FACIAL AGEING AND ANATOMY

Transcription

1 Cosmetic dermatology and ageing Dr Shyamalar Gunatheesan Dermatologist Honorary Consultant Royal Melbourne Hospital FACIAL AGEING AND ANATOMY How and why do we age? 1

2 The Aetiology of Ageing Extrinsic and intrinsic phenomenon External ageing (photoageing) occurs through UV and oxidative damage Internal ageing is likely hormonal and genetically regulated Ageing causes bone and soft tissue remodelling The Ageing Face Ageing of the skeletal structures occurs through bone atrophy and changes in the relative dynamics of bone expansion and bone loss There is loss of soft tissue fullness in certain areas and persistence of fat in others Hypertrophic vs Atrophic Ageing How fat you are affects how you age Fat and thin people age differently Cadaver and MRI studies show an increase in fat lateral to the nasolabial and labiomental creases in ageing adults consistent with hypertrophic fat storage pattern What does this mean? 2

3 Hypertrophic Ageing vs Atrophic Ageing In the heavy person, this fat accumulates in the lower third of the face leading to jowls and prominent submental fat. The areas prone to atrophic ageing such as the temples, submalar, infraorbital hollows stay the same in heavy and thin individuals. Weight assessment important. What happens to our facial structures as we age? 3

4 Progressive signs of ageing Earliest changes: Descent of the eyebrows, creating the appearance of smaller eyes Adapted from DeFatta. Evolution of midface rejuvenation Arch Facial Plast Surg 2009; 11: th Decade General skin laxity Psedoherniation of orbital fat through a weakened septum resulting from laxity in the orbicularis retaining ligaments and zygomaticocutaneous ligaments Descent of the malar fat pad and prominence of the nasolabial folds Formation of glabellar frown lines 4

5 5 th Decade Deepening of the forehead wrinkles, glabellar lines and crow s feet Jowling along the mandibular line Vertical lines in the perioral region 6 th Decade Prominent wrinkling in the perioral region and the neck Lateral canthus weakens, causing a downward slant of the lateral eyes Glabellar and forehead wrinkles continue to deepen and become evident even at rest Areas we age Worry lines Periorbital lines Nasolabial folds Perioral/ Smokers lines Lip border Glabellar lines Cheek augmentation Skin quality Smile lines Oral commissures Lip Body Chin augmentation 5

6 From: Mechanisms of Photoaging and Chronological Skin Aging Arch Dermatol. 2002;138(11): doi: /archderm Figure Legend: Ultraviolet irradiation stimulates generation of hydrogen peroxide (H 2O 2) in human keratinocytes. A, Time course for accumulation of H 2O 2 following UV irradiation from the UV-B/UV-A2 source of human keratinocytes. B, Time course of UV stimulation of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase activity in human skin in vivo. Skin samples were obtained at the indicated times after UV irradiation (UV-B/UV-A2 source) and analyzed for NADPH oxidase activity. Results are mean ± SEM (error bars) of 5 experiments. ROS indicates reactive oxygen species; 2MED, twice the minimal erythema dose. Date of download: 6/13/2015 Copyright 2015 American Medical Association. All rights reserved. 6

7 Mid Face Ageing Rohrich R et al Plast. Reconstr. Surg. 2007; 120 (Suppl.): 41S. Superficial and Deep Fat Pads Rohrich RJ, et al. Plast Reconstr Surg 2007; 119:

