analyses showed moderate change in epidermal thickness, increased broblast density, and new collagen formation on electron microscopy.
Neuromodulators Botulinum toxin A (BoNTA) blocks acetylcholine release at the neuromuscular junction and is FDA approved for the treatment of rhytides in those over age 18. The superiority of BoNTA versus placebo has been well documented in many randomized, controlled trials with higher satisfaction and increased responder rates seen in younger populations.11 BoNTA-induced neocollagenesis improves skin pliability, elasticity, and dermal architecture, softening static lines. Resultant muscle atrophy inhibits muscles of negative expression, slowing future wrinkle development. A multi-center, retrospective study of 207 BoNTA patients followed over 9.1 years reported a drop in perceived age by 6.9 years in 89.7% of patients.12 Identical twin studies have corroborated the cumulative and preventative effects of BoNTA over a 19-year period.13
Lasers and Light
Intense Pulsed Light Photodamage, dyschromia, telangiectasias, freckling, and acne in this age group may be treated with intense pulsed light (IPL). Neocollagenesis and elastic fiber proliferation are known benefits, with conversion to a younger pattern of RNA expression after 3 treatments.14 Lasers Acne scars in any age group are effectively treated with resur- facing lasers that offer additional anti-aging bene t. Fractional photothermolysis via ablative (AFL) and nonablative (NAFL) devices are effective alone or in combination for the treatment of rhytides.15
Cryolipolysis Cryolipolysis triggers adipocyte apoptosis and is FDA approved in patients over 18 with unwanted fat in the abdominal, ank, thigh, and submental regions. Average fat reduction has been reported between 10.3-25.5%16 with the additional bene t of improved skin texture, laxity, and cellulite. Younger patients are more likely to have localized fat bulges in the setting of normal body weight, which makes them ideal candidates. High Intensity Focused Ultrasound High Intensity Focused Ultrasound (HIFU) ablates subcutaneous adipose tissue and is FDA approved for the waistline. A 2.0 cm reduction in waist circumference was reported in a muti-center, randomized, sham-controlled, single-blinded trial of 180 patients after one HIFU treatment.17 Deoxycholic Acid Submental fullness may occur in all age groups and can be treated with Deoxycholic acid injection, an FDA approved method that triggers adipocyte lysis and cell membrane disruption. In two multi-center, randomized, controlled, double-blinded trials of over 500 patients who received up to 6 deoxycholic acid treatments, 70.0% and 66.5% of subjects saw a 1-grade improvement on the submental fullness score when rated by clinician and subject, respectively (P<0.001).18 An 8-fold improvement was seen on magnetic resonance imaging (MRI) when compared to placebo (P<0.001). Cellulite Devices Cellulite at any age may be treated by destroying brous sep- tae that bind down herniating adipose tissue. A multi-center study of 55 women who underwent 1 treatment with the FDA-approved vacuum-assisted controlled tissue release system, saw 93% improvement of buttock and thigh cellulite in 47 subjects (P<0.001).19 There was 96% improvement after 1 year, 98% after 2 years, and 94% satisfaction rate. Another study of 15 females with thigh and buttock cellulite who underwent Nd:YAG 1,440-nm laser treatment, reported improved contour in 66% of patients and reduced dimple depth by 49% at 6 months.20
30s and 40s
Signs of aging worsen with accumulated photodamage, continued collagen decline, and significant bony loss in the 30s and 40s, making dyschromia, laxity, rhytides, and accentuated skin folds of particular concern.
Hydroquinone Dyschromia and mottled hyperpigmentation may be treated with topical hydroquinone (HQ) or a HQ-free formulation used nightly after a topical retinoid. After 12 weeks of HQ or HQ-free lightener, a study of 36 females reported significantly reduced scores on the Mottled Pigmentation Area and Severity Index and improved sallowness.21
Fillers Injectable fillers restore youthful contour and reposition ligaments and vectors when bony volume loss and facial fat pad descent begins in the mid-30s. A 10-degree reduction in the maxillary angle between age 30 and 60 further results in mid-cheek volume loss, sunken hollows, and poor bony projection that may be compensated with soft tissue fillers.22 Hyaluronic acid (HA) injection was shown to decrease perceived age in 10 patients by 6.1-7.3 years and 7.8-9 years as judged by dermatologists and subjects, respectively.23 Injectable fillers are known to stimulate neocollagenesis, resulting in less frequency of treatments needed over time. Persistent