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The Aging Face and Facial Rejuvenation

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What is Facial Beauty? What makes someone more attractive is eye of the beholder and phi of the beholder. A look at how aging effects our beauty and what can be done to improve our facial beauty.

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The Aging Face and Facial Rejuvenation

  1. 1. Facial Beauty Presented by Dr. Scott K. Smith
  2. 2. What is Beauty? Is beauty only in the eye of the beholder….. Or ,are there some absolute values?
  3. 3. Beauty is a mystery! “I know not what beauty isbut I know that it touchesmany things", Dürer
  4. 4. Symmetry youthfulness clarity or smoothness of skinvivid color in the eyes and hair
  5. 5. “Personal beauty is a greater recommendation than anyletter of reference.”- Aristotle
  6. 6. Dental Emphasis to Oro-Facial
  7. 7. • It has long been said that beauty is in the eye of the beholder and thought that beauty varies by race, culture or era.
  8. 8. Beauty in the Eye of the Beholder?
  9. 9. Beauty in the Phi of the BeholderEvidence shows that our perception of physicalbeauty is hard wired into our being and based onhow closely ones features reflect phi in theirproportions. • 1.6180399
  10. 10. What is PhiPhi ( Ø ), is simply an irrational number like pi.What makes it more unusual is that it can be derived in many ways and shows up in relationships throughout the universe. Phi Ø can be derived through: *A numerical series discovered by Leonardo Fibonacci
  11. 11. Phi is Everywhere* The proportions of the human body* The proportions of many other animals* Plants* DNA* The solar system* Art and architectureThe ratio, or proportion, determined by Phi (1.618...) wasknown to the Greeks as the "Golden Section" and toRenaissance artists as the "Divine Proportion
  12. 12. Divine Proportion is Everywhere
  13. 13. • The head forms a golden rectangle with the eyes at its midpoint. The mouth and nose are each placed at golden sections of the distance between the eyes and the bottom of the chin.
  14. 14. • Science writer Eric Haseltine claimed (in an article in Discover magazine in September 2002) to have found that the distance from the chin to the eyebrows in Langloiss 32-composite faces divides the face in a Golden Ratio.
  15. 15. • A similar claim was made in 1994 by orthodontist Mark Lowey, then at University College Hospital in London. Lowey made detailed measurements of fashion models faces. He asserted that the reason we classify certain people as beautiful is because they come closer to Golden Ratio proportions in the face than the rest of the population.
  16. 16. • Beauty is not just in the eye of the beholder. Researchers say its also in the distance between the eyes and the mouth.• Researchers at the University of California, San Diego and the University of Toronto have identified the optimal relation between the eyes, the mouth and the edge of the face that distinguishes a beauty queen from a plain Jane.
  17. 17. Principles of Aesthetics• Balance• Rhythm• Proportion• Emphasis• Unity
  18. 18. Aesthetic Principles• Balance• Rhythm• Proportion• Emphasis• Unity
  19. 19. Balance• Visual Equilibrium• Symmetry?
  20. 20. Symmetry R and L superimposed
  21. 21. Rhythm• The human face communicates an incredible array of emotions which are an integral element of ones total beauty. The human face conforms most closely to phi proportions when we smile.
  22. 22. Unity• Coherence of the whole• Effect of all other disciplines working together to form esthetic harmony
  23. 23. Proportion
  24. 24. one third one third one third
  25. 25. Horizontal Fifths
  26. 26. Emphasis• Eyes• Cheeks• Peri-oral
  27. 27. The Aging Face• Extrinsic Factors• Intrinsic Factors
  28. 28. The Aging Face Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S
  29. 29. Extrinsic Factors Trauma Smoking Photodamage Gravity
  30. 30. Intrinsic Damage• Fibroblastic Synthesis Reduction• Breakdown of Cellular Membrane• DNA Repair Reduction
  31. 31. Components of Aging• Thinning of Dermis• Atrophy of Fat Pads• Loss of elasticity• Greater Visibility of Bony Landmarks• Increased Visibility of Vessels• Increased Mental and Mandibular Folds
  32. 32. Components of Aging• Development of Wrinkles and Furrows• Transverse Forehead lines• Drop of Eyebrow and Eyelid• Descent of Corner of Mouth• Thinning of Upper lip and Inversion of lip• Nasiolabial Fold Development• Rhytids – smokers lines• Atrophy of Cupids Bow
  33. 33. Aesthetic Principles• Balance• Rhythm• Proportion• Emphasis• Unity
  34. 34. Principles we CAN effect Proportion Emphasis Rhythm
  35. 35. Lipswhat defines lip structure and attractiveness.• Dentition• Width of upper vs. lower• Interlabial gap• Oral commissures should be located along vertical lines drawn from the medial limbus of the iris.
