PRIME Journal March/April 2023

INJECTABLES

What next for fillers and toxins?

AMWC TAKES PLACE ONCE AGAIN IN BEAUTIFUL MONACO FROM March 30th to April 1st. As ever, I’m sure those attending will enjoy the rich and lively discussions, excellent scientific content, new products on show at the numerous exhibition floors, and camaraderie the congress stimulates among its attendees.

In our March/April issue, which will benefit from extensive distribution at AMWC this year, we have published the findings of a readership survey regarding your thoughts on the state of the injectables market. Among the answers, we found that the majority of our readers (75%) believe marketing has overtaken scientific rigour in the field of injectables. This is further corroborated by only 7% of readers believing injectable manufacturers should prioritise investing more in marketing, with almost half (49%) responding they believe prioritising professional education to be the best investment injectable manufacturers can make.

This tells us physicians no longer want to be sold to; rather, they want to be shown the evidence of a product’s safety, efficacy, and reliability. Physicians tiring of the insistence of marketing over scientific rigour may be the reason why over 50% of respondents stated we no longer need any new botulinum toxin on the market.

Our readers also pointed to the need for more clinical trials on the injectables currently available, as well as more regulation and better training.

The survey results have been published within our cover feature in this issue, ‘Injectables: what next for fillers and toxins.’ Written by journalist and content strategist Rosalind Hill, the article tracks the changing landscape of the injectables market over the last 20 years before exploring what technological advancements and trends are on the horizon.

If you would like to attend AMWC Monaco in person next year, and I highly recommend you do, be sure to book your place at www. amwc-conference.com. From there, you can also book your attendance at any number of the AMWC events being held around the world in 2023, including Taiwan, India, the UK, Brazil, Colombia, and more! Aesthetic Multispecialty Society Premium Members will receive 20% off their delegate pass to AMWC 2024 as well as further enhanced benefits, and you can sign up here: multispecialtysociety.com.

Balraj Juttla Editor, PRIME balraj.juttla@informa.com

International Journal of Aesthetic and Anti-Ageing Medicine

Informa, Floor 4, 24 York St, Sydney, NSW 2000, Australia

ISSN 2159-8908 (print)

ISSN 2159-8916 (online)

Editor Balraj Juttla balraj.juttla@informa.com

Art Director David ‘Spike’ McCormack spike@spikedesigns.co.uk

Marketing Director Slim Hakimi slim.hakimi@informa.com

Production & Ads Department balraj.juttla@informa.com

Please send your manuscripts and press releases to: balraj.juttla@informa.com

All submitted manuscripts are evaluated on the basis of scientific quality, originality, appropriateness, contribution to the field and style. Manuscripts and accompanying files should be prepared in accordance with our Author Guidelines, which are available via www.prime-journal.com.

All content © 2023 Informa UK Ltd Images © Stock.adobe.com, unless otherwise stated

FACE CONFERENCE IS THE UK’S PREMIER MEDICAL AESTHETICS CONFERENCE and exhibition devoted to arming its delegates with the latest clinical information, practical tips and updates in the field of minimally invasive aesthetic treatments and anti-ageing medicine. FACE is the perfect place for physicians and aesthetic professionals who share a passion for the rapidly growing and constantly evolving market of aesthetics and anti-ageing medicine.

With 20 years of experience, FACE is the only conference in the UK — and one of the few in the world — to have in-depth agendas focussed on core segments of the non-surgical aesthetic marketplace.

FACE’s programme bridges the gap between the current level of academic training, and the pioneering advancements constantly arising within the aesthetics and dermatology field. With both UK and international leading practitioners contributing to the programme, you can be confident in the depth and quality of scientific research available at FACE.

As the industry evolves, so do the desires of patients, treatments, and safety protocols. At FACE we have crafted a premium scientific programme designed to empower you with evidence-based research and data. Our international expert panel comprises speakers from Europe, America, South America, and the UK providing a high-level agenda on the variety of topics including: Injectables, Threads, Skin, Equipment, Genital Rejuvenation, Hair and many more.

The Injectables Agenda at FACE takes the crown for being the most comprehensive injectables programme in the UK. Focusing on the knowledge that injectors need for 2023 and beyond, this agenda delves into the specifics of injection techniques to avoid nodules, and keeping safety at the forefront while delivering excellent natural results.

Our Skin Agenda focuses on diversity, diagnosing, and treating conditions across the Fitzpatrick scale. A holistic approach to skin is taught, with multiple factors included to help you create a bespoke treatment plan for your patient. Our partnership with the International Peeling Society means you will receive advanced training in this sector too.

Through plenary sessions, live demonstrations and tutorials, the experts will present the latest clinical and scientific advances and offer practical lifehacks to effectively sharpen your skills and acquire new ones.

FACE scientific committee members and experts represent every discipline within our field and have contributed many years to the education of doctors and to the advancement of aesthetics. No matter where you are in your aesthetic journey — looking to kick-start your career, gain confidence in a discipline, or upscaling your practice — everyone has something to gain at FACE.

SUBSCRIPTION RATES

UK: £180

Europe: €180

Rest of world: US$180

FACE Scientific Committee London, UK

PRIME JOURNAL EDITORIAL BOARD

BOARD MEMBER SPECIALISM

Dr Claude Dalle Anti-ageing & aesth. medicine France

Dr Wilmar Accursio Endocrinology Brazil

Dr Firas Al-Niaimi Dermatology & laser surgery UK

Dr Ashraf Badawi Dermatology

Egypt & Canada

Dr Janethy Balakrishnan Aesthetic & anti-ageing medicine Malaysia

Dr Lakhdar Belhaouari Plastic surgery

France

Dr Anthony Benedetto Cosmetic Dermatology USA

Dr Philippe Berros Oculoplastic surgery

Dr Dario Bertossi Maxillofacial surgery

Dr Pierre Bouhanna Dermatology – Hair surgery

Dr Fahd Benslimane Plastic Surgery

Dr Claude Chauchard Anti-ageing medicine

Dr Christophe de Jaeger Geriatrics

Monaco

Italy

France

Morocco

France

France

Dr Gerd Gauglitz Aesthetic Dermatology Germany

Prof Ilaria Ghersetich Dermatology Italy

Dr Michael H. Gold Dermatology USA

Dr Kate Goldie Aesthetic Physician UK

Prof Eckart Haneke Dermatology

Germany

Dr Steven Hopping Plastic surgery USA

Prof Andreas Katsambas Dermatology

Greece

Dr Mario Krause Anti-ageing medicine Germany

Dr Marina Landau Dermatology

Israel

BOARD MEMBER SPECIALISM COUNTRY

Dr Gustavo Leibaschoff Cosmetic Surgery USA

Dr Sohail Mansoor Dermatology UK

Prof Leonardo Marini Dermatology

Italy

Dr Sly Nedic Aesthetic & anti-ageing medicine South Africa

Prof Daniel Pella Cardiology Slovakia

Dr Chariya Petchngaovilai Dermatology Thailand

Prof Ascanio Polimeni Neuro-endocrinology Italy

Dr Herve Raspaldo Facial plastic surgery France

Dr Christopher Rowland-Payne Dermatology UK

Dr Neil Sadick Dermatology USA

Dr Hema Sundaram Dermatology USA

Dr Pakpilai Thavisin Dermatology & Anti-ageing medicine Thailand

Dr Patrick Treacy Aesthetic surgery Ireland

Dr Mario Trelles Plastic surgery Spain

Dr Ines Verner Dermatology Israel

Dr Octavio Viera Anti-ageing medicine Spain

Dr Jean-Luc Vigneron Aesthetic dermatology France

Prof Bernard Weber Genetics Luxembourg

Dr Sabine Zenker Dermatology Germany

Catherine Decuyper Industry expert & consultant France

Wendy Lewis Industry expert USA

Christophe Luino Industry expert & consultant France

NEWS

8 Gen Z are seeking out minimally invasive ‘tweakments’, according to AAFPRS

10 IBSA to make hypothyroidism treatment more affordable

INDUSTRY INSIDER

12 Lutronic hits a new milestone as the first medical device company from Korea with over 25 years of innovation

Taking a closer look at one of the leading energy-based device companies in the world

16 Injectables What next for fillers and toxins?

Our understanding and approach to injectables have undergone a seismic shift over the past 20 years. But where do we go from here? Rosalind Hill spoke with some leading physicians to find out

CASE REPORT

24 Nordlys selective waveband technology treatments for rejuvenation and redness in Asian skin

Diana Li, MD, reveals how she uses a unique protocol and Nordlys’ two new handpieces to address common skin concerns in Asian skin type-III

28 Sunekos injectable and the high-performance technique counteracting skin ageing

Elena Fasola, MD, details an injection technique to combat wrinkles, skin laxity, and photoageing dyschromia

PRACTICE PEARLS

34 Cold ablative fibre laser: a new solution for photoageing in all skin types

Michael Gold, MD, describes his success using the UltraClear™ system in his aesthetic practice

AESTHETIC FEATURES

38 Exploring the psychosocial aspects of ageing

Shino Bay Aguilera, Alec D McCarthy, Elina Theodorakopoulou, et al., examine the relationship between psychological and physiological ageing and the role of the aesthetic physician

44 Perioral myomodulation with filler injection

Tinchia Hsu, MD, and Yuchin Tsai, MD, discuss an easy and approachable method for perioral volume restoration and rejuvenation

50 Combining calcium hydroxylapatite and microfocused ultrasound for safe and efficient neck rejuvenation

Kerstin Ortlechner explains the importance of treating the signs of neck ageing and how a combination approach is her treatment of choice

56 Treating the nasolabial folds with a polycaprolactone filler

Expert consensus on the use of polycaprolactonebased Ellansé — a novel collagen-stimulating filler — for multi-site and multi-level injection of the outer facial contour to improve nasolabial folds

PRIME PEOPLE

60 Andreas Prinz

PRIME talks to Andreas Prinz, Managing Director of Croma, on recent developments, products, and their plans for long-term success

62 Mark Wilson

PRIME talks to Mark Wilson, VP International Marketing & Commercial Operations at Allergan Aesthetics, an AbbVie Company, on his vision for the future of the industry

PRACTICE MANAGEMENT

64 Unravelling the value of loyalty programmes to entice customers and keep them coming back Wendy Lewis takes a deep dive into strategies for engaging clients and building long-term relationships

82 A round-up of the major industry events happening around the world over the next 12 months

A round-up of news stories in the aesthetic and anti-ageing medicine industry

GEN Z ARE SEEKING OUT MINIMALLY INVASIVE ‘TWEAKMENTS’ ACCORDING TO AAFPRS

REPORT FINDS A SPIKE DRIVEN BY THE USE OF FILTERS AND SOCIAL MEDIA APPS

What started with a virtual obsession with filters has evolved into a real-life fixation with minimally invasive ‘tweakments’—and the zoomers (those succeeding Millennials and preceding Generation Alpha) are all over it. According to the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) 75% of facial plastic surgeons reported a spike in demand from clients under 30, and 79% agree that looking better in selfies continues to trend upward. Botox, fillers, microneedling, and chemical peels top the list of requested in-office procedures. As for low-downtime surgeries, lip lips and blepharoplasties reign supreme.

To that end, lip lifts, a new category for the 2021 survey, were up three percent in 2022; at least 73% of AAFPRS members performed lip lifts in 2022 versus 70% in 2021. As facemasks continue to become less and less prevalent, this intel doesn’t really come as a surprise. The trendy procedure aims to remove some skin under the nose in order to shorten the skin of the upper lip, overall increasing the amount of

visible pink lip. By removing this excess upper lip skin, it shortens the upper lip skin and everts the upper lip which results in a more youthful appearance. ‘We have seen more and more patients requesting lip lifts, to be performed as an isolated procedure, or in conjunction with other cosmetic surgery,’ says Theda C. Kontis, MD, facial plastic surgeon and President of the AAFPRS.

Another selfie-boosting procedure, the blepharoplasty, a.k.a. eye lid surgery has seen an upward climb in popularity. ‘Upper blepharoplasty removes the excess skin above the eyelid, reducing that hooded appearance that can occur naturally with age, while lower

blepharoplasty targets the fat pads below the eye, restoring a smoother, more youthful look,’ says Dr. Kontis. ‘Both are relatively minor procedures that lend themselves to tremendous patient satisfaction.’ Men and women often request this procedure to look less tired. Recovery is about one week, but it can be as little as 1–2 days for those working from home.

And while pre-juvenation and low-to-no downtime reign supreme for Gen Z-ers, 78% of AAFPRS members believe there will be a greater emphasis on earlier maintenance and age prevention starting in the 20s–30s to forestall bigger procedures and surgeries for later down the road. In fact, this year’s survey indicates that surgical procedure activity sees significant increase.

With any ‘tweakments’, Dr. Kontis reminds all patients to select a physician based on their qualifications. Credentials, knowledge and experience have always been important when it comes to choosing a board-certified facial plastic surgeon. Board-certified facial plastic surgeons specialize in surgery of the face, head and neck.

PICOWAY® LASER GAINS ADDITIONAL USES IN USA AND CANADA

Candela Corporation announced that the PicoWay® laser system has received FDA clearance and Health Canada licensing for expanded indications, including the challenging condition of melasma. In addition to its earlier indications for wrinkles, benign pigmented lesions, tattoo removal, and acne scars, the new clearance and license expand the platform’s capabilities to treat melasma, lentigines, café au lait macules, and Nevus of Ota.

The award-winning PicoWay laser has four true picosecond wavelengths and offers treatment versatility with multiple available applicators and beam delivery technologies.

Melasma is a skin condition that causes patches of spots, usually on the face, which are darker than one’s natural skin tone. The condition is common in darker skin types and especially prevalent in pregnant women due to hormonal changes -

between 15% to 50% of pregnant women (The PicoWay laser is contraindicated for use during pregnancy) will get melasma, leading the condition often to be referred to as the ‘mask of pregnancy’. A complicated skin disorder, often attempted to be managed with topicals and frequently relapsing and remitting for long periods, melasma can be notoriously challenging to treat.

‘Addressing melasma with the

PicoWay laser gives patients an important treatment modality to manage this difficult and often psychologically upsetting condition. Patients now have a treatment that specifically targets their pigmentary changes and can be used alongside other treatments like topicals to better manage this complex skin disorder,’ states double boardcertified Dermatologist Douglas Wu, MD, PhD of Cosmetic Laser Dermatology in San Diego.

IBSA TO MAKE HYPOTHYROIDISM TREATMENT MORE AFFORDABLE

IBSA

PARTNER WITH ONLINE PHARMACY TO OFFER

IBSA Pharma announced that it has entered into an agreement with Mark Cuban Cost Plus Drug Company, PBC (Cost Plus Drugs) to offer Tirosint® (levothyroxine sodium) oral capsules at a low cash price via the Cost Plus Drugs online pharmacy. The agreement is the first of its kind for a branded levothyroxine drug. Levothyroxine is a synthetic hormone used to treat hypothyroidism. It is one of the most widely dispensed prescription medications in the United States with an estimated 116 million prescriptions filled in 2016.

Tirosint capsules is the leading branded gel capsule formulation of levothyroxine in the US. It is formulated without excipients that can cause tolerability and drug absorption problems commonly observed with traditional levothyroxine tablet therapies. Tirosint has money savings options available for patients, their availability in the Cost Plus Drugs programme is a first for both companies.

Cost Plus Drugs launched its online pharmacy in 2021 and was co-founded by investor-entrepreneur Mark Cuban to reduce the cost of prescription medications. It offers the most commonly prescribed drugs at low transparent prices by negotiating prices directly with manufacturers and passing along the savings to consumers. ‘Everyone should have access to safe, affordable prescription drugs at transparent prices,’ commented Cuban at the company’s founding. Currently, most of Cost Plus Drugs’ offerings are generic drugs. The agreement with IBSA marks one of the company’s first forays into the branded segment of the US pharmaceutical market. Cuban is currently a Tirosint patient.

Commenting on the agreement, IBSA Pharma CEO Nicholas Hart stated that ‘hypothyroidism is a prevalent condition with significant public health implications. We are delighted to offer Tirosint capsules to patients via

TIROSINT

AT LOW COST

Cost Plus Drugs. Tirosint has been clinically proven to provide the benefits of levothyroxine, the standard of care for treating hypothyroidism, in a formulation that is free of gluten, dyes, lactose, sugars and other excipients commonly found in tablet formulations. These can be problematic for many patients. Studies have shown that up to 31% of levothyroxine-treated patients have gastrointestinal and other problems that can lead to underperformance of levothyroxine therapy and suboptimal control of hypothyroidism.’

Tirosint capsules is a prescription medication that IBSA Pharma markets to physicians and patients. Tirosint capsules are indicated to treat hypothyroidism in patients six years and older and available in a range of doses.

About hypothyroidism

Hypothyroidism is an endocrine disorder with numerous causes resulting in a deficiency in thyroid hormone. More than 27 million adults have been diagnosed with hypothyroidism and up to 13 million Americans have undiagnosed hypothyroidism. About 2% of the U.S. population has pronounced hypothyroidism, and as much as 10% has subclinical (mild) hypothyroidism. The condition is most common in women over 40 years of age and in the elderly of both sexes. The signs and symptoms of hypothyroidism are nonspecific and may include fatigue, forgetfulness, depression, constipation, muscle cramps, weight gain, dry skin and hair loss. TSH laboratory tests are recommended as first-line screening tests for thyroid dysfunction. Levothyroxine sodium is a synthetic version of a hormone that is normally produced by the thyroid gland. It is used to treat patients who suffer from hypothyroidism or inadequate levels of thyroid stimulating hormone (TSH).

THE COSMETIC SURGERY SAFETY SUMMIT 2023

The inaugural Cosmetic Surgery Safety Conference will be a platform for understanding methods to ensure patient safety in the field of cosmetic surgery.

The Conference will explore the legal, ethical, and medical issues surrounding cosmetic surgery. Including the most pertinent cases across Australia, as well as international case comparisons. Informa Australia will provide a non-biased, programme seeking to examine the real issues and outline some of the issues and misconceptions within reporting & complaints management.

Bringing together an extremely passionate audience of specialist plastic surgeons, surgeons, plastic and cosmetic surgery staff, barristers, and legal professionals.

Taking place on the 14–15th June 2023 at the Park Royal, Sydney, this event is not to be missed on any clinician’s and legal practitioners’ calendar.

Topics to be included:

■ Myth busting around reporting & complaints management: who’s who in the zoo of complaints?

■ Levelling the playing field: working together to build an extra layer of protection

■ Behind the data: Common notifications

■ Cosmetic surgery advertising guidelines

■ Address from the Medical Board

■ The role of TGA with cosmetic injectables

■ Can we create an endorsement process for cosmetic surgery?

■ How do we see a safe and functional cosmetic surgery sector?

■ Investigations within the hospital setting: the processes you need to be aware of

■ Can improving consumer patient education improve complaints?

■ What type of language is actually misleading?

■ The day you get sued: what you need to know

■ Reducing risk when consenting.

More than 27 million adults have been diagnosed with hypothyroidism and up to 13 million Americans have undiagnosed hypothyroidism.

532nm KTP & 1064nm Nd:YAG IntelliTrak Technology for complete and consistent treatment area coverage

World 1st Cryogen supported 532nm/1064nm system

Port Wine Stains |

Pigmented Lesions | Wrinkle Reduction | Rosacea |

Hemangiomas | Telangiectasia | ...etc.

Dr. Pablo Boixeda

Booth #N2

Hall Ravel

LUTRONIC HITS A NEW MILESTONE AS THE FIRST MEDICAL DEVICE COMPANY FROM KOREA WITH OVER 25 YEARS OF INNOVATION

LUTRONIC CORPORATION, THE FIRSTever aesthetic energy-based device company headquartered in Korea, is ringing in its 26th year as it braces for an even brighter future. The company is considered to be among the fastestgrowing firms in the laser industry.

Back to the beginning

Lutronic CEO Haelyung Hwang graduated from Yale University in New Haven, Connecticut, and worked as the Asian regional marketing director for a U.S. laser device company. He discovered that the Korean laser medical device market heavily depended on imports in the 1990s. He returned to Korea to establish a company based on the country’s outstanding electronic and electrical technology.

excellent clinical effects produced by Lutronic‘s medical devices and the global network based on these devices are my most proud achievements,’ Mr. Hwang says.

Secrets to their success

The Company boasts more than 100 engineers and over 500 current and pending patents, and they continue to launch new platforms year after year, even in the midst of a global pandemic.

‘Lutronic has always been a vertically integrated company,’ says James Bartholomeusz, Lutronic’s Chief Technical Officer. ‘Our technology is thoughtfully constructed, making it reliable, and it has an intense focus on unique technological solutions to complex aesthetic issues, he says.

email wl@wendylewisco.com

His brainchild, Lutronic, was founded in 1997. As few places in Korea developed lasers or any kind of medical devices at that time, Mr. Hwang acquired a lot of technology via overseas trips and papers.

Inspired by naysayers who didn’t believe Korea could become a hub for laser medical devices, Mr. Hwang doubled down on research and development, and it worked. Lutronic became the first Korean laser medical device approved by the US FDA in 2000. In 2001, it achieved its first export to Taiwan, leading to Lutronic’s reputation as a leading global brand. ‘The

‘The fastest-growing segment of the industry is skin of colour, and since our entire engineering and clinical staff are skin of colour, we have been at the forefront of designing devices with skin of colour as a primary objective,’ says Mr Bartholomeusz.

‘Lutronic is not slowing down; rather we are just getting going with more than 20 projects in some stage of development. In fact, Lutronic commits over 20% of its total revenue to R&D. Basically, this means that our five-year roadmap is stronger than most of our competitors combined,’ he says.

Hauke Albert Harms, Lutronic’s Senior Vice President

Taking a closer look at one of the leading energy-based device companies in the world

WENDY LEWIS is Founder/ President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy since 1997, author of 13 books, and frequent presenter on the international stage. Her first textbook, Aesthetic Clinic Marketing in the Digital Age (CRC Press) will debut a second edition in 2023.

of International Operations, started at Lutronic in 2017 as general manager at the direct subsidiary in Germany in Hamburg. He sums up the Company’s secret sauce, ‘We invest in people and branding, increase our production, scale up our efforts, and find the right partners.’

Their strategy also includes a steadfast promise to provide exceptional service for their practitioners to stand apart.

According to dermatologist and laser surgeon Omar Ibrahimi, MD, Founder of Connecticut Skin Institute, ‘Lutronic stands apart for their dedication to developing innovative technologies and treatment techniques that meet our needs as laser surgeons, as well as the needs of our patients. We can place trust in their premium technology, as well as the way they support our practice, which is a common complaint we hear about many other device companies. The Lutronic team treats our practice like family.’

According to Jeffrey Dover, MD, FRCPC of Skincare Physicians in Massachusetts, ‘What makes Lutronic special is their corporate culture, starting with R&D and extending to marketing, education, sales and service. From their founder and CEO Haelyung Hwang on down, they are committed to delivering a superior experience to practitioners so we can deliver maximal outcomes for our patients. They make excellent products and continue to push the envelope creating new, better and exciting devices. A new offering from Lutronic in the US is the Lutronic Academy Annual User Summit, a three-day event featuring hands-on training with a panel of expert Lutronic users where attendees can share their experiences and learn from each other. It’s a great opportunity to network with peers and take home pearls that can boost their practice.’

Advances through research

Lutronic’s technologies receive high praise from a long list of internationally recognised physicians, researchers, and educators.

The company’s robust investment in research and development has helped to enable them to consistently launch innovative new products based on their customer’s needs. Lutronic possesses a robust portfolio of core technologies, including design technology for laser sources, power supply devices, and control systems. It aims to build customer trust with improved quality and medical services. They pride themselves on the numerous certifications and clinical results their physicians around the world can achieve as among their critical success factors.

Mr. Hwang

Commitment to education

L’ACADÉMIE is a research, education and training facility integral to the Lutronic World Center in South Korea.

According to Dr R. Glen Calderhead, MSc, PhD, DrMedSci FRSM, Executive Managing Director, Medicoscientific Affairs, and Principal of

years 77% 20% 65 countries

cases

The excellent clinical effects produced by Lutronic‘s medical devices and the global network based on these devices are my most proud achievements.

Right: Haelyung Hwang CEO, Founder of Lutronic

Above: More than 100 Engineers worldwide working on new technologies

Dr Victor Gabriel Clatici about the Hollywood Spectra

L’ACADEMIE, ‘We offer comprehensive education on the fundamentals of light, lasers and energy-based medicine for our clinicians and business partners to stay up to date on our newest systems, optimal techniques, and treatment protocols.’

He continues, ‘In addition, we invite visiting faculty from around the world to give special lectures and share their knowledge about treatment strategies in actual clinical practice. It is an invaluable experience to take part in for our customers.’

Their newest hero product

According to Mr Bartholomeusz, ‘Lutronic has used our deep knowledge base and over 30 years of laser technology to build the ultimate dermatological workstation, DermaV. It offers the clinical functionality to address vascular and pigmented issues and incorporates the best aspects of both leading 595 and 532/1064nm technologies have had to offer. For the first time, we have a 532/1064nm solid-state laser that uses an optimised version of the cryogen skin cooling pioneered by UC Irvine.’

He continues, ‘We have been able to produce a laser that is three times more powerful than other 532nm systems with greater efficiency and without compromising safety.

DermaV is a potent and effective rejuvenation platform with speeds that make IPL devices inefficient by comparison. The addition of Lutronic’s proprietary intellitrak® technology features an unprecedented level of consistency and coverage for any colour-based aesthetic application.’

DermaV has been well received by practitioners who appreciate the ability to combine vascular, pigment, and rejuvenation into a single workstation. ‘The DermaV from Lutronic is a very powerful laser,’ says Dr Pablo Boixeda at the Pedro Jaén Group in La Moraleja, Madrid. ‘It is very versatile, so I can use it for treating all types of vascular lesions, skin rejuvenation, pigmented lesions, and multiple other medical and aesthetic indications. The very effective and adjustable skin cooling allows me to treat patients comfortably and deliver the best results.’

Dr Katharina Herberger, head of the laser department of dermatology at UKE Hamburg, has been using DermaV. ‘The DermaV IntelliTrak is especially helpful for larger areas, such as large port-wine stains, in order to avoid treatment gaps or overlaps.’

At my clinical practice, the Genius has become a game changer when treating aesthetic and medical clients. I treat acne scars, skin laxity and stretch marks etc. This is a very versatile platform.

Dr Emil Henningsen about the GENIUS

With practically no pain and zero downtime, with various combinations, The New Hollywood Spectra represents the perfect device for aesthetic and medical approaches!

Left: Derma V, Lutronic’s newest hero product

Lutronic’s Global KOL Network

Dermatologist Christine Dierickx, MD, in Luxembourg, shares her experience. ‘Lutronic stands out because of their emphasis on efficacy and safety in the interest of the patient. This contributes to an enhanced patient experience. From a physician’s point of view, there are no technical issues with this trusted technology, and the devices are ergonomically designed and easily movable, which contributes to ease of use. Finally, the company takes pride in their products and is always forward-thinking with a commitment to invest in R&D.’

