PP1 Flashcards
Physiologic or Intrinsic Aging
- Age 25 - 50: Dynamic to static
wrinkle transition - Age 50+: Collagen degradation
decrease in collagen content in dermis
Photoaging or Extrinsic Aging
- All ages
- UV exposure results in photoaging
– Manifests as wrinkles, lentigines, hyperpigmentation
- Sun exposure: responsible for 80% of facial aging – UV radiation directly induces collagen breakdown
Retinol (OTC)
- 20-fold less potent than tretinoin (dermal concentration 1000 fold less than tretinoin)
- Must be converted to tretinoin in vivo to become biologically active
- No significant trials have supported efficacy, in contrast to tretinoin
Tretinoin (all-trans retinoic acid)
- Naturally occuring vitamin A derivative
- Activates all RAR pathways (alpha, beta, gamma)
- Available by prescription only
- Approved by the FDA (Large body of evidence)
Tretinoin Pathway
- Effects are mediated through binding the nuclear
retinoid acid receptor (RARs) localized to specific
chromosomes - alpha (epidermis), beta (dermis),
and gamma (epidermis). - Regulate gene
expression directly on DNA.
Tretinoin Effects
- Increases collagen production: Induces types I and III
procollagen gene expression in human skin - results
increased deposition of collagen fibrils in dermis - Reduces collagen and elastin breakdown by inhibiting
MMPs (matrix metalloproteinases), UV exposure upregulates expression of these collagenases
How does Tretinoin minimize fine lines?
Due to increased collagen
production and collagen breakdown (via MMP
inhibition)
How does Tretinoin even skin tone?
Causing dispersion of the
melanin granules in the epidermis
How does Tretinoin smooth texture?
Adjusting skin histology
(epidermal hyperplasia), increasing GAGs
How does tretinoin decrease acne?
Prevents exfoliated keratinocytes from sticking together, decreased sebaceous gland activity
Peachy retinoid ingredients (4)
- Tretinoin
- HA
- Vitamin C
- Niacinamide
Level 1 retinoid
0.015%
(prior level 1 - 0.015%)
Level 2 retinoid
0.03%
(prior level 2 - 0.025%)
Level 3 retinoid
0.06%
(prior level 3 - 0.05%)
Level 4 retinoid
0.089%
(prior level 4 - 0.1%)
rarely used
Process of photoaging
- UVB radiation damages collagen and elastin (extracellular matrix)
- Drives the wrinkled appearance of sun-exposed skin.
Loss of collagen and elastin
leads to?
Wrinkled appearance
When does photoaging start to occur?
3-5 minutes of UV exposure, long before visible sunburn
What is critical in preventing photoaging?
Sunscreen
Acetylcholine (ACh)
The neurotransmitter that induces muscle contraction
Botulinum toxin A mechanism of action
- Breaks the snare protein to prevent the release of acetylcholine from the presynaptic nerve into the neuromuscular junction.
- By inhibiting neurotransmission between peripheral nerves and muscle fibers, the local skeletal muscle is temporarily denervated, weakened and cannot contract as aggressively
How does botox prevent the progression of dynamic
wrinkles to static wrinkles?
By reducing the amount of muscle contraction, botox
reduces the amount of collagen breakdown and remodeling
Frown lines muscle group
- Corrugator supercilii
- Procerus
- Depressor supercilii
Horizontal forehead frown lines muscle group
Frontalis
Corrugator supercilii action
Eyebrows drawn medially
Superior lateral orbicularis oculi action
Superior lateral eyebrow
depressor
Crow’s feet muscle group
Lateral orbicularis
Lateral orbicularis action
Lateral eyebrow depressor
Procerus & Depressor supercilii Action
Eyebrow depressors
Frontalis Action
Eyebrow elevator
Eyebrow lift muscle group
Superior lateral orbicularis oculi
Dynamic Index Textural Elements
no wrinkles with dynamic activity
Dynamic Depressions
mild depressions in the glabellar area surrounded by mild bulging of the glabellar muscles
Dynamic Grooves
moderate depressions during dynamic activity surrounded by moderate muscle contraction and bulging
Dynamic Furrow
grooves during dynamic activity surrounded by profound muscle contraction and bulging
Deep Dynamic Furrow
deep grooves during dynamic activity often with significant pull from the lateral corrugators
Static Index - No textural elements
no relaxed skin tension lines
Static Index - Faint textural elements
relaxed skin tension lines
Static Index - Fine Wrinkles
- fine linear depression in the skin surface, clearly deeper than
relaxed skin tension lines and persistent in its presence. - Often first seen in the frontalis
Static Index - Dermal Crease
a deep linear depression in the skin surface that is deeper and/or wider than a fine wrinkle distinguishable from a dermal groove by the absence of muscle contractions at rest
Static Index - Dermal Groove
a deep linear depression in the skin surface distinguishable from a dermal crease by the presence of persistent muscle contraction or spasm visible when the patient is “at rest”
Glabella skeletal anatomy
- Palpate the orbital rim (typically just below the eyebrows, but not always).
- Injections are always 1 cm above. Identify the supraorbital
notch
– Aligns with medial corrugators
Glabella muscular anatomy
- Palpate Procerus and
Corrugators. - Observe muscles during forceful contraction
Glabella Triangulation Points
- Procerus commonly aligns with medial end of eyebrows
- Lateral Corrugator: Medial to the mid-pupillary line
Frontalis skeletal anatomy
- Palpate the temporal fusion
line (guides lower treatment row lateral points) - Palpate orbital rim (lower treatment row is 2 cm above orbital rim)
Frontalis muscular anatomy
Palpate frontalis muscle,
focus on upper border.
Frontalis Triangulation Points
- Lateral lower treatment points are in the same plane as lateral
tip of eyebrow - Lower treatment row generally 2 finger breadths from eyebrow.
Lateral Canthal Skeletal Anatomy
- Palpate orbital rim
– Treatment points are just lateral to orbital rim
Lateral Canthal Muscular Anatomy
Palpate and identify each
patient’s unique fan-shaped pattern
Lateral Canthal Triangulation Points
1 cm from the lateral canthus of eye
