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Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates...

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Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor Director of Cosmetic and Laser Clinic Department of Dermatology Medical College of Wisconsin
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Page 1: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

Edit Olasz Harken, MD, PhD Aging Gracefully

Free Powerpoint Templates

Aging GracefullyOr Not?

Edit B. Olasz MD. PhD.Assistant Professor

Director of Cosmetic and Laser ClinicDepartment of DermatologyMedical College of Wisconsin

Page 2: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

Edit Olasz Harken, MD, PhD Aging Gracefully

The Desire for Beauty

• People tend to respond positively to good‐looking people without expectation of reward. 

• Good‐looking people tend to get away with everything.

Page 3: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

Edit Olasz Harken, MD, PhD Aging Gracefully

Reversal of Aging

• Competitive job pressures

• Divorce and return to dating

• The barrage of advertising media

• The wide availability of cosmetic services

• Less social stigmata about cosmetic procedures

• Explosion of medical and surgical technology

Page 4: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

Edit Olasz Harken, MD, PhD Aging Gracefully

What defines beauty?

What creates age?

Page 5: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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The Golden Ratio – Devine Proportion

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Page 7: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

Edit Olasz Harken, MD, PhD Aging Gracefully

What happens to the face with aging?

Page 8: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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Page 9: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

Edit Olasz Harken, MD, PhD Aging Gracefully

Page 10: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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Multiple Factors Contribute to Timing and Degree of Facial Aging

• Intrinsic factors– Genetics

– Time

– Evolution

– Expressivity

– Atrophy of dermis and subcutaneous tissue

– Bone resorption and change

• Extrinsic factors– Sun exposure

– Gravity

– Smoking

1. Fisher GJ. Cutis. 2005;75(Suppl 2):5-9. 2. American Academy of Dermatology. Available at: www.skincarephysicians.com/agingskinnet/basicfacts.html. Accessed January 16, 2013. 3. Freiman A et al. J Cutan Med Surg. 2004;8:415-423.

Page 11: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

Edit Olasz Harken, MD, PhD Aging Gracefully

Aging

• Photoaging

• Gravitational aging

• Volumetric aging

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Page 13: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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UV Damage

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How does the sun affect your skin?

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Skin Type – Your Ability to Tan

• Fitzpatrick skin phototype (1975)  

I Always burn, never tan

II Always burn, but sometimes tan

III Sometimes burn, but always tan

IV Never burn, always tan

V Moderately pigmented skin

VI Darkly pigmented skin

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Clinical Signs of Photoaging

• Lentigines

• Dyschromia

• Keratosis

• Telangectasia

• Loss of translucency

• Loss of elasticity

• Sallow color

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Glogau – Photoaging Scale

Type IEarly Photoaging

Mild pigmentary changesNo keratosisMinimal wrinkles

20’-30’No to light foundation

Type IIModerate Photoaging

Early senile lentiginesPalpable keratosisParallel smile lines

40’-50’Light to moderate foundation

Type IIIAdvanced Photoaging

Obvious dyschromiaVisible keratosisParallel smile lines static

50’ and olderHeavy foundation

Type IVSevere Photoaging

Yellow-gray color of skinPrior skin cancerWrinkles throughout

60’-70’ and older“Cakes and cracks”

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Stages of Photoaging

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UV Camera: The Damage Beneath Your Skin

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Resurfacing Without Volume Replacement –“Better but not younger”

Page 21: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

Edit Olasz Harken, MD, PhD Aging Gracefully

The Loss of Subcutaneous Fat

• Forehead

• Temporal fossa

• Premalar area

• Perioral area

• Earlobes

Page 22: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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Changes in the Underlying Cartilage and Bone

Page 23: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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Volume Loss

Dermal atrophy + Lipoatrophy

+

Muscle Atrophy + Bone and Cartilage Loss

=

Biometric Volume Loss

Page 24: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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Gravitational Aging:Inherent Loss of Elasticity

• Stretching

• Sagging of soft tissue

Page 25: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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Biometric Volume Loss and Gravitational Aging Inverts Geometry

The Triangle of Youth Evolves Into….The Pyramid of Age

Page 26: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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Approach of the Face ‐Non‐Surgical Facial Rejuvenation

UPPER THIRD

MIDDLE THIRD

LOWER THIRD

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Aging Gracefully?

