PRE- READING COURSE MATERIAL ADVANCED BOTOX AND DERMAL FILLERS Module 1
OVERVIEW Principles of dermatology and the ageing face Principles of advanced facial anatomy
OVERVIEW Principles of dermatology and the ageing face Principles of facial anatomy
DERMATOLOGY
SKIN ANATOMY The skin is made up broadly of 3 layers: - Epidermis - Dermis - Subcutis
SKIN ANATOMY SKIN EPIDERMIS DERMIS SUBCUTIS Stratum Corneum Stratum Stratum Lucidum Spinosum Stratum Granulosum Stratum Basale Papillary Dermis Reticular Dermis
SKIN ANATOMY SKIN EPIDERMIS DERMIS SUBCUTIS Stratum Corneum Stratum Stratum Lucidum Spinosum Stratum Granulosum Stratum Basale Papillary Dermis Reticular Dermis
SKIN ANATOMY The epidermis is the outermost layer of the skin, and protects the body from the environment. The epidermis layer itself is made up of five sublayers that work together to continually rebuild the surface of the skin.
SKIN ANATOMY The Basal Cell Layer The basal layer is the lowest/ innermost layer of the epidermis and contains basal cells that continually divide. The Squamous Cell Layer The squamous cell layer is located above the basal layer. Here, basal cells are pushed upward, however these maturing cells are now called squamous cells, or keratinocytes. The Stratum Granulosum & The Stratum Lucidum Keratinocytes from the squamous layer are pushed up through two thin epidermal layers called the stratum granulosum and the stratum lucidum. As these cells move further towards the surface of the skin, they get bigger and flatter and adhere together, and then eventually become dehydrated and die. The Stratum Corneum The stratum corneum is the uppermost layer of the epidermis, and is made up of 10 to 30 thin layers of continually shedding, dead keratinocytes. The stratum corneum is sloughed off continually as new cells take its place, but this shedding process slows down with age. Complete cell turnover occurs every 28 to 30 days in young adults, while the same process takes 45 to 50 days in elderly adults.
SKIN ANATOMY SKIN EPIDERMIS DERMIS SUBCUTIS Stratum Corneum Stratum Stratum Lucidum Spinosum Stratum Granulosum Stratum Basale Papillary Dermis Reticular Dermis
SKIN ANATOMY The Dermis The dermis is located beneath the epidermis and is the thickest of the three layers of the skin (1.5 to 4 mm thick), making up approximately 90 percent of the thickness of the skin. The main functions of the dermis are to regulate temperature and to supply the epidermis with nutrient-saturated blood. The dermis layer is made up of two sublayers: The Papillary Layer The upper, papillary layer, contains a thin arrangement of collagen fibers. The papillary layer supplies nutrients to select layers of the epidermis and regulates temperature. The Reticular Layer The lower, reticular layer, is thicker and made of thick collagen fibers that are arranged in parallel to the surface of the skin. The reticular layer is denser than the papillary dermis, and it strengthens the skin, providing structure and elasticity. It also supports other components of the skin, such as hair follicles, sweat glands, and sebaceous glands.
SKIN ANATOMY SKIN EPIDERMIS DERMIS SUBCUTIS Stratum Corneum Stratum Stratum Lucidum Spinosum Stratum Granulosum Stratum Basale Papillary Dermis Reticular Dermis
SKIN ANATOMY The Subcutis The subcutis is the innermost layer of the skin, and consists of a network of fat and collagen cells. The subcutis is also known as the hypodermis or subcutaneous layer, and functions as both an insulator, conserving the body's heat, and as a shock-absorber, protecting the inner organs. It also stores fat as an energy reserve for the body. The blood vessels, nerves, lymph vessels, and hair follicles also cross through this layer.
SKIN ANATOMY During the aging process, there is an ongoing loss of collagen and elasticity in the skin, resulting in the skin becoming lax. Collagen loss causes tissue atrophy and thinning of the skin, with increased rhytid (wrinkle) formation. Younger skin Older skin
THE AGEING FACE Loss of the underlying fat causes descent of the overlying structures in the ageing face. This occurs most predominantly in the following areas;
THE AGEING FACE Over many years the changes in skin laxity lead to loss of the volume and curves of the cheeks, resulting in bony contours. Tissue descent also causes increased nasolabial and labiomandibular folds
Static wrinkles are seen at rest, even on relaxation of the muscle. THE AGEING FACE There are two types of wrinkles: dynamic wrinkles and static wrinkles. The dynamic wrinkle is caused by animation or muscle function. Dynamic wrinkles can be seen here with movement and purposeful contraction of the muscle. They disappear when the patient relaxes.
OVERVIEW Principles of dermatology and the ageing face Principles of advanced facial anatomy
FACIAL MUSCLES THE UPPER THIRD OF THE FACE Corrugator supercilii Depressor supercilii
FACIAL MUSCLES Frontalis Procerus Depressor supercilii Corrugator supercilii Orbicularis oculi
FRONTALIS MUSCLE Frontalis Procerus Depressor supercilii Corrugator supercilii Orbicularis oculi
FRONTALIS MUSCLE Contraction of these key muscles causes wrinkling of the overlying skin. Origin: galea aponeurotica along the coronal suture Insertion: into the dermis at the level of the eyebrows. No bony insertions.
