ageless beauty slide deck

Attaining Ageless Beauty

Presenter: Name, MDSpecialty: SpecialtyCity, State: Practice location

Disclosure• Speaker’s Bureau, BioForm

Medical, Inc.

Attaining Ageless Beauty

• Beauty is ethnically, racially and culturally determined.

• Universal standards of beauty– Symmetry/Proportion– Smooth, convex contours

• Female:– High cheek bones– Gentle curve from cheek to

mouth• Male:

– Strong jawline– Prominent chin

– Smooth facial skin without crow's feet, deep nasolabial folds, sagging neck, jowls or upper/lower lid bags/wrinkles.

Facial Aesthetics

Henri Gaboriau, MD, Seattle, WA

Today’s Concept ofFacial Beauty

• Surface changes– Changes in skin pigmentation and texture

• Photo-damage• Trauma• Medications• Endocrine

The Process of Aging

• Subsurface Changes– Volume loss

• Soft tissue loss– Dermal atrophy– Muscle atrophy– Fat redistribution– Atrophy in the subcutaneous compartment

• Hard tissue loss– “Biometric volume loss”– Resorption of underlying bone, cartilage,

dentition

Werschler WP, Cosmetic Dermatology, Nov 2007, Vol 20 No 11

The Process of Aging

Facial Aging

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• Biometric Volume Loss/Alteration: BVL/A– “The cumulative effect of loss and

redistribution of biologic volume that can be measured”

– Shrinkage of time– Intrinsic component of the aging face

• Photo-damage is the (major) extrinsic component

Aging and BiometricVolume Loss

• Treating BVL/A for aesthetic improvement– Assess zones of the face for treatment– Visualize outcome

• Balance• Proportion• Symmetry

– Plan: Re-Volumization– “Pyramid of Age” to “Triangle of Youth”

New Approaches:Fillers and Toxins

• Restore volume• Contour facial anatomy• Compared to surgical procedures

– less invasive– low risk– little to no down time

• Cost effective

Dermal Fillers

Areas for Use of Dermal Fillers

Marionette Line

Nasolabial Fold

Malar Eminence/Zygomatic Arch

Mental Crease

Chin/MentumJawline/Pre-Jowl

Oral Commissure

Nasal Tip

Nasal Dorsum

InfraorbitalSub-Malar Area

Lateral Chin

Glabella

Upper

Mid

Lower

Lips

Lateral Brow

• Replacement vs. Stimulatory• Immediate vs. Delayed• Time limited vs. Permanent• Synthetic vs. Natural• Global vs. Local

Evolution of Fillers

• Product categories have become blurred

• No single simple classification system

• Most systems look @ MOA– Space occupying – Growth stimulating– Permanent implant

• “Replacement and/or Stimulatory”


• Utility of products has evolved– Wrinkle and line filling = old– Facial shaping = new– Approach is global balance,

symmetry, proportion


• Structure & Support• Regional Volume & Contouring

Evolution of Facial Filling

• RAVE– A method of assessing, planning

and performing volume enhancement to replace BVL

– A technique concept– Uses fillers to re-harmonize each

zone of the face

Regional Aesthetic Volume Replacement


• Contouring regional areas requires a filler that has:

