Zones of the Face. Age- Related Changes in the Face. CT Scan Shows Age- Related Decreases in Mean Angular Measurements. Upper zone Anterior

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1 Zones of the Face Upper zone Anterior Steve Yoelin MD Private Practice Newport Beach, California hairline to glabella Middle zone Glabella to nasolabial angle Lower zone Nasolabial angle to mentum Based on Leonardo Da Vinci s rule of 3s of the face Age- Related Changes in the Face CT Scan Shows Age- Related Decreases in Mean Angular Measurements Female, 25 to 44 years old Corrugator supercilii Frown Lines Wide, Deep Orbit Midface Resorption Orbicularis Oculi m. Nasolabial Fold Cheek Fat Female, 65 years old Glabellar Angle 77.1 Glabellar Angle 71.4 Pyriform Angle 60.5 Pyriform Angle 56.9 Maxillary Angle 64.4 Maxillary Angle 53.6 Jowl (Broken Jaw line) Platysma m. Obtuse Cervical Angle Platysma Plus Fat Jaw Resorption Zimbler MS et al. Facial Plast Surg Clin North Am. 2001;9: Nasal Area mm2 Reprinted with permission. Shaw RB Jr, Kahn D. Aging of the Midface Bony Elements: A ThreeDimensional Computed Tomographic Study Plast Reconstr Surg. 2007;119(2): Nasal Area mm2

2 The Triangle of Youth Becomes the Pyramid of Aging General Principles for the Upper Face Hyperfunctional rhytides are the most prominent feature in the upper face Botulinum toxin has become the standard of care for nonsurgical upper facial rejuvenation Volume changes in the upper face include deflation of the brow and hollowing of the temples Gravitational changes lead to descent of underlying muscle and soft tissue Adapted from Zimbler MS et al. Facial Plast Surg Clin North Am. 2001;9: Carruthers JD et al. Plast Reconstr Surg. 2008;121(5Suppl.):5S 30S. Elevator/Depressors/Abductors of Brows Facial muscles responsible for vertical and horizontal glabellar rhytides, forehead rhytides, and brow depression and elevation Corrugator Orbicularis Oculi Frontalis General Principles for the Midface Key to midface rejuvenation is volume restoration Dermal fillers Panfacial volumizing agents Malar contour should be restored Treatment of malar area improves surrounding areas, such as NLF Depressor Supercilii Procerus NLF, nasolabial fold. Adapted with permission. Fedok FG. Advances in minimally invasive facial rejuvenation. Curr Opin Otolaryngol Head Neck Surg. 2008;16(4): Carruthers JD et al. Plast Reconstr Surg. 2008;121(5 Suppl):5S 30S.

