Intrinsic factors: activity of mimic muscles, genetic or hormonal influences

Extrinsic factors: UV radiation (excessive sun exposure), chemical/ thermal/ mechanical stress/injuries, nutrition, alcohol, nicotine, psychological stress

Epidermis: 
Physiologic Aging: decrease in the organization of the stratum corneum, the height of the dermal-epidermal transition, the keratinocyte layers, the number of melanocytes and Langerhans cells, and mitotic activity
Photoaging: atrophy, loss of vertical polarity, thickening of the basal membrane, pigmentary mottling

Dermis: 
Physiologic Aging: skin atrophy, decrease in the number of fibroblasts, Pacini and Meißner corpuscles, blood vessels, mitotic activity, elastic fibers, occurrence of collagen type I and increase in the occurrence of collagen type III
Photoaging: dermoelastosis, increased basic substance

Age, gender

Comorbidities: wound healing/ scarring disorder
immunodeficiency, neuromuscular disorder (ALS, myasthenia gravis, Lambert-Eaton-syndrome), collagen vascular disease, immunologic skin condition (vitiligo)

Medication: antiplatelet/ anticoagulation,
 antineoplastic agents, antiinflammatory agents, antibiotics (aminoglycosides), retinoids (past 12 months), steroids

Allergies

Others: smoking, pregnancy/lactation, solarium use (past 6 months), tattoos

Prior treatments & effects

Prior surgery

Patients` preferences

Skin type (Fitzpatrick Classification)

Skin texture: normal, dry, oily, mixed, aged, sensitive

Dyspigmentation: hypopigmentation, hyperpigmentation, freckles, solar lentigines, nevi, dysplastic nevi

Vascular lesions: (spider) angiomas, rosacea, teleangiectasias 

Scarring and skin lesions: acne scars, surgical scars, traumatic scar, xanthelasmas,syringomas, dermatofibroma, seborrheic keratosis, actinic keratosis, suspicious lesion

Region of facial rhytids: forehead, glabellar complex, nasal region, lateral periorbital region, perioral region, marionette lines, chin, neck

Severity of facial rhytids: superficial rhytids on animation only (dynamic), deep rhytids on animation only (dynamic), superficial rhytids at rest, deep on animation (static), deep rhytids at rest, deeper on animation (static)

Volume: deep (periorbital) upper sulcus, (lateral periorbital lines,) tear through deformity, malar volume loss, nasolabial fold, lower lid-cheek junction, lateral perioral lines, upper lip lines, philtral columns, vermilion, lips, labiomental groove, perimental hollows, chin dimpling, nasal contouring, scar filling 

 LASER is an acronym for Light Amplification by Stimulated Emission of Radiation

 Lasers produce heat in the target tissue that rapidly dissipates by conduction depending on wavelength, pulse duration, pulse width, spot size and beam shape

Thermal effects induce collagen remodeling which results in tightening of the skin

 A suitable wavelength must be selected to target a specific chromophore in the skin

There are mainly two types of lasers for facial rejuvenation: 

Ablative lasers vaporize the epidermis and parts of the dermis also causing thermal damage (with each pass, the effect of ablation decreases and thermal damage increases)

Ablative lasers leave an open wound

Ablative lasers are more effective for facial rejuvenation than nonablative lasers

The most frequently used ablative lasers are CO2-lasers and ER:YAG-lasers

Discontinue oral isotretinoin 6-12 months before the treatment

Evaluate antiplatelet and anticoagulation medication

Apply acyclovir 400 mg 1-1-1 or valaciclovir 500 mg 1-0-1 48 hours before the treatment and continue until the reepithelization is completed

Evaluate the application of antibacterial and antifungal prophylaxis

Cleanse and desinfect the patient`s skin properly 

Apply metal eye shields for the patient

The treatment with ablative lasers is more painful than with nonablative lasers

Topical anesthesia: apply e. g. lidocaine and prilocaine cream (EMLA) 30-90 minutes prior laser treatment

Local anesthesia: use e. g. 4% articain hydrochloride with 1:200.000 epinephrine for nerve blocks

Systemic anesthesia

Keep the wounds moistured using either an occlusive dressing for 1-3 days (with frequent changes) and an open wound care afterwards or providing open wound care primarily with application of e. g. dexpanthenol, Synchroline Terproline Egf cream, Cosmelan cream

Apply ice packages to cool the treated areas

Apply appropriate pain medication

Continue acyclovir 400 mg 1-1-1 or valaciclovir 500 mg 1-0-1 48 hours until the reepithelization is completed

