the aging face and facial rejuvenation

Facial Beauty Presented by

Dr. Scott K. Smith

What is Beauty?

.

Is beauty only in the eye of the beholder….

Or ,are there some absolute values?

Beauty is a mystery!

“I know not what beauty is but I know that it touches many things",

Dürer

Symmetry youthfulness

clarity or smoothness of skin vivid color in the eyes and hair

“Personal beauty is a greater recommendation than any letter of reference.”

- Aristotle

Dental Emphasis to Oro-Facial

• It has long been said that beauty is in the eye of the beholder and thought that beauty varies by race, culture or era.

Beauty in the Eye of the Beholder?

Beauty in the Phi of the Beholder

Evidence shows that our perception of physical beauty is hard wired into our being and based on how closely one's features reflect phi in their proportions.

• 1.6180399

What is Phi

Phi ( 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

Phi is Everywhere

* The proportions of the human body* The proportions of many other animals* Plants* DNA* The solar system* Art and architecture

The ratio, or proportion, determined by Phi (1.618...) was known to the Greeks as the "Golden Section" and to Renaissance artists as the "Divine Proportion

Divine Proportion is Everywhere

• 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. 

• 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 Langlois's 32-composite faces divides the face in a Golden Ratio.

• 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.

• Beauty is not just in the eye of the beholder. Researchers say it's 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.

Principles of Aesthetics

• Balance• Rhythm• Proportion• Emphasis• Unity

Aesthetic Principles

• Balance• Rhythm• Proportion • Emphasis• Unity

Balance

• Visual Equilibrium• Symmetry?

Symmetry R and L superimposed

Rhythm• The human face communicates an

incredible array of emotions which are an integral element of one's total beauty.  The human face conforms most closely to phi proportions when we smile. 

Unity

• Coherence of the whole• Effect of all other disciplines working

together to form esthetic harmony

Proportion

one third

one third

one third

Horizontal Fifths

Emphasis

• Eyes• Cheeks• Peri-oral

The Aging Face

• Extrinsic Factors

• Intrinsic Factors

The Aging Face

Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S

Extrinsic Factors

Trauma

Smoking

Photodamage

Gravity

Intrinsic Damage

• Fibroblastic Synthesis Reduction

• Breakdown of Cellular Membrane

• DNA Repair Reduction

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

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

Aesthetic Principles

• Balance• Rhythm• Proportion • Emphasis• Unity

Principles we CAN effect

ProportionEmphasisRhythm

Lips

what 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.

Gordon Classification

• Zone A• Zone B• Zone C

Creating the Esthetic Smile

SNC00140.3g2

Aesthetic Treatments

Minimally Invasive Cosmetic Procedures

• 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

Botulinum toxin

Normal Neuromuscular Function

Arnon et al. JAMA 2001;285(8):1059-1070 (with permission).

Botulinum Toxin Mechanism of Action

Arnon et al. JAMA 2001;285(8):1059-1070 (with permission).

Botulinum Toxin Structure

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).

150 kD Neurotoxin

Non-toxic, non-hemagglutinin

(NTNH)

Hemagglutinin (HA)

Clostridium botulinum is a gram positive, anaerobic, rod-shaped bacterium that produces seven serologically distinct neurotoxins (A-G)1.