Enhancement

Rejuvenation

Restoration

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Treatment Approach to the Aging Face

• Photoaging

• Gravitational aging

• Volumetric aging

• Resurfacing

• Retightening

• Refilling

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Goals

• Reshape

– Retighten

– Refill

– Revolumize

• Resurface

– Retexture

– Recolor

Page 30: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

Edit Olasz Harken, MD, PhD Aging Gracefully

Combination Therapies

• Dyschromia – Topicals, peels, IPL, laser

• Wrinkles 

• Volume loss – Fillers, fat transplantation, implants

• Gravitational loss – Blepharoplasty, face lift

Dynamic – Botulinum Toxin

Static – Filler, laser resurfacing

Page 31: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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The dark and bright  side of sun exposure

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From sun tan oils to sunscreens 

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Public attitude toward tanning

“Pale is the new tan”

Page 34: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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FDA new sunscreen regulations

• Broad Spectrum designation

• Only SPF>15 can claim to reduce the risk of skin cancer and can be broad spectrum

• Ultra high SPF  is misleading

• "Waterproof," "sweat proof" or "sun block" banned

Page 35: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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What does broad spectrum mean?

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What does SPF mean?

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What’s in the bottle?

• Zinc oxide• Titanium dioxide

• Avobenzone• Mexoryl

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Inorganic vs. organic sunscreen

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How to apply sunscreen?

1. How much

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How to apply sunscreen?

1.  How much

2. When

Physical – anytime

Chemical – min 15 minutes 

3.  How often

Physical – when wet, sweaty

Chemical – every 2 hours of sun 

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Is there a safe way to tan?

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Vitamin D: wonder pill or overkill

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Low level of Vit D

Bone fracturesColorectal cancer

Decreased immune systemMultiple sclerosis

How to increase level

Tanning

Vitamin D Controversy

Page 44: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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Sources of Vitamin D

• Sunlight (90%)

• Dietary intake (10%)

• Vitamin supplements

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How does sun give you vitamin D?

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Skin type determines rate of vitamin D production

• Light skin burns readily, but achieve maximal vitamin D photosynthesis

– DNA damage, photoaging

• Darker skin does not burn, but also photosynthesize relatively limited amounts of vitamin D

– Limited DNA damage and photoaging

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Less than 10 minutes of UVB is sufficient

• If you have light skin: maximum photosynthesis reached in 2‐8 min midday

• Twice weekly midday sun exposure to face, arms and legs for 5‐30 min provides healthy level of vitamin D

Page 48: Aging Gracefully Or Not? · Edit Olasz Harken, MD, PhD Aging Gracefully Free Powerpoint Templates Aging Gracefully Or Not? Edit B. Olasz MD. PhD. Assistant Professor

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AAD Safe Sun Position

• UV irradiation causes 

– Non melanoma skin cancer

– Melanoma

– Photoaging

• The only established health benefit of UV irradiation is vitamin D synthesis

– HOWEVER vitamin D can be obtained from diet and supplements

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“Vitamin D from UV exposure is free and easy to get –why pass up the simplest way to improve your odds of 

preventing cancer?”

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Tanning beds

• FDA does not regulate it

• UVB similar to the sun in older units 

• UVA 10‐15 times higher than the sun

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Pre‐vacation tanning

• UVB induced tan = SPF 3 

• Tanning bed induced tan = SPF 1.3

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Tanning Bed UVA vs. Vitamin D UVB

• High pressure tanning beds: no or minimal UVB emission 

• UVB needed for Vitamin D production 

• Tanning bed emitting 1.5% UVB increases D3 levels, plateau reached after 4 sessions x 6 min

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Artificial tanning is “carcinogenic to humans”

• Tanning bed exposure before age 30, increases melanoma risk by 75%

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RECOLORING

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Lasers and Other Light Devices

