The Aging Face: Global Approach With Fillers and Neuromodulators
Nowell Solish, MD, FRCP(C)*
University of Toronto
Toronto, Ontario, Canada
The goal of treating the aging face is to restore facial balance and modify shadows. A facial evaluation should focus on areas of volume loss and opportunities to use neuromodulators (eg, botulinum toxin A) and the use of fillers. A thorough understanding of facial anatomy, including muscles, nerves, bone, and fat pads, is essential for effective and safe treatment.
Semin Cutan Med Surg 35(supp6):S120-S121
© 2016 published by Frontline Medical Communications
Aging face; botulinum toxin A; fillers; neuromodulators
As we age, bone and fat volume in the face and neck naturally decrease. Furthermore, rotational descent of the face occurs with aging, contributing to a lengthening of the face and the creation of lines, folds, and shadows. Youthful faces often have a heart-shaped pattern, but with age the face becomes more oval (elongated) or square (broadened, bottom heavy). For example, a baby’s face has a shape similar to an inflated beach ball, round and unlined. But the muscular atrophy, photodamage, and fat atrophy that occur with aging lead to an appearance more like a wrinkled, deflated beach ball.
In the midface, aging often increases fat in the lower areas and decreases volume in upper areas. The bone also resorbs and remodels. Resorption is common in the frontal bone, contributing to a convexity of the bone and ptosis of the brow. Resorption of the zygomatic angle makes the angle more acute, and the malar fat pad sags medially and creates or worsens the nasolabial fold. Other changes that contribute to the appearance of aging include periorbital hollowing, marionette lines, submalar hollowing, and periocular rhytidosis.
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Rutgers, The State University of New Jersey and Global Academy for Medical Education. Rutgers, The State University of New Jersey is accredited by the ACCME to provide continuing medical education for physicians.
Rutgers, The State University of New Jersey designates this enduring material for a maximum of 2 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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This activity is awarded 2.33 contact hours. (60 minute CH)
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Method of Participation
Participants should read the CE information below, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a Web page that will allow you to receive your certificate of credit via e-mail or you may print it out at that time.
Research continues to expand our understanding of the pathophysiology and management of skin diseases and age-related skin damage. Based on this evidence, new pharmacologic agents and medical devices continue to be developed, researched, and approved for use in the United States. New evidence and therapies have been developed for acne vulgaris, rosacea, psoriasis, onychomycosis/tinea, and facial rejuvenation. Clinicians need to understand the safety and efficacy of these new therapies in specific patient types.
Acne vulgaris affects 40 to 50 million people in the United States, with a prevalence as high as 85% in teenagers. A wide range of effective treatment strategies are now available to manage acne vulgaris, and new agents continue to be developed, offering an enhanced range of options. Psoriasis is an inflammatory skin disease for which a variety of agents, including several tumor necrosis factor (TNF) inhibitors, are approved for treatment. Recently, the use of TNF inhibitors for pediatric psoriasis has been investigated, and new biosimilar agents are in late stages of development for psoriasis. Clinicians may be reluctant to use TNF inhibitors in children with psoriasis and do not yet have clinical experience with biosimilar agents.
Rosacea is a common chronic skin condition affecting the face, affecting approximately 14 million Americans. No cure exists for rosacea, but health care professionals have several options to treat the symptoms, including new agents to treat facial erythema and inflammation. The use of these agents requires an understanding of their safety and use in combination therapy. Onychomycosis and tinea pedis are common fungal infections affecting the nails and feet, respectively. Newly approved topical agents for onychomycosis and tinea have demonstrated high cure rates in clinical studies.
Among the most common cosmetic procedures performed in the United States are the use of botulinum toxin A, soft tissue fillers, and laser treatments. In the last decade, a multitude of new products and devices have been developed for these indications, including new soft tissue fillers and novel laser technologies. The increased availability of options also increases the challenge of selecting the most appropriate agent or combination of agents for each patien
By reading and studying this supplement, participants should be better able to:
- Integrate into daily practice evidence-based recommendations on new and emerging therapies for common and uncommon dermatologic diseases
- Implement updated strategies for managing acne, rosacea, and psoriasis
- Discuss the use of biologic agents in the treatment of adult and pediatric psoriasis
- Review the status of biosimilars for use in dermatology
- Incorporate the recent advances in the treatment of acne vulgaris
- Discuss the safety, efficacy, and dosing of antibiotics for acne vulgaris
- Analyze emerging treatments for tinea and onychomycosis
- Identify the considerations in the selection of appropriate filler agents for treating different areas of the face
- Compare and contrast the efficacy and safety of agents, devices, and techniques currently available in aesthetic and procedural dermatology
- Determine the appropriate nonsurgical techniques for facial rejuvenation
- Describe the appropriate use of neuromodulators in the treatment of the aging face.
Individuals in a position to control the content of this educational activity are required to disclose: 1) the existence of any relevant financial relationship with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients with the exemption of non-profit or government organizations and nonhealth care related companies, within the past 12 months; and 2) the identification of a commercial product/device that is unlabeled for use or an investigational use of a product/device not yet approved.