A bright future

According to Mr Harms, ‘We are driven by teamwork, trust, and cooperation. The most exciting thing at Lutronic, besides growth, success, and the superior

quality of our products, is the people. Our mission is to deliver total confidence to our providers as well as measurable superior outcomes for patients. We pride ourselves to consistently bring innovative and novel technology to the market.’

Lutronic’s agenda for 2023 and beyond is ambitious. ‘We plan to build more marketing activities based on our strengths to achieve continuous growth through new products and services,’ explains Mr Hwang.

Learn More: www.lutronic-europe.com, www.us.aesthetic.lutronic.com/

Haelyung Hwang CEO, Founder

James Bartholomeusz CTO Lutronic

Hauke Albert Harms Senior Vice President International Operations

Dr. R Glen Calderhead MSc.PhD. DrMedSci Principal of L’ACADÉMIE

LUTRONIC — “BUSINESS IS MADE BETWEEN PEOPLE.”  — MR. HARMS

INJECTABLES WHAT NEXT FOR FILLERS AND TOXINS?

In the 20 years since Botox and the first hyaluronic acid filler were approved for cosmetic use, our understanding and approaches to treatment have seen a seismic shift. But where do we go from here?

Rosalind Hill spoke with some leading physicians to find out

INJECTABLES — NAMELY DERMAL FILLERS

and botulinum toxin— have been a mainstay in facial aesthetics for decades and are one of the most popular treatment options sought by patients, whether new or regular. According to data from Rare:Group, in the UK alone, 20% of the population is considering an aesthetic treatment at any one time, with 2 million of those contemplating dermal fillers and 5.4 million weighing up treatment with botulinum toxin1

The history of both treatment modalities is well-known among those working in the industry, with the Carruthers’ accidental discovery of the cosmetic properties of botulinum toxin A when treating patients for blepharospasm back in the 1980s, though Botox cosmetic wasn’t approved for the treatment of frown lines by the US FDA until 2002, followed by the approval of the first hyaluronic acid dermal filler the following year. Fastforward 20 years, and the US now has four toxins approved for cosmetic use, following the recent approval of Daxxify (daxibotulinumtoxinA-lanm) — and this could increase to seven in the coming few years if our experts’ predictions are correct. With dermal fillers, there are 19 brands approved for use in the US, though not all are marketed. Cross the pond to Europe, however, and 140 dermal fillers have been awarded CE Mark status. And while hyaluronic acid-based dermal fillers remain a mainstay of treatment for facial augmentation, newer formulations, such as calcium hydroxylapatite and poly-Llactic acid, have complemented the armamentarium of the aesthetic physician by allowing flexibility and adaptability in treatment approaches, whether used alone or in combination with hyaluronic acid. If you combine these treatments with exosomes, PRP, and laser and light technology, the results can often be astounding.

What’s most significant when considering the history of injectables in aesthetics, and the developments of the last 20 years in particular, is the understanding we now have of how these formulations and their combinations with other treatments work in vivo to allow physicians to create beautiful, natural, healthy-looking results. There is no denying the advances in the art and science of facial injectables, but have we now reached the pinnacle, or are there more potential advancements on the horizon?

PRIME spoke to some of the leading aesthetic physicians across the globe to understand more about how they’re working with toxins and fillers, and the advancements they’d hope to see in the coming years.

With time comes understanding

In the 20 years since the first FDA-approved dermal filler, many aesthetic physicians have re-evaluated the concept of how they behave, given the greater

understanding we now have of these products. Many readers will be familiar with a recent article by UK journalist and founder of The Tweakments Guide, Alice Hart-Davis, who underwent an MRI which showed that 35 ml of dermal filler product remained in her face following 20 years of treatments — and despite not having had any dermal filler treatments in the last 4 years2

‘Hyaluronic acids (HA) are, I think, still one of the mainstays in aesthetic medicine today. But I think we understand those fillers in a different way now,’ said Munich-based dermatologist Dr Sabine Zenker. ‘When we started, hyaluronic acid fillers were referred to as “dermal fillers” because they were most often injected superficially. But today, the number of indications has increased tremendously, and HA is often injected deeper — into the subdermal layer and up to the supraperiosteal region. That’s why it is so important to understand how to use different HA fillers, to understand their respective properties, to treat the face tridimensionally, and to use special techniques to sustainably change facial features.’

Indeed, once a HA filler is injected deeply, it is now known that its degradation pattern is completely different. Dr Zenker said: ‘We can see very tremendous and potentially long-lasting changes after HA injection over time, particularly where a patient has had treatments over decades, so you’ve really got to know your techniques, to work with the patient and understand how to avoid a puffy, bloated appearance, which can happen with the long-term use of fillers: every top-up treatment that a new doctor— or even the same doctor — does every six to 12 months goes, to some degree, on top of the previous one.’

UK-based aesthetic surgeon Mr Dean Rhobaye agreed and argued that this has perhaps been the greatest advancement in injectables across the past decade.

‘It’s about having a paradigm shift in the way we use fillers, the way we as physicians understand fillers, and the way our patients understand fillers as almost semipermanent, but they’re still reversible— you can still dissolve them after 10 years. If you view it that way, then they don’t keep on just coming back mindlessly for a topup, and that’s part of what contributes to an overfilled appearance,’ he said. And linked to Hart-Davis’ use of an MRI to investigate the long-term existence of filler in her own face, Dr Rhobaye believes that the use of imaging devices such as 3D, ultrasound, MRI and radiological studies should play a key part of the physician’s armamentarium for administering filler treatments, either to aid injection, avoid complications or for treatment planning.

‘I think overall, by far the most important thing in my mind is the fact that we have started to re-evaluate our concept of fillers and how they actually behave,’ he said. ‘And I think the biggest area that needs more research,

contact

In the 20 years since the first FDA-approved dermal filler, many aesthetic physicians have re-evaluated the concept of how they behave, given the greater understanding we now have of these products.

really, is how fillers integrate in vivo, in the human face and especially over time because that’s something that’s very poorly understood. So looking at the long-term in vivo behaviours of fillers; how they integrate; what things are likely to lead to increased migration, etc. I think that’s going to be crucial for the future of aesthetic medicine.’

‘With all the knowledge we acquired on anatomy, and with all the data we have about the physical, chemical, and biological features of hyaluronic acid, I think we now have a better understanding of how to use fillers, and particularly how to mix or layer two different viscosities, for example, or combine with other products and treatments,’ said Dr Zenker. However, she cautioned that patient loyalty is very different to what it was 20 or 30 years ago, with many patients now shopping around for deals, and the quality of treatment itself not necessarily being better despite the data and science built up over the years. And it seemed that, among the physicians PRIME spoke to for this article, this is a somewhat universal issue.

‘The reality is, it’s easy to inject fillers, but it’s difficult to get them right,’ said Mr Rhobaye. And US-based cosmetic dermatologist Dr Heidi Waldorf agrees: ‘Worldwide there is a race to increase the market not only of interested patients but also of providers. In the USA, the largest growing customer market for injectable companies are nonphysician extenders. There are certainly experienced extender injectors who train others and physicians who shouldn’t inject. However, whenever you rush to bring new providers on board, especially those without an indepth knowledge of anatomy and pathophysiology, and who have not been ingrained as we are in medical training with a core respect of the risks of what we do to protect against overconfidence, carelessness, and formulaic treatment, you drive the market to the lowest common denominator.’

And this links to a big issue many see in the aesthetic market today — that marketing has overtaken scientific rigour. In Germany (and many other countries besides), as Dr Zenker cautions, many patients are now looking for the best deal; in the UK, there has long been a problem with the regulation of medical aesthetic treatments; and in the US, the explosion of private-equity backed clinic chains in bigger cities like New York and Los Angeles that offer cut-price treatments has had mass appeal to younger patients, but at the expense of dermatologistrun clinics. All this represents what some may see as an uphill battle in the fight to put science squarely back at the centre of the industry.

‘I think the real question is: are there more people entering the space who don’t understand the science?’

said Dr Sabrina Fabi, a California-based cosmetic dermatologist. ‘And that may well be true because I think if you don’t understand the science, then you’re more likely to be swayed by the marketing. And that’s as true for physicians as it is for patients.’

Dr Sophie Shotter, an aesthetic doctor based in the UK, continued: ‘When we look at filler brands, the ones with the biggest market shares are the reputable brands, so I think it shows they’re doing both things right— scientific rigour and marketing. Some of the brands that are coming through with growing market share haven’t necessarily got the clinical studies behind them. The brands may not have the research, but whoever’s injecting them (and that’s not just laypeople; unfortunately, it is also medics) are not applying the same principles as they would to other medical treatments. I think overall, we’re very vulnerable to what a sales rep tells us, and we need to get better as a medical specialty at going back to basic scientific principles and be comfortable looking at proper independent scientific evidence as well.’

Mr Dean Rhobaye whole-heartedly agreed and, along with all the physicians we spoke to, called for more high-quality, critical scientific analysis in medical injectables, as well as sufficient headto-head studies to compare the commonly used fillers, citing that claims about the superiority of one filler brand over another are often biased and unfounded. But how can we ensure that this is done? To an extent, it requires the ‘self-policing’ of the industry by those who work in it and mentorship to ensure that the science remains at the fore. In many countries it is often the case that, among patients at least, aesthetic medicine treatments are seen as a beauty treatment in the same way that you might go for a facial or massage — and if these medical treatments are not perceived to be just that, then, of course, the marketing would overtake scientific rigour. This beauty versus medicine dichotomy has been particularly true in the UK, but in recent years many aesthetic physicians have placed emphasis on the education of current and prospective patients in this regard. And, with long-awaited regulations on non-surgical cosmetic procedures due to come into force in the UK this year, there may finally be a sea change for the industry— though there is certainly still some way to go.

What next for injectables?

Given the range of developments we’ve seen in injectables— and, indeed, throughout the wider aesthetic industry — across the last 20 years, you’d be forgiven for thinking that we have everything we need to treat patients. But this is an industry that never stays still for

The reality is, it’s easy to inject fillers, but it’s difficult to get them right.

long, and new innovations are seemingly constantly announced, though that’s no guarantee of staying power.

The most recent innovation that’s had tongues wagging is the approval and launch of Daxxify, a new neuromodulator that claims to have longer-lasting results (up to 6 months as opposed to 3 months) and with FDA studies finding a more prolonged effect compared to other toxins currently on the market. But do we really need a new neuromodulator?

‘It may seem as if the neurotoxin market is all said and done, but as we see emerging neuromodulators with slightly or completely different manufacturing, we can see and understand that they too have different properties, making some toxins more well-suited for certain applications,’ said Dr Shino Bay Aguilera, a dermatologist and dermatologic surgeon based in Florida. ‘Just like fillers, toxins have different “personalities.” Multiple botulinum toxin products are commercially available for cosmetic use, but each product has unique characteristics, and currently marketed products are not interchangeable.’

Drs Waldorf and Shotter agreed that whatever new toxins do come to the market must offer something different.

‘Any new neuromodulator needs to bring something different and advantageous to the market: faster onset, longer duration, more specificity (i.e. focus at injection point), more diffusion (i.e. spread to larger region around injection point), needle-free or other improved treatment modality,’ said Dr Waldorf.

‘You could argue that pre-mixed, ready-to-use neurotoxins offer something different, but that doesn’t really add a benefit to how I use toxin,’ said Dr Shotter. ‘I use different dilutions in different areas of the face, meaning a syringe with one dilution isn’t helpful to me.’ Dr Shotter told PRIME that what she is excited about, however, is a topical toxin (if it ever comes to fruition) and the current studies being undertaken into the effects of botulinum toxin E. But overall, of the currently available, clinically-proven toxins, the most important thing for a patient is that they have a reputable toxin brand and a reputable practitioner who is comfortable using that particular product.

Tel Aviv-based plastic surgeon Dr Nimrod Friedman additionally argued that for any kind of new neuromodulator, it’s not necessarily about the formulation of the product but the biology of how the patient’s body reacts to that product. ‘If we have another neuromodulator entering the market, which is doing the same as the others, just in different packaging, then I don’t think that there is any place for that, and I’m also afraid that we will become over-saturated like we see in the HA market. And as a result, it will be difficult to control the quality of those new products coming to market,’ he said.

Perhaps, however, what might be most beneficial in the neurotoxin space would be alternatives for those patients who have grown resistant to botulinum toxin A, and for

Mr Rhobaye, a cautious approach to any longer-lasting toxins should be taken.

‘It’s essential to consider the potential long-term effects of any neuromodulator, whether old or new,’ he said. ‘We know that the anatomical effects of neurotoxins begin to surpass the duration of pharmacological action with chronic use. For instance, long-term botulinum toxin treatment over many years can lead to gradual muscle atrophy, especially when inappropriately high doses are used. Despite this concern, very few studies have assessed the long-term consequences of repeated neurotoxin treatment, specifically in facial aesthetics and anatomy.

‘For the currently available toxins, the correlation between neuromodulation and time is non-linear, with a left-skewing “peak of myoinhibition.” Therefore, I wonder if a longer-acting neuromodulator, as opposed to a shorter-acting toxin, can worsen muscle atrophy because of a prolonged and more intense period of peak myoinhibition; the answer is we simply don’t know due to a lack of long-term head-to-head studies.’

Mr Rhobaye, therefore, cautions any practitioner considering the introduction of a new type of toxin to their practice to assess factors beyond the duration of action and cost, and argues that additional independent studies comparing the different neuromodulators and their behavioural characteristics would be beneficial for the global industry.

Does regenerative medicine offer a holy grail in treatment?

As for what’s next on the horizon with regard to dermal fillers, it’s easy to think that all bases are covered with over 140 different dermal filler products available in Europe. But as Dr Shotter mentioned with regard to

continued on page 22

Any new neuromodulator needs to bring something different and advantageous to the market: faster onset, longer duration, more specificity, more diffusion, needle-free or other improved treatment modality.

READER SURVEY

Fillers & toxins WHAT YOU SAID

WHAT DO YOU CONSIDER THE BEST INVESTMENT STRATEGY FOR NEUROMODULATORS/ FILLER MANUFACTURERS?

Stricter regulations for non-medical injectors. It’s a money making racket with no regard for human health and safety, when is this nightmare going to end?

DO YOU COMPLY WITH PATIENTS’ REQUESTS FOR A SPECIFIC BRAND OF FILLER?

■ YES, USUALLY 19.30%

■ YES, IF I HAVE IT AVAILABLE 35.09%

■ NO, I MAKE THE DECISION 45.61%

Finally common sense is slowly appearing and we should see more regulation and more education.

ARE THERE NEEDS THAT CURRENT SOFT TISSUE FILLERS DO NOT MEET OR AREAS WHERE THEY COULD BE IMPROVED?

DO PHYSICIANS NEED MORE BOTULINUM TOXIN PRODUCTS FOR AESTHETIC USE?

We could greatly benefit from patient education, first and foremost, as well as professional education. Less aggressive marketing will help give our field the noble medical recognition it deserves.

We need more breakthrough innovation.

WHAT ARE YOUR NON-NEGOTIABLES FOR NEUROMODULATOR PRODUCTS – THE CHARACTERISTICS THEY ABSOLUTELY MUST HAVE?

SELECTED

1 ST SAFETY

2 ND DURATION OF EFFECT

3 RD PREDICTABLE RESULTS

4 TH BIOCOMPATIBLE

5 TH EASY TO USE 6 TH AFFORDABLE

DO YOU COMPLY WITH PATIENTS’ REQUESTS FOR A SPECIFIC BRAND OF TOXIN?

■ YES, USUALLY 20.87%

■ YES, IF I HAVE IT AVAILABLE 38.26%

■ NO, I MAKE THE DECISION 40.87%

WHAT ARE YOUR NON-NEGOTIABLES FOR DERMAL FILLER PRODUCTS – THE CHARACTERISTICS THEY ABSOLUTELY MUST HAVE?

SELECTED IN ORDER OF PREFERENCE 1ST = MOST IMPORTANT 6TH = LEAST IMPORTANT

1 ST SAFETY

2 ND PREDICTABLE RESULTS

3 RD DURATION OF EFFECT

4 TH BIOCOMPATIBLE

5 TH EASY TO USE

6 TH AFFORDABLE

HAS MARKETING OVERTAKEN SCIENTIFIC RIGOUR IN THE USE OF INJECTABLES?

Currently, the injection market offers a lot of quality products that are safe, a large selection and that’s great!

In this moment , safety must be the most important quality to choose the brand.

For body shaping, the injectables in current use are too expensive considering their duration of effect.

how she uses toxins, our experts are similarly combining filler products and other treatment modalities (e.g. laser devices, biostimulators, skin boosters, exosomes) to create beautiful results. So it’s hard to imagine what an ideal injectable could look like or even what’s missing when the possibilities are seemingly endless despite a full roster of available products.

‘I think the future lies in hybrid injectables,’ said Dr Shotter. ‘We have a first in this class with HArmonyCa, but I believe others will follow. Products which combine one clinically proven ingredient (such as hyaluronic acid) with another, which provides an independent benefit. That may be collagen stimulation, it may be elastin stimulation, and who knows what else that I’ve not even contemplated.’

‘The number of HA filler brands that have entered the market in recent years, particularly in Europe, has undoubtedly increased significantly,’ said Mr Rhobaye. ‘Although subtle, there are rheological differences between each brand and subtype of HA filler that can be used to treat various indications more effectively than before. Future filler generations may become even more varied and specialised for sitespecific indications, which would be interesting to watch. For instance, high-cohesivity HA gels that can supplement bone support already exist to a certain degree. However, introducing ultra-firm gels that offer more substantial support and resistance to deformation would be very useful (notwithstanding the difficulties in injecting this kind of product and any safety concerns relating to their bio-integration).’

‘The holy grail,’ said Dr Waldorf, ‘is a single filler that is longer lasting, biostimulatory, hydrophobic (to reduce swelling), contains something to reduce bruising, and is reversible.’

The emergence of regenerative medicine

However, the holy grail is, in all likelihood, a long way off. So in the meantime, physicians are continuing to combine their treatment modalities to create the most efficacious results possible, not least with regard to combining biostimulators with the more ‘traditional’ hyaluronic acid dermal fillers. That said, newer, more cutting-edge treatment options are beginning to offer the promise of a different kind of holy grail.

‘We need to embrace bioregenerative technologies, as this is how we can actually help our patients get younger instead of faking younger,’ said Dr Aguilera. ‘The concept of

driving tissue regeneration in patients is gaining traction, and the time has come to move our efforts towards personalised regenerative aesthetic medicine.

‘I believe that injectable fillers still have their place in our industry, but as a collateral treatment. Injectable fillers do just that— fill. It is mechanical, and it has an art form, but it does not provoke the scientific curiosity of a physician to seek answers as to why we age. Bioregenerative techniques, however, spark a curiosity of what causes us to age and aims to decode the pathophysiology of the ageing process itself, which we now understand can be reversible and reprogrammed to an extent.’

Indeed, regenerative medicine and stem cell science have come on leaps and bounds in the last decade in other fields of medicine, not least in wound healing, which is intimately linked to aesthetic medicine. While exosome technology itself is still in its relative infancy, its power has already been unleashed on aesthetic medicine — often in combination with HA fillers — to address skin ageing and stimulate the production of collagen and elastin. But given the infancy of the technology, there is as yet no clear consensus on its long-term use for skin rejuvenation or hair restoration, despite the excitement3

The regenerative medicine landscape has progressed at warp speed across the last decade, and all the physicians we spoke to for this article agreed that exosome technology was promising, though they agreed that microneedling is perhaps not the most efficacious means of administration. But, it does offer the possibility of opening the industry into a more personalised form of aesthetic medicine, whereby we’re truly able to reprogramme the skin cells and offer patient-specific treatment paradigms for different tissues. Though, with all treatment options— new or old— it is essential for the industry that they are backed by science and have the data and evidence to support them.

References

1. PRIME Journal. Looking ahead: Industry trends for 2023 and beyond. PRIME Journal 2023; 13(1): 20–23. Available at: https://www.prime-journal. com/looking-ahead-industry-trends-for2023-and-beyond/ (accessed 28 February 2023)

2. Alice Hart Davis. How much filler did Alice’s MRI reveal? UK: The Tweakments Guide, Dec, 2022. Available at: https://

thetweakmentsguide.com/blog/ how-much-filler-did-alices-mri-reveal/ (accessed 28 February 2023)

3. Vyas KS, Kaufman J, Munavalli GS, et al. Exosomes: the latest in regenerative aesthetics. Regenerative Medicine 2023 18:2, 181-194. Available at: https://www. futuremedicine.com/doi/10.2217/ rme-2022-0134 (accessed 28 February 2023)

The concept of driving tissue regeneration in patients is gaining traction, and the time has come to move our efforts towards personalised regenerative aesthetic medicine.

NORDLYS SELECTIVE WAVEBAND TECHNOLOGY TREATMENTS FOR REJUVENATION AND REDNESS IN ASIAN SKIN

ABSTRACT

The Nordlys system is configured with pre-set aesthetic and dermatologic treatments, including the Selective Waveband Technology (SWT) and the sub-millisecond pulses for photorejuvenation and to target vascular and pigment problems in the facial area. This case report features clinical cases performed with a new protocol that combines two Nordlys SWT handpieces VL 555 and PR 530 to achieve an optimal reduction in the appearance of facial photodamage, pigmented lesions, redness, and telangiectasias with minimal to no downtime.

STUDIES SHOW TREATING COMMON SKIN DISORDERS SUCH AS photodamaged skin, pigmented lesions, diffuse facial redness, and facial telangiectasias with Selective Waveband Technology (SWT) is faster, safer, and more clinically effective than the traditional broadband intense pulsed light (IPL) treatment1 because it uses less energy to achieve outstanding results by filtering out unnecessary higher wavelengths, which in turn leads to better patient comfort.

IPL systems emit a broad continuous spectrum of light between 400 nm and 1400 nm, with portions of the spectrum blocked using optical cut-off filters. The Nordlys™ multiapplication platform incorporates narrowband SWT technology to filter out the shorter wavelengths and longer infrared wavelengths leaving those that best correspond with the absorption spectrum of specific skin chromophores. This also minimises unnecessary excess heating to the surrounding tissue2. By delivering true submillisecond light pulses with high energy that focus on the wavelength ranges of 530‑750 nm or 555 950 nm with high absorption in haemoglobin and oxyhaemoglobin, the Nordlys system precisely targets diffuse facial redness, rosacea, and facial telangiectasias2-5. A powerful Nd:YAG laser, with a longer 1064 nm wavelength, targets deeper leg vessels with a diameter of 0.1 mm to 3 mm2. Fractional non-ablative skin resurfacing with the Frax 1550™ laser handpiece can be used to address textural irregularities, such as striae and acne scars2

KEYWORDS

Pigment, redness, photoaging, Nordlys

The Nordlys system is configured with pre-set aesthetic and dermatologic treatments, including the Selective Waveband Technology (SWT) and the sub-millisecond pulses

Diana Li, MD, reveals how she uses a unique protocol and Nordlys’ two new handpieces to address common skin concerns in Asian skin type III

DIANA LI, MD, is a specialist in Dermatology and Venereology. Dermatologist at the Distinct HealthCare Clinic since 2019 and was the Vice Director of the Dermatology of First BCC Plastic Surgery Hospital in China from 2016 to 2019.

for photorejuvenation and to target vascular and pigment problems in the facial area*. The system also features fractional non-ablative capabilities for skin resurfacing and textural improvement.

This case report features clinical cases performed with a new protocol that combines two Nordlys SWT handpieces — VL 555 and PR 530 — to achieve an optimal reduction in the appearance of facial photodamage, pigmented lesions, redness, and telangiectasias with minimal to no downtime.

Methodology

All patients received a single-session treatment with the use of the SWT handpieces, consisting of two to four steps as described below. In most cases, pre-treatment with anaesthetic cream was not required as the pain score of the treatment was low — approximately 2 out of 10 points (0=no pain to 10=worst pain). Post-treatment patient care recommendations included regular moisturiser and sunscreen application. Patients were photographed before and 4–6 weeks after treatment using a standardised imaging system (Visia, Canfield Scientific Inc., Parsippany, NJ, USA).

Case reports

The first case was an Asian female with Fitzpatrick Skin Type III with freckles and photodamaged skin on both sides of the face. As a first step, the VL 555 handpiece was used to heat up the skin with a fluence of 10.4 J/cm2 using a 30 ms single pulse, 2–3 passes. The wider the pulse width, the deeper the penetration. The first step could provide gentle heat to the skin and prepare for later stimulation of subsequent heat on collagen.

To improve the redness over the entire face, the PR 530 handpiece was then used as the next step with the fluence set at 5.4 J/cm2 and a pulse duration of 2.5 ms with a 10 ms delay, split pulses. After steps one and two, the desired clinical endpoint was mild erythema.

Finally, the PR530 was used at a 5.4 J/cm2 fluence using a 2.5 ms single pulse to address the patient’s pigmented lesions until the clinical endpoint — brown spots appearing slightly darker — was achieved. Post-care moisturiser and sun protection were advised.

Step

Brightening and Improve

Discrete Pigmentation

Post-treatment care: Moisturiser and sunscreen with an SPF of 30 or higher

A B

| PIGMENTATION | CASE STUDY prime-journal.com | March/April 2023 ❚ 25

Figure 1 (A) before and (B) after images of photodamage with freckles following treatment using a combination of VL 555 and PR 530 handpieces.

Figure 2 (A) Before and (B) after Visia facial imaging of pigmented lesions following treatment using a combination of Nordlys SWT PR 530 and VL 555 handpieces shows significant improvement.

Post-treatment images demonstrate that the SWT treatment had significantly improved the patient’s skin colour and texture compared to the baseline photos (Figure 1).

In the second case, an Asian female patient with Fitzpatrick Skin Type III presenting with pigmented lesions and diffuse redness was treated with the PR 530 and VL 555 handpieces. The VL 555 handpiece was used with a fluence of 7.2 J/cm2 and a single 30 ms pulse for a total of three passes for skin rejuvenation. Next, the PR 530 was used over a fluence of 5.2 5.6 J/cm2 using a 2.5 ms with a 10 ms delay to reduce redness and brighten the entire face.

The PR 530 handpiece was also employed with a 5.2–5.4 J/cm2 fluence using a 2.5 ms single pulse to treat the patient’s pigmented lesions. Again, the clinical endpoint was mild erythema for steps one and two, and slightly brown spots lesions darkening for step three. As the patient did not have notable telangiectasia, step four was unnecessary. The patient was also advised to moisturise and use sunblock post-treatment.