– Robust strength– Longevity– Durability – Safety

RAVE


IFUs for Zyderm, Zyderm 2, Zyplast, CosmoDerm, Comoplast

Short-Term: Collagen Commercially AvailableConcentration of

CollagenIndications Size of

Syringe Available

Placement Degree of Overcorrectio

nZyderm 35 mg/mL bovine Fine lines: perioral,

periocular, glabellar0.5, 1.0, 1.5mL Superficial

papillary dermis150-200%

Zyderm 2 65 mg/mL bovine Mid to moderate rhytids: scars,

perioral

0.5, 1.0 mL Mid-dermis 100-150%

Zyplast 35 mg/mL Cross-linked with

gluteraldehyde bovine

Deeper rhytids and folds: nasolabial,

vermilion, marionette lines

1.0, 1.5, 2.0, 2.5 mL

Deep dermis No overcorrection

CosmoDerm 35 mg/mL human-derived

Fine lines: perioral, periocular, glabellar

1.0 mL Superficial papillary dermis

150-200%

Cosmoplast 35 mg/mL Cross-linked with

gluteraldehyde human-derived

Deeper rhytids and folds, nasolabial,

vermilion, nasolabial folds

1.0, 1.5 mL Deep dermis No overcorrection

IFUs for Juvederm™ Ultra, Juvederm ™ Ultra-Plus, Restylane®, Perlane®

Short-Term: Hyaluronic Acids

Juvederm™ Ultra Juvederm™ Ultra-Plus Restylane® Perlane®

HA Concentration

24 mg/mL 30 mg/mL 20 mg/mL 20 mg/mL

Durability 6+ months 6+ months 6 months 6+? Months

Needle 30g 0.5” 27g 0.5” 30g 27g

Level of Injection

Mid-dermis Mid to deep dermis Mid-dermis Deep dermis to Sub-Q

Indications Medium nasolabial folds, radial lip lines, medium

wrinkles, marionette lines

Nasolabial folds, cheek augmentation, lip

augmentation, marionette lines

Mild to moderate lines and folds

Deeper lines and folds, contouring, volumizing

• Polymethyl-methacrylate• PMMA microspheres in 3.5% bovine collagen

with 0.3% lidocaine– acts like a scaffold to allow fibroblast in-growth and

collagen production• Skin testing required• Injection plane: immediate subdermis or deepest

dermal level• Indicated for correction of nasolabial folds• Conservative treatment protocol

– Bring to correction over several treatments• Commercially available

– Artefill®

IFU for Artefill®

Permanent Fillers

Best of both worlds?– Long lasting– Not Permanent– Correct facial folds and wrinkles– Volumize– Stimulate collagen production

Semi-Permanent Fillers

Schweiger et al, Cosmetic Dermatology, May 2007, Vol 20 No. 5

Semi-Permanent Fillers

Poly-L-Lactic Acid Calcium Hydroxylapatite

Packaging Vial of Lyophilized PLLA Prefilled 1.3 mL and 0.3 mL Syringes

Injection Site Deep Dermis/Subdermis Deep Dermis/Subdermis

FDA Status HIV-Associated Facial Lipoatrophy Correction of Moderate to Severe Lines and Folds

HIV-Associated Facial LipoatrophyAverage Treatment

Sessions3-5 1

Onset =2 months post-injection Immediate

Duration of Correction 12 - 24 months 12 - 18 months

Adverse Reactions Local AE’s (ecchymoses, pain); Nodule Formation in 3% - 44%

Local AE’s (ecchymoses, pain)

• PLLA, sodium carboxymethylcellulose, non-pyrogenic mannitol

• Skin testing not required• Stimulates collagen production over

extended period of time• Volumizer• Must reconstitute prior to use• Treat to correction over several sessions• Commercially available: Sculptra®

Poly-L-Lactic Acid

Wm. Philip Werschler, MD, Spokane, WA

PLLA Volumizing

• CaHA microspheres uniform in 25-45 um diameter (30%) suspended in carboxy-

methylcellulose gel carrier (70%)• Skin testing not required, biocompatible• Stored at room temperature in ready to use

syringes 1.3 and 0.3 cc size• No special handling requirements• Commercially Available: Radiesse®

Calcium Hydroxylapatite

• When placed into soft tissue, Gel + CaHA particles provides immediate correction due to volume injected

• Over time the gel is resorbed and the CaHA particles stimulate the body to produce collagen– Collagen + CaHA

Particles




David Goldberg, MD, New York, NY

40x mag 40x mag

Picrosirius Red Type I Collagen

6 month human dermal explants

CaHA StimulatesNew Collagen Production

CaHA particles are slowly dissolved into calcium and

phosphate ions through normal metabolic processes

CaHA particles post-implantation

CaHA Particles Break Down Naturally

• FDA approved indications– Correction of moderate to severe lines and folds,

such as nasolabial folds, marionette lines, mental crease, etc.

– Correction of the signs of facial wasting resulting from HIV-associated facial lipoatrophy.

