What is Facial Beauty? What makes someone more attractive is eye of the beholder and phi of the beholder. A look at how aging effects our beauty and what can be done to improve our facial beauty.

1. Facial Beauty
Presented by
Dr. Scott K. Smith

2. What is Beauty?
Is beauty only in the eye of the
beholder….
.
Or ,are there some absolute values?

3. Beauty is a mystery!
“I know not what beauty is
but I know that it touches
many things",
Dürer

4. Symmetry
youthfulness
clarity or smoothness of skin
vivid color in the eyes and hair

5. “Personal beauty is a greater recommendation than any
letter of reference.”
- Aristotle

7. Dental Emphasis to Oro-Facial

8. • It has long been said that beauty is in the
eye of the beholder and thought that
beauty varies by race, culture or era.

9. Beauty in the Eye of the Beholder?

10. Beauty in the Phi of the Beholder
Evidence shows that our perception of physical
beauty is hard wired into our being and based on
how closely one's features reflect phi in their
proportions.
• 1.6180399

11. What is Phi
Phi ( Ø ), is simply an irrational number like pi.
What makes it more unusual is that it can be derived
in many ways and shows up in relationships
throughout the universe.
Phi Ø can be derived through:
*A numerical series discovered by Leonardo
Fibonacci

12. Phi is Everywhere
* The proportions of the human body
* The proportions of many other animals
* Plants
* DNA
* The solar system
* Art and architecture
The ratio, or proportion, determined by Phi (1.618...) was
known to the Greeks as the "Golden Section" and to
Renaissance artists as the "Divine Proportion

13. Divine Proportion is Everywhere

16. • The head forms a golden
rectangle with the eyes at
its midpoint. The mouth
and nose are each placed
at golden sections of the
distance between the
eyes and the bottom of
the chin.

17. • Science writer Eric Haseltine claimed (in
an article in Discover magazine in
September 2002) to have found that the
distance from the chin to the eyebrows in
Langlois's 32-composite faces divides the
face in a Golden Ratio.

18. • A similar claim was made in 1994 by orthodontist Mark
Lowey, then at University College Hospital in London.
Lowey made detailed measurements of fashion models'
faces. He asserted that the reason we classify certain
people as beautiful is because they come closer to
Golden Ratio proportions in the face than the rest of the
population.

19. • Beauty is not just in the eye of the beholder.
Researchers say it's also in the distance
between the eyes and the mouth.
• Researchers at the University of California, San
Diego and the University of Toronto have
identified the optimal relation between the
eyes, the mouth and the edge of the face that
distinguishes a beauty queen from a plain Jane.

20. Principles of Aesthetics
• Balance
• Rhythm
• Proportion
• Emphasis
• Unity

21. Aesthetic Principles
• Balance
• Rhythm
• Proportion
• Emphasis
• Unity

22. Balance
• Visual Equilibrium
• Symmetry?

23. Symmetry R and L superimposed

25. Rhythm
• The human face communicates an
incredible array of emotions which are an
integral element of one's total beauty. The
human face conforms most closely to phi
proportions when we smile.

27. Unity
• Coherence of the whole
• Effect of all other disciplines working
together to form esthetic harmony

28. Proportion

29. one third
one third
one third

30. Horizontal Fifths

33. Emphasis
• Eyes
• Cheeks
• Peri-oral

36. The Aging Face
• Extrinsic Factors
• Intrinsic Factors

37. The Aging Face
Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S

38. Extrinsic Factors
 Trauma
 Smoking
 Photodamage
 Gravity

39. Intrinsic Damage
• Fibroblastic Synthesis Reduction
• Breakdown of Cellular Membrane
• DNA Repair Reduction

40. Components of Aging
• Thinning of Dermis
• Atrophy of Fat Pads
• Loss of elasticity
• Greater Visibility of Bony Landmarks
• Increased Visibility of Vessels
• Increased Mental and Mandibular Folds

42. Components of Aging
• Development of Wrinkles and Furrows
• Transverse Forehead lines
• Drop of Eyebrow and Eyelid
• Descent of Corner of Mouth
• Thinning of Upper lip and Inversion of lip
• Nasiolabial Fold Development
• Rhytids – smokers lines
• Atrophy of Cupids Bow

43. Aesthetic Principles
• Balance
• Rhythm
• Proportion
• Emphasis
• Unity

44. Principles we CAN effect
Proportion
Emphasis
Rhythm

45. Lips
what defines lip structure and attractiveness.
• Dentition
• Width of upper vs. lower
• Interlabial gap
• Oral commissures should be located along vertical lines
drawn from the medial limbus of the iris.

