PRE- READING COURSE MATERIAL

FOUNDATION BOTOX® AND

DERMAL FILLERS
Module 1
 OVERVIEW

•  Principles of dermatology and the ageing face

•  Principles of facial anatomy

•  Principles of the aesthetic consultation and

consenting
 OVERVIEW

•  Principles of dermatology and the ageing face

•  Principles of facial anatomy

•  Principles of the aesthetic consultation and

consenting
DERMATOLOGY
SKIN ANATOMY

The skin is made up broadly of 3 layers:

-  Epidermis
-  Dermis
-  Subcutis
 SKIN ANATOMY

SKIN

EPIDERMIS SUBCUTIS
DERMIS

Stratum
Corneum Stratum Stratum Stratum
Lucidum Spinosum Basale Reticular
Stratum Papillary Dermis
Granulosum Dermis
 SKIN ANATOMY

SKIN

EPIDERMIS SUBCUTIS
DERMIS

Stratum
Corneum Stratum Stratum Stratum
Lucidum Spinosum Basale Reticular
Stratum Papillary Dermis
Granulosum Dermis
 SKIN ANATOMY

The epidermis is the outermost layer of the skin, and protects the body from the
environment.

The epidermis layer itself is made up of five sublayers that work together to
continually rebuild the surface of the skin.
 SKIN ANATOMY
The Basal Cell Layer
The basal layer is the lowest/ innermost layer of the epidermis and contains basal cells that
continually divide.

The Squamous Cell Layer

The squamous cell layer is located above the basal layer. Here, basal cells are pushed
upward, however these maturing cells are now called squamous cells, or keratinocytes.

The Stratum Granulosum & The Stratum Lucidum

Keratinocytes from the squamous layer are pushed up through two thin epidermal layers
called the stratum granulosum and the stratum lucidum. As these cells move further towards
the surface of the skin, they get bigger and flatter and adhere together, and then eventually
become dehydrated and die.

The Stratum Corneum

The stratum corneum is the uppermost layer of the epidermis, and is made up of 10 to 30
thin layers of continually shedding, dead keratinocytes. The stratum corneum is sloughed off
continually as new cells take its place, but this shedding process slows down with age.
Complete cell turnover occurs every 28 to 30 days in young adults, while the same process
takes 45 to 50 days in elderly adults.
 SKIN ANATOMY

SKIN

EPIDERMIS SUBCUTIS
DERMIS

Stratum
Corneum Stratum Stratum Stratum
Lucidum Spinosum Basale Reticular
Stratum Papillary Dermis
Granulosum Dermis
 SKIN ANATOMY
The Dermis
The dermis is located beneath the epidermis and is the thickest of the three layers of the
skin (1.5 to 4 mm thick), making up approximately 90 percent of the thickness of the skin.
The main functions of the dermis are to regulate temperature and to supply the epidermis
with nutrient-saturated blood.

The dermis layer is made up of two sublayers:

The Papillary Layer

The upper, papillary layer, contains a thin arrangement of collagen fibers. The papillary layer
supplies nutrients to select layers of the epidermis and regulates temperature.

The Reticular Layer

The lower, reticular layer, is thicker and made of thick collagen fibers that are arranged in
parallel to the surface of the skin. The reticular layer is denser than the papillary dermis, and
it strengthens the skin, providing structure and elasticity. It also supports other components
of the skin, such as hair follicles, sweat glands, and sebaceous glands.
 SKIN ANATOMY

SKIN

EPIDERMIS SUBCUTIS
DERMIS

Stratum
Corneum Stratum Stratum Stratum
Lucidum Spinosum Basale Reticular
Stratum Papillary Dermis
Granulosum Dermis
 SKIN ANATOMY

The Subcutis

The subcutis is the innermost layer of the skin, and consists of a network of fat
and collagen cells. The subcutis is also known as the hypodermis or
subcutaneous layer, and functions as both an insulator, conserving the body's
heat, and as a shock-absorber, protecting the inner organs.

It also stores fat as an energy reserve for the body. The blood vessels, nerves,
lymph vessels, and hair follicles also cross through this layer.
 SKIN ANATOMY

During the aging process, there is an ongoing loss of collagen and elasticity in
the skin, resulting in the skin becoming lax.

Collagen loss causes tissue atrophy and thinning of the skin, with increased
rhytid (wrinkle) formation.

Younger skin Older skin

 THE AGEING FACE

Loss of the underlying fat causes descent of the overlying structures in the
ageing face. This occurs most predominantly in the following areas;
 THE AGEING FACE
Over many years the changes in skin laxity lead to loss of the volume and curves
of the cheeks, resulting in bony contours.

Tissue descent also causes increased nasolabial and labiomandibular folds

 THE AGEING FACE
There are two types of wrinkles: dynamic wrinkles and static wrinkles.

The dynamic wrinkle is caused by animation or muscle function.

Dynamic wrinkles can be seen

here with movement and
purposeful contraction of the
muscle. They disappear when the
patient relaxes.