Joseph F. Fowler, Jr, MD
Consultant: Bayer Healthcare, Galderma Laboratories, L.P., GlaxoSmithKline, Johnson & Johnson, Medimetriks Pharmaceuticals, Inc., Ranbaxy Laboratories Ltd., SmartPractice Dermatology/Allergy, Valeant Pharmaceuticals North America LLC; Speakers Bureau: Galderma, SmartPractice, Valeant; Grant/Research Support: AbbVie Inc., Allergan, Inc., Amgen Inc., Anacor Pharmaceuticals, Inc., Bayer, Celgene Corporation, Centocor, Inc., Chugai Pharma USA, Inc., Dow Chemical Company, Eli Lilly and Company, Galderma, Genentech, Inc., Innovaderm Research Inc., Janssen Biotech, Inc., Johnson & Johnson, Merck & Co., Inc., Novartis Pharmaceuticals Corporation, Onset Dermatologics, LLC, Pfizer Inc., Precision Dermatology, Regeneron Pharmaceuticals, Inc., SmartPractice, Taisho Pharmaceutical Co., Ltd., Taro Pharmaceutical Industries Ltd., Valeant
Theodore Rosen, MD
Scientific Advisory Board: Anacor Pharmaceuticals, Inc., Merz Pharma North America Inc., Valeant
Jeffrey M. Sobell, MD
Grant/Research Support: Amgen, Celgene, Eli Lilly, Janssen, Merck, Novartis; Consultant: AbbVie, Amgen, Celgene, Eli Lilly, Janssen; Speakers Bureau: AbbVie, Amgen, Celgene, Janssen, Novartis
Nowell Solish, MD, FRCP(C)
Consultant/Grant/Research Support: Allergan, Galderma, Indeed Labs, Inc., Merz, Revance Therapeutics, Inc., Valeant
Linda F. Stein Gold, MD
Consultantand Scientific Advisory Board: Anacor, Bayer, Eli Lilly, Foamix Pharmaceuticals Inc., Galderma, LEO Pharma Inc., Medimetrix Pharmaceuticals, Inc., Novartis, Pfizer, Taro
Christopher B. Zachary, MBBS, FRCP
Consultant: Kythera Biopharmaceuticals, Inc., Sciton, Inc., Solta Medical; Scientific Advisory Board: Sciton and ZELTIQ Aesthetics, Inc.
In order to help ensure content objectivity, independence, and fair balance, and to ensure that the content is aligned with the interest of the public, CCOE has resolved all potential and real conflicts of interest through content review by a non-conflicted, qualified reviewer. This activity was peer-reviewed tor relevance, accuracy of content, and balance of presentation by: Jean Sines, RN, BSN, Staff Nurse, Department of Dermatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. Ms. Sines has no relevant financial relationships to disclose.
Field Testers: This activity was pilot-tested for time required by: Physicians: Brian Lee, MD, Sima Patel, DO, and Vijay Vanchinathan, MD. Nurses: Geraldine Bocchieri, RN, BSN, Kathleen Brown, LPN, and Stacy Johnson, RN. The field testers have no relevant financial relationships to disclose.
Rutgers, The State University of New Jersey: Tristan Nelsen, MNM, CMP, and Elizabeth Ward, MSJ, have no relevant financial relationships to disclose.
Global Academy for Medical Education Staff: Shirley V. Jones, MBA; Sylvia H. Reitman, MBA, DipEd; and Josh Kilbridge have no relevant financial relationships to disclose.
Off-Label/Investigational Use Disclosure
This activity discusses the off-label use of the following approved agents: adalimumab, cyclosporine ophthalmic emulsion, doxycycline, etanercept, fluconazole, isotretinoin, itraconazole, ketoconazole, methotrexate, minocycline (oral and foam), secukinumab, ustekinumab, and tumor necrosis factor inhibitors as a class.
Contact Information for Technical Questions
Please technical questions or concerns to Global Academy for Medical Education at 973-290-8225 or email [email protected].
This continuing medical education (CME/CE) supplement was developed from faculty presentations at the Skin Disease Education Foundation’s 40th Annual Hawaii Dermatology Seminar™, February 14-19, 2016. The Guest Editors/Faculty acknowledge the editorial assistance of Global Academy for Medical Education, LLC, and Josh Kilbridge, medical writer, in the development of this supplement. The manuscript was reviewed and approved by the Guest Editors as well as the Editors of Seminars in Cutaneous Medicine and Surgery for publication as a supplement to the journal. This activity was developed under the direction of the Faculty/Guest Editors, Global Academy for Medical Education, and Rutgers. The ideas and opinions expressed in this supplement are those of the Guest Editors and do not necessarily reflect the views of the supporters, Global Academy for Medical Education, Rutgers, or the Publisher.
Copyright © 2016 by Global Academy for Medical Education, LLC and Rutgers, The State University of New Jersey. All rights reserved. No part of this publication may be reproduced or transmitted in any form, by any means, without prior written permission of Global Academy for Medical Education and Rutgers. Global Academy for Medical Education and Rutgers will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein.
1. Gold MH. Use of hyaluronic acid fillers for the treatment of the aging face. Clin Interv Aging. 2007;2:369-376.
* Assistant Professor, University of Toronto, Toronto, Ontario, Canada
Publication of this CME/CE article was jointly provided by Rutgers, The State University of New Jersey, and Global Academy for Medical Education, LLC, with Skin Disease Education Foundation (SDEF) and is supported by educational grants from AbbVie Inc., Bayer Healthcare, Merz Pharma North America Inc., and Valeant Pharmaceuticals North America LLC.
Dr Solish has received an honorarium for his participation in this activity. He acknowledges the editorial assistance of Josh Kilbridge, medical writer, and Global Academy for Medical Education in the development of this continuing medical education journal article.
Nowell Solish, MD, FRCP(C): Consultant/Grant/Research Support: Allergan, Inc., Galderma Laboratories, L.P., Indeed Labs, Inc., Merz, Revance Therapeutics, Inc., Valeant.
Address reprint requests to: Nowell Solish, MD, 66 Avenue Road, Suite 1, Toronto, Ontario M5R3N8; [email protected]