Intense Pulse Light

Laser

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Intense Pulse Light

• Non‐coherent high intensity light filtered to achieve ranges of wavelength

• 550‐900 nm

• Multiple applications

– Redness

– Pigment

– Hair

– Photorejuvenation

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Photorejuvenation

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Solar Lentigo

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Vessels

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RESURFACING

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There is Always Airbrushing…

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Skin Resurfacing

• Dermabrasion– superficial

• Chemical Peeling– Supeficial

– Medium debth

– Deep ‐ ablative

• Laser resurfacing– Fractionated

– Ablative

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Laser Resurfacing

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Skin Regeneration Process

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Improvement of fine lines

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(RE)TIGHTEN

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New Techniques

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Radiofrequency Technology

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Clinical Application ‐Tightening

• Face

– Best for jawline, submental region

• Non‐facial

– Neck – excellent results

– Abdomen, arms and upper thighs

• Cellulite 

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US vs. RF vs. Laser

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Cryolipolysis

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Kythera’s ATX‐101

• Deoxycholic acid injection to dissolve fat

• Non‐surgical option for the treatment of submental fullness

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RELAX

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How do lines and wrinkles form?

• “Wrinkles merely mark where smiles have been” – Mark Twain

• Extensive sun (UVA) exposure

• Movement of muscles causes the skin to crease

• Skin becomes less elastic over time; repeated muscle movement      creates lines and wrinkles

• Weakening muscles prevent wrinkle formation

Corrugator muscle Corrugator muscle

Procerus muscle

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Wrinkles

Dynamic

• Lines, grooves and furrows

• Glabella, forehead, periorbital and perioral lines

Static

• Fine to deep lines with weathered skin

• Cheeks, lips, forehead

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Botulinum Toxin

• A purified protein complex derived from the bacterium Clostridium botulinum

• Seven serotypes: A, B, C1, D, E, F and G. 

• Block release of acetylcholine from presynaptic terminal of  neuromuscular junction (NMJ), causing local paralysis in area of functional denervation

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Approved for Aesthetic Use

BOTOX Cosmetic (onabotulinumtoxinA)

• FDA‐approved in 2002

• Approved in 80+ countries

• 20+ years of experience worldwide

• 50 U, 100 U per vial

• BOTOX and BOTOX Cosmetic are same formulation

XEOMIN (incobotulinumtoxinA)

• FDA‐approved in 2009

• Approved in 75+ countries

• 20+ years of experience worldwide

• 300 U per vial

• FDA‐approved in 2011

• Approved in 20+ countries

• 6+ years of experience worldwide

• 50, 100 U per vial

DYSPORT(abobotulinumtoxinA)

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Contraindications and Adverse Effects

• Contraindications– Myastania Gravis

– Amyotrophic Lateral Sclerosis

– Myopathies

– Calcium channel blockers

– Aminoglycoside antibiotics

– Pregnacy, lactation

• Adverse effects– Temporary bruising, nausea, headache, blepharoptosis, skin rashes (rare), flue‐like symptoms (rare)

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Glabellar Frown Lines

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Horizontal Forehead Lines

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Crow’s Feet Injections

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Bunny Lines Injection

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Perioral Wrinkles

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Mouth Frown

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Peau d’orange Chin 

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Horizontal Necklace Lines

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Platysmal Bands

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REVOLUMIZE

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Volume loss with aging

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Liquid face lift – Y lift

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Do they all look the same?

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Pillow Face, Chipmunk Cheeks, Piggy Eyes: The New Cosmetic Epidemic

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Following blindly the injection points

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The danger of over volumizing –aging gracefully?

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HA & Non‐HA Soft Tissue Fillers

Temporary biodegradable 

< 1 yr

Semipermanent biodegradable 

1–2 yr

Permanent nonbiodegradable 

≥ 2 yr

HA fillers CaHA microspheres  PMMA microspheres

PLLA microspheres

Cultured human fibroblasts

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Hyaluronic Acid Fillers

• Cross‐linked glycosaminoglycan polymers‒ Low rate of hypersensitivity reaction

• Minimally invasive – Little or no postprocedural recovery time

• Reversible – If desired after implantation, can be removed with 

hyaluronidase

• May stimulate collagenesis

NASHA, nonanimal stabilized hyaluronic acid.1. Wang F et al. Arch Dermatol. 2007;143(2):155-163.