46. Gordon Classification
• Zone A
• Zone B
• Zone C

47. Creating the Esthetic Smile

90. Aesthetic Treatments
Minimally Invasive Cosmetic
Procedures

91. Botulinum toxin
• Botulinum toxin type A (BoNT-A) works by
blocking the release of a neurotransmitter
necessary for muscles to contract
• The effects of BoNT-A last approximately 3-4
months, with complete re-activation of the
nerves and muscles
• BoNT-A has been available and used for
therapeutic uses since 1980

92. Normal Neuromuscular Function
Arnon et al. JAMA 2001;285(8):1059-1070 (with permission).

93. Botulinum Toxin Mechanism of Action
Arnon et al. JAMA 2001;285(8):1059-1070 (with permission).

94. Botulinum Toxin Structure
Clostridium botulinum is a gram positive, anaerobic, rod-shaped bacterium
that produces seven serologically distinct neurotoxins (A-G)1.
Non-toxic,
non-hemagglutinin
(NTNH)
Hemagglutinin (HA) 150 kD Neurotoxin
1Hathaway. In: Hauschild AHW, ed. Clostridium Botulinum: Ecology and
Control in Foods New York, NY: Marcel Dekker, Inc.;1993;54:pp 3-20.
2Inoue et al. Infect Immun 1996;64:1589-1594.
3Lacy et al. Nat Struct Biol 1998;5:898-902 (with permission).

95. Facial Areas Commonly Treated with
BoNT-A
Forehead
Glabellar lines
Brow lift
Bunny lines
Crow’s feet
Perioral lines
Gummy smile Oral
commissures
Peau d’orange
Platsymal
bands

96. 1. Frontalis
2. Procerus
3. Corrugator supercilli
4. Depressor supercilli
1
5. Temporalis
5
6. Obicularis oculi 3
7. Nasalis 2
8. Levator labaii superioris 4
alaeque nasi
9. Levator labaii 6
10. Zygomaticus minor 8 7
11. Zygomaticus major 10 9
12. Obicularis oris 11
13. Modeolus 12
13
14. Masseter
14
15. Depressor anguli oris
16. Depressor labii 15
16 17
17. Mentalis

97. BoNT-A treatment: Glabellar lines
Before After - Day 30
www.Botox.com

98. BoNT-A treatment: Forehead lines
Before After - Day 30
After - Day 120
Carruthers & Carruthers. Dermatol Surg 2007;33:S10-S17

99. BoNT-A treatment: Brow lift
Before After
Coleman & Carruthers. Dermatol Therap 2006;19:177-88

100. BoNT-A treatment: Perioral lines
Before After
Kane. Oral Maxillofacial Surg Clin N Am 2005;17:41-49

101. BoNT-A treatment: Gummy smile
Before After
Kane. Oral Maxillofacial Surg Clin N Am 2005;17:41-49

102. BoNT-A treatment: Oral commissures
Before After
Carruthers & Carruthers. Dermatol Surg 2003;29:468-76

103. Hyaluronic Acid Fillers

104. HA Treatment: Marionette lines
Before After
Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S

105. HA Treatment: Pre-jowl sulcus
Smith. Plast Reconstr Surg 2007;120(Suppl):67S-73S

106. HA Treatment: Lip Volumization
Before After After
Matarasso et al. Plast Reconstr Surg 2006;117(3 Suppl):3S-34S

107. HA Treatment: Nasolabial folds
Before
After

108. HA Treatment: Nasolabial folds
Before After – 2 weeks After – 38 weeks
Smith et al. AAD Summer 2006

109. HA Treatment: Nasolabial folds
Before After – 2 weeks After – 24 weeks
Smith et al. AAD Summer 2006

110. HA Treatment: Cheek Volumization
Before After – 10 days
Smith. Plast Reconstr Surg 2007;120(Suppl):67S-73S

112. Introduction to
The Next Generation In
Longer Lasting Wrinkle Correction

113. Radiesse vs CosmoPlast Clinical Study
®
Baseline 6 Months
Patient 1
Radiesse Control Radiesse Control
Patient 2
Radiesse Control Radiesse Control

114. Placement of Radiesse into the Skin
• Objective is to fill the depression and structurally support the
line and provide volume
– Inject Radiesse into the deep dermis and subdermal plane
– Use non-dominant index finger to guide needle
– Deeper threads can be placed to bolster depression
– Use thumb and forefinger to massage and mold Radiesse
Subdermal Plane