  36. 36. Gordon Classification• Zone A• Zone B• Zone C
  37. 37. Creating the Esthetic Smile
  38. 38. Aesthetic TreatmentsMinimally Invasive Cosmetic Procedures
  39. 39. Botulinum toxin• Botulinum toxin type A (BoNT-A) works by blocking the release of a neurotransmitter necessary for muscles to contract• The effects of BoNT-A last approximately 3-4 months, with complete re-activation of the nerves and muscles• BoNT-A has been available and used for therapeutic uses since 1980
  40. 40. Normal Neuromuscular FunctionArnon et al. JAMA 2001;285(8):1059-1070 (with permission).
  41. 41. Botulinum Toxin Mechanism of ActionArnon et al. JAMA 2001;285(8):1059-1070 (with permission).
  42. 42. Botulinum Toxin StructureClostridium botulinum is a gram positive, anaerobic, rod-shaped bacterium that produces seven serologically distinct neurotoxins (A-G)1. Non-toxic,non-hemagglutinin (NTNH) Hemagglutinin (HA) 150 kD Neurotoxin 1Hathaway. In: Hauschild AHW, ed. Clostridium Botulinum: Ecology and Control in Foods New York, NY: Marcel Dekker, Inc.;1993;54:pp 3-20. 2Inoue et al. Infect Immun 1996;64:1589-1594. 3Lacy et al. Nat Struct Biol 1998;5:898-902 (with permission).
  43. 43. Facial Areas Commonly Treated with BoNT-A Forehead Glabellar lines Brow lift Bunny lines Crow’s feet Perioral linesGummy smile Oral commissures Peau d’orange Platsymal bands
  44. 44. 1. Frontalis2. Procerus3. Corrugator supercilli4. Depressor supercilli 15. Temporalis 56. Obicularis oculi 37. Nasalis 28. Levator labaii superioris 4 alaeque nasi9. Levator labaii 610. Zygomaticus minor 8 711. Zygomaticus major 10 912. Obicularis oris 1113. Modeolus 12 1314. Masseter 1415. Depressor anguli oris16. Depressor labii 15 16 1717. Mentalis
  45. 45. BoNT-A treatment: Glabellar lines Before After - Day 30 www.Botox.com
  46. 46. BoNT-A treatment: Forehead lines Before After - Day 30 After - Day 120 Carruthers & Carruthers. Dermatol Surg 2007;33:S10-S17
  47. 47. BoNT-A treatment: Brow lift Before After Coleman & Carruthers. Dermatol Therap 2006;19:177-88
  48. 48. BoNT-A treatment: Perioral lines Before After Kane. Oral Maxillofacial Surg Clin N Am 2005;17:41-49
  49. 49. BoNT-A treatment: Gummy smile Before After Kane. Oral Maxillofacial Surg Clin N Am 2005;17:41-49
  50. 50. BoNT-A treatment: Oral commissures Before After Carruthers & Carruthers. Dermatol Surg 2003;29:468-76
  51. 51. Hyaluronic Acid Fillers
  52. 52. HA Treatment: Marionette lines Before After Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S
  53. 53. HA Treatment: Pre-jowl sulcus Smith. Plast Reconstr Surg 2007;120(Suppl):67S-73S
  54. 54. HA Treatment: Lip Volumization Before After After Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S
  55. 55. HA Treatment: Nasolabial folds Before After
  56. 56. HA Treatment: Nasolabial folds Before After – 2 weeks After – 38 weeks Smith et al. AAD Summer 2006
  57. 57. HA Treatment: Nasolabial folds Before After – 2 weeks After – 24 weeks Smith et al. AAD Summer 2006
  58. 58. HA Treatment: Cheek Volumization Before After – 10 days Smith. Plast Reconstr Surg 2007;120(Suppl):67S-73S
  59. 59. Introduction to The Next Generation InLonger Lasting Wrinkle Correction
  60. 60. Radiesse vs CosmoPlast Clinical Study ® Baseline 6 MonthsPatient 1 Radiesse Control Radiesse ControlPatient 2 Radiesse Control Radiesse Control
  61. 61. Placement of Radiesse into the Skin• Objective is to fill the depression and structurally support the line and provide volume – Inject Radiesse into the deep dermis and subdermal plane – Use non-dominant index finger to guide needle – Deeper threads can be placed to bolster depression – Use thumb and forefinger to massage and mold Radiesse Subdermal Plane
