AGING GRACEFULLY NANCY SILVERBERG, MD Chair, Department of Dermatology, Hoag Hospital Memorial Presbyterian Associate Clinical Professor of Dermatology, UCI

Skin Anatomy There are 3 skin layers: Epidermis Dermis Subcutaneous layer 3

Basal Layer Epidermis: The epidermis is the outermost layer and is primarily protective. It consists of 4 layers Stratum corneum, Stratum granulosum, Stratum spinosum, Stratum basale better known as the basel layer. Cells in the basal layer quickly respond to damage resulting in a process known as reepithelialization. Dermis: The layer of skin that lies just below the epidermis and is the connective tissue (collagen) layer of the skin that contains hair follicles, sweat glands, blood vessels and nerve endings. The dermis consists of two layers, the papillary layer which consist of finely textured collagen fibers which indent the base of epidermis and the reticular layer which contain course textured collagen fibers. Collagen fibers are the “strength of the skin” If the surface of the epidermis has been damaged over an extensive area it can grow back from epithelial cells which remain deep in the cutaneous adnexal structures (hair follicles, sweat and sebaceous glands). 4

What is skin aging? Collagen production slows (skin gets thinner) Elastin fibers break down (skin loses its ability to snap back after stretching) Subcutaneous fat decreases (skin looks less plump and smooth) Turnover of skin cells slows down Skin becomes dryer

What causes skin to age? Sun (ultraviolet light)—damages elastin and collagen fibers, causing wrinkles, and producing mottling and brown spots Cigarette smoking—damages elastin and decreases blood flow to skin Gravity—pulls on our bodies and with loss of elastin and collagen, causes sagging Sleeping positions—cause creases Facial expressions—muscles produce grooves in skin which gradually become etched in face

Prevention of skin aging AVOID ULTRAVIOLET LIGHT!!!!! Avoid deliberate tanning Stay out of sun between 10AM and 4PM Wear protective clothing (hats, long sleeves) Apply broad spectrum (UVA and UVB) sunscreen (SPF 25 or greater) year round

Treatment of Aging Skin Products Fillers and injectables Peeling and microdermabrasion Thermage Lasers Fraxel Fractional CO2

Products Sunscreen Moisturizers Tretinoin Everything else

Injectables and Fillers Botox cosmetic, Dysport Zyderm (bovine collagen) Restylane (hyaluronic acid) Juvederm (hyaluronic acid) Radiesse (hydroxyapatite) Evolence (porcine collagen) Sculptra (poly-L-lactic acid)

Botox

Restylane

Restylane

Juvederm

Juvederm

Sculptra

Peels and Microdermabrasion Light “lunchtime” peels: glycolic, beta, Jessner Medium depth peels: trichloroacetic acid Microdermabrasion: high pressure crystals delivered to skin which remove dead skin cells

Thermage Radiofrequency waves delivered to deeper skin layer which causes tightening of skin Produces heat in deeper layers of skin while maintaining cool on surface of skin Little recovery Not successful in all patients!

Thermage

Thermage

Laser Vascular lasers and intense pulsed light remove tiny blood vessels and brown spots Q switched lasers (Ruby, Versapulse, Medlite) remove brown spots Fraxel (fractionated erbium laser) Fractional CO2 (fractionated CO2 laser)

Intense Pulsed Light Intense Pulsed Light uses different wavelengths of light to target “broken” blood vessels and superficial brown spots. The light energy is changed to heat energy, which gradually fades the targeted pigment or vessels.

Intense Pulsed Light

Intense Pulsed Light

Fraxel Multiple tiny microscopic columns of erbium laser light treat a fraction of the skin at one treatment, making recovery much easier than resurfacing treatments. Requires multiple treatments Decreases fine lines, wrinkles, scars and skin blotchiness Not good for deep lines and sagging skin

Fraxel

Fraxel

Fractional CO2 (Active FX) Columns of high energy CO2 laser light interact with skin Only a fraction of the skin’s surface is treated, leaving small “bridges” of untreated skin Collagen in skin shrinks immediately Stimulates collagen remodeling over time Downtime usually less than one week Single treatment

Fractional CO2 (Active FX) Primary Targets: Fine lines and wrinkles of the face Crow’s feet around eyes Pucker marks (“smoker lines”) and frown lines Brown spots and blotchy, uneven skin tone Scars, especially acne scars

Fractional Resurfacing - Clinical Results Day 1 Day 7 Before

Fractional Resurfacing - Clinical Results 34

Fractional Resurfacing - Clinical Results Active FX: 1 treatment: CPG 3-6-3, 125 Hz, 100 mJ, double passage on crow’s feet; 6 months follow-up 35 35

Fractional Resurfacing - Clinical Results Right crow’s feet region of the previous patient before and after (6 months) 36 36 36

Fractional Resurfacing - Clinical Results Active FX: CPG settings: 3-6-3; 100 mJ fluence; 125 Hz; double passage on periorbital region 37 37 37

Fractional Resurfacing - Clinical Results 38 38

Fractional Resurfacing - Clinical Results

Fractional Resurfacing - Clinical Results 40 40

Fractional Resurfacing - Clinical Results Pre-Treatment 6 Weeks post Treatment

Fractional Resurfacing - Clinical Results Scar Revision

Fractional Resurfacing - Clinical Results TotalFX and Juvederm Combo Treatment

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