FRONTALIS MUSCLE CONTRACTION
GLABELLA COMPLEX Frontalis Procerus Depressor supercilii Corrugator supercilii Orbicularis oculi
GLABELLA COMPLEX Procerus Muscle Origin: tendinous fibres from the fascia overlying the nasal bone and upper part of the lateral nasal cartilage Insertion: lower medial forehead Corrugator supercilii Origin: Medial end of the superciliary arch of the frontal bone Insertion: Skin beneath the middle of the eyebrow Depressor supercilii Origin: midline of the frontal bone approximately 1cm above the medial canthal tendon Insertion: Skin and subcutaneous tissue beneath the eyebrow
GLABELLA COMPLEX MUSCLE CONTRACTION
ORBICULARIS OCULI Frontalis Procerus Depressor supercilii Corrugator supercilii Orbicularis oculi
CROW S FEET The orbicularis oculi muscle is a thin flat sphincteric muscle that originates from the frontal bone near the medial canthus. It consists of three parts: 1) Pars orbitalis or the orbital part of orbicularis oculi is the bulkiest among the three. Coarse fibers surround the entire orbit. It has two origins: the frontal bone and the maxilla. The insertion circles around the orbit. It contracts to close the eyes tight. 2) Pars palpebralis or the palpebral part covers the eyelid itself. It also encases the lacrimal sac and canaliculi. Compared to the pars orbitalis, it is made up of fine fibers. It originates from the medial palpebral ligament and inserts into the zygomatic bone, specifically at the lateral palpebral ligament. It acts to close the eyes gently. 3) Pars lacrimalis or the lacrimal part of the orbicularis oculi is responsible for anchoring the lacrimal canal towards the eye surface. Its origin is the lacrimal bone and its insertion is the lateral palpebral raphe.
CROW S FEET The medial portion of the orbicularis is a medial brow depressor and contributes to the glabella lines. It runs superficial to the depressor supercilii. The lateral portion of the orbicularis oculi is a lateral brow depressor and creates the wrinkling pattern known as crow s feet. The orbicularis oculi muscle interdigitates with the dermis of the skin throughout its course such that botulinium toxin injections need only be intradermal or very superficial to achieve the desired effects.
ORBICULARIS OCULI CONTRACTION
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE Zygomaticus minor A small thin muscle that is present in only one third of people, it passes from the zygoma medial to the zygomaticus major and inserts into the orbicularis oris muscle just medial to the modiolus. Zygomaticus major Origin: inferior aspect of the body of the zygoma Insertion: into the modiolus at the corner of the mouth. It lifts the corner of the mouth up and laterally.
CONTRACTION: ZYGOMATICS MAJOR
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE Levator labii superioris Origin: medial infraorbital margin and zygoma. Insertion: Medial part of the orbicularis oris Action: Elevation of the lip Levator labii superioris alequae nasi Origin: nasal process of the maxilla Insertion: medial orbicularis oris and the nasal ala. Contraction causes the central lip to elevate, the alae to flare, and the medial nasolabial fold to deepen.
CONTRACTION: ZYGOMATICS MINOR AND LEVATOR LABII SUPERIORIS
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE Nasalis This muscle consists of the pars alaris and the pars transversa. The pars alaris originates from the maxilla above the incisor teeth and inserts into the alar cartilage. Contraction dilates the nostrils. The pars transversa originates from the maxilla above the pars alaris and inserts into the cartilage of the nasal dorsum. Contraction brings the ala medially and contributes to the bunny lines on the side of the nose
CONTRACTION: ALAR PART OF NASALIS AND LEVATOR LABII SUPERIORIS ALAEQUE NASII
CONTRACTION: PROCERUS AND TRANSVERSE PART OF NASALIS
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE Depressor septi This is a small muscle under the nose which pulls the tip of the nose inferiorly during smiling. Origin: from the nasal spine of the maxilla Insertion into the lower lateral cartilages.
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE Orbicularis oris The orbicularis oris is a sphincter-like muscle that surrounds the mouth Insertion: into the modiolus at the mouth corners. Action: Pursing and opening of the lips. Essential for articulation. Contraction contributes to vertical lip lines, which can be improved with tiny quantities of botulinum toxin injected superficially about 5mm from the vermilion border and symmetrically.
CONTRACTION: ORBICULARIS ORIS
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE Depressor anguli oris Origin: inferior border of the mandible just lateral and superficial to the depressor labii inferioris muscle, which is the main depressor of the central lower lip. Action: draws down the corners of the lips Depressor labii inferioris Origin: oblique line of the mandible, continuous with the fibres of the platysma muscle Insetion: deep to the skin of the lower lip, blending in with theorbicularis oris muscle Action: draws down the lower lip
CONTRACTION: DEPRESSOR ANGULI ORIS
CONTRACTION: DEPRESSOR LABII INFERIORIS
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE Mentalis Origin: periosteum of the mentum Insertion: dermis overlying the chin. Contraction causes the chin to depress and multiple indentations to become visible (chin dimpling) One or two injections of botulinium toxin into the mentalis muscle can smooth out the chin dimpling appearance.
CONTRACTION: MENTALIS
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE The risorius is a muscle of facial expression which arises in the fascia over the parotid gland and passes horizontally forward, super:icial to the platysma and inserting onto the skin at the angle of the mouth
CONTRACTION: RISORIUS
FACIAL MUSCLES THE MID AND LOWER THIRD OF THE FACE Platysma Origin: clavicles, first rib and dermis of the chest Insertion: mandible. The muscle is very superficial along its course and intimately related to the dermis. Fibres decussate as they approach the mandible, either close to the mandible or more inferiorly at the level of the hyoid bone. In about 10%, the platysma does not decussate and stays separate throughout its course. The posterior part of the platysma muscle passes superiorly and over the mandible towards the modiolus and depressor anguli oris muscle. This pulls the sides of the mouth down during grimacing. Sometimes fibres insert into the dermis just lateral to the mouth and creases become evident in the skin.
CONTRACTION: PLATYSMA
SUMMARY Principles of dermatology and the ageing face Principles of advanced facial anatomy
NOTES