PP1

Question 1

Physiologic or Intrinsic Aging

Answer 1

• Age 25 - 50: Dynamic to static
  wrinkle transition
• Age 50+: Collagen degradation
  decrease in collagen content in dermis

Question 2

Photoaging or Extrinsic Aging

Answer 2

• 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

Question 3

Retinol (OTC)

Answer 3

• 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

Question 4

Tretinoin (all-trans retinoic acid)

Answer 4

• Naturally occuring vitamin A derivative
• Activates all RAR pathways (alpha, beta, gamma)
• Available by prescription only
• Approved by the FDA (Large body of evidence)

Question 5

Tretinoin Pathway

Answer 5

• 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.

Question 6

Tretinoin Effects

Answer 6

• 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

Question 7

How does Tretinoin minimize fine lines?

Answer 7

Due to increased collagen
production and collagen breakdown (via MMP
inhibition)

Question 8

How does Tretinoin even skin tone?

Answer 8

Causing dispersion of the
melanin granules in the epidermis

Question 9

How does Tretinoin smooth texture?

Answer 9

Adjusting skin histology
(epidermal hyperplasia), increasing GAGs

Question 10

How does tretinoin decrease acne?

Answer 10

Prevents exfoliated keratinocytes from sticking together, decreased sebaceous gland activity

Question 11

Peachy retinoid ingredients (4)

Answer 11

• Tretinoin
• HA
• Vitamin C
• Niacinamide

Question 12

Level 1 retinoid

Answer 12

0.015%
(prior level 1 - 0.015%)

Question 13

Level 2 retinoid

Answer 13

0.03%
(prior level 2 - 0.025%)

Question 14

Level 3 retinoid

Answer 14

0.06%
(prior level 3 - 0.05%)

Question 15

Level 4 retinoid

Answer 15

0.089%
(prior level 4 - 0.1%)
rarely used

Question 16

Process of photoaging

Answer 16

• UVB radiation damages collagen and elastin (extracellular matrix)
• Drives the wrinkled appearance of sun-exposed skin.

Question 17

Loss of collagen and elastin
leads to?

Answer 17

Wrinkled appearance

Question 18

When does photoaging start to occur?

Answer 18

3-5 minutes of UV exposure, long before visible sunburn

Question 19

What is critical in preventing photoaging?

Answer 19

Sunscreen

Question 20

Acetylcholine (ACh)

Answer 20

The neurotransmitter that induces muscle contraction

Question 21

Botulinum toxin A mechanism of action

Answer 21

• 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

Question 22

How does botox prevent the progression of dynamic
wrinkles to static wrinkles?

Answer 22

By reducing the amount of muscle contraction, botox
reduces the amount of collagen breakdown and remodeling

Question 23

Frown lines muscle group

Answer 23

• Corrugator supercilii
• Procerus
• Depressor supercilii

Question 24

Horizontal forehead frown lines muscle group

Answer 24

Frontalis

Question 24

Corrugator supercilii action

Answer 24

Eyebrows drawn medially

Question 24

Superior lateral orbicularis oculi action

Answer 24

Superior lateral eyebrow depressor

Question 24

Crow's feet muscle group

Answer 24

Lateral orbicularis

Question 25

Lateral orbicularis action

Answer 25

Lateral eyebrow depressor

Question 25

Procerus & Depressor supercilii Action

Answer 25

Eyebrow depressors

Question 25

Frontalis Action

Answer 25

Eyebrow elevator

Question 25

Eyebrow lift muscle group

Answer 25

Superior lateral orbicularis oculi

Question 26

Dynamic Index Textural Elements

Answer 26

no wrinkles with dynamic activity

Question 27

Dynamic Depressions

Answer 27

mild depressions in the glabellar area surrounded by mild bulging of the glabellar muscles

Question 28

Dynamic Grooves

Answer 28

moderate depressions during dynamic activity surrounded by moderate muscle contraction and bulging

Question 29

Dynamic Furrow

Answer 29

grooves during dynamic activity surrounded by profound muscle contraction and bulging

Question 30

Deep Dynamic Furrow

Answer 30

deep grooves during dynamic activity often with significant pull from the lateral corrugators

Question 31

Static Index - No textural elements

Answer 31

no relaxed skin tension lines

Question 32

Static Index - Faint textural elements

Answer 32

relaxed skin tension lines

Question 33

Static Index - Fine Wrinkles

Answer 33

- 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

Question 34

Static Index - Dermal Crease

Answer 34

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

Question 35

Static Index - Dermal Groove

Answer 35

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”

Question 36

Glabella skeletal anatomy

Answer 36

- 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

Question 37

Glabella muscular anatomy

Answer 37

- Palpate Procerus and Corrugators. - Observe muscles during forceful contraction

Question 38

Glabella Triangulation Points

Answer 38

- Procerus commonly aligns with medial end of eyebrows - Lateral Corrugator: Medial to the mid-pupillary line

Question 39

Frontalis skeletal anatomy

Answer 39

- Palpate the temporal fusion line (guides lower treatment row lateral points) - Palpate orbital rim (lower treatment row is 2 cm above orbital rim)

Question 40

Frontalis muscular anatomy

Answer 40

Palpate frontalis muscle, focus on upper border.

Question 41

Frontalis Triangulation Points

Answer 41

- Lateral lower treatment points are in the same plane as lateral tip of eyebrow - Lower treatment row generally 2 finger breadths from eyebrow.

Question 42

Lateral Canthal Skeletal Anatomy

Answer 42

- Palpate orbital rim – Treatment points are just lateral to orbital rim

Question 43

Lateral Canthal Muscular Anatomy

Answer 43

Palpate and identify each patient’s unique fan-shaped pattern

Question 44

Lateral Canthal Triangulation Points

Answer 44

1 cm from the lateral canthus of eye