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9 Cosmetic dermatology and ageing Medical interventions Dr Shyamalar Gunatheesan From: Mechanisms of Photoaging and Chronological Skin Aging Arch Dermatol. 2002;138(11): doi: /archderm Figure Legend: Model depicting solar UV irradiation damage to skin connective tissue. Ultraviolet irradiation (jagged arrows) activates growth factor and cytokine receptors on the surface of keratinocytes (KC) and fibroblasts (FB). Activated receptors stimulate signal transduction cascades that induce transcription factor AP-1, which stimulates transcription of matrix metalloproteinase (MMP) genes. In fibroblasts, AP-1 also inhibits procollagen gene expression. Matrix metalloproteinases are secreted from keratinocytes and fibroblasts and break down collagen and other proteins that comprise the dermal extracellular matrix. Imperfect repair of the dermal damage impairs the functional and structural integrity of the extracellular matrix. Repeated sun exposure causes accumulation of dermal damage that eventually results in characteristic wrinkling of photodamaged skin. Date of download: 6/13/2015 Copyright 2015 American Medical Association. All rights reserved. Physical Findings Skin appears older than chronological age with all skin components affected Face, lateral neck and dorsal hands more severely affected Posterior neck is also involved in male patients Poikiloderma describes the combination of epidermal atrophy, hyperpigmentation, hypopigmentation and telangiectasia 9

10 Physical Findings Skin appears loose and without resilience Epidermis is thinned and dry Pigmentation is uneven and blotchy with lentigines Fine wrinkles lateral to the eyes and deep furrows form on forehead, at angles of mouth and posterior neck Physical Findings Telangiectatic blood vessels appear on ears and lateral cheeks Pilosebaceous units are prominent and dilated with retained keratin ( solar comedones), especially lateral to the eyes The skin of the dorsal hands and arm bruises with minimal trauma Skin beneath the chin is unaffected Actinic Damage 10

11 Photoageing Treatment Sun protective clothing and regular use of sunscreens slows progression of solar damage Sun protective measures alone improve photoageing and prevent further damage Topical retinoids such as tretinoin (0.01%, 0.05%) and tazoretene 0.1% reverse some photoageing over several months Treatment Epidermal hyperkeratosis decreases Pigmentation becomes more uniform and lighter New collagen is deposited within the papillary dermis Improvement is dose-dependent and persists as long as the retinoid is continued 11

12 The Tretinoin Story Tretinoin = Retinoic Acid = all-trans- Retinoic Acid First used topically for acne Retin A Discovered to have anti-aging properties Method of action complex and still not fully understood Only chemical to be clinically proven for anti-aging and accepted by FDA Renova Many physicians still consider it the only topical rejuvenation with hard science Tretinoin or Retinol Tretinoin RX High levels of irritation Chronic peeling Excessive dryness Cost expensive Also effective for acne Significant regulations limit dispensing option Retinol Cosmetic Lower levels of irritation Minimal peeling Mildly drying Cost less expensive Independent rejuvenation effects Office dispensed Different Retinoids Retinol pure Vitamin A converts in part to tretinoin, but also has photodamage repair effects independent of conversion Retinyl Palmitate artificially stabilized Vitamin A must convert to retinol to be effective Retinaldehyde closer to tretinoin in conversion process, but just as irritating and not as effective as Tretinoin Tretinoin the biologically active form of Vitamin A which binds to the nuclear receptors RAR & RXR O Sorg, et al. Cosmetic Dermatology: Products & Procedures. Edited by Z.D. Draelos, Blackwell Publishing Chapter 38: Retinoids S. Kang et al. Application of Retinol to Human Skin In Vivo Induces Epidermal Hyperplasia and Cellular Retinoid Binding Proteins Characteristic of Retinoic Acid but Without Measureable Retinoic Acid Levels or Irritation. The Society for Investigative Dermatology: 1995: J Boehnlein et al. Characterization of Esterase and Alcohol Dehydrogenase Activity in skin. Metabolism of Retinyl Palmitate to Retinol (Vitamin A) During Percutaneous Absorption. Pharmaceutical Research, Vol. 11, No. 8, 1994:

13 Approximate Conversion ratios of Retinol to Tretinoin 3.75% Retinyl palmitate 1.6% Retinol 0.53% Retinaldehyde.025% Retinoic Acid (Tretinoin) Conversions are approximate, highly idiosyncratic & significantly dependent on vehicles used Treatment Topical fluorouracil daily and pulse regimens Peeling agents alpha hydroxy acids reduce hyperkeratosis, promote epidermal thickening and new collagen formation in papillary dermis. The betahydroxy acids improve solar comedones and epidermal texture Laser resurfacing Non-ablative and ablative? Fractional From: Enhancing Patients Satisfaction and Sun-Protective Behaviors Using the ABC Method of Physician- Patient Communication Arch Dermatol. 2012;148(9): doi: /archdermatol Date of download: 6/14/2015 Copyright 2015 American Medical Association. All rights reserved. 13

14 From: Enhancing Patients Satisfaction and Sun-Protective Behaviors Using the ABC Method of Physician- Patient Communication Arch Dermatol. 2012;148(9): doi: /archdermatol Date of download: 6/14/2015 Copyright 2015 American Medical Association. All rights reserved. From: Topical Fluorouracil for Actinic Keratoses and Photoaging: A Clinical and Molecular Analysis Arch Dermatol. 2009;145(6): doi: /archdermatol Figure Legend: Mean scores of clinical photoaging measures after topical fluorouracil therapy over the course of the 24-week study. The measures were graded on a scale of 0 (none) to 9 (severe photoaging). *P <.05 compared with before therapy. Date of download: 6/14/2015 Copyright 2015 American Medical Association. All rights reserved. From: Topical Fluorouracil for Actinic Keratoses and Photoaging: A Clinical and Molecular Analysis Arch Dermatol. 2009;145(6): doi: /archdermatol Figure Legend: Two pairs of randomly ordered clinical images from each of 2 patients. Such images were presented to investigators not involved in the clinical assessment of patients to see whether they could distinguish between pretreatment and posttreatment photographs. A, At week 10, the investigators were able to distinguish between pretreatment and posttreatment photographs by the improvement in wrinkles and sallowness. B, At week 24, the investigators were able to distinguish between photographs by the improvement in actinic keratoses, wrinkles, and lentigines. Date of download: 6/14/2015 Copyright 2015 American Medical Association. All rights reserved. 14

15 From: Effect of Carbon Dioxide Laser Resurfacing on Epidermal p53 Immunostaining in Photodamaged Skin Arch Dermatol. 2004;140(9): doi: /archderm Figure Legend: Effect of carbon dioxide laser resurfacing on p53 immunostaining. Resurfacing significantly decreased p53 immunostaining at 3 weeks and 6 months after treatment compared with baseline (asterisk; P<.05). Bars indicate means; limit lines, standard errors. Date of download: 6/14/2015 Copyright 2015 American Medical Association. All rights reserved. Pre Fraxel Post Fraxel 15

16 Pre and Post Fraxel Solar Lentigenes Pigmentation Post inflammatory Drug induced Metabolic conditions such as Addison s, Hyperthyroidism Photoaggravated Connective Tissue Disorders Melasma 16

17 Melasma Acquired brown hyperpigmentation of the face and neck in genetically predisposed women, 10% in men Forehead, malar eminences, upper lip, chin most frequently affected More prevalent after sunlight exposure Prolonged heat exposure can contribute Melasma 2nd and 3 rd trimesters of pregnancy Oral contraceptives or exogenous estrogens Intensity of colour varies with deeper pigmentation in darker skinned people. Colour is usually uniform but can be blotchy Can have inflammatory component 17

18 Melasma Txt Aggressive sun protection and avoidance UVA, UVB and visible light blockade Hydroquinone in various concentrations Tretinoin Azelaic acid gels Superficial peels with glycolic acid Oral tranexamic acid- lysine analog Rosacea Facial acne like eruption of people over age of 30. Does not scar like acne Ocular disease is common More common in fairer skin individuals Exacerbating factors like spicy foods, alcohol, sunlight Ocular grittiness and soreness common Rosacea Physical Findings Erythema, telangiectasias and pustules primarily on forehead, cheeks and nose Telangiectasia not a constant feature Rhinophymatous changes Conjunctivitis, lacrimation 18