  62. 62. Radiesse Delivers Greater ImprovementThan Restylane At Every Time Point Radiesse vs. Restylane How much improvement on average over time? Radiesse Improvement 1.2RADIESSE Mean Improvement from Baseline (WSRS) Restylane Improvement 1 RESTYLANE 0.8 0.6 0.4 0.2 0 3 mos 6 mos 9 mos Time post 2nd injection
  63. 63. Radiesse Delivers Longer LastingImprovement Radiesse vs. Restylane Improvement over Time (GAIS) % Patients 100 Radiesse Improved at 9 months: Restylane 90 Radiesse = 79% 80 % of Patients with Improvement Restylane = 44% 70 60 50• More Patients 40 are Improved at 30 20 Every Time 10 Point 0 3 mos 6 mos 9 mos Time post 2nd injection
  64. 64. Radiesse & Restylane Histology – 4 weeks Radiesse Moderate tissue response Gel carrier replaced by native fibrinogen, elastin and collagen under the normal tissue repair mechanism Restylane • Minimal tissue response • No native fibrinogen, elastin and collagen is manufactured to replace absorbtion of HA
  65. 65. Mechanism of ActionWhen placed into soft tissue, Radiesse Over time the gel is resorbed and theprovides immediate correction CaHA particles stimulate and supportGel + CaHA Particles in-growth of new collagen Collagen + CaHA Particles
  66. 66. Radiesse vs Restylane Split Face Study ® Restylane RadiesseBefore Treatment 6 Months (post last injection) Restylane Radiesse 9 Months (post last injection)
  67. 67. Addressing Some Misconceptions1. Radiesse cannot form bone in soft tissue • Micro-motion presence; No bone morphogenic proteins; No osteoblast progenitor cells2. Radiesse particles do not migrate • Exhaustive pre-clinical studies have demonstrated no migration • Particles are 25-45µm & thus too large (>15 microns) to be encapsulated by macrophage and migrate via lymphatic system • Collagen infiltration around particles hold them in place3. Radiesse will not obstruct X-rays • If visible, its only faint & whispy and won’t interfere • Barely visible on diagnostic x-ray, clearly evident bilaterally on CT scan with no masking of other structures4. Lip Nodules are not Granulomas • Zero granulomas reported in multicenter clinical trials (>1,000 patients) • CaHA molecular and chemical composition is identical to that in the human body and does not generate a foreign body Rx • Not seen as a foreign body so no delayed inflammatory response • Not for use in lips due to muscle motion & cohesive properties of the gel carrier • Nodules are not granulomas – nodules are early onset, accumulations of product, which are distinct from late onset granulomatous foreign body reactions
  68. 68. Fractional CO2 Resurfacing June 2011
  69. 69. Resurfacing History Ablative CO2 Full Resurfacing 1991  Erbium 1997 Non-Ablative Resurfacing 1996  IPL 1996  Nd:YAG & Others 2000 Non-Ablative Fractional Resurfacing 2004  Fraxel Ablative Fractional Resurfacing 2006  CO2 & Erbium
  70. 70. Photo Low Energy + Damage High Density1. Tone Moderate Energy Texture + Moderate Density Color2. Rhytides High Energy + Scars Low Density 1. Photo courtesy of Mark Rubin, M.D. 2. Photo courtesy of Mark Taylor, MD3. 3. Photo courtesy of Yasmina Carvajal, M.D.
  71. 71. • When the laser pulses at thousandths of a second, the water in skin (skin is 90% water) heats up to a very high temperature.• The water is instantly vaporized into a smoke plume and residual heat, proportional to the pulse energy (mJ), spreads into the surrounding tissue.• Immediate contraction and epidermal dyschromias are removed.• Ablated tissue and thermal spread of heat causes a natural healing response that stimulates new collagen growth to restructure and restore the dermis to resemble new, undamaged skin. 124
  72. 72. Wound Healing Immediately After Post 2 Days•Ablated epidermis • Volume collapse of ablated column for•Ablated column extends deep into the immediate contraction. dermis. • Re-epithelialization is complete.•Uniform thermal heat to surrounding • Ongoing collagen stimulation for 3-6 months tissues.