The persistent erythema of the patient had significantly improved, and lightly pigmented lesions were cleared with no adverse effects. The patient was highly satisfied with the result. Post-treatment photos displayed a noticeable improvement in the patient’s facial redness, skin colour, and texture compared to pre-treatment photos (Figure 2).

In the third case, an Asian female patient with Fitzpatrick Skin Type III had pigmented lesions and diffuse redness

Key points

Using Selective Waveband Technology (SWT) in the Nordlys system is safe, comfortable, and clinically effective for patients in addressing common skin concerns

Three female patients with Fitzpatrick Skin Type III were treated using two Nordlys SWT handpieces and a new 2–4 steps protocol to target skin tone, vascular and pigmentation problems

All patients showed distinct improvement in skin conditions after one session without any complications or adverse events

Case report results show that treating Fitzpatrick Skin Type III patients with Nordlys’ powerful, multifunctional SWT handpieces can optimally reduce and visibly improve a range of common skin conditions.

over both sides of the face due to photoaging. To rejuvenate the entire face, the VL 555 handpiece was used to deliver a 30 ms single pulse with a 7.2–10.4 J/cm2 fluence until mild erythema was perceived.

The PR 530 handpiece was then used to brighten the whole face using a 2.5 ms with a 10 ms delay pulse duration with a 5.4–5.6 J/cm2 fluence — again until mild erythema was achieved.

Next, the PR 530 handpiece was used to target the patient’s pigmented lesions using a 5.2–5.4 J/cm2 fluence with a 2.5 ms single pulse until the brown spots appeared slightly darker.

In the fourth step, visible vessels were targeted using the PR 530 handpiece with an 8.9–14.1 J/cm2 fluence and 10–15 ms single pulse until the telangiectasias became slightly darkened or disappeared. Moisturisers and sun protection were advised for post-treatment care.

The post-treatment photos showed a significant improvement in skin colour and texture compared to the baseline photos. Pigmented lesions and facial telangiectasias were effectively cleared (Figure 3).

No complications or adverse effects were reported in this case study.

Conclusion

This case study presents a single-session protocol to address multiple skin concerns, including, but not limited to dark spots, uneven skin tone and texture, and telangiectasias.

This simple 2- to 4-step approach allows users to combine different SWT handpieces and settings for optimal treatment outcomes according to patient needs.

All patients in this study had distinct improvement in their dark spots and skin tone after only a single session without any complications, or adverse events reported. Results showed that the Nordlys system is a powerful, comprehensive, multi-functional, and convenient device that, combined with different SWT handpieces, can improve multiple common skin conditions for Fitzpatrick Skin Type III patients.

Declaration of interest Candela Medical funded the submission of this case report

* It also targets vascular and pigment problems in leg veins, striae, or scars (with the Frax1550)

References

1. Bjerring P, et al. Facial photo rejuvenation using Two different intense pulsed light (IPL) wavelength bands, Lasers Surg Med, 2004;34(2):120-126.

2. Nordlys User Manual for EU, 2020.

3. Ellipse Frax 1940 510(k) clearance (K192951), March 2020.

4. Tirico MCCP, Jensen D, Green C, Ross

EV. Short pulse intense pulsed light versus pulsed dye laser for the treatment of facial redness. J Cosmet Laser Ther. 2020;22:60-64.

5. Iyengar S. et al. (2018) Intense Pulsed Light (SWT®). In: Nouri K. (eds) Lasers in Dermatology and Medicine. Springer, Cham.

Figures 1–3 © Diana Li, MD

Figure 3 (A) Pre- and (B) post-treatment Visia facial imaging of pigmented lesions and visible blood vessels. The treatment combining Nordlys SWT PR 530 and VL 555 handpieces shows significant improvement in skin colour and texture and helps clear pigmented lesions and facial telangiectasias.

SUNEKOS INJECTABLE AND THE HIGH PERFORMANCE TECHNIQUE COUNTERACTING SKIN AGEING

Dr Elena Fasola details an injection technique to combat wrinkles, skin laxity, and photoaging dyschromia

ABSTRACT

The increase in life expectancy, together with the impact of the recent Covid-19 pandemic, which has been associated with long video conferencing sessions, has seen an increase in the demand for minimally invasive procedures aiming at improving people’s appearance. One of the most important pathophysiological aspects which underlies skin ageing is the loss of the extracellular matrix (ECM) homeostasis. The main reasons are the reduction of fibroblast activity, the reduction of their number and a down regulation of their membrane receptors, in quantitative and qualitative terms. This condition, related to ageing, causes a decrease and change in composition of the main macromolecules of which the ECM (collagen, elastin and hyaluronic acid) with consequences on homeostasis of ECM and skin health.

Thanks to the use of the patented HY6AA formula, two products, one based on low molecular weight hyaluronic acid (SuneKOS Performa) and the other with a high molecular weight hyaluronic acid (SuneKOS 1200) both added to a specific six amino-acids formula delivered by a new technique, named High Performance Technique (HPT), it is possible to counteract the complex process of skin ageing in a relatively short time through a minimally invasive treatment, achieving very interesting results in both sexes.

KEYWORDS

High Molecular Weight HA, Sunekos, High Performance

Technique Skin ageing

WITH THE COVID-19 PANDEMIC, THE NUMBER OF PEOPLE working from home and meeting online has markedly increased. Almost everyone, for personal or business reasons, increased the time spent on video calls, leading to the socalled ‘Zoom Boom’. Psychologically, this led and resulted in an increased demand for cosmetic facial surgeries. Due to the impact of COVID-19, there is an expected 51% increase in demand for facial injectables. As in all other fields, minimally invasive surgeries are replacing invasive surgeries. In the US, nearly 15.6M cosmetic surgical procedures were performed in 2020, out of which nearly 13.2M were minimally invasive. Minimally invasive surgeries drive market growth for two reasons: patient preference and the wide range of available treatment options. In 2021 the global facial injectable market size was estimated to be $16.1 B. The compound annual growth rate (CAGR) for the years from 2022 to 2030 is 9.1%1

ELENA FASOLA, MD, MICROSURGEON & AESTHETIC PHYSICIAN, AIGEF General Secretary & Tutor at the Italian post graduate School of Aesthetic Medicine

Skin ageing

Microscopically, one of the most important pathophysiological aspects of ageing is the loss of the extracellular matrix (ECM) homeostasis. One of the leading causes for this is the reduction of fibroblasts, both in quantitative and qualitative terms, causing a decrease in collagen and elastin. Another key factor is hydration loss.

Ageing determines not only a noticeable reduction in total skin collagen but also a change in composition. Indeed, every type of collagen has distinct relevance and role in the tissues.

First of all, type III collagen makes up 50% of the collagen in the dermis of neonatal skin but only 5% of the collagen in adult ageing skin. It supports the structure of hollow organs such as large blood vessels, the uterus and the intestines. It is found in other tissue (e.g. dermis) along with collagen type 12. On the other hand, type IV collagen anchor plates between different types of fibrils. It decreases with age after 35 years. Although type IV collagen is a basement membrane component and declines with ageing, the total thickness of this membrane increases, which suggests a reduction in tissue turnover3 Therefore, we can conclude that ageing determines not only a noticeable reduction in total skin collagen but also a change in its composition.

Ageing is characterised by an increase in elastin degradation; this is due both to increased matrix metalloproteinases (MMP) and decreased elastin production.

Besides collagen, at a microscopical level, many other molecules and components are of key importance. First of all, elastin is a protein able to stretch and contract. It is produced by the fibroblasts of the dermis. In quantitative terms, it represents 2% of the weight of the dermis, secreted in the form of a monomer (tropoelastin). It contributes together with the fibrillin microfibrils to form a three-dimensional network. Concluding, it confers elasticity to the skin.

Ageing is characterised by an increase in elastin degradation; this is due both to increased matrix metalloproteinases (MMP) and decreased elastin production4

Fibronectin, on the other hand, is a dimeric glycoprotein produced by many cells and tissues, present in connective tissue. Fibronectin plays a major role in cell adhesion and in anchoring reticular collagen fibres and cells. Many homologous molecules able to bind together the components of the extracellular matrix are derived from fibronectin. With ageing, fibronectin decreases.

Hyaluronic acid (HA) is a key component of the skin at a microscopical level. Depending on its molecular weight, its properties differ.

Low molecular weight HA (LMWHA) up to 200 kDa regulates homeostasis. This is due to its capability of water retention, which also hydrates the skin.

Moreover, stimulating fibroblasts, it promotes the synthesis of dermis structural elements (collagen, elastin and blood vessels). It also has an immunomodulatory effect.

On the other hand, high molecular weight HA (HMWHA) 1000–1500 kDa acts as an antioxidant. It has anti-inflammatory properties and, acting as a ROS ‘scavenger’, it protects fibroblasts and dermal structural elements.

Any decrease in hyaluronic acid directly causes a reduction in fibroblast activity, as well as down-regulation of CD44, RHAMM receptors and gene-transcriptors for HA. Moreover, ageing is also characterised by a hyaluronidase increase, causing direct hyaluronic acid destruction5

Macroscopically, ageing is characterised by wrinkles, laxity, and dyschromia. The rationale behind counteracting ageing is based on restoring the ECM.

Langer’s lines, also called Langer lines of skin tension or cleavage lines, are topological lines drawn on a map of the human body. They are parallel to the natural orientation of collagen fibres in the dermis and generally perpendicular to the underlying muscle fibres (Figure 1). Langer’s lines have relevance to forensic science and the development of surgical techniques6. The lines were first discovered by Austrian anatomist Karl Langer in 1861. They may be, more easily, defined as folding lines upon which skin falls during the ageing process7–8

Can we counteract skin ageing?

Cutaneous facial ageing can be counteracted by using a protocol combining two products; both consist of a specific formula based on non-cross-linked hyaluronic acid of different molecular weights, added to a pool of 6 amino acids (HY6AA Formula). These two products are the following:

■ Sunekos 1200 containing high molecular weight hyaluronic acid (HMWHA 1200 kDa) and a mix of 6 amino-acids (glycine, L-proline, L-lysine MHC, L-leucine, L-valine, L-alanine) (HY6AA formula) may act as a ROS ‘scavenger’, protecting the fibroblasts and the ECM. Due to its hygroscopic properties, it performs a re-hydrating action.

■ Sunekos Performa (HY6AA formula) contains low molecular weight hyaluronic acid (LMWHA 200 kDa) and a specific mix of 6 amino-acids (glycine, L- proline, L-lysine MHC, L-leucine, L-valine, L-alanine) in a 3.5 ml of premixed solution.

Performa contains the HY6AA formula in a new ratio of HA vs amino acids. This formula improves the stimulation of collagen production (mainly type 4 and 7) and elastin by reducing the hyaluronidase action by 40%, therefore increasing the longevity and the effect of the injected HA, an endogenous one, to support an improved ECM turnover. Moreover, low molecular weight HA helps to regulate the microcirculation with the overall result of restoring homeostasis of the ECM9

In an in vitro study, cultured human fibroblasts were exposed to an HY6AA formula and controlled with untreated tissues. Both groups were then compared and

Figure 1 Facial skin tension lines known as the Langer lines

Figure 3 Illustration of Sunekos 1200 injection protocol

Figure 2 Scheme of treatment sessions

analysed 72 hours after. Treated fibroblasts showed significantly increased elastin (Eln) and fibronectin (Fbn1) mRNA levels. In this way, oxidative stress decreases together with UV exposure damage.

In conclusion, the HY6AA formula appears to restore the ECM’s homeostasis in ageing through an accurate and precise process of stabilisation and stimulation of multiple molecules10

In an ongoing observational pilot study, 50 female patients were enrolled, ranging from 40 to 67 years of age. Patients underwent three sessions of treatment at 14-day intervals. At each visit, 3.5 ml of the HY6AA formula was injected.

From preliminary analysis, the treatment with HY6AA formula resulted in improved elasticity, improvement in wrinkle appearance and a reduction in photoaging dyschromia.

Amelioration regarding elasticity was tested with a pinching test. Visia skin analysis was used for the analysis of wrinkle reduction, and we observed a 44% decrease in wrinkles in the periocular area and a 71% decrease in the forehead.

With regard to skin pigmentation related to ageing, a 50% decrease was observed in rosacea, a 49% decrease in photoaging dyschromia, and a 40% decrease in general chromatic inequalities11

Full-face high-performance technique Indication

To counteract all aspects of the complex skin ageing process, which include both chronic and photo ageing. The specific indications are wrinkles, skin laxity, and photoaging dyschromia.

Protocol

The treatment protocol is carried out as follows (Figure 2). During the first treatment session, both products are injected, firstly Sunekos 1200 and immediately followed by Sunekos Performa. After an interval of 14 days (2 weeks), only Sunekos Performa is injected again. Finally, after a further 14 days, the last injection of Sunekos Performa is delivered. In some particularly pronounced cases of chrono and photo-ageing, a fourth injection of Sunekos Performa may be required.

Technique

The injection technique for Sunekos 1200 can be summarised as follows (Figure 3).

The injection with Sunekos 1200 is performed with either a 25G or 27G cannula or a 27G or 30 G needle. The choice of the cannula by the doctor depends on the quality and thickness of the patient’s skin. The entry point of the cannula is located about halfway along the longitudinal axis of the nasolabial fold, the cannula is inserted to 2 cm of its length, and the product is released into the subdermal layer in quantities up to a maximum of 0.6 ml (from 0.3 to 0.6 ml) with a retrograde technique. Using the same entry point as the cannula, the product is deposited at a second identified point at the junction

between the hemi-pupillary line and a line drawn between the tragus and the wing of the nose. In this second point, 0.3 ml of product is deposited with the bolus technique in the same subdermal plane where the cannula is located.

The third point of product deposit is identified halfway between the vertical line that passes from the labial chant and the median line of the face. At this point, 0.3 ml of product is injected with a 27 G or 30 G needle into the deep dermis with a bolus technique. Depending on the condition of the chrono- and photo-ageing of the patient, other optional points may be considered for treatment (Figure 3).

The injection of Sunekos Performa consists of multiple injections of small product boluses (0.1 ml per bolus), all injected into the medium/deep dermis with a 27G–30G–32G needle, following lines orthogonal to the Langer lines of the face (Figure 4).

Figure 5 Female patient 57 years of age, (A) before and (B) after 3

sessions of full face HPT

Figure 4 Illustration of Sunekos Performa multiple injection protocol

– optional 1 point just below the chin

B

Per hemiface, the first three injections are performed at about 1.5-2 cm from each other along a line drawn between the tragus and the wing of the nose. Another five injections are performed with the same distance between them. The first four injections are performed along another line that passes between the tragus and the chin protuberance, the fifth immediately below the chin, at the level of the chin guard spine, always in the middle/deep dermis. Three more injections are performed about 1.5 cm between them and 1.5 cm above and along the profile of the body of the mandible.

The treatment session is completed through another six injections per each side of the face. At the level of the forehead, the injections are made at a distance of about 1.5 cm between them along three lines placed in a fan or triangle (whose angle is located on the hemi-pupillary line at 1.5 cm from the roof of the orbit) and orthogonal to the Langer lines. Also, in this case, the amount of product injected per bolus is 0.1 ml.

Contraindications

The contraindications to the treatment are not dissimilar to other hyaluronic acid-based injectable products:

■ Presumed or confirmed sensitivity towards one of the contents or ingredients of the product

■ Ongoing inflammatory or infectious diseases affecting the treatment area

■ Ongoing anti-inflammatory/anti-coagulant therapy, or patients affected by coagulation factor disorders

There are no known overdose events as well as unwanted adverse events, but the author recommends not to use the products in patients:

■ with non-absorbable facial filler,

■ treated with botulinum toxin within a short period of time or in the same session or the same area of injection of Sunekos

■ treated with cross-linked HA filler in the same area, at the same time and in the same plane as the Sunekos injections.

As observed for now, the only secondary effects were redness at the injection site, slight swelling and, rarely, small ecchymosis. Symptoms, on the other hand, were described as a slight burning sensation (immediately

after the injection) and a feeling of warmth, which spontaneously disappeared in about 1 hour.

Results

The improvement of signs of chrono and photo-ageing obtained using the full-face HPT (High-Performance Technique) with the combined protocol of the two products (Sunekos 1200 + Sunekos Performa) are evident in both the female and male sex (Figures 5 and 6).

Conclusions

The injection of these two products, Sunekos 1200 and Sunekos Performa, allows us to face and counteract skin ageing in a transversal way:

■ Thanks to their different composition (different molecular weights of hyaluronic acid and different proportions of the amino acids), they perform two different and complementary actions: the first product re-hydrates the deep dermis and adds an anti-free radical effect, while the other regenerates the extracellular matrix.

■ The products are injected into two different dermal layers, one subdermal with a cannula and the other intradermal with a needle treating the tissue to full thickness.

The dermis is treated following orthogonal lines to the Langer lines to enhance the traction forces perpendicular to the skin laxity lines.

Declaration of interest Funding for this research was provided by Professional Dietetics

Key points

One of the most important pathophysiological aspects which underlies skin ageing is the loss of the extra-cellular matrix (ECM) homeostasis.

The condition can be treated with two products using a patented HY6AA formula, one based on low molecular weight hyaluronic acid (SuneKOS Performa) and the other with a high molecular weight hyaluronic acid (SuneKOS 1200) both added to a specific six amino-acids formula

Delivered via a new technique called the High Performance Technique (HPT), it is possible to counteract the complex process of skin ageing in a relatively short time through a minimally invasive treatment

References

1. Facial Injectable Market Size, Share & Trends Analysis Report By Product (Collagen, Hyaluronic Acid, Botulinum Toxin Type A, Calcium Hydroxylapatite, Polymer Fillers), By Application (Aesthetic, Therapeutic), By Region, And Segment Forecasts 2022–2030

Published Date: Apr, 2022

2. Bingci Liu, Zenglu Xu, Ruirao Yu, Jiabi Wang, Zengfang Wang, C.Randall Harrell. The Use of Type I and Type III Injectable Human Collagen for Dermal Fill: 10 Years of Clinical Experience in China. Semin Plast Surg. 2005 Aug; 19(3): 241–250. Tissue Repair, Regeneration, and Engineering in Plastic Surgery

3. F.Vasquez et al. Changes of the basement membrane and type IV collagen in human skin during ageing. Maturitas. 1996 Nov

4. Characteristic of the Ageing Skin. Advances in wound Care. February 2013

5. Ye J, Zhang H, Wu H, et al. Cytoprotective effect of hyaluronic acid and hydroxypropyl methylcellulose against DNA damage induced by thimerosal in Chang conjunctival cells. Graefes Arch Clin Exp Ophthalmol. 2012; 250(10): 1459-1466.

6. Method and apparatus for determining the lines of optimal direction for surgical cuts in the human skin. US Patent 6418339. Archived from the original on 2013-04-21.

7. Karl Langer, ‘Zur Anatomie und Physiologie der Haut. Über die Spaltbarkeit der Cutis’. Sitzungsbericht der Mathematischnaturwissenschaftlichen Classe der Wiener Kaiserlichen Academie der Wissenschaften Abt. 44 (1861)

8. Langer, K (January 1978). “On the anatomy and physiology of the skin”. British Journal of Plastic Surgery. 31 (1): 3–8. doi:10.1016/0007-1226(78)90003-6. PMID 342028.

9. B. De Servi A. Orlandini E. Caviola – M. Meloni . Amino acid and hyaluronic acid mixtures differentially regulate extra cellular matrix genes in cultured human fibroblasts. Biol Regul. Homeost Agents. May-Jun 2018; 32(3):517-527. PMID: 29921376

10. Laura Tedesco. A designer mixture of six amino acids promotes the extracellular matrix gene expression in cultured human fibroblasts. Bioscience, Biotechnology, and Biochemistry, 2022, Vol. 86, No. 9, 1255-1261

11. E. Fasola, E.A. Kutera. Pilot Study evaluating the therapeutic effects of a new pre-mixed injectable product of low molecular weight (LMW) hyaluronic acid added to six amino acids (HY6AA + Formula) in facial skin aging. JDC, August 2022

Figure 6 Male patient 57 years of age, (A) before and (B) after 3 sessions of full-face HPT

Figures 1–6 © Elena Fasola

COLD ABLATIVE FIBRE LASER A New Solution for Photoageing in All Skin Types

Michael Gold, MD, describes his success using the UltraClear™ system in his aesthetic practice

THE USE OF LASERS TO IMPROVE THE appearance in signs of photodamage and ageing, such as wrinkles, pigment, and loss of tone and texture, has been a popular procedure in cosmetic practices for decades.

Promising results using a fully ablative infrared 10,600 nm carbon dioxide (CO2) laser were first reported by Fitzpatrick et al1, but carried drawbacks such as a long downtime after treatment and significant side effects, including patient discomfort, scarring, and hyperpigmentation2,3. It was later demonstrated that more rapid healing with fewer and less severe side effects could be achieved with the introduction of fractional lasers years later by Manstein et al4, using either ablative or, more recently, non-ablative lasers. However, other practical issues for incorporating these into an aesthetic practice remained. Application of topical anaesthesia was typically required up to 60 minutes before each treatment. The procedure itself could require up to 60 minutes, and the downtime following the procedure could last weeks, significantly affecting the acceptance of these procedures in many patients. Furthermore, many patients of darker skin types were contraindicated due to a higher risk of developing long-term hyperpigmentation.

A new cold ablative 2910 nm fibre laser is showing promise to eliminate most, if not all, of these concerns and provide a much-needed solution for treating patients.

MICHAEL GOLD, MD Dermatologist, Gold Skin Care Center, Nashville, Tennessee, USA

Among the advantages of this new technology in clinical practice is full-face treatments can be performed in under 20 minutes.

Technology

We have recently begun exploring the use of a new midinfrared 2910 nm, cold ablative, fractional fibre laser (UltraClear™, Acclaro Corporation, Smithfield, RI) for general facial photo rejuvenation. The UltraClear is a firstof-its-kind mid-infrared fractional laser that can be customised to produce coagulative effects, delivered as fractional arrays of rings, ablative effects as highly uniform microbeams, or as a combination of both for the treatment of general facial photodamage. Representative beam array patterns from the UltraClear are shown in Figure 1

Among the advantages of this new technology in clinical practice is fullface treatments can be performed in under 20 minutes. In addition, healing times are rapid, typically lasting only a few days, as can be seen in the day-today time sequence of photos shown in Figure 2

Furthermore, the controlled superficial effects of this new laser device are beginning to show in separate early studies. The versatility of the various 3DMIRACL, Clear, Clear+, Ultra, and UltraClear modes provide choices ranging from lunchtime treatments with depth settings as soft as 10 microns, to three-dimensional deep collagen remodelling at 1500 micron depths.

Even skin of colour, including Fitzpatrick skin types IV, V, and VI, can be safely treated with a much lower risk of post-inflammatory hyperpigmentation. The flexibility for practitioners to treat patients of all skin types underscores the excellent return on investment.

Another distinct benefit is that these quick treatments can be safely delegated to physician extenders.

Clinical results

Our patients were treated using the fractional cold ablation ULTRA mode customised using the 15 mm

square and rectangular patterns, 2.0% coverage and a depth setting of 500 microns with high coagulation.

A 65-year-old female with Fitzpatrick skin type III presented with a history of facial photodamage, including mild to moderate fine lines and wrinkles and diffuse pigmentation. She received a single, full-face treatment with UltraClear. Figure 3 illustrates her results from before and four weeks after one treatment.

Figure 4 shows another 58-year-old patient with very positive pigment clearance on the forehead.

Discussion

To date, the fractional 2910 nm fibre laser used in our practice produces clinically beneficial results after a single treatment. Discomfort during treatment was

A B C D

Even skin of colour, including Fitzpatrick skin types IV, V, and VI, can be safely treated with a much lower risk of postinflammatory hyperpigmentation.

Figure 1 UltraClear beam patterns. Cold ablative rings, central zones or both in combination are user configurable. Shown is an example of a 6x6, 36 microbeam array

Figure 2 Healing PostUltraClear. (A) Before, (B) 3 days post one treatment, (C) 6 days post one treatment, (D) 7 days post one treatment. Photos courtesy of Bengston Center for Aesthetics and Plastic Surgery, Grand Rapids, MI, USA.

minimal without the need for topical anaesthesia application. Initial mild erythema was common but treated skin generally returned to a healthy normal appearance within three days with noticeable clearance of benign lentigines.

The short downtime following treatments due to rapid healing provides a desirable outcome for all patients. In our practice, patients were pleased to be able to resume normal social functions or return to work very quickly. This represents a distinct advantage for dermatologists and aesthetic doctors to meet many of the most common patient demands.

From a practical standpoint, the fact that no topical anaesthesia was used or required made the treatment sessions an attractive offering for our cosmetic laser practice and has resulted in the adoption of over 100 of

these novel devices in just under one year since the company launched the product into the market. US Food and Drug Administration (FDA) clearance was achieved in December 2021 for not only the general skin resurfacing procedures presented in this article but also wrinkles, scar revision (including acne scars), telangiectasia, and spider veins. Many other indications are currently being studied in clinical trials.

The system’s autoclavable tips offer the distinct benefit of not requiring per-patient consumables for treatments, which substantially reduces the usage costs for the practitioner. Further, the first-of-its-kind fibre laser design dramatically reduces service costs, when needed, up to 70%, as compared to other infrared lasers that utilise articulated arm technology. In addition, the shortened time required to complete the treatment is another key

benefit for both the patient and practitioner, resulting in a procedure that is cost-effective and fits well within any practice’s business model.

Good results were seen after as little as a single treatment session; however, we now recommend a series of two or three treatments spaced approximately four weeks apart. Maintenance treatments can be performed on an as needed basis.

The combination of an effective, fractional, low downtime procedure offered by the novel 2910 nm fractional fibre laser should find considerable utility, filling a need in general dermatologic and cosmetic laser practices as identified in previous works5,6

References

1. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD. Pulsed carbon dioxide laser resurfacing of photoaged facial skin. Arch Dermatol 1996;132:395-402

2. Ross EV, Grossman MC, Duke D, Grevelink JM. Long-term results after CO2 laser skin resurfacing: a comparison of scanned and pulsed systems. J Am Acad Dermatol 1997;37:709-718.

3. Nanni CA, Alster TS. Complications of carbon dioxide

concept for

5.

Figure 3 (A) and (B) before and (C) and (D) Four Weeks After one UltraClear Treatment

Figure 4 Pigment clearance (A) before and (B) 4 weeks after one UltraClear treatment

laser resurfacing. An evaluation of 500 patients. Dermatol Surg 1998;24:315–320.

4. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new

cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004;34:426-38

Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing. J Am Acad Dermatol 2008 May;58(5):719-37

6. Geronemus RG. Fractional Photothermolysis: Current and Future Applications. Lasers Surg Med 2006;37,179-185

Disclosure Dr. Gold is a consultant to Acclaro Medical and is compensated for speaking on their behalf.