Static wrinkles are seen at rest,

even on relaxation of the muscle.
 OVERVIEW

•  Principles of dermatology and the ageing face

•  Principles of facial anatomy

•  Principles of the aesthetic consultation and

consenting
 FACIAL MUSCLES
THE UPPER THIRD OF THE FACE

Corrugator supercilii

Depressor supercilii
 FACIAL MUSCLES

Frontalis
Procerus
Corrugator
Depressor supercilii supercilii

Orbicularis oculi
 FRONTALIS MUSCLE
Frontalis
Procerus
Corrugator
Depressor supercilii supercilii

Orbicularis oculi
 FRONTALIS MUSCLE

Contraction of these key muscles causes wrinkling of the overlying skin.

•  Origin: galea aponeurotica along the coronal suture

•  Insertion: into the dermis at the level of the eyebrows. No bony insertions.
FRONTALIS MUSCLE CONTRACTION
 GLABELLA COMPLEX
Frontalis
Procerus
Corrugator
Depressor supercilii supercilii

Orbicularis oculi
 GLABELLA COMPLEX

Procerus Muscle

•  Origin: tendinous fibres from the fascia overlying the nasal bone and upper part
of the lateral nasal cartilage
•  Insertion: lower medial forehead

Corrugator supercilii

•  Origin: Medial end of the superciliary arch of the frontal bone

•  Insertion: Skin beneath the middle of the eyebrow

Depressor supercilii

•  Origin: midline of the frontal bone approximately 1cm above the medial canthal
tendon
•  Insertion: Skin and subcutaneous tissue beneath the eyebrow
 GLABELLA COMPLEX
MUSCLE CONTRACTION
 ORBICULARIS OCULI
Frontalis
Procerus
Corrugator
Depressor supercilii supercilii

Orbicularis oculi
 CROW’S FEET

The orbicularis oculi muscle is a thin flat sphincteric muscle that originates from
the frontal bone near the medial canthus. It consists of three parts:

1)  Pars orbitalis or the orbital part of orbicularis oculi is the bulkiest among the
three. Coarse fibers surround the entire orbit. It has two origins: the frontal
bone and the maxilla. The insertion circles around the orbit. It contracts to
close the eyes tight.
2)  Pars palpebralis or the palpebral part covers the eyelid itself. It also encases
the lacrimal sac and canaliculi. Compared to the pars orbitalis, it is made up
of fine fibers. It originates from the medial palpebral ligament and inserts into
the zygomatic bone, specifically at the lateral palpebral ligament. It acts to
close the eyes gently.
3)  Pars lacrimalis or the lacrimal part of the orbicularis oculi is responsible for
anchoring the lacrimal canal towards the eye surface. Its origin is the
lacrimal bone and its insertion is the lateral palpebral raphe.
 CROW’S FEET

The medial portion of the orbicularis is a medial brow depressor and contributes to
the glabella lines. It runs superficial to the depressor supercilii.

The lateral portion of the orbicularis oculi is a lateral brow depressor and creates
the wrinkling pattern known as crow’s feet.

The orbicularis oculi muscle interdigitates with the dermis of the skin throughout its
course such that botulinium toxin injections need only be intradermal or very
superficial to achieve the desired effects.
ORBICULARIS OCULI CONTRACTION
 OVERVIEW

•  Principles of dermatology and the ageing face

•  Principles of facial anatomy

•  Principles of the aesthetic consultation and

consenting
 THE AESTHETIC CONSULTATION

•  Introduce yourself and confirm the patient (date of birth)

•  Establish the client’s desires for the outcome of the treatment

•  Take a full medical, surgical and aesthetic history and confirm

any allergies

–  Particular note should be taken to any condition affecting the

neuromuscular junction such as Myasthenia Gravis, Amyotrophic Lateral
Sclerosis and Eaton Lambert Syndrome.
–  In the aesthetic history, assess the patient’s expectations and any body
dysmorphia

•  Take a full medication history and establish if the client smokes

 THE AESTHETIC CONSULTATION

•  Use a hand held mirror in front of the patient and ask them to tell you what they
are trying to modify

•  Discuss the options with the patient. It is essential that they are aware that;

–  Treatments are not permanent and Botox cannot ‘remove’ static wrinkles
–  Treatments do not work immediately
–  Treatment doses may need to be altered/ increased over time
–  Ongoing maintenance and treatment will be required
–  An initial ‘standard’ dose regime will be used and the client will be reviewed in 2 weeks to
assess the outcome of treatment- at which point more treatment can be offered, if
required

•  Discuss the cost with the client before any treatment in undertaken
•  Consent for photography and store this appropriately in the medical notes
•  Explain the aftercare required
 CONSENT

•  Your client must be consented appropriately according to

GMC and NMC guidelines. You can use the following
documents as a guide;

•  Consent: pa+ents and doctors making decisions together (GMC,

2008)
•  Principles of pa+ent consent (GDC 2009)
•  Consent (NMC, 2010)

h"p://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp
Consent. NMC. h"p://www.nmc-uk.org/Nurses-and-midwives/Advice/Consent/
(Accessed October 2012)
 CONSENT

•  Risks and complications for the procedures can

be reviewed in this document under ‘Botox and
Dermal fillers’ sections

•  You should give your client sufficient time (ideally

a minimum of 2 weeks) to process the information
and understand the procedure fully, before asking
them to sign the consent form

•  Ensure they are given the opportunity to ask any

questions
 OVERVIEW

•  Principles of dermatology and the ageing face

•  Principles of facial anatomy

•  Principles of the aesthetic consultation and

consenting
NOTES