Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Facial Changes Caused by Smoking: A Comparison between Smoking and Nonsmoking Identical Twins

Okada, Haruko C. M.D.; Alleyne, Brendan B.S.; Varghai, Kaveh; Kinder, Kimberly M.D.; Guyuron, Bahman M.D.

Plastic and Reconstructive Surgery: November 2013 - Volume 132 - Issue 5 - p 1085–1092
doi: 10.1097/PRS.0b013e3182a4c20a
Cosmetic: Original Articles
Press Release
Best Paper

Background: The purpose of this study was to identify the specific components of facial aging secondary to smoking, by comparing standardized photographs of identical twins with different smoking histories.

Methods: During the Twins Days Festival in Twinsburg, Ohio, from 2007 to 2010, 79 pairs of twins were identified, in which only one twin smokes or where one twin smoked at least 5 years longer than his or her counterpart. Questionnaires were obtained and standardized photographs were taken by professional photographers. A panel of three blinded judges analyzed the twins’ facial features and graded wrinkles using the validated Lemperle Assessment Scale, and ranked age-related facial features on a four-point scale.

Results: Smoking twins compared with their nonsmoking counterparts had worse scores for upper eyelid skin redundancy, lower lid bags, malar bags, nasolabial folds, upper lip wrinkles, lower lip vermillion wrinkles, and jowls. Lower lid hyperpigmentation in the smoking group fell just short of statistical significance. Transverse forehead wrinkles, glabellar wrinkles, crow’s feet, and lower lip lines accentuated by puckering did not have a statistically significant differences in scores. Among twins with greater than 5 years’ difference in smoking duration, twins who had smoked longer had worse scores for lower lid bags, malar bags, and lower lip vermillion wrinkles.

Conclusions: This study details the specifics of facial aging brought on by smoking, which primarily affects the middle and lower thirds of the face. It also demonstrates that a 5-year difference in smoking history can cause noticeable differences in facial aging in twins.


Cleveland, Ohio

From the Departments of Plastic Surgery and Otolaryngology–Head and Neck Surgery, Case Western Reserve University, University Hospitals of Cleveland.

Received for publication November 13, 2012; accepted May 8, 2013.

Disclosure:The authors have no financial interest to declare in relation to the content of this article. No external funding was received.

Bahman Guyuron, M.D., Department of Plastic Surgery, Case Western Reserve University, University Hospitals of Cleveland, MS 5044, 11100 Euclid Avenue, Cleveland, Ohio 44106,

©2013American Society of Plastic Surgeons