115. Radiesse Delivers Greater Improvement
Than Restylane At Every Time Point
Radiesse vs. Restylane
How much improvement on average over time?
Radiesse Improvement
1.2RADIESSE
Mean Improvement from Baseline (WSRS)
Restylane Improvement
1
RESTYLANE
0.8
0.6
0.4
0.2
0
3 mo's 6 mo's 9 mo's
Time post 2nd injection

116. Radiesse Delivers Longer Lasting
Improvement
Radiesse vs. Restylane
Improvement over Time (GAIS)
% Patients 100
Radiesse
Improved at 9 months: Restylane
90
Radiesse = 79% 80
% of Patients with Improvement
Restylane = 44% 70
60
50
• More Patients 40
are Improved at 30
20
Every Time 10
Point 0
3 mo's 6 mo's 9 mo's
Time post 2nd injection

117. Radiesse & Restylane Histology – 4 weeks
Radiesse
Moderate tissue response
Gel carrier replaced by native
fibrinogen, elastin and collagen under the
normal tissue repair mechanism
Restylane
• Minimal tissue response
• No native fibrinogen, elastin and
collagen is manufactured to replace
absorbtion of HA

118. Mechanism of Action
When placed into soft tissue, Radiesse Over time the gel is resorbed and the
provides immediate correction CaHA particles stimulate and support
Gel + CaHA Particles in-growth of new collagen
Collagen + CaHA Particles

119. Radiesse vs Restylane Split Face Study ®
Restylane Radiesse
Before Treatment 6 Months
(post last injection)
Restylane Radiesse
9 Months
(post last injection)

120. Addressing Some Misconceptions
1. Radiesse cannot form bone in soft tissue
• Micro-motion presence; No bone morphogenic proteins; No osteoblast progenitor cells
2. Radiesse particles do not migrate
• Exhaustive pre-clinical studies have demonstrated no migration
• Particles are 25-45µm & thus too large (>15 microns) to be encapsulated by macrophage and migrate via lymphatic system
• Collagen infiltration around particles hold them in place
3. Radiesse will not obstruct X-rays
• If visible, its only faint & whispy and won’t interfere
• Barely visible on diagnostic x-ray, clearly evident bilaterally on CT scan with no masking of other structures
4. Lip Nodules are not Granulomas
• Zero granulomas reported in multicenter clinical trials (>1,000 patients)
• CaHA molecular and chemical composition is identical to that in the human body and does not generate a foreign body Rx
• Not seen as a foreign body so no delayed inflammatory response
• Not for use in lips due to muscle motion & cohesive properties of the gel carrier
• Nodules are not granulomas – nodules are early onset, accumulations of product, which are distinct from late onset
granulomatous foreign body reactions

121. Fractional CO2 Resurfacing
June 2011

122. Resurfacing History
 Ablative CO2 Full Resurfacing 1991
 Erbium 1997
 Non-Ablative Resurfacing 1996
 IPL 1996
 Nd:YAG & Others 2000
 Non-Ablative Fractional Resurfacing 2004
 Fraxel
 Ablative Fractional Resurfacing 2006
 CO2 & Erbium

123. Photo Low Energy
+
Damage
High Density
1.
Tone Moderate Energy
Texture +
Moderate Density
Color
2.
Rhytides High Energy
+
Scars
Low Density
1. Photo courtesy of Mark Rubin, M.D.
2. Photo courtesy of Mark Taylor, MD
3. 3. Photo courtesy of Yasmina Carvajal, M.D.

124. • When the laser pulses at thousandths of a second, the
water in skin (skin is 90% water) heats up to a very high
temperature.
• The water is instantly vaporized into a smoke plume and
residual heat, proportional to the pulse energy
(mJ), spreads into the surrounding tissue.
• Immediate contraction and epidermal dyschromias are
removed.
• Ablated tissue and thermal spread of heat causes a
natural healing response that stimulates new collagen
growth to restructure and restore the dermis to resemble
new, undamaged skin.
124

125. Wound Healing
Immediately After Post 2 Days
•Ablated epidermis • Volume collapse of ablated column for
•Ablated column extends deep into the immediate contraction.
dermis. • Re-epithelialization is complete.
•Uniform thermal heat to surrounding • Ongoing collagen stimulation for 3-6 months
tissues.