The system’s autoclavable tips offer the distinct benefit of not requiring per-patient consumables for treatments, which substantially reduces the usage costs for the practitioner.

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EXPLORING THE PSYCHOSOCIAL ASPECTS OF AGEING

Shino Bay Aguilera, Alec D McCarthy, Elina Theodorakopoulou, Saami

Khalifian, Kelly McMahon, Saranya P Wyles, Doris J Day, Sabrina Ghalili, and Patricia Ogilvie examine the relationship between psychological and physiological ageing and the role of the aesthetic physician

ABSTRACT

As the global population ages, there is increasing interest in improving the quality of the later years of life. The World Health Organization postulates that by 2050, the global population of people aged 60 years and older will double, and the number of persons aged 80 years and older will triple, reaching 426 million. We are living longer, but the question remains: Are we living better? The advancement of modern medicine has successfully increased the human lifespan; however, this has not been proportionally reflected in human healthspan. Beyond well-studied hallmarks of healthy ageing, such as highquality nutrition, physical activity, limiting stress, and mindfulness, there exists interest in how self-perception of ageing impacts one’s

psychological well-being. It is postulated that improving one’s psychological well-being may also positively impact physiological ageing. Of particular interest is the perspective that mismanaged physiological ageing may have a broader impact on individuals (i.e., psychological), society (i.e., worsening societal mental and physical health), and the overall healthcare system. Does physical attraction, or cosmetic procedures that either enhance or maintain physical beauty, promote positive psychology and empower individuals to age with integrity? Moreover, can these enhancements indirectly reduce healthcare utilisation costs in the ageing population? Based on emerging evidence, we propose that the psychosocial aspect of ageing is quintessential in the continuum of successful ageing.

KEYWORDS

Psychosocial ageing, psychology of ageing, psychosocial distress, functional aesthetics, successful ageing, self-perception of ageing

THE WORD ‘BEAUTIFUL’ IS AN adjective that we often associate with something we like. According to Hesiod, an ancient Greek poet in the 6th century BC, the chorus of the muses suggested:

‘Only that which is beautiful is loved, that which is not beautiful is not loved.’ Aesthetic medicine focuses on the subjective nature of beauty itself. It also aims to address what many people fear: unattractiveness. Attractiveness is deeply ingrained in our survival instincts and desires1,2. Humans are naturally communal beings, as procreation and belonging are important elements of group dynamics. Therefore, we need to feel that we are able to attract a mate and be attractive to a group. Attractiveness is closely associated with the survival of individuals and species. Biologically, we are designed to identify signs of reproductive health and fitness in one another for procreation and protection3,4

However, the physiological and subsequent psychological effects of chronological ageing are inevitable. Chronological and environmental ageing result in architectural changes across tissue planes (i.e., skin, fat, muscle, and bone) that alter the ratios and proportions of an otherwise youthful face5. As we age, our epigenome, or molecular factors that control gene expression, begin to deteriorate, and unlike genetic insults, epigenetic changes are reversible through lifestyle modification6. If left unaltered, ageing is a progressive phenomenon. Aesthetic providers have the ability to interrupt this physiological process with procedural, injectable, and topical treatments. While most aesthetic treatments primarily address phenotypic changes in patients, there are likely significant positive associated psychosocial changes as well7,8. In essence, aesthetic treatments may help improve poor self-perception and/or depression, which may manifest as improved ageing.

(LEFT TO RIGHT)

SHINO BAY AGUILERA, DO, Shino Bay Cosmetic Dermatology & Laser Institute, Fort Lauderdale, FL, USA; ALEC D MCCARTHY, PHD, Merz Aesthetics, Raleigh, NC; ELINA THEODORAKOPOULOU, MD, PHD, Pretty You Dermatology, Athens, Greece; SAAMI

KHALIFIAN, MD, Grossmont Dermatology Medical Clinic, La Mesa, CA, USA; KELLY MCMAHON, PA-C, Shino Bay Cosmetic Dermatology & Laser Institute, Fort Lauderdale, FL, USA; SARANYA P WYLES, MD, PHD, Mayo Clinic Department of Dermatology, Rochester, MN; DORIS J DAY, MD, NYU Langone Medical Center, New York, NY; SABRINA GHALILI, BS, SUNY Downstate College of Medicine, Brooklyn, New York, USA; PATRICIA OGILVIE, MD, Skin Concept Institute for Dermatology, Munich, Germany

email cpk7144@gmail.com

Aesthetic medicine focuses on the subjective nature of beauty itself. It also aims to address what many people fear: unattractiveness.

Two hypothesised mechanisms may be at play in helping individuals feel and behave younger. The first is psychological; it is based on how a person feels when they look in the mirror and see an appearance that is more in line with their perceived self-image and their desired youthfulness9. The second is biological; it may be associated with neurochemical changes in the brain when people have aesthetic treatments. Indeed, the positive impact of self-image on depression and other mental health disorders has been documented and implicated as a potential modulating target for aesthetic intervention10

Recent studies have demonstrated the safety and efficacy of botulinumtoxinA injections in the glabella in improving depressive symptoms in patients with major depressive disorder and other mood symptoms11. A randomised, observational clinical study looking at fMRI brain imaging before and after glabellar botulinum toxin injections showed decreased activity in the thalamus, suggesting a modulatory role on brain activity12. A possible confounder would be that decreased motor input from frowning may decrease thalamic activity. Nonetheless, patients treated with botulinumtoxinA in the glabella had a decrease in depressive symptoms that manifested as improved quality of life and improved mental health outcomes. To summarise the increasing body of literature connecting aesthetics and psychology: self-perception can impact mental health. Addressing aesthetic concerns in patients improves their selfperception and, in turn, their psychological state of mind. While these concepts may be somewhat intuitive, their

In essence, aesthetic treatments may help improve poor self-perception and/or depression, which may manifest as improved ageing.

importance was thrust to the forefront during the onset of the COVID-19 pandemic. The ‘Zoom Boom’ led to widespread video calling, which suggested that the more time someone spends analysing their own appearance, the more inclined they were to receive aesthetic treatments13. Similarly, during COVID-19, interest in aesthetic procedures, weight loss, and dieting increased14–16. At the same time, rates of depression and social media usage also increased17,18. The correlation between increased self-observation and aesthetic procedures may be explained by the interconnectedness of self-image and psychology.

Exploring trends

We performed a simple analysis on Google Trends, probing temporal and regional changes on self-image. Google Trends is a publicly-accessible online tool that temporally and geospatially analyses a percentage of Google web searches. Search interest is reported as relative search volume (RSV) and reflects the quantity of searches for a particular term relative to the total number of searches carried out on Google and has been used frequently in healthcare to predict or analyse public interest trends13,14,19,20. RSV is scaled from 0–100 and is not a reflection of absolute search volume. Assessing relative searches is valuable for evaluating social trends, especially between search phrases. Up to 5 terms can be searched relative to one another. Further, geospatial data, which is reported as the average RSV over the given timeline, sheds insight into the regionality of a particular social phenomenon. Overall, Google Trends allows clinicians and researchers to assess and compare social interest in trends, terms, procedures, and thought processes, both independently and relative to other search phrases over defined time intervals and geographies. While no demographic data of searchers is procured, Google Trends also includes related search queries and topics. Related queries and topics are defined as terms or topics searches also searched for (in addition to the primary word or subject being analysed).

Results

In this study, a panel of researchers and healthcare providers working in dermatology and aesthetic medicine procured a list of searches to be investigated. The following phrases were selected for social analysis: ‘Why do I look old?’ and ‘Why do I feel old?’. The temporal data was smoothed with a second-order smoothing polynomial and plotted (Figure 1 A and C). The geospatial data was plotted with bar graphs (Figure 1 B and D). The global map incorporates a colour gradient, where darker colours correlate with higher RSVs. Finally, related search queries were included to contextualise changes in search volume. Results suggest an increase in searches for ‘why do I feel old?’ over the past 10 years (2012–2022), including a significant increase in the rate of change starting in 2020, following the COVID-19 pandemic. This pattern was also highly correlated with searches for ‘why do I look old?’ thus implying a relationship between looking older and feeling older. The observed trend

Table 1 Top related searches for ‘Why do I feel old?’ and ‘Why do I look old?’ and their relative search volume (RSV) Table 2 Rising related searches for ‘Why do I feel old?’ and ‘Why do I look old?’ and their % change in search interest over 10 years

Why

In this study, a panel of researchers and healthcare providers working in dermatology and aesthetic medicine procured a list of searches to be investigated.

Public search interest in either (A) toxins or fillers (as measured with ‘toxin/filler near me’) and (B) aesthetic providers (measured as plastic surgeon/dermatologist/ medspa near me)

was not defined to a distinct geography as psychosocial aspects of ageing permeate across global borders, ethnicities, and cultures. However, the United States, United Kingdom, Philippines, and Canada were among the top search countries for both phrases.

Another interesting observation from this simple analysis was in top/rising related queries. Several top related searches stood out to the authors: ‘Why do I feel tired?’, ‘Why do I feel sick?’, ‘Why do I feel alone?’, ‘Why do I feel empty?’, ‘Why do I feel depressed?’ were all related search terms tied to people searching ‘Why do I feel/look old?’ Select top related searches are given in Table 1

Similarly, rising related searches (those with the most significant changes over the time interval explored) are also provided. These perhaps shine the most light on emerging trends related to perceptions of ageing. Select rising related queries are presented in Table 2. Several rising phrases were ‘breakthrough’ searches (breakthrough results are those with more than a 5000% change over the time interval) and included ‘Why do I feel so empty’, ‘Why am I so tired’, ‘Why am I always tired’, ‘Why do I hate myself’, ‘Anxiety attack’, ‘Depression symptoms’, and ‘Why do I look ugly’. These related queries contextualise the dramatic changes in the

Figure 2 Search term popularity

The results from our analysis largely support the notion that aesthetic providers have the ability to not only address aesthetic concerns but also improve the mental health of patients.

observed psychosocial phenomenon: negative feelings/ thoughts (psychological) and physical feelings of illness are related to increased negative changes in self-image. These findings support the notion that looking older and feeling older are related and carry with them a host of negative feelings and symptoms. Further, interest in dermal fillers and botulinumtoxinA have experienced dramatic increases in public interest that further correlates to searches seeking plastic surgeons, dermatologists, and medspas (Figure 2 A and B). The increased efforts by the general public to identify aesthetic providers for consultations or treatments is likely reflective of the positive changes in the perception of aesthetic treatments and also of a larger portion of the public desiring treatments.

The role of aesthetic medicine

The results from our analysis largely support the notion that aesthetic providers have the ability to not only address aesthetic concerns but also improve the mental health of patients. The downstream effects of which may be both psychological and physical. Aesthetic providers have the unique opportunity to identify insecurities that can lead to distorted self-perceptions and heal patients by treating their individual beauty concerns, which can be applied across all genders, age groups, and backgrounds. The notion of beauty is constantly reinforced to patients, and every provider should take an approach to assess both aspects of psychosocial ageing.

There has been an aim to promote positive perceptions of ageing in young and old individuals alike — which is where aesthetic medicine conveys its value to patients and the global healthcare system. Cosmetic procedures by trained aesthetic providers may improve physical beauty with the intention of manifesting positive general well-being. A large longitudinal survey of 8,434 participants found that greater facial attractiveness (as well as lower BMI and greater height) was associated with higher psychological well-being and a lower risk of depression21. Indeed, positive psychology can be beneficial in overall disease prevention, and aesthetic medicine is a field that aims to support this mentality. Ageism directly impacts the healthcare system from a cost perspective. A study of Americans aged 60 years and older revealed that the 1-year cost of ageism (in relation to discrimination aimed at older people, negative age stereotypes, and negative self-perceptions of ageing) was $63 billion, or 1 of every $7 dollars spent on the eight most expensive health conditions in 2013. The highest ageism predictor accounting for $33.7 billion dollars of the total cost was negative self-perceptions of ageing22. Another longitudinal study of 85,225 adults revealed that within a 5-year timeframe, individuals with high or increasing life dissatisfaction were significantly associated with higher healthcare utilisation costs23. A cynical attitude towards the future is financially draining the healthcare system today, and measures to combat this can have patientand society-wide benefits.

Key points

Succesful ageing leads to living a healthy life with integrity

Aesthetics treatments ensures a healthier lifespan of individuals taking the burden from the health care systems

Looking youthful allows for self-permission to stay young and healthy

A higher percentage of people are becoming increasingly aware of the negative associations with aging and are actively seeking interventions with HCPs

Conclusion

Science increasingly favours the co-localisation of the mind and body connection and its effect on overall wellbeing. Our thoughts, emotions, and mentality can elicit an array of symptomatology, promoting either ease or dis-ease within the body. Ageing in itself is a disease where the body deteriorates at a rate relative to intrinsic and extrinsic stressors. Several studies support the theory that self-perceptions of ageing have a direct impact on overall health and well-being from an individual standpoint to the global healthcare system. Aesthetic medicine, occasionally considered a nonessential specialty, contributes to positive perceptions of ageing and therefore benefits both society and the medical community in the contemporary era of prolonged lifespans. Research has supported that both positive and negative age stereotypes can have beneficial and detrimental effects, respectively, on various physical and cognitive outcomes24. Furthermore, American culture subliminally fosters a cynical view of prolonged lifespans. On the contrary, if our thoughts can make us sick, they also have the power to make us well. Our data suggest a steady increase in negative changes in selfperception, which were linked to symptoms of psychological and physiological illnesses like anxiety and feelings of loneliness. This data further warrants the long-term need for aesthetic providers to improve patient self-perception. An ideal aesthetic provider should manage the ageing process for a patient and, in addition to meeting their aesthetic needs, help to bring positive mental changes that can result in a beautiful, productive, and meaningful life with patients achieving successful physical and psychological ageing.

Declaration of interest Dr Aguilera trains for/conducts research for Merz Aesthetics, Galderma, Allergan. Dr Khalifian is a clinical investigator, consultant, speaker, and on the advisory board for: Allergan/AbbVie, Galderma, and Merz. Dr McCarthy is a medical science liaison for Merz Aesthetics. Dr Wyles is a consultant for Rion and Allergan/AbbVie.

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Our thoughts, emotions, and mentality can elicit an array of symptomatology, promoting either ease or dis-ease within the body.

Known as myomodulation, this phenomenon describes how dermal fillers, especially hyaluronic acid (HA) fillers, alter the activity of facial mimetic or sphincter muscles they are strategically placed within or beside, and could potentially be used to deliberately change facial musculature.

PERIORAL MYOMODULATION WITH FILLER INJECTION

Tinchia Hsu, MD, and Yuchin Tsai, MD, discuss an easy and approachable method for perioral volume restoration and rejuvenation

ABSTRACT

Data on facial myodynamics have increased recently following reports of filler injection-based aesthetic interventions. While fillers are used predominantly to address facial hollowing and bony deficits, and neurotoxins are typically used to facilitate muscle paralysis and prevent superficial laxity of the skin, both are difficult to administer with precision. This is particularly true of the highly complex but delicate perioral area where over twenty muscles insert into the modiolus and are involved in myomodulation. We devised an easy and approachable

AGEING ENCOMPASSES VOLUME deteriorations that affect bone and tissues1–5. In perioral ageing, resorption of underlying bone and dentition1, together with loss of soft tissue volume, can manifest as reduced upper lip volume, tissue elasticity, thickness, and contour, alongside vertical rhytids, lip ptosis, vermilion border eversion, and skin photoaging or altered texture1,3,6–8. The entire perioral area encompasses the orbicularis oris, levator labii superioris, levator labii alaeque nasi, depressor angular oris, depressor labii inferioris, and risorius9. However, the ‘J’ shape that is characteristic of younger lips is achieved by the orbicularis oris, while the ‘I’ shape associated with ageing occurs due to upper lip elongation and concavity10. Consequently, perioral rejuvenation procedures have increased in recent years11 and traditionally involve autologous fat transfers, filler injections, and perioral laser resurfacing12 to modify perioral volume change, enhance perioral definition, and improve rhytids and marionette lines12.

Dermal fillers, customarily used in facial volumisation or to relieve static rhytids and folds and restore volume loss13–17, have been shown to change muscle movement in specific structural deficiencies. Known as myomodulation, this phenomenon describes how dermal fillers, especially hyaluronic acid (HA) fillers, alter the activity of facial mimetic or sphincter muscles they are strategically placed within or beside13,18, and could potentially be used to deliberately change facial musculature19,20. HA filler-based myomodulation was also postulated13 to affect muscle function following placement in specific injection planes and tissue depths, while

treatment plan for precise perioral rejuvenation through filler injectionbased perioral myomodulation. Our treatment incorporates three concepts of muscle dynamics: length-tension relationships, muscle pulley and lever systems, and functional muscle groups (synergists and antagonists). By enhancing the function of muscle synergists and inhibiting the muscle antagonists, the movement direction of the modiolus could be modulated with hyaluronic acid fillers and avoid the need for injections of neuromodulator, thus avoiding the potential for complications related to toxin diffusion in this mobile area.

muscle function was hypothesised to have been increased by submuscular fillers but reduced by supramuscular and intramuscular fillers. This was supported21 by observations that sub-mentalis fillers markedly reduced mentalis hyperactivity, suggesting that placement depth was an important consideration in myomodulation. However, we believe that the intramuscular fillers are responsible for this activity since the mentalis originates from the mandible. Whether myomodulation facilitates or obstructs muscle action 13,22–24 remains unclear, and myomodulation with HA fillers is still a novel strategy as published data on treatment outcomes is limited25

We devised an approach for the placement of HA fillers that allows the strategic direction of movements of the modiolus and perioral area. Our approach works synergistically with the modiolus’ constituent muscles while inhibiting antagonistic muscle movements (Figure 1). We report here the representative results from two patients treated with our injection strategy.

Materials and methods Patients

Patients who presented with a downward mouth curvature and requested aesthetic treatments to correct this were enrolled. Patients were excluded from the study if they had a known allergic reaction to fillers, were undergoing anticoagulant or immunosuppressant therapy, had autoimmune disease, diagnosed psychological disorders like body dysmorphic disorder, or were pregnant or breastfeeding.

Patients’ faces were studied for the presence of drooping of buccal fat and mouth corners, deficient

TINCHIA HSU, MD, Blossoms Clinic, Republic of China, Taiwan; YUCHIN TSAI, MD, Blossoms Clinic, Republic of China, Taiwan; email jia711231@gmail.com

KEYWORDS

Perioral myomodulation, volume restoration, fillers

lateral suborbicularis oculi fat (SOOF) and lateral deep medial cheek fat pad (DMCF), and an overactive depressor anguli oris (DAO). To assess their suitability for perioral myomodulation, the zygomaticus major muscle (along the length of the upper margin of the temporal process) and the modiolus were palpated lightly by placing a finger on the temporal process to lift the area and allow soft tissue volume loss to be observed and estimated. Soft tissue above the DAO muscle was similarly estimated by palpating along the length of the modiolus and the oblique line of the mandible. Lips were assessed with patients in a seated position, who performed facial animations (including smiling, pursing lips, and expressing sadness) and facial relaxation (without clenching the jaw or teeth) to achieve a resting state. These actions allowed an estimation of soft tissue volume, as deficits here could also contribute to loss of lip contour.

Treatment

Anaesthetic EMLA® Cream 5% (lidocaine and prilocaine 1:1) was applied to the face 15 minutes prior to filler injections. Using 0.5-inch long, 27G and 30G needles (as supplied with filler; TSK Laboratory, Japan), the superior temporal septum and the temporal ligamentous adhesion were injected with a total of 1 mL of Belotero® Intense (Merz/Anteis SA, Geneva, Switzerland). The lateral SOOF and lateral DMCF were injected with a total of 2 mL of Belotero® Intense; the nose was straightened with injections of 0.5 mL of Belotero® Intense, and 1.5 mL of Belotero® Balance (Merz/Anteis SA, Geneva, Switzerland) was placed above the DAO. While 0.5 mL of Belotero® Intense was injected into the chin, and 1.5 mL of Belotero® Balance was superficially injected into the nasolabial fold and lip vermillion border. Specifically, filler was injected into the sub-SMAS beneath the orbicularis oculi, levator anguli oris (LAO), and levator labii superioris. With each injection point, small boluses (0.1–0.15 mL/point) were placed adjacent to strong ligamentous adhesions (the superior temporal septum, the temporal ligamentous adhesion, the lateral portion of the orbital malar ligament, and the zygomatico-cutaneous ligament) for structural

support. Medium boluses (0.2–0.3mL/point) were placed in the lateral SOOF and DMCF to restore the lifting capacity of the levator muscles. Tiny boluses (0.05–0.1mL/ point) were placed in the subcutaneous layer for aesthetic refinements. Due to the high vascularity of the perioral area, patients were monitored for adverse reactions like hematoma, ischemia or mottled skin for up to 30 minutes after injection. Post-treatment, patients were instructed not to massage the injected area and to keep the injection site dry and clean. They were also advised to avoid skin irritants or excessive sunlight exposure on the face for at least 1 week. To mitigate pain, they were advised to take acetaminophen for 3 days immediately post-treatment, as required.

Evaluations

Patients were followed up at 10-, 90- and 270-days posttreatment. Evaluations included assessments of overall aesthetic improvements, lip contours, and positions of mouth corners (modiolus). The Merz Global Satisfaction Scale (GSS) was used to score the patients’, physician injector’s and independent physician’s satisfaction with treatment outcomes, while the physician injector and independent physician also scored satisfaction using the visual analogue scale (VAS).

Results

The representative outcomes of our HA filler-based perioral rejuvenation are demonstrated through a 36-year-old female patient (Figure 2). Overall, the patient demonstrated a younger appearance, a less pronounced downturn of the mouth corners, and less skin laxity in the treated area. Immediately post-injection, the perioral area appeared more balanced, while movement of the modiolus superiorly and posteriorly produced a more defined facial contour. Placing Belotero® Intense in the lateral SOOF and lateral DMCF elevated the modiolus while placing Belotero® Balance above the DAO blocked the modiolus’ downward and lateral traction force, resulting in midface lifting. Injections of Belotero® Intense in the chin aimed not to protrude the chin but to relieve mentalis strain and harmonise the whole face, while superficial injections of Belotero® Balance relieved the nasolabial fold and produced a more defined lip contour. One 32-year-old female patient (data not shown) presented with a downturned lip contour due to a prominent right upper lip defect, a diminished overall lip body volume, and a volume-deficient superficial lateral lip suggesting a fat compartment deficiency above the DAO. Injection of Belotero® Balance (2 mL) elongated her lips and positioned the mouth corner laterally, restoring the lip contour and creating a more defined facial contour and a happier appearance. In general, the placement of 12 threads (9mL) of CaHA should lead to a visible facial ‘rejuvenation’, but in this patient, modiolus motion was not prominent due to the severity of bony loss and buccal fat herniation. All patients post-treatment demonstrated a more youthful and elevated facial appearance.

The results of our myomodulation strategy persisted at 270 days post-treatment, especially tissue lifting of the

Overall, the patient demonstrated a younger appearance, a less pronounced downturn of the mouth corners, and less skin laxity in the treated area.

Figure 1 Schematic of muscles modulating the mouth corner and interfacing at the modiolus.

A A

B B

SOOF and DMCF at 90 days. The 36-year-old patient’s VAS and GSS (Table 1) ratings of their marionette lines and oral commissures were high, even up to 270 days postprocedure. We expect that the more severe the patient’s presentation, the more effective the myomodulation treatment will be. This patient’s result demonstrates that achieving effective myomodulation of mouth corners requires midface volume loss (especially in the SOOF), a supra-DAO deficit, a downturned mouth corner and skin laxity. Due to the limitations of improvements in the mobility of individual muscles, an effective filler dose of 6–10 mL should be used to ensure synergistic effects. Postprocedure, one patient experienced mild injection site swelling, and two patients experienced mild bruising. No hematomas or other adverse effects were noted, all of which resolved without requiring treatment. No severe adverse events occurred, and no patient required retreatments.

Discussion

Our patients had deficiencies in the lateral SOOF and lateral DMCF, which diminished the support typically provided by the zygomaticus major and LAO to the modiolus system, while an overactive DAO caused sagging of mouth corners. Our myomodulation approach enhanced the synergistic activity of the perioral muscles in which HA filler is placed while inhibiting their antagonistic activity, allowing us to control the direction of modiolus movement. The persistence of treatment outcomes at 180 days is encouraging as the highly-mobile perioral area resorbs filler the most, compared to other facial areas.

Perioral musculature is unique but complex due to a

C C

Table 1 Patient and physician ratings of myomodulation treatment

Treatment Results.

Photographs of a 36-year old patient taken (A) before, (B) 90 days and (C) 270 days posttreatment, with 4 ml of Belotero® Intense and 4 ml of Belotero® Balance.

need to generate delicate movements for fine or subtle facial expressions. At least twenty muscles are involved in the myomodulation26 of mouth corners and are situated within a web-like structure comprising the complicated myodynamic system of the face. Multiple muscles insert into the modiolus, including the LAO, zygomaticus major, buccinator, risorius, depressor anguli oris and orbicularis oris27

Like others13, our approach (Figure 3) considers facial muscle dynamics as part of a holistic functional unit encompassing muscle length, tension, synergism, and

Figure 2

Figure 3 The concept of perioral myomodulation using fillers. (a) In youth, facial bony structures and connective tissue give strong support to the face and myodynamics function optimally, giving a youthful face. (b) Congenital or aging processes contribute to an enhanced, downward and lateral movement of the modiolus, leading to buccal fat herniation. (c) Fillers can be used to rebalance the modiolus. Fillers shown in red that are injected beneath the levator muscle, increase levator muscle strength. Fillers shown in yellow, that are injected above the depressor muscle, decrease its lateral and downward movement. The superior and posterior movement of the modiolus creates a youthful appearance and prevents “widening of the face”.

antagonism. Myomodulation outcomes may be variable due to static and dynamic changes that alter the structure and motion of the facial musculature and SMAS. Moreover, relative to skeletal muscles elsewhere in the body, the smaller facial muscles undergo a more subtle change following treatment. The modiolus system is surrounded by facial structures like the facial bone, buccal fat, superficial and deep fat compartment, and ligamentous tissue. Its mobility is thus also determined by the structures in which it is confined. Myomodulation is most optimal when treatment considerations include these factors, careful patient selection, and synergistic performance of aesthetic interventions.