  73. 73. Stratum Corneum: 2 – 3 DaysBasal Layer: 4 – 6 DaysPapillary Dermis: 7 – 8 DaysMid Dermis: 8 – 10 DaysReticular Dermis: 10 – 12 Days
  74. 74. Full Ablative CO2 Resurfacing  The “Gold Standard”  Single Treatment  Dramatic ResultsPhotos Courtesy of Dr. Sarnoff
  75. 75. Full Ablative CO2 Resurfacing • It was the “Worst of times” • Prolonged downtime (up to 1month) • Increased incidence of side effects • This is why we provide Erbium!Photos Courtesy of Dr. Sarnoff
  76. 76. New Decrease need for power IncreaseTraditional CO2 need for Fractional CO2 scanning 2 mm 150 µmFull Face Ablation Tissue SparingProlonged Healing Shortened Healing
  77. 77. Fractional Laser Treatment A fraction of the skin area is treated with an array of relatively small spots. frac·tion·al -of, relating to, or being a fraction - relatively small: inconsiderable frac·tion·ate - to divide or break up - divide into different portions
  78. 78. Any Golfers out there?Very Similar theory…. To improve the condition of the green, Golf Course Superintendents don’t remove the entire putting green, they remove a portion, or fraction of it!!!
  79. 79. What’s Happening Today……
  80. 80. Pigmentation Problems? Hair Problems ? Wrinkles? Acne? Courtesy of Nora Grace
  81. 81. Hair Removal, Skin Rejuvenation, Acne Treatments, Vascular Treatments and Skin Tightening____________________________________________________________________________________________________________________________________________________________ ____ The Multi-Application Intense Pulsed Light System
  82. 82. What is Intense Pulsed Light?• Broad Spectrum Light Source – 420 to 1200 nm wavelength range – Filtered wavelengths to provide multiple applications• Delivered in Millisecond Pulses – Pulse duration 2ms to 9ms – TPW (total pulse width) from 10ms to 500ms – Up to 16sec in Skin Tightening• High Energy Output – 50j/cm2 max energy – 22 – 35j/cm2 typical treatment parameters
  83. 83. Why Use Intense Pulsed Light?• Multiple Applications – Hair Removal, Photo Rejuvenation, Pigmented Lesions, Vascular Lesions, Acne, Small Veins, Rosacea, Fine Lines• Popularity of skin rejuvenation treatments – Excellent for clearance of sun damage, pigmented lesions, vascular lesions, fine lines, and acne• Fast and effective hair removal – 40 x 10mm square spot Vs 6, 8, 10, 12mm round spot – Excellent long term results – rivals laser technology
  84. 84. Wavelength Penetration
  85. 85. What is Variable Pulsing?• New method of delivering Pulsed Light energy in a safe and effective manner• Allows for peak power adjustments – Peak power is the measure of total energy/ time – NaturaLight adjusts for high peak power when needed (fine hair, light pigment, ect) , low peak power (coarse hair, larger vascular) or medium power, depending on treatment parameters, goals, etc.• Peak power adjustments increase efficacy• Peak power adjustments increase safety• These manipulations dramatically alter the way the energy is delivered to the skin and allow increased controls for the physician
  86. 86. FotoFacial, PhotoRejuvenation, Skin Rejuvenation, IPL Skin Treatments… What do these treatments do?Improve the tone and texture of the face, neck, chest, hands, etc. Tone• Pigmentation, vascular, flushing, broken capillaries• All caused by sun damage Texture• Treatments reduce fine lines, reduce the appearance of pores, add laxity to the skin
  87. 87. Non-Ablative Photo Rejuvenation What patients want…• No downtime• Affordable procedure• Fresh and healthy looking skin• Painless and easily tolerated treatment• Safe and effective
  88. 88. Photo Rejuvenation• Patient consult – Expectations – Herpes prophylaxis?• Treatment coarse and follow up – After care• Technique and settings• Complementary treatments – Microdermabrasion. – Cosmeceuticals – Botox – Sunless Tanning
  89. 89. Pigmentation ProblemsCourtesy of Focus Medical
  90. 90. Pigmentation Problems Immediate Post Treatment 30 days laterCourtesy of SaratogaAesthetics
  91. 91. Pigmentation/MelasmaOutstanding results from typically very stubborn pigmentation
  92. 92. Skin Tightening – Before/AfterThe jaw line and neck was the focus of the treatment.
  93. 93. Vascular Treatments Vascular LesionsRosacea - Treatments reduce the overall redness and flushing  Facial Veins – Small broken capillaries up to 1mm diameter  Other Vascular Lesions –hemangioma, cherry angioma, PWT
  94. 94. Small Facial Veins
  95. 95. Vascular Before and AfterLook at the flushing and redness of the neck with thispatient. The after picture shows a much more eventone without the visible redness.
  96. 96. Forehead Glabellar lines Brow lift Bunny lines Crow’s feet Perioral linesGummy smile Oral commissures Peau d’orange Platsymal bands
  97. 97. Nasofacial Angle
  98. 98. Frankfort Plane
  99. 99. Mentocervical Angle

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