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Currently Marketed HA Fillers

Trade Name

HA Conc., mg/mL Type Lidocaine

Needle Size, G FDA Approval

Restylane Restylane‐L

20 NASHANoYes

30

2003, 2011 (lips)

2010, 2012 (lips)

Juvéderm UltraJuvéderm Ultra XC

24 Hylacross HANoYes

3020062010

Juvéderm Ultra PlusJuvéderm Ultra Plus XC

24 Hylacross HANoYes

2720062010

PerlanePerlane‐L

20 NASHANoYes

27 or 29

20072010

Restylane Silk 20 NASHA Yes 30 2014

Belotero Balance 22.5Cohesive 

Polydensified Matrix HA

No 30 2011

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Currently Marketed Non‐HA Fillers

Trade Name Source Depth

Particle Size (diameter) Lidocaine

Needle Size 

FDA Approval

Radiesse1 CaHA Deep dermis25–45 m 

microspheresNo 28 G 2006

Artefill1 PMMA Reticular dermis

30–50 m microspheres

Yes 26 G 2006

Sculptra aesthetic1

PLLADeep dermis or subQ

40–63 m microspheres

No 26 G 2009

laViv2Autologous fibroblasts

Superficial papillary dermis 

10‐15 m No 30 G 2011

1. Broder KW et al. Plast Reconst Surg. 2006;118(3S):7S-14S. 2. laViv [package insert]. Fibrocell Technologies Inc; Exton, PA: 2011.

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Calcium Hyroxylapetite (Radiesse®)– Calcium based‐microspheres suspended in a natural gel.

– Microspheres form scaffold to support and stimulate collagen.

4 Weeks 16 Weeks

36 Weeks

72 Weeks

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Stimulatory Fillers

• Poly‐L‐Lactic Acid (Sculptra®)– A biodegradable aliphatic polyester– Series of 3 injection, lasts 2 years– Approved for facial lipoatrophy in people with HIV lipodystrophy syndrome 

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Flow Characteristics of Fillers:Elasticity (G') and Viscosity (η*)

• Firm to palpation

• More tissue lifting 

• Contour stability 

• Higher extrusion force during injection

● Soft to palpation

● More tissue spreading 

● Moves with facial movement

● Lower extrusion force during injection

High Low

Sundaram H et al. Dermatol. Surg. 2010;36:1859-1865.

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Product Elasticity* Viscosity*

Radiesse 1,407 349,830

Radiesse + 0.3% lidocaine 554 143,100

Restylane‐L 565 131,310

Perlane‐L 549 127,090

Restylane 514 119,180

Juvéderm Ultra Plus XC 136 32,152

Juvéderm Ultra XC 111 27,034

Juvéderm Ultra Plus 75 17,699

Belotero Balance 30 9,217

Juvéderm Ultra 28 7,307

*All measured at 0.7 Hz (physiologically relevant for stresses common to skin).Sundaram H et al. Dermatol Surg. 2010;36:1859-1865. Sundaram H et al. J Drugs Dermatol. 2012;11(8 Suppl):S12-S24. Data on file, Merz.

Flow Characteristics of Fillers:Elasticity & Viscosity

Less spread

More lift,

firmer

Less lift,

softer

More spread

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Tailoring Treatment for Optimal Outcomes

Low G' and 

viscosity

High G'and 

viscosity

Slide courtesy of  Hema Sundaram, MD.

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Tear Through Correction

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Melolabial Folds

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Lip Augmentation

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Hand Rejuvenation

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Pan‐Facial Restoration

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Most Common Side Effects

Significant persistent swelling 

(particularly the lips)

Overcorrection  with lumpiness

Tyndall effect from 

overly superficial placement

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Arterial and Venous Occlusion

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SUMMARY

• Protect your skin from the sun

• Don’t compete with the stars or your neighbor

• Be the best you can be

• Never retire but put new tires on; resurface, revolumize, refresh and relax

• Never stop playing

• Age with grace: young at heart, slightly older at other places.

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