Myomodulation may involve simple mechanical changes, stimulation of intramuscular cutaneous mechanoreceptors, and perhaps through filler-induced impairment of muscle movement. The concept of myomodulation originates from magnetic resonance imaging demonstrating that youthful facial convexity was due to deep fat compartments beneath levator muscles28 while age-related bone regression and fat loss were due to the loss of this convexity. Consequently, the levators straighten and have a stronger effect on depressor muscles13,22 so that loss of structural support can be restored by positioning fillers beneath the muscle and near its insertion point. This placement allows the filler to function as a fulcrum to restore tissue convexity and muscle tension13,23. However, we feel that this outcome depends on the area being treated and can be used successfully for the nasolabial fold. In the zygomaticus major, placement near the muscle origin creates a more vertically-positioned ‘apple cheek’, as fillers near the insertion lead to a heavy appearance. Conversely, muscle activity can be limited by the superficial placement of filler within the mentolabial angle or intramuscular placement within the periorbital or perioral sphincters19. In the perioral area, HA fillers may reduce lip elevation and restore muscular imbalances

caused by structural deficiencies, regardless of volume loss13. Nasolabial fold myomodulation can be achieved by injecting filler near the point of skin insertion13

In another study20, volumising HA fillers injected into the SOOF were found to lift the midface, possibly because of the filler’s high G’ and cohesivity, which resisted migration and vertical pressures. Injecting fillers into the midface does not lift the SOOF as it is attached to the bone, but it does produce a myomodulating, midface lift as the filler causes a slight contraction of the striated orbicularis oculi muscle, which lifts the overlying superficial malar fat and its cutaneous sheath. This lifting of muscle anteriorly occurs even when very little filler (0.5 cc–1 cc) is placed in the SOOF, as long as the injected HA is in direct contact with the muscle or inside it. Myomodulation may also occur via HA filler-mediated muscle relaxation. HA filler-mediated nasolabial fold augmentation in the levator labii superioris facilitates myomodulation and relieves gingival show, while HA fillers in the orbicularis oris facilitate myomodulation of thin lips by relaxing muscle tension and skin tightness to restore a fuller lip.

Our procedure requires injection of HA fillers beneath the zygomaticus major, on the supraperiosteal layer, with caution exercised due to the presence of transverse facial arteries. Beneath the LAO, fillers should be injected in the sub-superficial muscular aponeurotic system (SMAS) layer, with caution exercised due to infraorbital and facial arteries or their branches in the area. Above the DAO, fillers must be injected precisely into the supra-SMAS layer. However, less-experienced injectors may inadvertently inject into the deep-SMAS to sub-SMAS layers, leading to suboptimal results or damage to the inferior labial artery. Perioral muscles are delicate structural layers interspersed with narrow spaces, especially in elderly patients.

Cannulas can be used to increase safety, but the perioral myomodulation by needle injection is superior, despite the risk of vascular events, because blunt cannulas only insert into up to four layers and will attenuate the subtle effects of perioral myomodulation. Aesthetic interventions in the perioral area are especially challenging due to the intricate anatomy and dynamic nature of the lower face29. To increase success in perioral myomodulation procedures, a comprehensive and

Unlike neurotoxins, fillers can be used with high accuracy and produce durable outcomes.

thorough understanding of facial anatomy (particularly perioral musculature and vessel distribution), together with meticulous injection technique, is imperative. Gentle manoeuvring and filler injections also lower the risk of nerve injuries.

Cohesive HA fillers, like the Belotero® fillers, are recommended for the perioral area, as they give better tissue integration, more natural results, and few to no bumps or nodules30. However, others have noted that fillers with a moderate G’ and moderate cohesivity are also ideal for lip rejuvenation31,32. Fillers are less durable in highly mobile areas like the mouth due to high shearing forces that cause their degradation33,34, but it is essential to avoid harder or less-cohesive fillers that may cause complications like nodules1. Fillers that can cause the Tyndall effect are also best avoided in patients with Fitzpatrick Skin Type I–II with static perioral rhytids35

Our study was limited by a lack of split-face or other controls to demonstrate the absence of myomodulation following filler injection. However, this would have been difficult to demonstrate as the muscles of the perioral area interface with each other so that myomodulating one functional, mimetic muscle group would have impacted others19. Due to its dynamic nature, video recordings of patients before and after myomodulation treatment would also allow filler-induced changes in muscle activity to be visualised more effectively19,24. We are currently also in the process of collecting long-term data on the durability of our intervention. Further study is needed to confirm the precise mechanisms by which myomodulation occurs and whether fillers affect muscle movements by weakening the underlying musculature or if they integrate subcutaneously to produce a lifting effect, especially in the middle third of

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Key points

Precise and delicate modulation of the modiolus system is key to perioral rejuvenation

Superior and posterior movement of the modiolus creates a youthful and defined facial contour

Compared to neurotoxins, fillers offer an unparalleled accuracy and effect duration within highly complex areas like the perioral modiolus system

Perioral myomodulation should be included in wholeface aesthetic treatments

the face24. Future work will include photographic quantification of outcomes, e.g., with QuantifiCare technology.

Conclusion

Facial volume restoration treatments typically achieve lifting in isolated areas due to the application of neurotoxins and facial fillers in discrete areas. Unlike neurotoxins, fillers can be used with high accuracy and produce durable outcomes, even in facial tissues with high mobility and complexity, such as the perioral modiolus system. As the perioral area should not be injected with high quantities of neurotoxins, which can lead to facial palsy-like appearances or an unbalanced face, our strategy was devised to achieve a holistic restoration of volume to the whole face. Moving the modiolus superiorly and posteriorly created a youthful and defined facial contour for our patients and showed that a precise and careful modulation of the modiolus system is key to effective perioral rejuvenation.

Declaration of interest Merz Asia Pacific Pte Ltd provided the study products and funds for editing of the manuscript by Dr Shawna Tan of Medical Writers Asia. Dr Tinchia Hsu was responsible for all study design, conduct, analyses, and manuscript review.

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Facial Fillers: A Comprehensive Technical Guide and Retrospective Case Series. Aesthetic Plast Surg. 2022 Nov 28. doi: 10.1007/s00266-022-03193-y. Epub ahead of print. PMID: 36443415.

20. . Belhaouari L, Tomassety M, Quinodoz P, De Boulle K. Myomodulation and hyaluronic acid [Internet]. PRIME Journal. Informa PLC; 2020 [cited 2022Dec11]. Available from: https://www. prime-journal.com/myomodulation-and-hyaluronicacid/

21. . Cheng C, Cheng IT. Observation and Potential Mechanisms of Mentalis Myomodulation by Hyaluronic Acid Filler in the Treatment of Microgenia. Plast Reconstr Surg. 2021 Jun 1;147(6):1085e-1087e.

22. . de Maio M. Myomodulation with Injectable Fillers: An Update. Aesthetic Plast Surg. 2020 Aug;44(4):1317-1319.

23. . de Maio M. MD Codes™: A Methodological Approach to Facial Aesthetic Treatment with Injectable Hyaluronic Acid Fillers. Aesthetic Plast Surg. 2021 Apr;45(2):690-709. doi: 10.1007/ s00266-020-01762-7. Epub 2020 May 22. Erratum in: Aesthetic Plast Surg. 2021 Feb 17;: PMID: 32445044; PMCID: PMC8012343.

24. . Kane MAC. Commentary on Myomodulation with Injectable Fillers: An Innovative Approach to Addressing Facial Muscle Movement. Aesthetic Plast Surg. 2018 Oct;42(5):1360-1363.

25. . Germani Vieira M, Rogerio V, Roschel P, Rabelo V, Teixeira T, Muñoz-Lora VRM. Myomodulation using hyaluronic acid fillers as an efficient and innovative treatment for gummy smile: A case report. J Oral Biol Craniofac Res. 2022 May-Jun;12(3):376-380.

26. . Kim HJ, Seo KK, Lee HK, Kim J. (2016). Clinical Anatomy for Botulinum Toxin Injection. In: Clinical Anatomy of the Face for Filler and Botulinum Toxin Injection. Springer, Singapore. https://doi. org/10.1007/978-981-10-0240-3_2.

27. . Dao DPD, Le PH. Anatomy, Head and Neck, Eye Levator Anguli Oris Muscle. [Updated 2022 May 5]. In:

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www. ncbi.nlm.nih.gov/books/NBK547688/?report=classic

28. . Le Louarn C, Buthiau D, Buis J. Structural aging: the facial recurve concept. Aesthetic Plast Surg. 2007 May-Jun;31(3):213-8.

29. . Varga R. Providing Optimal Rejuvenation to the Jawline and Perioral Area Using Neuromodulators and Hyaluronic Acid Dermal Fillers. Plast Surg Nurs. 2021 Apr-Jun 01;41(2):98-104.

30. . Prasetyo AD, Prager W, Rubin MG, Moretti EA, Nikolis A. Hyaluronic acid fillers with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature review. Clin Cosmet Investig Dermatol. 2016 Sep 8;9:257-80.

31. . Wick EH, Ostby E, Grunebaum LD. Lip rejuvenation and filler complications in the perioral region. Plast Aesthet Res 2022;9:8.

32. . Fagien S, Bertucci V, von Grote E, Mashburn JH. Rheologic and Physicochemical Properties Used to Differentiate Injectable Hyaluronic Acid Filler Products. Plast Reconstr Surg. 2019 Apr;143(4):707e720e.

33. . Carruthers A, Carruthers J, Monheit GD, Davis PG, Tardie G. Multicenter, randomized, parallel-group study of the safety and effectiveness of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/ml smooth, cohesive gel) alone and in combination for lower facial rejuvenation. Dermatol Surg. 2010 Dec;36 Suppl 4:2121-34.

34. . Küçüker İ, Aksakal IA, Polat AV, Engin MS, Yosma E, Demir A. The Effect of Chemodenervation by Botulinum Neurotoxin on the Degradation of Hyaluronic Acid Fillers: An Experimental Study. Plast Reconstr Surg. 2016 Jan;137(1):109-113.

35. . Micheels P, Besse S, Flynn TC, Sarazin D, Elbaz Y. Superficial dermal injection of hyaluronic acid soft tissue fillers: comparative ultrasound study. Dermatol Surg. 2012;38(7 Pt 2):1162-1169.

Figures 1–3 © Tinchia Hsu

Table 1 © Tinchia Hsu

COMBINING CALCIUM HYDROXYLAPATITE AND MICROFOCUSED ULTRASOUND FOR SAFE AND EFFICIENT NECK REJUVENATION

Kerstin Ortlechner explains the importance of treating the signs of neck ageing and how a combination approach is her treatment of choice

ABSTRACT

We ask a lot of our necks in this modern age. ‘Tech neck’ was already a burgeoning phenomenon but in the age of increased working from home, with many of us still holding meetings virtually, it’s taken on a new life. And holding our heads at a downward-looking angle to our smartphones for many hours a day combined with the delicate anatomy of the neck is a recipe for tech-neck related complaints.

Many patients already know, that a preventative, reparative antiageing routine is non-negotiable if you want to keep your skin looking healthy and youthful. Unfortunately, most people forget that the skin below their face is included in this maxim. Just as your face can show the effects of time and environmental damage, so too can the skin on your neck. Dark spots, wrinkles, loss of firmness, and elasticity are all

THE NECK IS AN IMPORTANT AND underappreciated factor in a person’s appearance, and addressing this area is important for a balanced approach to rejuvenation. Because this region remains generally uncovered, the chest and décolletage are at high risk for UV exposure and damage, which further accelerate the effects of ageing1

Changes in the appearance of the neck are often one of the first signs of ageing2. The muscles of the neck are constantly engaged during daily activities, twisting, bending, and engaging the platysma muscle, even more so in the modern tech-centric world. With constant use of cell phones and computers, people tend to hold their heads down for a significant portion of the day — recent global estimates suggest people use the internet for a daily average of almost 7 hours3. The physical

common issues that can appear as you age.

The rising popularity of aesthetic procedures on the face has created a gap between face and nonfacial areas. Patients are often left with an abrupt contrast between the rejuvenated face and the rest of the body.

A whole face-neck-chest approach should be a new treatment paradigm in aesthetic medicine. The combination of calcium hydroxylapatite, which improves neocollagenesis, angiogenesis and skin mechanical properties, and microfocused ultrasound with Visualisation, which promotes collagen and elastin production to reduce fine wrinkles and enhance skins overall texture, is a perfect match for a safe and efficient neck rejuvenation, proved by clinical studies and research.

consequences of constantly looking down lead to issues such as ‘tech neck,’ and this strain can contribute to accelerated ageing in the neck and chest area2. In addition, the platysma is a depressor muscle and can pull the tissue along the mandible downward, creating a sad or sagging appearance4,5.

With the increasing demand for non-invasive procedures to achieve a more refreshed, rejuvenated appearance, more patients than before are focused on facial aesthetics6. This rising popularity and the increasing number of aesthetic procedures performed on the face have created a growing need for intervention in the neck, as patients are often left with an abrupt contrast between the rejuvenated face and the rest of the body, especially the neck and décolletage. The need to manage this discordance is a substantial awareness gap for patients and is also not always top of mind for

KERSTIN ORTLECHNER, OEADV, ÖGDC, IDS Dermatologist and Board Certified by the Austrian Academy of Dermatology and Dermatosurgery; Vienna, Austria email kerstin.ortlechner@icloud.com

KEYWORDS

MFU-V, CaHA, Neck rejuvenation

With 70% of respondents in a recent survey reported being unsatisfied with features in the chin and neck area, it is important that clinicians are proactively educating patients about the need for treatment in the neck, as well as the face.

clinicians. Consequently, the same anti-ageing care that is given to the face is lacking for the neck7

Signs of ageing in the neck

Aesthetic concerns of the neck include visible platysmal bands, horizontal neck lines (necklace lines), skin laxity, loss of firmness, and increasing skin crepiness1. With 70% of respondents in a recent survey reported being unsatisfied with features in the chin and neck area, it is important that clinicians are proactively educating patients about the need for treatment in the neck, as well as the face8. Treating both areas is needed to achieve the most natural-looking results with aesthetic procedures.

Age-related changes in the neck can be attributed to tissue degeneration, gravity, and muscular damage over time5. Several anatomical features make the neck area particularly susceptible to the effects of ageing, such as thinner skin compared with other body areas, slower cell renewal, lower lipid content, and more skin stretching5,7,9. Dermal thinning and lipoatrophy result in the increased visibility of muscles and deep rhytides, as well as other signs of photodamage, such as lentigines, telangiectasia, and dyschromia. Lower fat content relative to other body areas makes it more obvious when facial fat is lost with age. Sex and body mass index (BMI) also impact the depth of the superficial fascia in the face and neck9. Paramedian platysmal bands are caused by the large amount of stretching of the skin of the neck, along with strong muscle contractions of the platysma, agerelated skin laxity, and an elevation of the medial platysma muscle fibres, which are not attached in the facial adhesion zone.

Each of these features contributes to an aged appearance in the neck area. To address the multifactorial effects of ageing and to promote optimal outcomes, a combination approach is most often required. Depending on the severity, some areas may also require multiple procedures over many visits. This article details a multilayer, combination treatment approach for treating agerelated cosmetic issues in the neck and décolletage.

Approach

Skin quality plays a key role in the way age, attractiveness, and health are perceived. Even small changes in skin surface and pigmentation patterns can have a strong impact on perceived facial attractiveness; the skin’s appearance can add or subtract as much as 20 years to a person’s perceived age10. In a recent consensus statement by expert dermatologists and aesthetic physicians, there

was strong consensus that good skin quality is defined as healthy and youthful in appearance. The below approaches aim to rejuvenate skin quality to restore volume, promote tightness, and improve skin texture to counteract the effects of ageing on the neck. This combination approach is used frequently in the author’s practice and consistently gives rise to satisfying results for patients, resolution/prevention of any discordance between the face and the neck, and rejuvenation of the neck and decolletage.

Microfocused ultrasound with visualisation

Microfocused ultrasound with visualisation (MFU-V) is a non-invasive treatment that stimulates the production of collagen and elastin to shrink and tighten skin11 MFU-V creates thermal coagulation points (TCPs), small areas of thermal injury, at precise depths within the mid-to-deep reticular layer of the dermis and subcutis11,12. The generation of TCPs triggers the healing process and neocollagenesis, which progresses into gradual skin remodelling leading to shrinkage and tissue tightening. Importantly, the addition of ultrasound visualisation (V) to MFU facilitates the precise deployment of ultrasound energy to the desired region for safe and reliable tightening and lifting of loose skin, including on the neck and décolletage11. For treating cosmetic issues in the neck area, MFU-V is the only non-invasive ultrasound with visualisation FDA-cleared to improve lines and wrinkles of the décolleté11. The efficacy and tolerability of MFU-V for cosmetic purposes are well-established, and patients treated using MFU-V require no surgery or downtime. By using MFU-V to address laxity in the neck and decolletage, the laxity itself is addressed, but the skin also behaves as younger skin with higher collagen and elastin content13

Calcium hydroxylapatite

Calcium hydroxylapatite (CaHA) is a biodegradable, injectable filler that restores volume, boosts collagen production, and is highly effective for facial rejuvenation procedures14. While the undiluted product is an excellent tool for revolumisation and creating lift and projection in the face, injection of hyperdiluted CaHA improves the skin’s mechanical properties by stimulating neocollagenesis, elastin production, dermal cell proliferation, and angiogenesis15-17. CaHA injection results in a long-lasting aesthetic effect characterised by tight and elastic skin with increased thickness14. The hyperdiluted

For treating cosmetic issues in the neck area, MFU-V is the only FDAapproved non-invasive treatment to correct rhytids in the décolletage.

CaHA procedure itself is straightforward, and a cannula is used to deposit the product in the deep subcutaneous layer, where it induces collagen and elastin. Most often, patients require 2–3 sessions, 3–4 months apart, and patients should be informed that while a filler is being used, the results are not immediate but take approximately 3 months to be apparent18. In the neck and décolletage, lessdiluted CaHA filler can also be used to correct deep rhytids that cannot be addressed with skin tightening agents alone1. Similarly to MFU-V, the neocollagenesis and thicker and younger-behaving skin resulting from CaHa treatment improves the appearance of laxity as well as fine lines.

MFU-V and CaHA — better together

Combining treatments can be a powerful tool. The combination of MFU-V and CaHA facilitates a multimodal approach that targets several effects of ageing in the neck and décolletage. Initial treatment using MFU-V shrinks and tightens loose skin, which can be followed by CaHA injection to fill in deep lines and restore missing volume. MFU-V and fillers such as hyperdilute CaHA are particularly suited for the treatment of the thin tissue in the neck area, in which deeper or ablative treatments are less applicable1. The utility of the combination of MFU-V and CaHA for treating cosmetic issues in the neck is supported by clinical studies and expert consensus, as discussed in the following section.

Supportive evidence

A 2015 expert consensus identified combination CaHA and MFU-V for the early intervention and restoration of age-related changes in the neck1. In cases of both prevention and treatment of the signs of ageing in the neck, there was strong consensus (agreement by ≥95% of advisors) for performing skin-tightening procedures using botulinum toxin as first-line therapy. At the same time, for restoration and reactivation, they advised using MFU-V and CaHA in the second and third lines, respectively1. If performing a single session to address more severe effects of ageing, experts recommend performing skin-tightening first, using MFU-V to address skin laxity, and then applying injectable therapies to fill deeper lines1. For combination applications to stimulate neocollagenesis, reduce fine wrinkles, and improve skin texture in the neck and décolletage, panel experts suggest MFU-V combined with low-viscosity HA fillers or CaHA diluted 1:1 or 1:2 using sterile saline or lidocaine1

Individually, CaHA and MFU-V are well-tolerated and have established safety profiles. More than two decades of research support the tolerability of CaHA, and microfocused ultrasound technology has been approved since 200914,15,19. When used in combination, CaHA and MFU-V are similarly safe. The first study to evaluate the safety of a combination of CaHA+MFU-V was conducted in 2014 by G. Casabona20. This split-thigh study reported no granuloma or histologic changes in a patient treated with MFU-V following injection with CaHA or hyaluronic acid fillers20. The efficacy of the filler was not affected. On the contrary, compared with single agents, areas treated using the combination approach exhibited an increased

number of collagen fibres. Thus, the addition of MFU-V to treatment with filler appeared to enhance and improve the quality of newly synthesised collagen and elastin fibres, supporting more natural outcomes20

A split-face clinical study with 20 participants illustrated the benefits of the combined use of diluted CaHA, injected subdermally, with MFU-V to correct agerelated changes in the face, neck, and décolletage17

Benefits identified in this study included stimulation of neocollagenesis, increased biosynthetic activity, increased quantity and quality of collagen and elastin fibres, and remodelling of the superficial and deep layers of the dermis17. Patients experienced age-related improvements in all treatment areas17. The procedures were well tolerated, and patients reported high levels of satisfaction with the treatment by the end of the study17

Figure 2 (A) Before and (B) after treatment with MFU-V and CaHA

Figure 1 (A) Before and (B) after treatment with MFU-V and CaHA

Another study in a larger patient population (N=45) from 2018 also reported positive outcomes with combination therapy for the neck and décolletage. In this study, procedures in the neck area were well-tolerated by men and women; 90% reported mild pain, and 10% reported no discomfort at all. Patients had significant improvements in the appearance of their necklines and décolletage scores. Neckline scores improved from 2.6 (moderate to severe lines) at baseline to 1.3 (mild lines) 90 days after treatment. Overall, the treatment led to very high levels of patient satisfaction21

Personal experience

In the experience of the author, who over the past 2 years has treated approximately 50 patients with this dualtreatment modality in the neck area, combination MFU-V plus diluted CaHA shows similar positive outcomes when used to treat the neck. The treatment approach for MFU-V depends on how many lines are present and how deep the lines are on a patient’s neck. Skin quality, the amount of collagen, and the thickness of the skin can all affect treatment. It is important to recognise the need to tailor treatment to each individual patient to avoid unwanted side effects or ineffective outcomes. When using CaHA in the neck area, the product should always be hyperdiluted: 1:1, 1:2, or 1:3 dilution may be appropriate

References

1. Fabi SG, Burgess C, Carruthers A, et al. Consensus Recommendations for Combined Aesthetic Interventions Using Botulinum Toxin, Fillers, and Microfocused Ultrasound in the Neck, Décolletage, Hands, and Other Areas of the Body. Dermatol Surg. Oct 2016;42(10):1199-1208. doi:10.1097/ dss.0000000000000869

2. Qiu H, Zhao R, Cao L, Liu S, Yu D, Wang H. The Aesthetic Concerns of Botulinum Toxin Type A in the Treatment of Neck Wrinkles: A Systematic Review. Aesthet Surg J. May 18 2021;41(6):Np592-np601. doi:10.1093/asj/sjaa312

3. DATAREPORTAL. Digital 2022: Global Overview Report. Updated January 26, 2022. Accessed June 29, 2022. https://datareportal.com/reports/ digital-2022-global-overview-report.

4. Levy PM. The ‘Nefertiti lift’: a new technique for specific re-contouring of the jawline. J Cosmet Laser Ther. Dec 2007;9(4):249-52. doi:10.1080/14764170701545657

5. Brandt FS, Bellman B. Cosmetic use of botulinum A exotoxin for the aging neck. Dermatol Surg. Nov 1998;24(11):1232-4. doi:10.1111/j.1524-4725.1998. tb04103.x

6. American Society of Plastic Surgeons. Plastic Surgery Statistics Report 2020. Accessed August 2,

Key points

Holding our heads at a downward-looking angle to our smartphones for many hours a day is a recipe for tech-neck related complaints

Specific anatomical features on the neck make it more prone to ageing than other parts of the body

The rising popularity of aesthetic procedures in the face has created a gap between face and nonfacial areas

A whole face-neckchest approach should be a new treatment paradigm in the aesthetic medicine

2022. https://www.plasticsurgery.org/documents/ News/Statistics/2020/plastic-surgery-statistics-fullreport-2020.pdf.

7. Kim E, Cho G, Won NG, Cho J. Age-related changes in skin bio-mechanical properties: the neck skin compared with the cheek and forearm skin in Korean females. Skin Res Technol. Aug 2013;19(3):236-41. doi:10.1111/srt.12020

8. American Society for Dermatologic Surgery 2021 Consumer Survey on Cosmetic Dermatologic Procedures. https://www.asds.net/portals/0/PDF/ consumer-survey-2021-infographic.pdf

9. Casabona G, Frank K, Koban KC, et al. Influence of Age, Sex, and Body Mass Index on the Depth of the Superficial Fascia in the Face and Neck. Dermatol Surg. Nov 2019;45(11):1365-1373. doi:10.1097/ dss.0000000000001909

10. Fink B, Grammer K, Matts PJ. Visible skin color distribution plays a role in the perception of age, attractiveness, and health in female faces. Evolution and Human Behavior. 2006;27(6):433-442.

11. Fabi SG, Joseph J, Sevi J, Green JB, Peterson JD. Optimizing Patient Outcomes by Customizing Treatment With Microfocused Ultrasound With Visualization: Gold Standard Consensus Guidelines from an Expert Panel. J Drugs Dermatol. May 1

depending on the thickness of the patient’s skin. The author prefers RADIESSE® (Merz North America, Inc) without lidocaine and dilutes it with saline and 1% Xylanaest® (Gebro pharma) plus epinephrine. The total dilution is 1.5mL Radiesse plus 1 mL saline and 0.5 ml Xylanest plus epinephrine. The author recommends using a blunt-tip cannula and prefers the threading technique. Massage the product out to avoid bumps and lumps.

As shown in Figure 1, patients experience tightening and lifting of the skin along the jawline and neck, improvements in the visibility of the jawline, and decreased skin laxity. Similar results were obtained for women and men (Figure 2).

Ultimately, thorough patient consultation and education are key to managing expectations and supporting satisfaction with the treatment. Explain to patients that it is not possible to achieve miracles with this treatment, but enhancing and improving their appearance is very attainable. In this era of prioritising a natural look, MFU-V is the only treatment available that does not alter unique aspects of the patient’s face; there is no risk for ballooning or overfilled faces with this approach. Combination with the biostimulatory activity of CaHa is key. Do not neglect the neck!

Conclusions

The neck is a key component of facial appearance that should be considered as part of a treatment plan to improve facial aesthetics. Combination treatment with CaHA and MFU-V is safe and effective for treating the neckline and leads to high levels of patient satisfaction. Clinicians should consider this combination approach for the correction of age-related changes in the neck and décolletage.

Declaration of interest Dr Ortlechner advises Loreal, Vichy, SkinCeuticals, Eucerin, MERZ Aesthetics, and Dyson

2019;18(5):426-432.

12. Laubach HJ, Makin IR, Barthe PG, Slayton MH, Manstein D. Intense focused ultrasound: evaluation of a new treatment modality for precise microcoagulation within the skin. Dermatol Surg. May 2008;34(5):727-34. doi:10.1111/j.1524-4725.2008.34196.x

13. Casabona G, Kaye K. Facial Skin Tightening With Microfocused Ultrasound and Dermal Fillers: Considerations for Patient Selection and Outcomes. J Drugs Dermatol. Nov 1 2019;18(11):1075-1082.

14. Loghem JV, Yutskovskaya YA, Philip Werschler W. Calcium hydroxylapatite: over a decade of clinical experience. J Clin Aesthet Dermatol. Jan 2015;8(1):38-49.