• Inject sub-dermis to pre-periosteal• Needle length: 27g 0.5”-1 ¼”, 28g .75”


– Nasolabial Folds– Marionette lines– Oral Commissures– Mental Crease– Malar and Submalar– Hands– Nasal Augmentation

– Infraorbital rim– Prejowl sulcus– Chin contouring– Acne scars– Deep glabellar

furrows– Lateral brow– Tear trough

Busso M, Cosmetic Dermatology, Vol. 19, No. 6, September 2006; Graivier M, Plastic and Reconstructive Surgery, Vol. 120, Supplement, November 2007; Busso M, Dermatologic Therapy, Vol 20, 2007; Dayan S, ENT Journal, Vol 86, January 2007

• Not Recommended– Above inferior orbital rim

CaHA Treatment Areas

Smith et al., Dermatogolic Surgery 2007, 33:S112-S121

CaHA Adverse Events

117 Patient RADIESSE vs Cosmoplast Study

100 Patient HIV-Associated Lipoatrophy Study

RADIESSE Total Reporting Symptoms

N(%)

CONTROL Total Reporting Symptoms

N(%)

RADIESSE Total Reporting Symptoms N(%)

Ecchymosis 74 (63.2) 50 (42.7) 65 (65.0)

Edema 81 (69.2) 52 (53.0) 99 (99.0)

Erythema 78 (66.7) 84 (71.8) 57 (57.0)

Granuloma 0 (0.0) 0 (0.0) 0 (0.0) Zero Granulomas

Needle Jamming 0 (0.0) 0 (0.0) 0 (0.0)

Nodule 1 (0.9) 1 (0.9) 0 (0.0) 0.9% Nodules

Pain 33 (28.2) 26 (22.2) 39 (39.0)

Pruritis 21 (18.0) 24 (20.5) 21 (21.0)

Treatment for Successful Outcomes

• Many different types of anesthesia can be used in filler injections:• Topical anesthetics• Nerve blocks• Tissue infiltration• Mixing lidocaine with material • Skin cooling

• Make your patient comfortable- it is recommended to provide some level of local anesthesia

• This reduces patient pain and anxiety about their procedure and makes the experience more pleasant

Anesthetic Options

• Why and Where– Adjust the cohesiveness of CaHA to use it as

a layering rather than a bulking filler• NLF, ML, etc.• Mid-face, cheeks • Hands• Temporal

– Provide a less-painful alternative– Prevents the need for anesthetic blocks

during the procedure

Lidocaine Mixing: CaHA

• 0.15 cc of 2% plain Lidocaine• Luer lock-to-luer lock connector (Baxa) • 3 cc syringe• Transfer CaHA to syringe containing

anesthetic and mix by “swishing” back and forth

• For a homogeneous mixture throughout the syringe, mix back and forth 10 times

• The mixing needs to occur immediately before injection

• Dispose of unused product, do not save

Busso M, et al, Dermatol Ther. 2007 Nov-Dec;20(6):385-7

Lidocaine Mixing: CaHA

Susan Weinkle, MD, Bradenton, FL

Lidocaine Mixing Technique



• Results are best when CaHA is laid down in fine threads (LINE FILLING) or in and placed in the dermis: sub-cutaneous junction (aka, subdermal plane)

• CaHA is also successfully placed in the subcutaneous to supraperiosteal space to fill in deep depressions or to obtain a volume effect (LINEAR THREADS OR SMALL BOLUSES)

Subdermal PlaneSub-Q

Where is CaHA Injected?

CaHA

Depth of injection is dependent

on area being augmented• Deep dermis/subdermal plane for treating a lines

– Nasolabial folds, marionette lines, mental crease, etc.– Retrograde linear threading of material

• Subcutaneous/supraperiosteal for restoring volume resulting from skeletal loss or if placing material against bone– Mid-face: infraorbital and malar, submalar, pre-jowl sulcus,

etc.– Retrograde linear threading or bolus injections

• The trend is towards treating ZONES of the face rather than distinct lines and wrinkles

• Historically, using fillers to efface discreet lines has been the approach of most practitioners

• This focuses on injecting fillers directly into the line

• CaHA placement in the tissues for effacing distinct lines should be in the subdermal plane with linear threads


Best Techniques forBasic Filling

Using 0.75” 1.25” or 1.5” Needle Using 0.5” Needle

CaHA: Nasolabial Folds

27- or 28-gauge needle appropriate

Before Immediately After(1.3 cc total)

6 MonthsHenri Gaboriau, MD, Seattle, WA

CaHA: Nasolabial Folds

Samuel Lam, MD , Dallas, TX

Before After 6 months0.4 cc per side

CaHA: Marionette Lines

Before

After 16 months

CaHA: Pre-Jowl Sulcus

Michael Jasin, MD Tampa, FL

• Re-volumize to address loss of volume due to aging process– vs. filling individual lines

• Ideal for the mid and lower face • An ideal filler for volumizing would be

one that provides:– Strength– Longevity– Durability– Safety– Natural feel

Werschler WP, Cosmetic Dermatology, December 2007; Vol 20, No 12.