Apply antibacterial and antifungal prophylaxis (if necessary)

Recommend sunscreen (at least SPF 30) after reepithelialization

Dyspigmentations, erythema, edema, pruritus, flaking, acne, contact dermatitis, scarring, infections, ectropion

Ablative lasers can cause wounds in variable depths     

The more superficial the wound, the shorter the recovery time

The deeper the wound, the better the rejuvenation effect

Several treatment sessions may be necessary

ER:YAG-lasers produce more selective tissue vaporization and less thermal coagulation than CO2-lasers

Due to the increased thermal damage CO2-lasers produce more collagen remodelling (resulting in skin tightening) than ER:YAG-lasers

The endpoints should be clearly understood before starting a laser treatment

Nonablative lasers spare the epidermis and cause thermal damage in the dermis stimulating collagen formation only and leaving the skin surface intact 

There is a great variability of nonablative lasers. The most frequently used nonablative lasers are Erbium-doped-fractional-lasers (Fraxel, Solta Medical) to treat dyschromia, fine rhytids and scars

Recovery time after nonablative laser treatment is minimal compared to an ablative laser treatment

Even if several sessions are performed, the results are very variable

Botulinum toxin is a neurotoxin produced by Clostridium botulinum, a gram-positive anaerobic bacterium

Botulinum toxin inhibits the synaptic transmission at the neuromuscular junction irreversibly targeting the SNAP/SNARE complex and inhibiting acetylcholine release 

There are eight types of botulinum toxin, two types (type A and type B) are FDA approved for clinical use.

Indication: dynamic lines, folds and furrows

Preparation:

Injection tools: 1 ml syringes, 30-/ 32-gauge needles

Anesthesia: possibly topical

Side effects/ complications: allergic reaction, injection site pain, bleeding, bruising, headache, brow/ eyelid ptosis, facial asymmetry, nausea, dysphagia, respiratory compromise, infection, acne

Contraindications: skin infection, allergy/ hypersensitivity to ingredients e.g. albumin (Botox®, Dysport®, Xeomin®) or lactose (Dysport®)
Use with caution: myasthenia gravis, Lambert-Eaton syndrome, coadministration of aminoglycoside antibiotics, inflammatory skin disorder, pregnancy, lactation

Posttreatment care: no massage of treated area, cold packs, limited activity for 1 d, next visit 2 weeks after application

Effect: 1-4 days after application

Longevity: 3-6 months

Goal: m. frontalis

Technique: 

Goal: m. corrugator supercilii, m. depressor supercilii, m. procerus, m. nasalis

Technique: 

Goal: m. orbicularis oculi

Technique: 

Goal: m. orbicularis oris

Technique: 

Goal: m. depressor anguli oris

Technique: 

Goal: m. mentalis

Technique: 

Goal: platysma

Technique:

Face Recurve® is a concept developed by Le Louarn, Buthiau and Buis to counteract the cutaneous and structural aging of the face in a preventive and curative way.The Face Recurve® concept is based on studies which have shown that certain parts of certain mimic muscles (so-called Age Marker Fascicles) lead to an increased redistribution of deep fat deposits towards the surface through their contraction (facial expression). The ability of the mimic muscles to relax completely also decreases with increasing age. This leads, for example, to the formation of glabellar fold, tear trough, naso-labial fold, bitterness fold and cervical bands.To counteract this process, partial chemical denervation is performed first, followed by combined application with tissue fillers. In the case of progressive aging, surgical separation of the Age Marker Fascicles is performed, if necessary in combination with further tightening interventions.

Botulinum toxin inhibits the synaptic transmission at the neuromuscular junction irreversibly

There are substances of different manufacturers. Note that the injection units differ between the manufacturers

Knowledge of anatomic structures is fundamental

Facial analysis is required before every treatment

Consider asymmetries and pretreatment brow/ lid ptosis

Create a harmonic appearance of the whole face

Avoid complete paralysis

Overtreatment should be avoided due to the non-antagonizable effect of botulinum toxin

Effect occurs 1-4 days after application

Repeat treatment after 3-6 months

biocompatible

no side effects causing

nonpalpable

ready to use

easy to applicate

potentially reversible

minimal downtime

Glycosaminoglycan biopolymer of disaccarids

Physiologic, hydrophilic component of the skin restoring dermal hydration as well as improving skin structure and elasticity

Mostly nonanimal based

Expands after injection while absorbing water

Available in different viscosities (form stability), with different crosslinking (longevity) and also with lidocaine