15. Yutskovskaya Y, Kogan E, Leshunov E. A randomized, split-face, histomorphologic study comparing a volumetric calcium hydroxylapatite and a hyaluronic acid-based dermal filler. J Drugs Dermatol. Sep 2014;13(9):1047-52.

16. Berlin AL, Hussain M, Goldberg DJ. Calcium hydroxylapatite filler for facial rejuvenation: a histologic and immunohistochemical analysis. Dermatol Surg. Jun 2008;34 Suppl 1:S64-7. doi:10.1111/j.1524-4725.2008.34245.x

17. Yutskovskaya YA, Sergeeva AD, Kogan EA. Combination of Calcium Hydroxylapatite Diluted With Normal Saline and Microfocused Ultrasound With Visualization for Skin Tightening. J Drugs Dermatol. Apr 1 2020;19(4):405-411. doi:10.36849/jdd.2020.4625

18. Lorenc ZP, Black JM, Cheung JS, et al. Skin Tightening With Hyperdilute CaHA: Dilution Practices and Practical Guidance for Clinical Practice. Aesthet Surg J. Jan 1 2022;42(1):Np29-np37. doi:10.1093/asj/ sjab269

19. Merz. Ultherapy System: Instructions for use. Merz North America, 2019. Accessed June 29, 2022. https://ultherapy.com/app/ uploads/2021/10/1015107IFU-Rev-A-US-Instructionsfor-Use.pdf.

20. Casabona G, Michalany N. Microfocused ultrasound with visualization and fillers for increased neocollagenesis: clinical and histological evaluation. Dermatol Surg. Dec 2014;40 Suppl 12:S194-8. doi:10.1097/dss.0000000000000231

21. Casabona G, Nogueira Teixeira D. Microfocused ultrasound in combination with diluted calcium hydroxylapatite for improving skin laxity and the appearance of lines in the neck and décolletage. J Cosmet Dermatol. Feb 2018;17(1):66-72. doi:10.1111/ jocd.12475

Figures 1–2 © Kerstin Ortlechner

The neck is a key component of facial appearance that should be considered as part of a treatment plan to improve facial aesthetics.

TREATING THE NASOLABIAL FOLDS WITH A POLYCAPROLACTONE FILLER

Expert consensus on the use of polycaprolactone-based Ellansé — a novel collagen-stimulating filler — for multi-site and multi-level injection of the outer facial contour to improve nasolabial folds

ABSTRACT

In May 2022, the China Medical Adviser Board (MAB) and dozens of domestic experts discussed and reached a consensus on the clinical application of polycaprolactone-based Ellansé S a novel collagenstimulating filler— for multi-site and multi-level injection of the outer facial contour to improve nasolabial folds. The purpose of this consensus is to provide clinical reference and advice for clinicians to use Ellansé to improve nasolabial folds.

IN MAY 2022, THE CHINA MEDICAL ADVISER Board (MAB) and dozens of domestic experts discussed and reached a consensus on the clinical application of polycaprolactone-based Ellansé S (AQTIS Medical B.V., The Netherlands) — a novel collagen-stimulating filler — for multi-site and multi-level injections on the outer facial contour to improve the nasolabial folds. The purpose of this consensus is to provide clinical reference and advice for clinicians on how to use Ellansé to improve nasolabial folds.

KEYWORDS

Ellansé, Polycaprolactone, nasolabial folds

The nasolabial fold, a depression area on the face extending from the lateral alae nasi to the corner of the mouth, is a demarcation line separating the cheek and jaw and a marker of facial ageing1. It can now be treated through face lifting, surgery, and filler injection, among which, the filler injection is a minimally invasive procedure producing a reliable filling effect with very good safety and stability when avoiding surgical wounds or incisions as well as some postoperative complications. Because of this, it is highly accepted among patients and widely used.

At present, the injection of fillers is the most extensively

used method for the correction of nasolabial folds. In this consensus, external contour injections are applied to improve nasolabial folds, which introduces the concept of the ligament line. In this method, one end of the ligament attaches to the bone and supports the soft facial tissues with the bone surface as a fulcrum. In the meantime, the lateral injection of fillers (i.e. external contour injection) can strengthen the ligament’s supporting effect in the ligament area and pull the soft tissues in the middle and lower faces upward to produce a lifting effect2–4. With the lifting effect, the skin moves toward the ears and temples, and the sagging soft tissues gradually return to their original position, thus improving the nasolabial folds due to soft tissue ptosis5,6. Injection at the temples, middle cheek, and lower mandible may not only lift the ligaments but also produce a noticeable lifting effect, as these sites are most likely to show signs of ageing2. A novel injection technique is proposed as guidance for the effective operation of filler in these areas.

Ellansé is a novel collagen-stimulating filler with high safety and efficacy. According to a study conducted by Hassan Galadari comparing polycaprolactone (PCL) and

hyaluronic acid (HA) in the correction of nasolabial folds, Ellansé had a longer maintenance time for correction treatment of nasolabial folds, and the average injection volume of PCL fillers was 13% less than that of HA7

Material characteristics

The main component of Ellansé are the 25-50 μm polycaprolactone (PCL) microspheres suspended evenly in gels composed of carboxymethylcellulose (CMC). Ellansé features superior viscoelasticity8 compared to other biofillers, and PCL degrades in vivo by means of bulk degradation9. Unlike other regenerative materials that will elicit strong secondary inflammatory responses as they degrade in vivo9, PCL microspheres keep their volume and morphology unchanged during degradation (i.e. no secondary inflammatory reaction will be elicited).

CMC has been Generally Recognized As Safe by the FDA. In rheology, CMC is a pseudoplastic fluid; the viscosity of CMC decreases significantly with the increase of shear stress, and such a sharp decrease in viscosity makes it easy to be injected through thinner needles. Ellansé S has a very high elastic modulus G’, which is about 1000Pa8. The rheological properties of

The purpose of this consensus is to provide clinical reference and advice for clinicians on how to use Ellansé to improve nasolabial folds.

the filler with high cohesion can produce a good lifting effect and can increase tissue projection by providing hardness and resistance to muscle and gravity to achieve lifting10. Therefore, for this technique, we suggest the injection of fillers of a high elastic modulus (G′) or high cohesion with needles to maximise the lifting effect.

CMC gel in the filler has an immediate filling effect and is gradually absorbed by the human body after 2–3 months14–15; while CMC gel degrades, PCL stimulates approximately the same amount of new collagen. Ellansé’s lasting filling effect comes from collagen regeneration and deposition. Ellansé has the following efficacies:

■ The immediate filling effect through the CMC gel

■ Lasting shaping effect based on Type I collagenous fibre scaffold formed by biostimulation of PCL microspheres

■ Extremely high elastic modulus G′ resulting in good supporting and lifting effect.

Clinical application of Ellansé S for multi-site and multi-level injections on the outer facial contour to improve nasolabial folds

The external contour injection is a multi-level injection method that can improve the nasolabial folds and ensure the safety of the injection process. The injection levels selected by this method are on the periosteum, between the deep temporal fascia and the superficial temporal fascia, and the subcutaneous fat layer, which are

relatively safe levels with relatively few significant vessels and nerves.

Injection method and effect

Before injection, a facial photo shall be taken after face cleansing. After disinfection with iodophor, the treatment is conducted from top to bottom, from outside to inside, and from deep to shallow according to the scheme for external contour injection.

For shaping the external contour of the temporal hairline, the injection levels are the subcutaneous fat layer, the middle temporal fascia layer, and the periosteum. The injections should result in the removal or reduction of the temporal contour, improving temporal depression, lifting the soft tissues in the middle and lower faces, and improving nasolabial folds.

When injecting at the cheek, the injection level targeted is the subcutaneous fat layer. This should result in the removal or reduction of the contour of the posterior cheek, improving cheek depression, lifting the soft tissues in the middle and lower faces, and improving nasolabial folds.

At the mandibular margin, the injection layer is the subcutaneous fat layer or on the periosteum. Resulting in the aesthetic effect of lifting and shaping the mandibular margin, drawing away the contour, improving cheek depression, lifting the soft tissues in the middle and lower faces, and improving nasolabial folds.

Points for attention when performing this treatment:

■ Within 4 hours, the injection site should be protected from contact with water;

■ Within 24 hours, no makeup is allowed at the injection site;

■ Within 3 days, no facial massage is allowed to avoid displacement, and excessively exaggerated facial expressions should be avoided;

Key points

The main component of Ellansé is 25-50 μm polycaprolactone (PCL) microspheres

Ellansé features superior viscoelasticity compared with other biofillers

The treatment is conducted from top to bottom, from outside to inside, and from deep to shallow

The external contour injection technique can effectively lift the soft tissues in the middle and lower faces and improve nasolabial folds by multi-site and multi-level injection on outer facial contour

■ Within 7 days, no alcohol, spicy food, allergy-causing food, etc. is allowed, and strenuous exercise should be avoided; and

■ Within 6 months, long-term oral administration of hormones, immunosuppressants and other drugs affecting collagen regeneration is not recommended.

Efficacy and safety of Ellansé S in clinical application

In a study conducted by Marion Moers-Carpi et al. on the long-term safety and efficacy of Ellansé S in Europe, the WSRS score showed a significant improvement rate of 84% after 12 months and 64% after 18 months; according to GAIS assessment, the improvement rate was 91% after 12 months, 83% after 18 months, and more than 50% of subjects believed that skin quality had been improved within 18 months11

From the launch of Ellansé in Europe in 2009 to October 2021, the incidence of adverse events of Ellansé was 0.0619%, equivalent to one adverse event in every 1,616 clinical cases; most of the reported adverse events were minor, such as nodules and swelling, which were often associated with injection operation. In which nodule/mass accounted for 0.277%, swelling 0.0181%,

Figure 1 Case picture of nasolabial fold correction by external contour injection. (Left) Before, (Middle) after, and (Right) 3 months after. Photos courtesy of Dr. Dai Xia (The 8th minimally invasive Cosmetology committee of Chinese Medical Association Cosmetology Society)

bruising/hematoma 0.0015%, infection 0.0012%, and induration 0.0075%. Ellansé has been established in Europe for 13 years and is a safe and effective collagenstimulating filler certificate by the National Medical Products Administration in 2021.

Discussion

Since Furnas introduced the concept of the ligament line13, many studies have focused on how it could be further used for facial rejuvenation. A study conducted by Gabriela Casabona et al. in 2019 described the lifting effect of temporal injection on the lower face, providing evidence for the lifting effect of temporal injection on the middle and lower faces14. According to the study of Schenck et al., the injection at the outer side of the ligament line, followed by an injection at the inner side, can not only lift the middle and lower faces but also reduce the dose required for the medial face area (inner side of the line of ligaments) to achieve an aesthetic effect

From the perspective of anatomy, the external contour injection can lift facial soft tissues and reduce the appearance of nasolabial folds. However, for the sake of injection in a safe and effective manner, there are still several principles to be followed. First, inject from top to bottom, which can prevent the soft tissue that has already returned to its original position from moving down again; Secondly, inject from outside to inside, where the continuous nature of fascia

The main component of Ellansé are the 25-50 μm polycaprolactone (PCL) microspheres suspended evenly in gels composed of carboxymethylcellulose (CMC).

References

1. Miao Xiaoyan, Zheng Jie, Dou Shuqian, et al. Clinical Efficacy Observation of Deep Injection of Hyaluronic Acid in Nasolabial Fold Area and Nasal Base Area[J]. Chinese Journal of Aesthetic Medicine, 2022,31(06):36-39

2. Freytag L, Alfertshofer M G, Frank K, et al. Understanding Facial Aging Through Facial Biomechanics: A Clinically Applicable Guide for Improved Outcomes[J]. Facial Plast Surg Clin North Am, 2022,30(2):125-133.

3. Cong L Y, Duan J, Luo C E, et al. Injectable Filler Technique for Face Lifting Based on Dissection of True Facial Ligaments[J]. Aesthet Surg J, 2021,41(11): P1571-P1583.

4. Casabona G, Bernardini F P, Skippen

B, et al. How to best utilize the line of ligaments and the surface volume coefficient in facial soft tissue filler injections[J]. J Cosmet Dermatol, 2020,19(2):303-311.

5. Casabona G, Frank K, Koban K C, et al. Lifting vs volumizing-The difference in facial minimally invasive procedures when respecting the line of ligaments[J]. J Cosmet Dermatol, 2019, 18(5): 1237-1243.

6. Haidar R, Freytag M D D, Frank K, et al. Quantitative Analysis of the Lifting Effect of Facial Soft-Tissue Filler Injections[J]. Plast Reconstr Surg, 2021,147(5):765e-776e.

7. Galadari H, van Abel D, Al Nuami K, Al Faresi F, Galadari I. A randomized, prospective, blinded, split-face,

helps the medial soft tissue move, which can reduce the injection volume. Finally, inject from deep to shallow, where injection into the bone surface is given as the first step to provide support for the overlying soft tissues, which is like laying the foundations of a building. Only in this way can the soft tissues better return to their original positions. If you inject first into the shallow fat layer, it can result in unnatural facial expressions or a ‘false face.’

The excellent high viscoelasticity of Ellansé can produce a good lifting effect; meanwhile, PCL microspheres stimulate collagen production, and the filling effect is aesthetic and natural without creating a ‘false face.’ The external contour injection technique can effectively lift the soft tissues in the middle and lower faces and improve nasolabial folds through multi-site and multi-level injections on the outer facial contour. Ellansé, a structurally stable filler injected in a safe and reliable manner, can produce a long-lasting filling effect, both aesthetic and natural, and with which the subjects expressed a high degree of satisfaction.

Acknowledgements

consensus was discussed and approved by Luo Shengkang, Li Qin, Cui Haiyan, Shi Bing, Yang Rongya, Lin Shangli, Wang Hang, Zhao Hongyi, Song Weimin, Huang Jianmei, Liu Bin, Wang Yongshu, Zhu Bainian and Chen Ruihong at “Expert Consensus Seminar on Ellansé” held in May 2022. This consensus is prepared by:

single-center study comparing polycaprolactone to hyaluronic acid for treatment of nasolabial folds. J Cosmet Dermatol. 2015 Mar;14(1):27-32. doi: 10.1111/jocd.12126. Epub 2015 Jan 6. PMID: 25564797.

8. Christen M O, Vercesi F. Polycaprolactone: How a Well-Known and Futuristic Polymer Has Become an Innovative Collagen-Stimulator in Esthetics[J]. Clin Cosmet Investig Dermatol,2020,13:31-48, doi:10.2147/ccid. S229054.

9. Woodruff M A, Hutmacher D W. The return of a forgotten polymer— Polycaprolactone in the 21stcentury[J]. Progressin Polymer Science2010,35(10):1217-1256, doi:

10.1016/j.progpolymsci.2010.04.002.

10. Cong LY, Duan J, Luo CE, Luo SK. Injectable Filler Technique for Face Lifting

Based on Dissection of True Facial Ligaments. Aesthet Surg J. 2021 Oct 15;41(11):NP1571-NP1583. doi: 10.1093/asj/ sjaa348. PMID: 33300562.

11. Moers-Carpi M, Christen MO, Delmar H, et al. EuropeanMulticenter Prospective Study Evaluating Long-Term Safety and Efficacy of the Polycaprolactone-Based Dermal Filler in Nasolabial Fold Correction. Dermatologic surgery: official publication for American Society for Dermatologic Surgery ,2021, 47(7): 960-965.DOI:10.1097/ DSS.0000000000002978.

12. Ellansé EXPERT GUIDELINE

13. Furnas DW. The retaining ligaments of the cheek. Plast Reconst Surg. 1989;83(1):11–6.

14. Casabona G, Frank K, Koban KC, Freytag DL, Schenck TL, Lachman N, Green JB, Toni S, Rudolph C, Cotofana S. Lifting vs volumizing-The difference in facial minimally invasive procedures when respecting the line of ligaments. J Cosmet Dermatol. 2019 Aug 12. doi: 10.1111/jocd.13089. Epub ahead of print. PMID: 31402563.

15. Schenck TL, Koban KC, Schlattau A, et al. The functional anatomy of the superficial fat compartments of the face. Plast Reconstr Surg.2018;141(6):1351-1359.

Our clear goal is to become a much stronger global player, joining the ranks of the top three.

ANDREAS PRINZ

In recent years, Croma has become an important player in the industry. What were the major developments in 2022?

You may be aware that we added a botulinum toxin to our already broad portfolio last year. It was the missing puzzle piece that propelled us into the top player segment. We started with the roll-out in our European core markets. This phase is complete – and we will now launch in further markets.

Croma is an Austrian family company. Remind us, how did the family business get started?

We did not start in a garage — but in a pharmacy at the heart of Vienna. My parents, both pharmacists, founded Croma in 1976. Since our foundation, we

have been striving for innovation; first we in-licensed innovative products, later we started on the R&D of our own products. We kicked off our HA syringe production in a tiny, five square-metre clean room in that pharmacy. Our roots actually lie in ophthalmology and orthopaedics. About 25 years ago we launched our first ophthalmological hyaluronic acid products. It was only in 2009 that we started moving into dermatological aesthetics. We completely shifted our focus to minimally invasive aesthetics in 2014 and built our complete portfolio.

Can you elaborate — what is a complete portfolio for you?

For us, a complete portfolio means covering all relevant minimally invasive aesthetic medicine segments: toxin, a

broad range of HA fillers, PDO threads and biostimulators. Here, we currently have platelet-rich plasma and PN (polynucleotide) injectables. We are further complementing this with our own skincare line.

What do you personally see as an important trend in our industry?

There is a clear trend towards more holistic treatments, smartly combining different products and techniques to achieve the ultimate result. To support these holistic treatments, we want to offer our customers all the products required in their practice for their full face approach from one trusted source. That is why we have built one of the most comprehensive portfolios in the industry in recent years.

PRIME talks to Andreas Prinz, Managing Director of Croma, on recent developments, products, and their plans for long-term success

And what’s next in the pipeline?

Our R&D teams are working on nextgeneration biopolymers and composites. We have a disruptive, proprietary technology supporting our nextgeneration HA fillers. This will result in a plethora of new products. We will move from ‘face only’ products to products for the body as well.

You surprised the industry right before Christmas last year when you announced that you are combining with a SPAC. Can you tell us more about that?

We are and will remain a successful Austrian family business. The launch of our botulinum toxin was an inflection point for us as a company. It paved the way for a major growth step. Our clear goal is to become a much stronger global player, joining the ranks of the top three. To give us this impetus, we needed a strong partner.

Who are the proponents behind this SPAC?

Our partner is EHC, European Healthcare Acquisition & Growth Company, a strategic investor. It is comprised of former German top pharma industry leaders, who were at the helm of Merck, Qiagen or Gerresheimer, to name a few. They believe in our business model and prospects. As you mentioned, EHC is a SPAC and trades on the Euronext in Amsterdam.

You mentioned that Croma will remain an Austrian family business. How so, if the plan is to go public?

My family will hold a significant majority of the future combined company and we will continue to pilot Croma. My colleague and company CFO Peter Haidenek and I will be the two members of the management board of the resultant combined company. And, of course, we will keep our headquarters and manufacturing site right where we are today.

I heard you opened a new manufacturing site?

We opened our new and now fully automated HA syringe manufacturing plant close to Vienna in 2018. Today, we are a leading manufacturer of premiumquality HA syringes. We have transferred the high standards for ophthalmology

and orthopaedics to HA for aesthetic use. We are currently producing 7 to 8 million syringes per year.

And if the transaction is successful — where will Croma be heading?

We will invest in our sales team and sales execution, ramping up our support for our customers in our markets. We will expand geographically, which has always been a priority for us. Today we have 13 subsidiaries in Europe and Brazil and 60 distribution partners. That is not the end of it. We will also drive innovation, and we will strengthen our clinical program to bring our innovations to the market faster.

You mentioned ramping up the support for your customers. What makes Croma special with regard to customer support in your opinion?

We are a growth company. Being that ourselves, we care for the long-term success of our customers. We want to support them in their business and their growth. We value partnership with our customers. They can count on personal support. We try to be available 24/7 and to act fast, with flexibility and solutionorientation – which is not a given in our industry.

MARK WILSON

Allergan Aesthetics is one of the biggest names in the industry. What would you attribute that success to?

For me, the key has been building a deep understanding of practitioners and their patients. And based on this, constantly innovating to deliver quality sciencebacked technologies and treatments that meet their unmet needs and advance the field of aesthetic medicine. As a company, we are always looking to encourage open dialogue and listen to all perspectives. From connecting with thousands of consumers globally each year to understand their changing views, to listening to our customers and what they tell us about their patients’ motivations and needs. As the world around us evolves, we are driven by our mission to

empower confidence in the patients and practitioners of today and tomorrow.

How does Allergan Aesthetics support practitioners and patients?

Everyone is different, and it’s important for us to understand the individual needs of the patients our customers serve. They are more than just a face or body, just like a practitioner is more than just an injector or a technician. And I see us as more than just a pharmaceutical company. By taking a 360° view, we look at all angles of the aesthetics journey to support practitioners and their patients at every step of the way. From the very first consultation to the moment a practitioner uses one of our products, we’re focused on being there to listen, enhance their skills and support them and their patients.

The Allergan Medical Institute (AMI) provides bespoke, quality educational programs to practitioners all around the world to help them hone their skills and pursue the highest levels of clinical excellence. Through various forums we aim to train over 75,000 practitioners globally every year. We offer expert-led training, online learning, and exclusive resources, so practitioners can confidently deliver outcomes that help their patients achieve their aesthetic goals.

Enhancing the patient-practitioner consultation is key. Through AMI and investment in consumer education we aim to support practitioners to navigate, communicate, and enhance this process to ensure patients are informed and empowered to confidently get the best out of their aesthetics journey.

PRIME talks to Mark Wilson, VP International Marketing & Commercial Operations at Allergan Aesthetics, an AbbVie Company, on his vision for the future of the industry

The world is changing — how can you continue to meet the expectations of patients?

In recent years, we have seen a vast increase in consumer awareness and openness to aesthetics, combined with a rise in treatment options available. This means that expectations are naturally changing, and there is a need for us to better understand the evolving patient.

Last year we commissioned the Future of Aesthetics Global Trends Report to identify and understand the underlying social and cultural drivers and trends that are shaping the industry, so we can better prepare for the future.1 Our findings showed that people of all ethnicities, backgrounds and ages are seeking out aesthetic medicine, and that beauty is dropping the gender divide. Ultimately, people want to see themselves reflected and represented. By exploring these trends, we’re aiming to help practitioners understand how to connect, treat, and cater for the patient of tomorrow.

This in-depth understanding of patient needs also enables us to focus on what’s next. With science as our foundation, we continue to innovate to discover tomorrow’s therapies so that our diverse and comprehensive product portfolio can support individual patients’ aesthetics journey.

As the new VP of international marketing and commercial operations, what is your vision for the future of aesthetics?

The aesthetics industry is set to grow at a faster pace than ever before2 and we need to adapt and prepare for that. Our report only provided a glimpse of what’s to come, but it’s evident that inclusive beauty is the future, with gender and ethnicity no longer limiting aesthetic desires. For many, aesthetics is now part of everyday selfcare, a shift we are seeing all over the world. But we also know that people need to be informed and able to make aesthetics choices that are right for them. Education will therefore be central to the future of this industry.

As leaders in the industry, we also have a part to play in growing the aesthetics market responsibly. An important part of future proofing the industry is that as aesthetics treatments are medical procedures, it is driven by high ethical standards. This was a key

finding in our report, that ethics is a priority for practitioners and patients. We hold ourselves to a high standard, and so do our customers, which is why ethics will be one of the topics we’re covering during our AMI symposia at AMWC this year.

Then finally, our company ethos is about the power of confidence: of shaping your own life, your own business, your own look. And so, when I think about a vision for the future, from an Allergan Aesthetics perspective, it will be continuing to focus on doing everything we can to help make that happen.

What are you excited about for the year ahead?

2022 was a busy year for Allergan Aesthetics. We reached the global milestone of shipping 100 million syringes of JUVÉDERM®, 3 which is a great source of pride for everyone at the company and demonstrates our dedication to patients and practitioners globally. We also launched HArmonyCa™, our first hybrid injectable, which is now available across many European markets as well as Latin America. This year, we will be building on these achievements and continuing to help our customers unlock their patient’s individuality with Allergan Aesthetics 360°, for all their practice, product, and patient needs. This year is set to be exciting!

Allergan Aesthetics will be at AMWC in Monaco this year. To unlock your patient’s individuality with Allergan Aesthetics 360° visit us on booth K2 and join our symposia ‘Discover your 360° with Allergan Aesthetics: Practice, Products, Purpose’ at 10.45AM on Thursday 30 March and ‘Unlocking your patient’s individuality with Allergan Aesthetics 360°’ at 9.45AM on 31 March, both in the Salles de Princes, Grimaldi Forum.

Disclaimers

This is a promotional material funded and developed by Allergan Aesthetics, an AbbVie company.

• Licence details and indications may vary between countries— Please consult individual product Directions for Use.

• HArmonyCa™ Lidocaine is referred to as HArmonyCa™ throughout. Common postoperative adverse events can include erythema, edema (swelling), pain, tenderness, and itching.

• Patients may experience potential side effects after treatment with Juvéderm® facial filler, which include: inflammatory reactions (redness, oedema, erythema, etc.), haematomas, induration or nodules, staining or discolourations at the injection site, etc.

• Adverse events should be reported to your local regulatory authority and Allergan Aesthetics office.

References

1. Allergan Aesthetics. The Future of Aesthetics Global Trends Report. May 2022. ALL-AGNA-220005.

2. Medical Insight. The Global Aesthetic Market Study: XIX. November 2021.

3. Allergan Aesthetics. Data on File. REF-96563

UNRAVELLING THE VALUE OF LOYALTY PROGRAMMES TO ENTICE CUSTOMERS AND KEEP THEM COMING BACK

Wendy Lewis takes a deep dive into strategies for engaging clients and building long-term relationships

THE LOOMING THREAT OF RECESSION, supply chain disruptions, higher fuel costs and rising interest rates may present challenges for keeping clients coming back to your aesthetic clinic on a regular basis. So, how are you planning to protect the future of your aesthetics business?

One age-old strategy that tends to pop up when the heat is on is to slash your prices. Try to resist the temptation!

First, this move sends the wrong message to your clients and competitors. It can make you seem desperate for sales. Sure, it may be easy to lower your prices during a slow period, but that can make it much harder to raise your rates to a more reasonable level in the near future. Moreover, too-frequent discounting can have a long-term effect on your position in the marketplace and put a dent in your bottom line. Discounting attracts a different kind of client, so proceed with caution.

Instead of reducing fees or scaling back on service and perks, think about how you can maximise the value you offer to clients. Get past the transactional aspect of your relationship with them and consider ways you can enhance the experience your clinic provides. Start by focusing on

patients’ needs and wants.