19 Rosacea- Txt Metronidazole gel 5% sulphur Azelaic acid gel Oral antbiotics- doxycycline, minocycline, erythromycin, clarithromycin, azithromycin Isotretinoin Vascular lasers Ageing Algorithm 19

20 Botulinum toxin Commercially available typically in a lypophilized form Requires reconstitution with saline prior to use Indications in aesthetic medicine include the treatment of facial dynamic wrinkles, platysmal bands and facial asymmetry Cosmetic Rejuvenation Botulinum toxin (BT) is a neurotoxin produced by Clostridium botulinum, a gram positive anaerobic bacterium Blocks acetycholine release after binding to the presynaptic cholinergic receptors Thereby preventing muscular contraction of the affected muscles Cosmetic Rejuvenation Botulinum toxin (BT) is a neurotoxin produced by Clostridium botulinum, a gram positive anaerobic bacterium Blocks acetycholine release after binding to the presynaptic cholinergic receptors Thereby preventing muscular contraction of the affected muscles 20

21 Botulinum Toxin BT can be combined safely with a series of other minimally invasive procedures such as fillers and lasers Muscular effects usually appear from hours after injection, maximum level at 2 weeks and last 4-6 months BT - Contraindications Pregnancy and breastfeeding Neuromuscular diseases such as myasthenia gravis, Eaton Lambert syndrome, Bell s paralysis and peripheral neuropathy Concomitant usage of medications such as quinine, calcium channel blockers, aminoglycosides, NSAIDs and penicillamine Known hypersensitivity to any component 21

22 Soft Tissue Augmentation The ideal soft tissue filler would be characterized by the following properties: safety, efficacy, reproducibility, ease of administration, low abuse potential, non carcinogenicity, non migratory, cost effective, semi or non permanent, government sanctioned, physiologic Fillers The available fillers have varying levels of particle size, desired placement depth, biodegradibility, allergenicity and durability Atrophic scarring Rhytides Volume loss Lip atrophy Contour defects Fillers- Indications 22

23 Fillers Critical to understand the technique and substrate of each filler substance and potential side effects in order to achieve the most optimal outcomes Hyaluronic Acid fillers HA is a naturally occurring linear polysaccharide that is present universally in living organisms as part of the extracellular matrix Acts a lubricant and moisturiser due to its hydrophilic properties HA fillers ideal as they integrate with the surrounding tissue Hyaluronic Acid fillers The molecule is stabilized with cross-linked hydroxyl groups, conferring longevity. The higher the concentration, the stiffer is the product and the longer it lasts. The larger the particle and the greater the concentration of the filler- more lift. Can be dissolved with hyaluronidase. 23

24 Gel Particles Stimulate New Collagen Production Wang et al Archives of Dermatology Epidermis Dermis Fragmented Collagen Fibers Fibroblasts NASHA TM NEW Intact Collagen Fibers Gel particles cause mechanical Stretching of fibroblast cells which produce NEW collagen Gel Particles provide longevity - 18 months duration with one re-treatment Same correction as at 2 week post treatment Fold did not return to baseline after 18mths Narins et al Treatment of moderate to severe NSF to optimal correction 97% of all patients (75) maintained at least one score difference at 18mths No difference seen between 4.5 or 9 month re-treatment schedule Confirmation of collagen formation Midface Rejuvenation According to DeFatta, two of the most common causes of a patient s initial consultation for facial rejuvenation are changes in the midface Underlying cause is the loss of subcutaneous volume 24

25 Midface Rejuvenation This should start with restoration of the malar contour This results in an overall lifting effect, impacting other areas such as nasolabial folds and tear troughs Correct placement of the filler to achieve the desired results Intra-Orbital Foramen Infra-orbital foramen Facial Nerves 25

26 Important Vasculature Angular artery Infra-orbital artery Facial artery Musculature Most of the midface vasculature (infraorbital vessels) are DEEP to the muscle This is important when injecting dermal fillers in the midface 26

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