3 General Principles for the Lower Face: Restoring Volume The primary goals are to restore volume, control muscle hypermobility, and treat for rhytides View and treat the lower face as a whole rather than as individual regions Treatment with fillers is considered standard of care However, consider combination treatment with botulinum toxin and dermal filler where appropriate When treating the lips, it is important to consider shaping as well as volumizing When treating the perioral area with botulinum toxin, avoid overtreatment to prevent mouth incompetence Injectable Botulinum Toxins Produced by various strains of Clostridium botulinum Seven known serotypes Serotypes A and B developed for clinical use Serotype A OnabotulinumtoxinA = BOTOX Cosmetic AbobotulinumtoxinA = Dysport IncobotulinumtoxinA = Xeomin Serotype B rimabotulinumtoxinb = MYOBLOC Carruthers Carruthers JD et JD al. et Plast al. Reconstr Plast Reconstr Surg. 2008;121(5 Surg. 2008;121(5 Suppl):5S-30S. Suppl):5S-30SC. Botulinum Toxin Overview of products Product OnA(Botox) AboA (Dysport) IncA (Xeomin) Manufacturer Allergan Ipsen (Europe) Medicis (USA) Merz Pharmaceuticals Units per vial 50 or 100 Botox Units (BU) 300 Dysport Units (DU) 50 or 100 Xeomin Units (XU) Active ingredient (molecular weight) Total toxin protein per vial (active toxin + NAPs b ) Excipients Bacterial Source Botulinum toxin serotype A Complex (900 kda) Botulinum toxin serotype A Complex ( kda) a Uncomplexed Botulinum toxin serotype A (150 kda) 5 ng 2.61 ng 0.6 ng (in 100 units) Human serum Albumin 500 µg NaCl 0.9 mg Clostridium botulinum, Hall strain c Human serum Albumin 125 µg Lactose 2.5 mg Clostridium botulinum, Hall strain c Human Serum Albumin 1 mg Sucrose 4.7 mg Storage conditions 2-8 C 2-8 C Up to 25 C Purification process Dialysis and acid precipitation then vacuum dried Column chromatography then freeze dried (lyophilized) Cartee, TB, Monheit, G. Clin Plastic Surg 38 (2011) a Molecular weight of AboA is not firmly established b Neurotoxin-associated proteins. c There are numerous Hall strains and the manufacturers do not necessarily use identical bacteria. Clostridium botulinum, Hall strain c Column chromatography then freeze dried (lyophilized) OnabotulinumtoxinA, AbobotulinumtoxinA and IncobotulinumtoxinA are FDA approved for cosmetic use (glabellar lines). Botulinum Toxins Pre- ExisPng Neuromuscular Disorders Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junctional disorders (e.g., myasthenia gravis or Lambert- Eaton syndrome) should be monitored particularly closely when given botulinum toxin Patients with neuromuscular disorders may be at increased risk of clinically significant effects including severe dysphagia and respiratory compromise from typical doses of Botox Cosmetic, Dysport, Xeomin and Mybloc

4 Commonly Used Hyaluronic Acid Based Fillers Non- HA SoT Tissue Fillers Collagen SPmulator Manufacturer/ Distributor Q-Med/Medicis Aesthetics Allergan Restylane Restylane /-L* Perlane /-L* Trade Name Juvéderm Ultra Plus/XC* Juvéderm Ultra/XC* Mentor Corporation Prevelle SILK* Anika Therapeutics Hydrelle * All HA fillers approved for NLFs. Restylane approved for submucosal implantation for lip augmentation in patients over 21. *Preparation with lidocaine. Syringe Size 0.4 ml,, 2.0 ml 0.5 ml, 0.9 ml Calcium hydroxylapatite (Ca HA) Radiesse Manufactured by Merz Aesthetics Major mineral constituent of bone >10 years of use in dentistry and reconstructive surgery Injected Ca HA particles act as a scaffold for new collagen No animal- based ingredients; skin testing is not required Over time, Ca HA particles slowly dissolve into calcium and phosphate ions through normal metabolic processes Indications Moderate to severe facial wrinkles (NLF) HIV- associated lipoatrophy FDA Consumer Health Information. June 26, Ca HA Sapijaszko = RADIESSE MJA. Skin ; PLLA Ther = SCULPTRA Lett 2007;12(8):4-7. Sculptra Aesthetic [prescribing information]. Bridgewater, NJ: Sanofi-Aventis; Narins RS. Dermatol Surg 2008;34:S100-S104. Rossner F et al. Journal Cosmetic Dermatology Radiesse Prescribing Information. San Mateo, Calif: BioForm Medical Inc.; ComplicaPons: Botulinum Toxin Complication Prevention Treatment Brow ptosis Avoid treating lower portion of frontalis Treat brow depressors Eyelid ptosis Proper injection technique (avoid placement deep and medial to lateral orbital rim) iopidine drops 0.5%, naphazoline, (Vasocon-A, Naphcon-A, Opcon-A) 1 drop to affected eye for 4 6 hrs as needed Headache Bruising (Hematoma) Avoid injection below periosteum Avoid blood vessels NSAIDs, ibuprofen Wear magnification when injecting