For example, what are they looking for that you may not be delivering? Do you need to offer evening or Saturday appointments? Are they keen to take advantage of package pricing for the most popular repetitive treatments? Are you offering incentives that keep patients coming back to your clinic and make them think twice about straying?

As former First Lady Michelle Obama said, ‘When they

Enhance the experience you offer

Ask yourself, ‘Where is there room for improvement?’ You probably already have the answers from your patients. It’s important to evaluate your reviews carefully and take client feedback seriously. If you want more intel, try sending a survey to a specific segment of current clients to learn more about their thoughts and experiences. This can be accomplished via email or text messaging. These tools can be very enlightening, and they are likely to tell their friends and family anything they are willing to tell you. To get the most honest responses, make the survey

anonymous or name optional.

Think of it as a ‘How are we doing?’ exercise. It demonstrates that you care about what they think and are trying to engage with them on a deeper emotional level to keep them loyal to your practice or medspa.

Building lasting trust

In my view, establishing customer loyalty from the first time a patient or client connects with your brand is a critical success factor. This includes any query by any means of communication, such as a standard phone call, email, text, chat, or a comment on one of your social channels.

Building trust will help clients to feel secure and safe in the knowledge that you are an expert in what you do, with an absolute right to be doing it. If they like and respect you as well as your team, are content with the treatments and results you deliver, and their experience resonates with their hearts and minds, the relationship will be strengthened over time.

Maintaining trust with current patients and clients is equally critical. Aim for consistency with messaging, services, wait times (or lack thereof), ease of appointment scheduling, billing, and more. Each visit to your clinic or medspa should meet their expectations and be consistent with their expectations. Aesthetic patients, in my experience, do not like surprises unless they are the good kind (which are always welcome).

Key benefits of a loyalty programme

Consumers are flocking to loyalty programmes more than ever before across all companies they do business with. This strategy is one of the most effective ways to leverage client relationships to entice them to return for repetitive treatments.

According to Shopify, over 90% of companies have some type of customer loyalty programme. ‘Loyalty programmes have proven themselves as one of the most effective tactics for increasing revenue and inspiring customer loyalty. As many as 84% of consumers say they’re more apt to stick with a brand that offers a loyalty programme, and 66% of consumers say the ability to earn rewards changes their spending behaviour.’1

Loyalty and membership programmes are well known to improve customer retention rates by keeping them engaged with your practice. Offering customers ‘points’ and ‘perks’ for their loyalty can help to acquire and retain customers cost-effectively.

According to Theda C. Kontis, MD, FACS, a facial plastic surgeon in Pikesville, MD, and President of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), ‘In our practice, we offer a special benefit programme to our injectable patients. For example, when they buy 5, they will get the 6th one free. This presents a huge saving to patients; they can get a neurotoxin or dermal filler and save from $450 to $800 USD.’

‘In a very competitive market, we have seen patients return to our office for treatments rather than jumping around and price shopping. However, with the advent of new fillers and toxins that are lasting longer, it takes

patients a long time to get a free one, so the benefit has less impact,’ she says.

Look to major retailers for ideas

Familiarise yourself with how airlines and hotel chains operate their loyalty programmes—you’re likely a member of a few of these yourself! Take a closer look at what restaurants, nail salons, and hair emporiums in your local market are doing to get a sense of what your patients and clients may be accustomed to from other popular service-based businesses.

Once a client has made contact with or visited your clinic, it’s vital to maintain that relationship and strengthen it at every opportunity. The power of reciprocity can be incredibly useful, whereby a positive action is met with a positive response. Remember, this is not a gift without ties but a gesture that can be followed up with a request.

For example, this thank-you ‘gift’ could come in the form of loyalty incentives, discount codes, or educational content such as aftercare advice, how-to guides and tutorials. In turn, the client may wish (or you could ask them) to return to the clinic again (perhaps for additional services), refer friends and family, provide positive feedback, or share your business on social media.

The anatomy of a loyalty programme

Delivering the ultimate experience for every customer touch point — before, during, and after product purchase or treatment — is a smart strategy for this competitive aesthetic market. To bolster loyalty, reward postpurchase clients and patients with something extra in terms of convenience, sampling, access to new product trials, or anything else patients have expressed a desire for. There are several ways to structure a loyalty programme.

Point-based loyalty programmes

These are the most common type of rewards programmes. They allow clients to accumulate reward points that can be redeemed for cash back, perks, extra treatments, or products. Points can be earned from purchases, as well as by sharing their experience on social channels, leaving reviews, birthdays, inviting friends to participate in special events, and more.

As an aesthetic provider, you may already be familiar with point-based loyalty programmes, as many companies offer some variation of this concept. In the US, AbbVie’s Alle programme is a notable example, and its strengths lie in its wide portfolio of brands that fall under the rewards umbrella. These include Botox Cosmetic®, Juvéderm® products, Kybella®, CoolSculpting®, Natrelle® breast implants, SkinMedica®, and Latisse®, as well as non-invasive skin treatments and surgical procedures.

‘Earn points on Allē Brands, as well as a variety of other in-office products and treatments like microdermabrasion, laser hair removal, and more. When you’re ready to use your points, just let your provider know you’re an Allē

WENDY LEWIS is Founder/ President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy since 1997, author of 13 books, Editor in Chief of beautyinthebag.com, and frequent presenter on the international stage. Her first textbook, Aesthetic Clinic Marketing in the Digital Age (CRC Press) will debut a second edition in 2023. contact wl@wlbeauty.com

One age-old strategy that tends to pop up when the heat is on is to slash your prices. Try to resist the temptation!

Member, and they’ll redeem them from your Allē Wallet. Every 100 points earns you $10 in savings toward a future Allē product or treatment.’2

Tiered loyalty programmes

Tiered programmes offer clients different benefits depending on their rank, and the metrics used to determine rank can include the amount of money spent, the number of purchases, and engagement. These customer rewards programmes give clients a goal. The higher their tier, the more exclusive and better rewards they’ll receive. Clients simply sign up for the programme and start getting rewards right away. The more they spend with a brand, the more perks they get.

The swim and beachwear brand Cupshe offers a brilliant example. Their ‘Sunchasers’ club has four tiers, ‘Shore’, ‘Sand’, ‘Sea’, and ‘Sun’, which members move up as they spend more. To keep shoppers notified of their current position, the bikini brand shows shoppers their current tier, points balance, and how close they are to moving up as soon as they log in. Members in all tiers get baseline perks.

With Cupshe’s tiered loyalty programme:

■ Engaged members now spend 38% more than average shoppers

■ Loyalty programme fans spend 26% more than one-time shoppers

■ Long-term customers have a 43% higher repeat purchase rate compared to newly acquired customers.

Experiential rewards

You can also offer experiential rewards, such as early or VIP access to new services or clinical trials, and unique offers that are only available to members of your loyalty programme. Sephora’s Beauty Insider loyalty programme wraps tiers, points and experiential rewards all in one. Tiers and points are based on spending (with higher tiers earning up to four times the points per dollar spent), and members enjoy additional perks such as birthday gifts, exclusive invitations to store events, private beauty chats with industry experts and more. Members can use points as cash, redeem them for merchandise, and donate the cash value of their points to charity.

Cupshe has integrated these rewards into its tiered loyalty programme as well. Members in higher tiers unlock more elite perks, such as premier shipping, invites to member events, and priority customer service. For newer brand fans, seeing there are attractive rewards on the horizon motivates them to return and spend3

Paid loyalty programmes

Paid loyalty, or fee-based loyalty programmes, give clients immediate and ongoing benefits for a participation fee, which can be recurring or a one-time offer.

According to McKinsey, many companies are capitalising on emerging loyalty models as a way of satisfying and retaining their increasingly connected and experience-driven consumers.

They noted three elements of a successful paid loyalty programme4

Benefits clearly outweigh fees to encourage sign-ups Members stick around for more experiential advantages such as personalised experiences and member-only perks

Keep engagement levels high through a continuous cycle of interaction that elevates the programme’s value to clients.

The most obvious example of a successful paid loyalty programme is Amazon Prime which offers the widest range of products across almost every category.

Memberships

Like paid loyalty programmes, memberships create natural customer touchpoints through semi-annual offers, gifts with purchases, and sampling. You can also leverage exclusive content, first access to new products, favourable pricing, and innovative treatment and product bundles that are ownable to your best clients. Your raison d’etre should be to introduce patients and clients to services and products they have not tried yet, rather than offering specials on what they already buy.

Consider the iconic American Express Membership Rewards programme:

‘2X Membership Rewards Points: Membership Rewards-enrolled Card Members get at least 1 Membership Rewards® point for every eligible dollar spent on their Membership Rewards programmeenrolled American Express® Card. Those same Card

Tiered programmes offer clients different benefits depending on their rank, and the metrics used to determine rank can include the amount of money spent, the number of purchases, and engagement.

4 LOYALTY PROGRAMME MODELS

Points-based loyalty programmes: Offer points for signing up, posting a review, inviting 3 friends to follow your Instagram, product or treatment purchases, or buying a gift card.

Tiered loyalty programmes: Designate tiers for clients based on the amount they spend on treatments or products or treatments. For each tier reached, they get special offers,

complementary treatment add-ons or products. Paid loyalty programmes: Members pay a monthly or annual fee in return for special perks and benefits.

Value-based loyalty programmes: Award users with points for every amount spent. When they reach a specified amount, they are awarded with a complimentary gift or perk.

Members will also get at least 1 additional point for each dollar of eligible travel purchases made on amextravel. com with their Membership Rewards programmeenrolled American Express Card… .’

American Express has proven that, in some cases, a paid loyalty programme can be well received if the benefits offered are worth the price of admission. When offering this type of programme, it’s likely that patients will ‘do the math’ to ensure the spend is worth it. This is why it is so important to include exclusive discounts that span the scope of your practice. These can include gift certificates that are valid for the patient’s birthday month (with a minimum spend) or free samples with every skincare purchase.

Elements of a successful loyalty programme

It’s essential to surprise patients so they do not get complacent. You want to keep them on their toes rather than having them wait for a special offer before they try and buy. Using the same benefits all the time, such as the proverbial 20% off on your private-label skincare brand, is so overused that the effect has diminished.

Whichever route you choose, loyalty programmes help aesthetic establishments create deep, long-lasting relationships with their clients—and significantly increase the likelihood that they will be long-term patients.

Mark Hamilton, a facial plastic surgeon in Greenwood, Indiana and Chair of the AAFPRS Public Information Committee, has had success with a model where the patient paid a monthly fee. ‘This would give them a basic aesthetic treatment every month as well as discounts on other treatments. We referred to them as our ‘VIP’ patients. Patients who were committed to skincare were very satisfied with the plan because they benefited from regularly scheduled appointments to maintain their skin,’ he explained. ‘In addition, all treatments were offered at a discount due to their monthly fee, as were any add-on procedures and skincare products. These VIP patients would also get special prizes or gifts at events and around major holidays. They appreciated the special attention and

discounted services as well as the regular treatments to keep their skin looking its best.’

‘For a start-up practice or one that is trying to expand their business, subscription plans can be incredibly popular when priced competitively. They create a steady and recurring patient base that can often become very loyal to the practice,’ he adds.

Beware of hidden caveats

Keep in mind that offering discounts or extra service perks for treatments and products your patients are already purchasing will be less effective than striving to introduce them to something that is complementary but they haven’t experienced yet.

For example, an obvious example is a neurotoxin patient who has yet to try a facial filler in your hands. That would be a natural pairing and serves the purpose of letting the patient experience a different treatment that, in fact, complements the treatment they are already coming to your clinic for. Similarly, you may have a patient who is having a fat-reducing treatment series for her postpartum baby belly. You may entice her to try a complimentary mini session on an adjacent area (such as flanks or inner thighs). An alternative would be to offer a muscle-toning treatment to complement her fat-reducing series. This serves the dual purpose of educating the patient on how to achieve an enhanced result to what she has always bought into, plus giving her a taste of something that she has not tried yet.

Ideally, steering your patients to experience new treatments and products that you offer may serve to expand their relationship with your brand and increase long-term loyalty and referrals.

Taking the plunge

Considering the ever-changing aesthetic market today, competition is increasing, which necessitates thinking outside of the box. If every medspa, chain of laser outlets, gym, salon and other health and beauty businesses in your local market are offering some form of loyalty or membership model, it is probably time to consider jumping on board.

References

1. Lindsey Peacock. 7 Innovative Customer Loyalty Programs and How To Start. Shopify, June 22, 2022. Ottawa, Canada. Available at: https://www.shopify.com/blog/ loyalty-program [last accessed 6th March 2023]

2. Allergan Aesthetics. How Allē works. AbbVie, 2023. Irvine, CA, USA. Available at: https://alle.com/how-alle-works [last accessed 6th March 2023]

3. Loyalty Lion. Relationships that go beyond points and rewards. Loyalty Lion 2023. London, UK. Available at: Loyaltylion.com [last accessed 6th March 2023]

4. Julien Boudet, Jess Huang, and Ryter von Difloe. Coping with the big switch: How paid loyalty programs can help bring consumers back to your brand. Atlanta, GA. October 2020. McKinsey & Company. Available at: https://www.mckinsey.com/capabilities/growth-marketing-and-sales/ our-insights/coping-with-the-big-switch-how-paid-loyalty-programs-canhelp-bring-consumers-back-to-your-brand [last accessed 6th March 2023]

5. American Express. Travel. New York City, NY, US. 2023. Available at: https://tinyurl.com/4tz7kwbp [last accessed 6th March 2023]

Whichever route you choose, loyalty programmes help aesthetic establishments create deep, longlasting relationships with their clients— and significantly increase the likelihood that they will be long-term patients.

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SECRET DUO SMARTCURE™ OPENS A

NEW SPACE IN THE FIELD OF MINIMALLY INVASIVE FACE AND NECK TREATMENTS

Gabriel Rucinski, MD, discusses the improvements he experienced in neck and chin lifting using SECRET DUO SmartCure™ single-thermo coagulation technology

SECRET DUO RF endolifing and thermal lipolysis with blunt cannula needle proved to be a safe and effective alternative treatment option for lower face, chin, and neck improvement.

Mechanism of action

SECRET DUO SmartCure™ was used in this procedure to treat 30 patients who received subcutaneous thermal lipolysis in combination with radiofrequency microneedling and Er:glass fractional laser treatments on the cheeks, chin, and neck.

Treatment included thermal lipolysis and endolifting using radiofrequency emitted by a blunt 19 G cannula blunt needle. The indications for the procedure were significant flaccidity and drooping of the skin in the area of the chin, jawline, and neck, as well as an excessive amount of subcutaneous fat in the above areas. In all cases, RF endolifting treatments were combined with 3–4 sessions of radiofrequency microneedling and Er:glass laser every 3 weeks.

Treatment method

The treatment areas were marked with a sterile marker. Infiltration anesthesia of the cannula insertion sites was performed at two points on both sides.

SECRET DUO blunt RF 19 G 70 mm cannula needle mounted on SmartCure™ was inserted through the prepared holes by 18 G needle, Subcutaneous thermolysis was performed using the SmartCure™ 19 G 70 mm cannula bilaterally in the

region of the jaw line and the lateral surface of the neck and chin. The procedure consisted of inserting and withdrawing the cannula along the places identified with a marker to obtain a temperature reading from the skin surface of 42°C with a thermal imaging camera and lasted about 1 minute after this reading. During the procedure, excessive overheating and deep penetration of the cannula in the jawline were avoided in order to protect the superficially located mental branches of the VII nerve. The duration of the procedure was determined by the temperature read from the surface of the skin. On average, the entire procedure lasted about 20–30 minutes, which in terms of body surface area gave 2–3 minutes per 3–4 cm. Some patients underwent combined microneedling RF and Er:glass laser therapy, the treatments were planned at 3-week intervals.

Conclusion

After the initial RF endolifting treatment with a blunt cannula, a noticeable difference in the appearance of the lower face, chin, and neck was seen, followed by a gradual improvement over the following 6 months. The skin around the jaw line visually lifted during later combined sessions using RF microneedling and non-ablative Er:glass laser, and the face appeared more youthful. The patient also experienced a general increase in skin quality, a decrease in wrinkles, and a decrease in sagging as a result of a full face microneedling and Er:glass laser procedure. The patient had edema for two weeks, with only a minimal amount of interruption. There were no additional issues found. The combination of these three therapy techniques in the neck, chin, jawline, and lower cheeks proved to be very safe and effective.

GABRIEL RUCINSKI, MD, Bellamed Clinic, Elblag City, Poland

Figure 1 (A) Before and (B) after SECRET DUO SmartCure™ Bilateral jaw line and side surfaces of the neck and chin area lifting using blunt 19 G cannula and RF microneedling treatment.

CELLBOOSTER®: A NEW ERA IN INJECTABLE BOOSTERS WITH PATENTED CHAC TECHNOLOGY

Suisselle unveils the benefits of its brand-new CELLBOOSTER® range developed with its exclusive patented CHAC technology, which allows for the first of its kind stabilised booster complex without the use of a binding agent

CELLBOOSTER® IS A NEW CATEGORY OF skin boosters. It is not a regular blend of active ingredients but stabilised complex boosters born from the patented CHAC technology, developed by Suisselle. The CELLBOOSTER® products are a CE-marked* Class lll Medical Device.

CHAC technology provides the opportunity to create high molecular weight hyaluronic acid (HMW-HA)-based products that can effectively and efficiently deliver vitamins, minerals, and amino acids to the skin. This technology allows for the development of formulas that can answer patients’ specific needs with long-lasting anti-ageing results.

To improve and regenerate the skin at a cellular level, the CELLBOOSTER® product range has four different formulations to target specific skin issues.

CHAC technology in brief CHAC Technology provides a way to integrate biologically active ingredients into hyaluronic acid (HA) macromolecules under mechano-stimulated conditions, such as simultaneous pressure and shear deformation. This technology modifies and exploits the natural features of HMW-HA. Bioactive components such as vitamins and amino acids are simultaneously integrated and uniformly distributed onto the HA macrochains, forming a large complex that can be viewed as an exclusive macromolecular ‘depot’ of biologically active material. Multiple molecular complexes are formed using CHAC technology. These molecular complexes are based on the formation of weak and reversible bonds between the bioactive components and HA. In this way, the active components are protected within the supramolecular HA complexes, and HA is partially protected from hyaluronidase degradation. The resulting stabilized HMW-HA then becomes an optimal vehicle for transporting active and essential nutrients to the skin, ensuring their effective delivery and improved bioavailability for longer-lasting results.

CELLBOOSTER® Glow study results

In France, Dr. Sylvie Boisnic conducted an independent

study at the GREDECO Laboratory. The study aimed to demonstrate the depigmenting and anti-ageing effectiveness of CELLBOOSTER® Glow injected into the dermis of human skin. Therefore, an ageing experiment was performed by exposing the skin to ultraviolet rays. An anti-ageing effect was observed after injection of CELLBOOSTER® Glow, with a significant increase in pro-collagen type I, elastin, and sulfated glycosaminoglycans. The depigmenting effect of CELLBOOSTER® Glow was also demonstrated by a significantly decreased number of pigmented cells (Figure 1).

Focus on CELLBOOSTER® Shape (HMW-HA + L-carnitine + vitamin C)

CELLBOOSTER® Shape takes advantage of CHAC technology with a combination of two key ingredients in its formulation, L-carnitine and vitamin C. The role of L-carnitine, together with vitamin C as a cofactor, is to reduce fatty acid deposits in adipocytes. Carnitine improves the transport of

GABRIEL SIQUIERDAMETO, MD, is an aesthetic physician, founder and director of Dameto Clinics International and member of the research group NEOMA, University of Girona, Spain

Figure 1 (A) Control skin and (B) skin after 1 injection with CELLBOOSTER® Glow (Fontana staining, x400)

Figure 2 (A) before and (B) after double chin treatment using 3 sessions with 2 weeks intervals with CELLBOOSTER® Shape, Pictures courtesy of Dr. Marco Cerrano (Switzerland)

fatty acids into the mitochondria, so they can be broken down through β-oxidation to acetyl CoA to obtain usable energy via the Krebs cycle. This becomes a natural way to diminish local fat accumulation without the need to damage adipocytes, as in other methods. In addition, L-carnitine can suppress inflammation, reduce oxidative stress, and modulate cell metabolism. The combination with vitamin C will enhance the activity, as with adequate levels, approximately 30% more fat can be oxidized. The continuous and sequential delivery of these ingredients into the tissue using CHAC technology will improve and accelerate the results without cellular damage; thus, no burning sensation or inflammation will occur.

Benefits for patients

The effect on patients is stable and noticeable. Thanks to the unique components of each formulation, the CELLBOOSTER® range can address various skin issues. It is very effective and instantly improves dull, tired-looking skin and superficial wrinkles. In addition, it ameliorates sluggish blood circulation, aiding the body in flushing out ageing toxins. CELLBOOSTER® can also be used to address hyperpigmentation, skin dryness, non-cicatricial alopecia and ‘lit-fromwithin’ skin glow. With a quick course of three sessions, 2 weeks apart, patients can expect results to last up to 4 months. For optimal results, it is recommended that patients continue the treatment once every 1–2 months to maintain their desired appearance. Another benefit is that CELLBOOSTER® products increase the elastin, hyaluronic acid, and collagen production in the body, improving well-being and appearance. Each treatment plan is unique to every patient, and different products can be combined depending on the aesthetic needs of the patient. Full success was observed when the treatment was complete.

For more information, visit: www.suisselle.com

*Medical Devices Class III, regulated health products bearing the CE marking (CE 0373). Only to be administered by appropriately trained healthcare professionals who are qualified or accredited in accordance with national law.

“CELLBOOSTER® is a new category of skin boosters. It is not a regular blend of active ingredients but stabilised complex boosters born from the patented CHAC technology, developed by Suisselle.”

Figure 3 (A) Before and (B) after 3 sessions with 2 weeks intervals with CELLBOOSTER® Glow. Pictures courtesy of Dr. Gabriel Siquier (The Netherlands)

MD CLASS III SWISS MADE

Figure 5 (A) Before and (B) after alopecia areata barbae treatment with CELLBOOSTER® Hair. Results after 6 sessions with 2 weeks intervals. Pictures courtesy of Dr. Gabriel Siquier (The Netherlands)

Figure 4 (A) Before and (B) after 3 sessions with 2 weeks intervals with CELLBOOSTER® Lift. Pictures courtesy of Dr Gabriel Siquier (The Netherlands)

MD CLASS III SWISS MADE

TREATING HAIR LOSS WITH SYLFIRM X

So Jin Lee, MD, Director of the Lee So Jin Clinic in South Korea explains how they perform hair loss treatments using the SYLFIRM X

IN AN ERA WHERE grooming and self-care have gained increasing importance, the number of patients visiting a clinic for hair loss treatment is continuously increasing. Additionally, the number of middle-aged and male patients, as well as young and female patients, is increasing.

I run a clinic specialising in hair loss treatment in South Korea, and I am using SYLFIRM X, a RF microneedling device mainly used for skin rejuvenation, skin tightening, and lifting, scarring, melasma and rosacea, as a method of hair loss treatment. Both myself as a physician and my patients are very satisfied with the SYLFIRM X hair loss treatment, and I would therefore like to share my knowledge and clinical experience with treatment methods for hair loss.

Hair loss

Before talking about treatment for hair loss, I would like to give a brief explanation of hair. Hair has a growth cycle consisting of the following three phases: anagen, catagen, and telogen. During the anagen phase, the dermal papilla is supplied with nutrients from the blood vessels and the hair grows for 3–6 years. In the catagen phase, the dermal papilla contracts and separates from the blood vessels for 2–3 weeks, and in the telogen phase, dermal papilla activity stops, and hair is separated from the hair follicles in a process lasting 3–4 months. As this cycle repeats, hair grows and falls out. In general, hair loss occurs when there is an abnormality in the growth phase, resulting in a gradual shortening of the growth cycle, which in turn causes the hair to become thinner and fall out.

Through consultation, the causes and influential factors of hair loss are identified. Hair loss can be caused by a variety of reasons, including heredity, ageing, drugs, nutritional status, physical hair damage, stress, and seborrheic skin. Accordingly, there are various

types of alopecia (hair loss); among them, androgenetic alopecia, which is caused by genetic factors and hormones, is the most common. Though this condition is commonly termed male pattern hair loss, it occurs in both men and women.

In addition, by examining the condition of the scalp, the number of hairs, and the thickness of the hair, the symptoms and degree of hair loss can be verified. The type of alopecia can be classified according to the symptoms or the number and range of areas where hair loss occurs, or according to the shape of the hair falling out, of which the M, O, and U types are the most common.

Treatments

Based on the findings above, one or several treatment methods are selected and implemented. Moreover, when considering treatment methods, pathophysiological factors affecting hair growth can also be considered. Many studies have shown that cytokines such as fibroblast growth factor (FGF), insulin-like growth factor (IGF), keratinocyte growth factor (KGF), vascular

endothelial growth factor (VEGF), plateletderived growth factor (PDFG), and stem cell factor (SCF) are present in the hair follicle regions and promote hair growth.

Treatment options range from scalp care, use of hair loss products and medications, to energy-based device (EBD) treatment and hair transplant surgery.

For scalp care, scalp scaling and the use of hair loss products are often applied to prevent hair loss. In the case of medications, oral or topical agents are usually used, but the products used differ slightly depending on gender. For men, a topical agent, such as minoxidil, and oral medications, such as Finasteride and Dutasteride, are largely used, while for women, topical applications, such as minoxidil and 17α-Estradiol, are used most commonly.

Several types of EBDs have been used to treat hair loss. For example, low-level light therapy is used to increase the photobiomodulation of hair regrowth, while mesotherapy, which involves the direct, automatic injection of drugs into the scalp, has been used for efficient drug delivery.

Figure 1 Male patient in his 50s. (A) Before and, (B) 7 treatments after SYLFIRM X hair loss treatment.

SYLFIRM X

Among these options, my clinic regularly uses SYLFIRM X. SYLFIRM X is the world’s first and only dual-wave RF microneedling device with CE and FDA approval, and is primarily used to treat a variety of face and body indications, including wrinkles, skin laxity, and scars, melasma, and rosacea. This can also be applied to hair loss.

RF microneedling delivers the thermal effect of RF to the desired skin layer by inserting needles into the skin in a controlled manner. Considering the thermal effect of RF, which causes tissue denaturation or coagulation, and the physical damage of the needles, there may be concerns about hair follicle damage in terms of the safety of hair loss treatment.

However, one pre-clinical study conducted by Dr. Jongju Na, et al. in 2015 in a porcine model confirmed that RF microneedling did not damage hair follicles1, while another pre-clinical murine study conducted by Hyunjo Kim in 2018 confirmed the same2

By using the appropriate pulse duration and power, RF microneedling can stimulate the hair follicles and improve hair loss by increasing blood circulation and cytokine production in the surrounding area. Moreover, when the drug is applied immediately after SYLFIRM X, the open channels created by microneedling increase drug penetration, and the skin subjected to RF heat action is more receptive to the drug action.