126. Stratum Corneum: 2 – 3 Days
Basal Layer: 4 – 6 Days
Papillary Dermis: 7 – 8 Days
Mid Dermis: 8 – 10 Days
Reticular Dermis: 10 – 12 Days

127. Full Ablative CO2 Resurfacing
 The “Gold Standard”
 Single Treatment
 Dramatic Results
Photos Courtesy of Dr. Sarnoff

128. Full Ablative CO2 Resurfacing
• It was the “Worst of times”
• Prolonged downtime (up to 1month)
• Increased incidence of side effects
• This is why we provide Erbium!
Photos Courtesy of Dr. Sarnoff

129. New
Decrease
need for
power
Increase
Traditional CO2 need for Fractional CO2
scanning
2 mm 150 µm
Full Face Ablation Tissue Sparing
Prolonged Healing Shortened Healing

130. Fractional Laser Treatment
A fraction of the skin area is
treated with an array of
relatively small spots.
frac·tion·al
-of, relating to, or being a fraction
- relatively small: inconsiderable
frac·tion·ate
- to divide or break up
- divide into different portions

131. Any Golfers out there?
Very Similar theory….
To improve the condition of
the green, Golf Course
Superintendents don’t
remove the entire putting
green, they remove a
portion, or fraction of it!!!

132. What’s Happening Today……

133. Pigmentation Problems?
Hair Problems ?
Wrinkles?
Acne?
Courtesy of Nora Grace

134. Hair Removal, Skin Rejuvenation,
Acne Treatments, Vascular Treatments
and Skin Tightening
____________________________________________________________________________________________________________________________________________________________
____
The Multi-Application Intense Pulsed Light System

135. What is Intense Pulsed Light?
• Broad Spectrum Light Source
– 420 to 1200 nm wavelength range
– Filtered wavelengths to provide multiple applications
• Delivered in Millisecond Pulses
– Pulse duration 2ms to 9ms
– TPW (total pulse width) from 10ms to 500ms
– Up to 16sec in Skin Tightening
• High Energy Output
– 50j/cm2 max energy
– 22 – 35j/cm2 typical treatment parameters

136. Why Use Intense Pulsed Light?
• Multiple Applications
– Hair Removal, Photo Rejuvenation, Pigmented Lesions, Vascular
Lesions, Acne, Small Veins, Rosacea, Fine Lines
• Popularity of skin rejuvenation treatments
– Excellent for clearance of sun damage, pigmented lesions, vascular
lesions, fine lines, and acne
• Fast and effective hair removal
– 40 x 10mm square spot Vs 6, 8, 10, 12mm round spot
– Excellent long term results – rivals laser technology

137. Wavelength Penetration

140. What is Variable Pulsing?
• New method of delivering Pulsed Light energy in a safe
and effective manner
• Allows for peak power adjustments
– Peak power is the measure of total energy/ time
– NaturaLight adjusts for high peak power when needed (fine hair,
light pigment, ect) , low peak power (coarse hair, larger vascular)
or medium power, depending on treatment parameters, goals,
etc.
• Peak power adjustments increase efficacy
• Peak power adjustments increase safety
• These manipulations dramatically alter the way the
energy is delivered to the skin and allow increased
controls for the physician

141. FotoFacial, PhotoRejuvenation, Skin
Rejuvenation, IPL Skin Treatments…
What do these treatments do?
Improve the tone and texture of the
face, neck, chest, hands, etc.
Tone
• Pigmentation, vascular, flushing, broken capillaries
• All caused by sun damage
Texture
• Treatments reduce fine lines, reduce the appearance of
pores, add laxity to the skin

142. Non-Ablative Photo Rejuvenation
What patients want…
• No downtime
• Affordable procedure
• Fresh and healthy looking skin
• Painless and easily tolerated
treatment
• Safe and effective

143. Photo Rejuvenation
• Patient consult
– Expectations
– Herpes prophylaxis?
• Treatment coarse and follow up
– After care
• Technique and settings
• Complementary treatments
– Microdermabrasion.
– Cosmeceuticals
– Botox
– Sunless Tanning

144. Pigmentation Problems
Courtesy of Focus Medical

145. Pigmentation Problems
Immediate Post Treatment
30 days later
Courtesy of Saratoga
Aesthetics

146. Pigmentation/Melasma
Outstanding results from typically very stubborn pigmentation

147. Skin Tightening – Before/After
The jaw line and neck was the focus of the treatment.

148. Vascular Treatments
Vascular Lesions
Rosacea - Treatments reduce the
overall redness and flushing
 Facial Veins – Small broken
capillaries up to 1mm diameter
 Other Vascular Lesions –
hemangioma, cherry angioma, PWT

149. Small Facial Veins

150. Vascular Before and After
Look at the flushing and redness of the neck with this
patient. The after picture shows a much more even
tone without the visible redness.

151. Forehead
Glabellar lines
Brow lift
Bunny lines
Crow’s feet
Perioral lines
Gummy smile Oral
commissures
Peau d’orange
Platsymal
bands

163. Nasofacial Angle

164. Frankfort Plane

165. Mentocervical Angle