Facial Areas Commonly Treated with BoNT-A

Forehead

Brow lift

Perioral lines

Platsymal bands

Glabellar lines

Oral commissures

Peau d’orange

Gummy smile

Crow’s feetBunny lines

1. Frontalis

2. Procerus

3. Corrugator supercilli

4. Depressor supercilli

5. Temporalis

6. Obicularis oculi

7. Nasalis

8. Levator labaii superioris alaeque nasi

9. Levator labaii

10. Zygomaticus minor

11. Zygomaticus major

12. Obicularis oris

13. Modeolus

14. Masseter

15. Depressor anguli oris

16. Depressor labii

17. Mentalis

1

2

3

4

5

6

78

910

11

1213

14

15

16 17

BoNT-A treatment: Glabellar lines

Before After - Day 30

www.Botox.com

BoNT-A treatment: Forehead lines

Carruthers & Carruthers. Dermatol Surg 2007;33:S10-S17

Before After - Day 30

After - Day 120

BoNT-A treatment: Brow lift

Before After

Coleman & Carruthers. Dermatol Therap 2006;19:177-88

BoNT-A treatment: Perioral lines

Kane. Oral Maxillofacial Surg Clin N Am 2005;17:41-49

Before After

BoNT-A treatment: Gummy smile

Kane. Oral Maxillofacial Surg Clin N Am 2005;17:41-49

Before After

BoNT-A treatment: Oral commissures

Carruthers & Carruthers. Dermatol Surg 2003;29:468-76

Before After

Hyaluronic Acid Fillers

HA Treatment: Marionette lines

Before After

Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S

HA Treatment: Pre-jowl sulcus

Smith. Plast Reconstr Surg 2007;120(Suppl):67S-73S

HA Treatment: Lip Volumization

Before After After

Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S

HA Treatment: Nasolabial folds

Before

After

HA Treatment: Nasolabial folds

Before After – 2 weeks After – 38 weeks

Smith et al. AAD Summer 2006

HA Treatment: Nasolabial folds

Before After – 2 weeks After – 24 weeks

Smith et al. AAD Summer 2006

HA Treatment: Cheek Volumization

Before After – 10 days

Smith. Plast Reconstr Surg 2007;120(Suppl):67S-73S

Introduction to

The Next Generation In Longer Lasting Wrinkle Correction

Radiesse vs CosmoPlast® Clinical Study

Radiesse Control

Baseline 6 Months

Radiesse Control

Patient 1

Patient 2

Radiesse Control Radiesse Control

Placement of Radiesse into the Skin

Subdermal PlaneSubdermal Plane

• 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

Radiesse Delivers Greater Improvement Than Restylane At Every Time Point

Radiesse vs. RestylaneHow much improvement on average over time?

0

0.2

0.4

0.6

0.8

1

1.2

3 mo's 6 mo's 9 mo's

Time post 2nd injection

Me

an

Imp

rov

em

en

t fr

om

Ba

se

line

(W

SR

S)

Radiesse Improvement

Restylane ImprovementRADIESSE

RESTYLANE

% Patients Improved at 9 months:

Radiesse = 79%

Restylane = 44%

• More Patients are Improved at Every Time Point

Radiesse Delivers Longer Lasting Improvement

Radiesse vs. RestylaneImprovement over Time (GAIS)

0

10

20

30

40

50

60

70

80

90

100

3 mo's 6 mo's 9 mo's

Time post 2nd injection

% o

f P

atie

nts

wit

h I

mp

rove

men

t

Radiesse

Restylane

Radiesse & Restylane Histology – 4 weeks

Restylane• Minimal tissue response• No native fibrinogen, elastin and

collagen is manufactured to replace absorbtion of HA

RadiesseModerate tissue response

Gel carrier replaced by native fibrinogen, elastin and collagen under the normal

tissue repair mechanism

Mechanism of Action

When placed into soft tissue, Radiesse provides immediate correctionGel + CaHA Particles

When placed into soft tissue, Radiesse provides immediate correctionGel + CaHA Particles

Over time the gel is resorbed and the CaHA particles stimulate and support in-growth of new collagenCollagen + CaHA Particles

Over time the gel is resorbed and the CaHA particles stimulate and support in-growth of new collagenCollagen + CaHA Particles

Radiesse vs Restylane® Split Face Study

Restylane Radiesse

6 Months (post last injection)

9 Months (post last injection)

Restylane Radiesse

Before Treatment

Addressing Some Misconceptions

1. Radiesse cannot form bone in soft tissue

• Micro-motion presence; No bone morphogenic proteins; No osteoblast progenitor cells