5 Tear troughs Inappropriate placement of dermal filler Glabellar Necrosis Nodule of filler product is visible under this patient s right eye, 1 supratrochlear artery 2 supraorbital artery 3 dorsal nasal artery 4 superficial temporal artery Cohen JL. Understanding, Avoiding, and Managing Dermal Filler Complications. Dermatol Surg. 2008;34(S1):S92 S99. Copyright 2008 by the American Society for Dermatologic Surgery, Inc. Reprinted with permission from John Wiley and Sons. infraorbital artery Lip AugmentaPon resulting from superficial placement of HA* Superficial small linear threads of filler are apparent at the left lower lid *Restylane Bailey SH, Cohen JL, Kenkel JM. Aesthet Surg J. 2011;31(1): Copyright 2011 by The American Society for Aesthetic Plastic Surgery, Inc. Reprinted by Permission of SAGE Publications. Preven&on of ComplicaPons Secondary to Dermal Filler InjecPon - Ischemia Philtrum Dimple Vermilion Border Philtrum Column Labial Commissure Labial Tubercle Inject slowly (<0.3 ml/min) and with low pressure Consider the use of a blunt cannula, rather than syringe Labiomental Crease needle to prevent embolic event Watch for danger signs such as sudden or delayed pain or Enhancement of vermilion border Volume (plumping) Enhancement of tubercles (upper lip, 3; lower lip, 2) Eversion Enhancement of lip above gingivolabial sulcus Cummings CW et al. Cummings Otolaryngology: Head and Neck Surgery. 4th ed. Philadelphia, PA: Elsevier Health Sciences; blanching KNOW YOUR ANATOMY! Carruthers JD et al. Plast Reconstr Surg. 2008;121(5 Suppl):5S 30S. Cohen J. Dermatol Surg. 2008;34:S92 S99. Shanz S et al. Br J Dermatol. 2002;146: Permission Pending. Kim,YJ, Kim, SS, Song WK, Lee SY, Yoon JS. Opthal Plast Reconstr Surg, 2 011; 27(6): 152_155.

6 Managing Necrosis Secondary to Dermal Filler Injection INJECTION Apply ice immediately post-injection BRUISING, SWELLING, PAIN (severe) RESOLVES WITHIN 30 MINUTES OBSERVE DISCONTINUE INJECTIONS Adapted from Dayan, S, Journal of Drugs & Dermatology Adapted from Kassir, R, Kolluru A, Kassir M. Dermatol Surg. 2011; 10: DISCONTINUE INJECTIONS Massage BRUISING Presentation FOLLOWUP & FURTHER MANAGEMENT Follow patient daily for further signs of occlusion/necrosis Continue hyaluronidase & 2% nitroglycerin paste as needed OBSERVE (Arnica gel) ASSESS FOR OCCLUSION Immediate or early blanching followed by a dusky purple discoloration TREATMENT Inject 10 30U hyaluronidase per 2x2 cm area Continue ASA, antacid & topical oxygen therapy until wound has healed If edema progresses begin methylprednisone therapy (Medirol Dose pack) Consider hyperbaric therapy for necrosis resistant to above-mentioned treatment options If ischemia is not reversed, contact plastic or reconstructive surgeon IF OCCLUSION SUSPECTED Massage 2 % Nitroglycerin Paste into area and apply warm compresses Begin 325 ASA (enteric coated) and antacid regimen Initiate antibiotic regimen as needed Consider application of topical oxygen cosmeceutical therapy BID HA SoT Tissue Filler Eraser Hyaluronidase - Vitrase Distributed by ISTA Pharmaceuticals Purified preparation of ovine testicular hyaluronidase protein enzyme Modifies the permeability of connective tissue through the hydrolysis of hyaluronic acid Inject just beneath the HA depot Hyaluronidase should not be injected in an area which has been treated with botulinum toxin within the previous 48 hours (spread function of MOA of hyaluronidase) Indication Adjuvant to increase the absorption and dispersion of other injected drugs; for hypodermoclysis and as an adjunct in subcutaneous urography for improving resorption of radiopaque agent Vitrase Prescribing Information. Irvine, Calif: ISTA Pharmaceuticals; 2006 RzANy, B, Becker-Wegerich, P, et al. J Cosmetic Dermatol. 2009; 8: Thank you!