niamtu says. “My favorite classification system is mild, moderate and severe.”

It is, however, important to have a standardized classification system in some situations outside of research, according to Dr. Niamtu. Those include when communicating with other doctors for a higher degree of accuracy, and for medical records, medical-legal situations or insurance coding, where applicable.

Three Wrinkle classification systems at a glance:

The Modified Fitzpatrick Wrinkle Scale is a clinically reliable validated tool for nasolabial wrinkle severity assessment, according to this study.

The Glogau Wrinkle Scale ( was developed by dermatologist Richard Glogau, MD.

Merz Aesthetics Scales measure the upper face, mid-face, lower face and neck, platysmal and hands, according to the company website

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