2. 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 place

3. 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 structures

4. 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

Fractional CO2 Resurfacing

June 2011

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

Rhytides

Scars

Rhytides

Scars

Tone

Texture

Color

Tone

Texture

Color

Low Energy

+ High Density

Low Energy

+ High Density

2. Photo courtesy of Mark Taylor, MD2. Photo courtesy of Mark Taylor, MD3. Photo courtesy of Yasmina Carvajal, M.D.3. Photo courtesy of Yasmina Carvajal, M.D.

Target of TreatmentPhoto

Damage

Photo

Damage

1. Photo courtesy of Mark Rubin, M.D.1. Photo courtesy of Mark Rubin, M.D.

2. 2.

1. 1.

3. 3.

Moderate Energy

+ Moderate Density

Moderate Energy

+ Moderate Density

High Energy

+ Low Density

High Energy

+ Low Density

124

• 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.

Ablative Lasers

Immediately After Post 2 Days

• Ablated epidermis• Ablated column extends deep into

the dermis. • Uniform thermal heat to sur-

rounding tissues.

• Volume collapse of ablated column for

immediate contraction. • Re-epithelialization is complete. • Ongoing collagen stimulation for 3-6

months

Wound Healing

Wound Healing Time

Stratum Corneum: 2 – 3 Days

Basal Layer: 4 – 6 Days

Papillary Dermis: 7 – 8 Days

Mid Dermis: 8 – 10 Days

Reticular Dermis: 10 – 12 Days

Full Ablative CO2 Resurfacing

The “Gold Standard”

Single Treatment

Dramatic ResultsPhotos Courtesy of Dr. Sarnoff

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

Fractional CO2 Fractional CO2 Traditional CO2Traditional CO2

2 mm2 mm 150 µm150 µm

Full Face Ablation

Prolonged HealingFull Face Ablation

Prolonged Healing

Tissue Sparing

Shortened HealingTissue Sparing

Shortened Healing

Decrease need for power

Increase need for scanning

Decrease need for power

Increase need for scanning

Old vs. New Technology

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

Fractional Laser Treatment

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!!!

What’s Happening Today……

Pigmentation Problems?

Courtesy of Nora Grace

Hair Problems ?

Wrinkles?

Acne?

Hair Removal, Skin Rejuvenation,

Acne Treatments, Vascular Treatments

and Skin Tightening______________________________________________________________________________________________________________________________________________________________

__ The Multi-Application Intense Pulsed Light System

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

• 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

Why Use Intense Pulsed Light?

Wavelength Penetration

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

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

Non-Ablative Photo Rejuvenation

What patients want…

• No downtime• Affordable procedure• Fresh and healthy looking skin• Painless and easily tolerated

treatment• Safe and effective

Photo Rejuvenation

• Patient consult– Expectations– Herpes prophylaxis?

• Treatment coarse and follow up– After care

• Technique and settings• Complementary treatments

– Microdermabrasion.– Cosmeceuticals– Botox– Sunless Tanning

Pigmentation Problems

Courtesy of Focus Medical

Pigmentation Problems

Courtesy of Saratoga Aesthetics

Immediate Post Treatment

30 days later

Pigmentation/Melasma

Outstanding results from typically very stubborn pigmentation

Skin Tightening – Before/After

The jaw line and neck was the focus of the treatment.

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

Vascular Treatments

Small Facial Veins

Vascular Before and After

Look at the flushing and redness of the neck with this patient. The after picture shows a much more even tone without the visible redness.

Facial Areas Commonly Treated with BoNT-A

Forehead

Brow lift

Perioral lines

Platsymal bands

Glabellar lines

Oral commissures

Peau d’orange

Gummy smile

Crow’s feetBunny lines

Nasofacial Angle

Frankfort Plane

Mentocervical Angle