Advanced Techniques for Filling

Before After 10 months1.6 cc total

Peter Karlsberg, MD, Ventura, CA

CaHA: Peri-Oral Volume Restoration

Before After*Note change in NLF correction with only mid-face volume restoration

Michael Jasin, MD, Tampa, FL

Re-volumizing Mid-face Improves NLFs

• Ideally suited for re-volumizing and enhancing facial contours– Has tissue expanding plus collagen-inducing

properties– Triple effect

• Filling• Lifting• Pulling

– Semi-permanent• Longevity

Busso M, Cosmetic Dermatology, Vol. 19, No. 6, September 2006

Advanced Injection Techniques: CaHA

Depth of injection facial map

Marionette Line

Nasolabial Fold

Malar Eminence/Zygomatic Arch

Mental Crease

Chin/MentumJawline/Pre-Jowl

Oral Commissure

Nasal Tip

Nasal Dorsum

InfraorbitalSub-Malar Area

Lateral Chin

Glabella

Upper

Mid

Lower

Lateral Brow

Subdermal

Subcutaneous/Supraperiosteal

• Outline area to be treated with patient upright (optional)

• Use conservative amounts of anesthetic for field infiltration so as not to distort tissue

• 1.25” or 1.5” 27g needle • Place material in subcutaneous

to supraperiosteal space• Inject multiple threads of

material in a retrograde manner (~0.05 cc/thread)

• Layer additional threads in deeper plane (Sub-Q) to provide volumizing effect

• Mold as needed, but be gentle with the tissue

CaHA: Malar/Zygomatic Augmentation


Depth of needle placement


Before 4 Months(2.6 cc total)

10 Months



• Treat the entire zone to provide volume and create a natural appearance

• Areas- Inferior lateral orbital rim

Malar eminence Infraorbital hollow• Try to achieve a blending

between the lower eyelid, nasolabial fold, and the cheek

• Injection depth: Deep– subcutaneous/supraperiosteal

• Linear threads or small boluses

Mariano Busso, MD, Miami, FL

Mid-Face Volume Replacement

• Outline area to be treated with patient upright (optional)

• Make the patient comfortable- infraorbital block and field infiltration into areas to be injected or lidocaine mixing

• In using field infiltration use conservative amounts so as not to distort tissue

• 1.25” or 1.5” 27g needle • Place material in subcutaneous to supraperiosteal

space and stay below the inferior orbital rim• Inject multiple threads or boluses• Mold as needed, but be gentle with the tissue

Mid-Face Volume Enhancement

Before After 9 months(2.0 cc/cheek)Miles Graivier, MD, Roswell, GA


Before After 6.5 ccMariano Busso, MD, Miami, FL


• DO NOT inject above the inferior orbital rim • Amount placed may not be identical for each

side due to asymmetry• At the completion of the procedure, the area

should be free of nodularity and feel smooth• Swelling is to be expected, do not overcorrect as

more can always be added later• Apply cold packs/ice to the treated areas and

continue at home to reduce bruising and swelling

Pearls for the Mid-Face

• Immediate outcome : improvement immediate• Provides augmentation lasting a year or more in

most patients• Adverse event profile is minor and similar to other

injectables• The firmness of the injected material will soften by

2 weeks and it will become like the resident soft tissue

• The patients are ecstatic with the immediate result and this contributes to a positive quality of life

Pearls for the Mid-Face

• Young face, “experienced” hands• Hands subject to same aging process as

faces• Subsurface Changes

– Volume loss• Soft tissue loss

– Dermal atrophy– muscle atrophy– fat redistribution– Atrophy in the subcutaneous compartment

Hand Rejuvenation

• While tenting skin, needle is placed in areolar plane between subcutaneous and superficial fascia layers

• Avoid injecting into extensor tendons and their synovial sheaths, retinaculum and muscles

• Can inject small or large boluses• Material is easily moldable• Some moderate swelling is normal and will

resolve within 1-3 weeks• Results tend to improve over 2-4 weeks

Busso M, Applebaum D, Dermatologic Therapy, Vol 20, No 6, Nov-Dec 2007

Hand Rejuvenation: CaHA

Michael Jasin, MD, Tampa, FL




Before Immediately After 1.3 ccMichael Jasin, MD, Tampa, FL


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