Effect: Immediately

Longevity: 4-12 months depending on crosslinking of HAs

Reversal correction: use hyaluronidase to treat irregularities or solve perfusion problems

Calcium hydroxyapatite microspheres suspended in aquaous gel

Biodegradable in calcium and phosphate ions

Gel is replaced by collagen

Not easy to mold

Used to treat medium-to-deep creases

Avoid perioral/ periorbital region (do not apply to superficial)

Effect: immediately

Longevity: 9-12 months

PLLA is metabolized to carbondioxide or glucose and replaced by collagen

The initial effect results from inflammatory processes

Biodegradable, very viscous

Reconstitute at least three hours before injections (better overnight)

Used to treat medium-to-deep rhytids

Avoid perioral/ periorbital region (do not apply to superficial)

Effect: after 8-12 weeks

Longevity: 18-24 months

PMMA beads are covered with bovine collagen

The collagen is resorbed and replaced by connective tissue

Needs skin testing prior to use

Used to treat medium-to-deep rhytids

Avoid perioral/ periorbital region (do not apply to superficial)

There are several treatments necessary to create volume

Effect: 6-8 weeks after application

Longevity: (semi-)permanent

Reversal correction: use triamcinolone to treat irregularities

Indication: filling of rhytids (creases, furrows and lines), volume restoration, reshaping

Preparation: choose substance individually (especially depending on area to treat), cleanse and desinfect the patient’s skin properly Injection tools: 1 ml syringes, 25-/27-/30-gauge needles or canulas depending on the filler’s viscosity

Anesthetics: possibly topical or nerve blocks

Side effects/ complications: injection site pain/ discomfort, bleeding, ecchymosis, edema/swelling, allergic reaction/ hypersensitivity, infection, intravasal injection, skin necrosis/ ulcerations, vision loss, irregularities, nodule formation, over-/ undercorrection, asymmetries

Contraindications: allergy to ingredients, collagen (vascular) disease (for some fillers)

Application techniques: serial puncture (droplet technique), linear threading, fanning, cross-radial technique (cross-hatching); aspirate before injection, especially in “danger zones”; the thinner the skin and the more superficial the injection is required, the smaller the molecule size of the filler should be 

Dr. Mauricio de Maio's  MD Codes help to define the area to treat and how much volume to apply

Posttreatment care: digital molding and massage of the treated area, cold packs, limited facial expression for 48 hours, consider steroids application after great volume injections, limited activity for 1 d

Forehead reshape: deep injection, serial puncture (several injection points), combinate with botulinumtoxin

Temple reshape: deep injection, serial puncture (few injection points)

Periorbital reshape:
Filling of upper orbital sulcus: deep injection, serial puncture (few injection points)
Filling of tear trough deformity: superficial injection, linear threading

Malar reshape: multilevel injection, fanning or cross-radial

Nasal (re)shape: deep injection, serial puncture (few injection points)

Nasolabial reshape: multilevel injection, fanning or cross-radial, possibly combinate products with different viscosities

Lip reshape:
Filling of upper lip lines: superficial injection, linear threading, combinate with skin resurfacing and/ or botulinumtoxin
Filling of philtral columns: superficial injection, linear threading
Definition of vermilion-cutaneous junction: superficial injection, linear threading
Upper lip augmentation: superficial injection, linear threading

Marionette reshape: multilevel injection, fanning or cross-radial, possibly combinate products with different viscosities

Chin reshape:
Filling of mental crease: subcutaneous injection, linear threading, combinate with botulinumtoxin
Filling of prejowl sulcus: subcutaneous injection, fanning

Jawline (re)shape: subcutaneous injection, linear threading

There is a great variety of fillers with different profiles regarding sensitivity, usability and longevity 

The thinner the skin and the more superficial the injection is required, the smaller the molecule size of the filler should be

Consider multilevel filling or the usage of fillers with different viscosities to treat deep rhytids

Essential for a successful facial rejuvenation treatment is a solid knowledge of the anatomy of the face

Find out what bothers the patient most (e.g. single lines or "angry"/ "tired" look)

Facial analysis is a very important step to evaluate skin conditions (e.g. thickness, Fitzpatrick type, dyspigmentation) as well as static and dynamic rhytids

Discuss and balance realistic treatment goals also in terms of recovery time

Define the treatment strategy individually by possibly combining laser resurfacing, muscle chemodenervation and application of soft tissue fillers

Dynamic rhytids can be treated well with botulinum toxin

Static rhytids can be treated well with skin resurfacing, soft tissue fillers or surgery