To verify the effectiveness of SYLFIRM X hair loss treatment, patients were treated with only the device without applying any drugs or hair loss products. As a result, it was confirmed that hair count and hair thickness were improved even with SYLFIRM X treatment alone. Nevertheless, hair loss is not a simple problem of hair, but a result of complex causes and factors, and for the satisfaction of patients who expect a faster and better effect, combination therapy using SYLFIRM X and hair loss products is predominantly performed in my clinic.

The parameters I primarily use, are CW1, 0.7–0.8 mm, power 4–5, and 1–2 passes. A needle depth up to 1.0 mm is used in consideration of skin thickness and drug penetration, however, many patients in my clinic are sensitive to pain,

therefore, 0.7–0.8 mm is preferably used to reduce the procedural discomfort. For seborrheic, inflammatory, or sensitive scalp, the PW2 mode is used instead, and the therapeutic effect is very satisfactory. Therefore, it is recommended to change the mode according to the condition of the scalp.

My clinical tip for the SYLFIRM X procedure is to part the hair during the application; this makes the procedure easier and improves RF transmission within the skin.

SYLFIRM X is very convenient as an operator because the parameter setting and operation are very intuitive, simple, and easy. In addition, compared to other EBD treatment methods such as mesotherapy, there are fewer issues such as pain and bleeding, making it preferable for patients.

Immediately after SYLFIRM X treatment, 2–3 ml of hair products, usually serum, is applied to the treated skin. The serums I use are high-priced products containing growth factors or products that include ginkgo leaf extract, multivitamins, high-concentration amino acids, or/and multi-minerals. To take full advantage of each product’s ingredients, different products are used at every visit.

Furthermore, I prepare my own serum in-house by mixing multivitamins to promote energy metabolism of scalp cells, stem cell

growth factors to stimulate hair follicle cells, amino acids to help cell activation, and vasodilators to improve blood circulation and deliver effective nutrients to hair roots, and minerals to improve scalp cell metabolism.

A minimum of 8 SYLFIRM X treatments are generally recommended at intervals of 1–2 weeks, and patients usually start providing feedback after 3 treatment sessions. Patients provide feedback that their hair falls out less at first, later they say that overall hair volume and thickness increase, and the increase in hair volume starts at the back of the head and progresses forward.

In conclusion, SYLFIRM X is safe and effective for hair loss treatment as well as treatment for various skin concerns and problems, providing high satisfaction to both physicians and patients.

For more information, visit www.violmedical.com

“SYLFIRM X is safe and effective for hair loss treatment as well as treatment for various skin concerns and problems, providing high satisfaction to both physicians and patients.”

Figure 2 Male patient in his 50s. (A) Before and, (B) 8 treatments after SYLFIRM X hair loss treatment.

SUNEKOS CELL 15

A NEW APPROACH TO THE TREATMENT OF CELLULITE

Dr Mark Holmes discusses the benefits of low weight hyaluronic acid and six amino acids to address cellulite

SUNEKOS CELL 15 IS A new injectable medical device for the noninvasive treatment of cellulite using a patented mix of low molecular weight hyaluronic acid (HA), six essential amino acids (AA) and bicarbonate salts.

It achieves this by optimising the protein turnover of the extracellular matrix (ECM), improving the micro-circulation and counteracting the ECM acidosis and inflammation reducing fibrosis in the process. This is a process of neocollagenesis rather than the typical collagenase1,2

Cellulite is a dimpled lumpy skin appearance mainly represented in the gluteo-femoral area occurring almost exclusively in females. This chronic skin condition is widespread and affects more than 85% of females over the age of 20.

The cellulite treatment market is rapidly expanding. In 2019, the global cellulite treatment market size was $1.35 billion. By 2026 it has been predicted to reach $2.8 billion.

Edemato-fibroscerotic panniculopathy (EFP) was named by S.B. Curri. Four stages were described. Stages I and II of cellulite present as an edemato–inflammatory condition of the tissue associated with hypo-oxygenation and acidosis3,4

Stages I and II can be treated with Sunekos Cell applying the Across Tension Lines needle (ATL-n) technique5

The pathogenetic mechanism of late stage cellulite is mostly related to the ageing of tissues

(inflammation/acidosis) already degenerated in fibrosis and subsequently in sclerosis. The sclerosis is irreversible. This condition is often related to menopause when the decrease of the hormones is worsening the process.

Stages III and IV can be treated with Sunekos Cell and Cannula and the Across Tension Lines cannula (ATL-c) technique5

For Crewe, there are three dominant contributors to the pathogenesis of dysfunctional adipose tissue6:

■ unresolved inflammation

■ inappropriate extracellular matrix (ECM) remodelling

■ insufficient angiogenic potential.

Sunekos Cell 15

Sunekos cell 15 is indicated for treating Cellulite types I-IV in the following areas1,5:

■ gluteal/trochanteric area

■ thighs

■ abdominal area

■ arms

■ other areas of the body affected by cellulite.

Sunekos Cell 15, produced by Professional Dietetics, consists of one ampoule of their patented formula of premixed HY6AA (low molecular weight hyaluronic acid, six essential amino acids) and one vial of carbonate and bicarbonate salts. When mixed they create an injectable volume of 15 ml.

Low molecular weight HA has a stimulating action on fibroblasts and neo-angiogenesis, through binding with specific receptors for HA fragments7

The HY6AA formula produces optimal neo-synthesis of collagen and elastin (glycine, L-proline, L-lysine MHC, L-leucine, L-valine, L-alanine).

The carbonate and bicarbonate salts help to regulate to regulate the physiological pH reducing the typical acidosis and latent inflammation that characterises both the early and late stages of the disease.

A recent study of Sunekos Cell involved 20 females with cellulite grade II–IV. Four treatments were carried out 2–3 weeks apart. 2.5 mls were injected with a cannula into three areas on each leg for a total of 15 mls per session1

Results were assessed using digital pictures, the GAIS scale and mean weight pre-treatment, and at 8 weeks and 12 weeks after the first treatment. A two point improvement was noted.

I have been using Sunekos Cell in my own clinic for 11 months, my patients have been very pleased with the results regardless of whether they have cellulite grade I, II, III or IV.

I do not treat patients with localised skin inflammation or infection, unrealistic expectations, soft tissue auto-immune disease or very advanced stage IV cellulite.

As part of a holistic approach patients are encouraged to improve any pre-disposing lifestyle factors:

■ smoking

■ poor diet

■ lack of exercise

■ tight fitting clothing.

Patients are assessed while standing.

DR MARK HOLMES, Aesthetic Physician, London, UK

Cellulite can be treated with just Sunekos Cell 15, however should there also skin laxity, I use injectable Sunekos Body once the Sunekos Cell treatment is completed.

The ampoule of HY6AA and the vial of bicarbonate salts are mixed together. The ampoule is then gently rolled between the fingers for a minimum of 30 seconds to ensure proper mixing.

Each ampoule contains a total of 15 ml, 7.5 ml for each leg.

I typically treat the trochanteric area and two out of five other possible areas with 2.5 ml to each area (Figure 1):

■ lateral thigh

■ anterior superior thigh

■ anterior inferior thigh

■ posterior superior thigh

■ posterior inferior thigh.

When the patient is standing, I mark each area as a 12 x 12 cm box and take a photo so I know exactly where to inject on subsequent visits. A 30 G needle or a 27 G cannula and 2.5 ml syringe are used depending on the technique for the specific stage. Injections are made perpendicular to the tension lines of the skin using the ATL-n or ATL-c technique (Across Tension Lines needle or cannula)5. For the needle, the volume injected at each point is 0.15 ml. After the treatment the injected area is massaged.

Three treatments are performed 2 to 3 weeks apart for cellulite types I and II and four treatments for types III and IV. It’s important to stress to the patient that the part of sclerosis in type IV is not reversible.

I use the Sunekos Cell 15 in conjunction with the Nutrakos pH7 oral supplement. Waste accumulates in the connective tissue, damaging collagen, impairing the efficiency of the

microcirculation and promoting water retention.

Tissue acidosis is one of the main factors responsible for the appearance and worsening of cellulite. Nutrakos pH7, a specific combination of carbonates and bicarbonates, helps to restore the acid-base balance. I recommend they take one sachet a day for two months.

Results

Many patients have already noticed improvement when they come back for their second treatment. However, it is stressed that the optimal results will be 3 to 4 weeks after the last treatment. Typical results are an improvement in skin appearance with reduced dimpling. Results continue to improve after each treatment and have been maintained at the 6 month follow up (Figure 2). At this stage one or two treatments are performed as maintenance with a further follow up planned at 12 months to repeat the whole process.

Those treated commonly refer their friends, family and colleagues a good indicator of treatment satisfaction.

Sunekos Cell 15 is extremely well tolerated with no downtime and minimal pain. Some patients have had minimal bruising, but no adverse effects have been experienced.

References

1. A. Sparavigna. Injective treatment of the so-called cellulite: a new approach aimed at restructuring extracellular matrix of deeper layers of the skin. Efficacy and safety of a new specific formula (part 1 & 2) - JPD Vol 18 n2 2022

2. Fasola E, Kutera E. Pilot study evaluating the therapeutic effects of a new pre-mixed injectable product

of low molecular weight (LMW) hyaluronic acid added to six amino acids (HY6AA +Formula) in facial skin aging. J Dermat Cosmetol. 2022;6(3):74-77

3. S.- Curri Localised Adiposity and oedematofibrosclerotic panniculopathy. Ed Sepem, Milan 1990 4.

4. Curri S.- Compendium of clinical

and instrumental semy-semy of panniculopathy - Ed.Edra, Milan 1993.

5. Fasola E. Cellulite rebuild rather than destroy-Prime Vol 13 Issue 1 2023

6. Clair Crewe, Yu Aaron An, Philipp E. Scherer The ominous triad of adipose tissue dysfunction: inflammation, fibrosis, and impaired angiogenesis.

7. Tedesco L., Rossi F. Ruocco C., Ragni M., Carruba M.O., Valerio A., Nisoli E. A designer mixture of six amino acids promotes the extracellular matrix gene expression in cultured human fibroblasts. Bioscience, Biotechnology,

and Biochemistry, 2022, Vol. 86, No. 9, 1255-1261.

Figure 2 (A) Before, and (B) after treatment

“Those treated commonly refer their friends, family and colleagues a good indicator of treatment satisfaction.”

Figure 1 Treatment sites

SUNEKOS® PERFORMA THE ENHANCED FORMULA FOR SKIN RENOVATION

Dr Rita Nandi discusses the evidence and her experience of wrinkle reduction and skin texture improvement using Sunekos® Performa

SUNEKOS® PERFORMA IS an injectable treatment which gives rise to a renewal of the dermal tissue through regeneration of the extracellular matrix (ECM) using a unique patented combination of hyaluronic acid and specific amino acids which lead to new collagen and elastin production. Collagen and elastin form a large bulk of the ECM. The homeostasis of the ECM is crucial for the optimal functioning of cells and organs and leads to ageing when it is lost in the skin.

Skin ageing occurs as a result of extrinsic and intrinsic factors, which not only reduce the amount of collagen available within the dermis but the composition too. For example, type III collagen forms 50% of the collagen in neonatal skin but only 5% of the collagen in ageing adult skin. Also, type IV collagen, which forms anchor plaques between structural collagen types in

the dermis, decreases with age after 35 years and the epithelial basement membrane thickness increases with age, suggesting a reduction in cell turnover. Along with this, we have a reduction in the number of fibroblasts leading to a decreased amount of collagen and elastin production along with an increase in collagen and elastin degradation through the action of Matrix Metalloproteinases (MMP). There is a loss of hydration due to a reduction in hyaluronic acid, which occurs as a result of a reduced number of fibroblasts, increased hyaluronidase activity and down-regulation of CD44 and RHAMM membrane receptors, leading to a reduction in gene transcription for hyaluronic acid1

Sunekos® Performa

Sunekos® Performa is a new injectable by Professional Dietetics that can be used to improve the appearance of the skin of the face, neck, décolletage and hands, so it is a very versatile product. It results in skin that looks plumper, tighter, brighter and more hydrated, with a reduction in the appearance of fine lines and wrinkles and an improvement in the appearance of dark circles and eye bags. It has replaced Sunekos® 200 in the injection protocols, which have been updated recently to reflect the new patented formula within Sunekos® Performa. The updated formula consists of the same six specific amino acids and low molecular weight hyaluronic acid (HY6AA+ Formula) but in a different ratio of HA vs AA. The new formula has been clinically shown to cause a 40%

reduction in the degradation of hyaluronic acid by hyaluronidase through the hydrophobic action of the specific amino acid formula. It has been clinically shown to prolong the beneficial action of hyaluronic acid at the injection site to stimulate receptors on the fibroblasts for longer and produce more collagen IV, elastin and fibronectin, producing more constituents of the ECM, resulting in improved skin elasticity and firmness, further hydration and producing an increased antioxidant action2-4

Sunekos® Performa consists of a 3.5ml premixed vial composed of 35 mg of non-crosslinked LMWHA ranging between 50–250kDa and 128 mg of the six specific amino acids. The mixture has been shown to help rebuild the ECM effectively by stimulating the production of elastin, all the main types of reticular collagen fibres of the dermis and Type IV and Type VII collagen. The expression of fibronectin mRNA levels was also found to be increased after 72 hours of treatment compared to untreated cells. The combination of higher amounts of collagen type IV and VII along with fibronectin (the latter plays an important role in cell adhesion and anchoring reticular collagen fibres and cells) leads to an improvement in skin firmness1,3,4

Study method

A pilot study which looked at the effect of Sunekos® Performa on facial skin ageing showed that in 10 female patients aged between 40–67 years old recruited to the study, there was an improvement in skin texture, dyschromia, skin elasticity and

RITA NANDI, MBCHB, BSC (HONS), MRCGP (2015), Cosmetic Doctor, NHS GP

appearance of fine lines and wrinkles. They each claimed not to have had any other aesthetic treatments during the last year. Each patient was injected three times with a two-week gap between treatments. Evaluations were made at baseline and every two weeks before injection. A fourth evaluation was made four weeks after the third treatment session. Each treatment involved being injected with a total of 3.5 ml of the premixed HY6AA+ Formula using the High Performance Technique (HPT), injecting 0.1ml boluses into the deep dermis over the whole face, including the periocular area and forehead, perpendicular to the natural tension lines of the skin (Langer Lines).

Results

VISIA analysis of the treated patients showed an overall 71% reduction in the appearance of wrinkles on the forehead and a 44% reduction in wrinkles in the periocular area. Skin texture had visibly improved and skin dyschromia due to photo-ageing had improved by 16%. Skin elasticity was assessed via the use of a standardised Pinching Test and the VAS scale was utilised to evaluate the progress of skin tension and elasticity with each treatment. All patients noticed a significant improvement in skin tension and elasticity. According to the Global Aesthetic Improvement Scale (GAIS), all patients noticed an improvement in appearance. After the first treatment, 28% of patients noted a moderate improvement in appearance and the remaining patients noticed a significant improvement in appearance. None of the patients reported any worsening or lack of improvement. The study concluded that undergoing treatment with the patented formula HY6AA+ Formula showed an

improvement in the texture, colour and firmness of the skin. It was also interesting to note that despite the product being non-crosslinked, the tissue volume had also improved. There were minimal side effects reported and the patients tolerated the treatment very well1

Sunekos® Performa can be used along with Sunekos® 1200 as part of their injection protocols to treat the face and hands. The protocols vary depending on the problem areas being treated. The higher molecular weight of Sunekos® 1200 acts as a free radical scavenger offering protection to the constituents of the dermis.

Discussion

I, as a medical aesthetics practitioner, treat patients in clinic with Sunekos® frequently. I use it for patients presenting with signs of ageing over the face, neck, décolletage and hands. What sets it apart from other injectable treatments I am trained in is that it can be used to treat the riskier areas of the forehead and delicate periocular area and that there have not been any reported cases of vascular occlusion with its use so far. I have received great feedback from patients and they often see a benefit after the first treatment, which encourages them to complete the recommended course. I use it frequently in the periocular area and have seen an improvement even in older patients with pseudoherniated orbital fat with a reduced appearance of their ‘eye bags’ after treatment. The product comes as a generous 3.5ml vial, so patients are more satisfied that they are getting value for their money as they can have more problem areas treated with one vial. Despite the large volume of product, it is

References

relatively thin and has low resistance when being injected, so treatments can be carried out quickly and with ease. There is minimal pain on injection and the patient can have numbing cream applied to the skin beforehand if they wish. Downtime is again minimal, and the patient can resume their day as normal other than the usual aftercare. I have noticed superior results in the clinic since using Sunekos® Performa compared to when using their older Sunekos® 200. Sunekos® can be bought in EU countries starting from January 2023.

1. Fasola E, Kutera E. Pilot study evaluating the therapeutic effects of a new pre-mixed injectable product of low molecular weight (LMW) hyaluronic acid added to six amino acids (HY6AA +Formula) in facial skin aging. J Dermat Cosmetol. 2022;6(3):74-77.

2. Tedesco L, Nisoli E. Measurement of hyaluronidase activity on hyaluronic acid in presence or absence of a specific amino acid formula [under publication]

3. B De Servi, Orlandini A, Caviola E, M

Meloni. Amino acid and hyaluronic acid mixtures differentially regulate extra cellular matrix genes in cultured human fibroblasts. Biol Regul Homeost Agents. 2018;32(3):517-527.

4. Tedesco L., Rossi F. Ruocco C., Ragni M., Carruba M.O., Valerio A., Nisoli E. A designer mixture of six amino acids promotes the extracellular matrix gene expression in cultured human fibroblasts.

Bioscience, Biotechnology, and Biochemistry, 2022, Vol. 86, No. 9, 1255-1261

Figure 1 Evaluation after one treatment out of a two-treatment session course (A) Before, and (B) after treatment

“I have received great feedback from patients and they often see a benefit after the first treatment, which encourages them to complete the recommended course.”

AN INNOVATION IN ROSACEA TREATMENT

Nora Schiffers, MD, an expert in minimally invasive aesthetic medicine, unveils a treatment protocol for rosacea using the GOURI PCL-based collagen stimulator

ROSACEA DISEASE AMOUNTS to 5.5% of the reasons for a doctor visit internationally1. It is a chronic inflammatory skin disease that occurs primarily in the centrofacial area and usually manifests between the ages of 30–50. The most common causes for this condition are immune dysregulation, genetic alterations, neurocutaneous mechanisms, and Demodex mites. The classic symptoms of rosacea include facial flushing as well as recurrent phases of transient to permanent erythema of the face, especially in the area of the cheek, nose, forehead as well as chin. Frequently, telangiectasia, as well as papules, pustules, and also phymatous changes, usually in the form of rhinophyma, occur2-3.

Studies have shown the symptoms of rosacea disease can cause severe psychological suffering in patients, as they primarily affect the visible areas of the face. Leading to a profoundly negative impact in terms of quality of life for the patient4

Gouri represents an innovation in the field of minimally invasive rosacea treatments. It is the first fully liquefied and particle-free PCL (polycaprolactone) on the market. Injection of Gouri leads to the stimulation of fibroblasts and, consequently, to neocollagenesis. The result is an improvement of the connective tissue with an increase in elasticity and a refined skin appearance, as well as alleviation of rosacea symptoms, such as flushing or erythema. Due to its complete liquefaction, Gouri distributes itself throughout the entire tissue with only a few punctures.

Gouri was first introduced in the market as an anti-ageing solution, which prevents ageing by replenishing collagen fibre levels and restoring the skin’s young look. However, recent cases of Gouri usage on patients with rosacea and the results observed allow us to make an assumption that the efficacy of the product extends beyond

that. Although the pathophysiological processes of rosacea are not fully understood, some studies point out the relation between the matrix metalloproteinases (MMPs) levels and the development of rosacea6. It is known that alterations made to the ECM by MMPs might contribute to premature skin ageing7; therefore, it is suggested that the injection of Gouri balances the MMP/ECM ratio through the normalisation of collagen levels. This, in our opinion, can result not only in an antiageing effect but also in long-term improvement of conditions like rosacea.

Case 1

A 54-year-old female, a Caucasian patient who had been suffering from increasingly severe rosacea subtype I for years, was treated with 2 ml of Gouri on her face over 3 sessions. Gouri was injected with a 25G cannula within the erythema areas at intervals of 4 weeks. Immediately after treatment, a slight increase in redness and swelling was evident, which disappeared again within a few days. Between sessions, a significant reduction in swelling and flushing was observed, as well as in erythema on the face. Also, the telangiectasias became less visible.

References

1. Gether L, Overgaard LK, Egeberg A, Thyssen JP. Incidence and prevalence of rosacea: a systematic review and meta-analysis.Br J Dermatol. 2018;179:282–289

2. Tan J, Almeida LM, Bewley A, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea Consensus

Summary

In summary, a significant alleviation of rosacea-related symptoms, such as redness, swelling and erythema, was observed in the patient. Due to the collagen production effect stimulated by Gouri, an additional improvement of the skin’s appearance as well as a slight lifting effect, is noticeable. As a treatment option for rosacea, Gouri has almost no side effects and no downtime. Patients’ symptoms are alleviated almost immediately, leading to a marked increase in the quality of life of patients through heightened self-esteem and reduced social anxiety.

(ROSCO) 2019 panel. Br J Dermatol. 2017;176:431–438.

3. Tan J, Steinhoff M, Berg M, et al. Shortcomings in rosacea diagnosis and classification. Br J Dermatol. 2017;176:197–199.

4. Baldwin HE, Harper J, Baradaran S, Patel V. Erythema of rosacea affects health-related quality of life: results of a survey

conducted in collaboration with the National Rosacea Society. Dermatol Ther (Heidelb).2019;9:725–734.

5. Jang YH, Sim JH, Kang HY, Kim YC, Lee ES. Immunohistochemical expression of matrix metalloproteinases in the granulomatous rosacea compared with the non-granulomatous rosacea. J

Eur Acad Dermatol Venereol. 2011 May;25(5):544-8. doi: 10.1111/j.1468-3083.2010.03825.x. PMID: 20698913.

Pittayapruek

Int J Mol Sci. 2016 Jun 2;17(6):868.

6.

P, Meephansan J, Prapapan O, Komine M, Ohtsuki M. Role of Matrix Metalloproteinases in Photoaging and Photocarcinogenesis.

Figure 1 (A) Before and (B) 4 weeks after rosacea treatment with 2 ml of Gouri on the face over three sessions

Under the scientific supervision of the AMS

In partnership with the Aesthetic Multispecialty Society (AMS), the 2023 AMWC Awards honors physicians for their innovative protocols and techniques, in addition to treatment results in the field of aesthetic & anti-aging medicine. The ceremony is also an occasion to reward the best products and devices in the industry.

This year’s 9th edition saw over 1,000 applications from 50 different countries. Out of the 500 shortlisted submissions, over 150 reached the finals in the proposed 22 categories. A jury composed of renowned doctors voted using strict criteria based on originality, effectiveness, and final results.

The AMWC Awards is a pioneering competition in this aesthetics field, inviting hundreds of international peers to cast their vote. Winners are celebrated along their peers at AMWC Monaco.

View the finalists on the AMWC website : www.amwc-conference.com

Or scan this QR code

INJECTABLES FOR SKIN REVITALIZATION

AESTHETIC DEVICES

ANTI-AGING SUPPLEMENTS

REGENERATIVE AESTHETIC MEDICINE

COSMETICS

ezGEL Vild Nord Collagen Gold

Jalupro Superhydro

PRP MyCollagenLift

MELA BRIGHT [C+]

ASCEplus HRLV

ASCEplus EXOBALM

REGENERATING MASK TREATMENT INFRACYTE® Luscious Lips®

ASCEplus SRLV

LASERS, LIGHTS AND ENERGY-BASED DEVICES

INJECTABLE DERMAL FILLERS

DuoGlide

HArmonyCa TM

Dermablate

Revanesse® ShapeTM

AviClear

ART FILLER® LIPS SOFT

Jovena

QuadroStarPRO

Hyal System DUO

MeDioStar PicoStar

Hyal System ACP

INJECTABLE BODY FILLERS

INFINI PREMIUM FILLER B BODY Variofill® for Gluteal Augmentation HYAcorp MLF2

Lanluma

CONGRATULATIONS TO THE PHYSICIAN FINALISTS

CONDITION IMPROVEMENT TREATMENT

Prof. Dr. GENTILE Pietro - Italy

Dr. MARGARA Andrea - Italy

Dr. MCGINNISS Vincent - USA

Dr. SPADA Julieta- Argentina

Dr. YU Arthur - USA

ENERGY-BASED TREATMENTS

Dr. DOROBANTU Alexandra - Romania

Dr. MCGINNISS Vincent - USA

Dr. PEREZ WILLIS Kateryn Michelle - Peru

Dr. RAMIREZ Sylvia - Singapore

Dr. REAL Julia - Brazil

Dr. RUPEKA Jason - USA

Dr. TSAI Jenghaw - Taiwan

GENITAL REJUVENATION

Dr. AMARAL Vívian de Carvalho - Brazil

Dr. CARDOSO MARTINS Maria Roberta - Brazil

Dr. GONZALEZ ISAZA Pablo - Colombia

Dr. HERRERA Arturo - Mexico

Dr. MAZZEO Francesca - Italy

HAIR RESTORATION

Dr. BOTOACA Ducu - UK

Dr. BOUHANNA Pierre - France

Dr. CRISOSTOMO Marcio - Brazil

Prof. Dr. GENTILE Pietro - Italy

Dr. KANNAIAH Thallapally - India

Dr. NARUPAVES Nuttorn - Thailand

INTEGRATIVE MEDICINE CASES

Dr. AMARAL Vívian de Carvalho - Brazil

Dr. FISCHER Tanja - Germany

Dr. JANOVSKA Jana - Latvia

Dr. LEIBASCHOFF Gustavo - USA

Dr. LLANO Francisco - Mexico

Dr. MARGULIES Michael - France

Dr. MONCADA Ivan &

Dr. BARCELLONA Carolina- Spain

Dr. SOMSUP Sarittha - France

Ms. TRAWINSKA Julia, PhD - Poland

NON-SURGICAL BODY SHAPING

Dr. BELCIU KERNS Roxana - USA

Dr. BOTOACA Ducu - UK

DR. BURGER Melinda - South Africa

Dr. CHACUR Roberto - Brazil

Dr. LIMA Adma - Brazil

Dr. RUPEKA Jason - USA

Ms. TRAWINSKA Julia, PhD - Poland

Dr. TSAI Jenghaw - Taiwan

NON-SURGICAL FACIAL BEAUTIFICATION

Dr. ASAWAWORARIT Patchanon - Thailand

Dr. BAUTZER Carlos Alexandre - Brazil

Dr. BOTOACA Ducu - UK

DR. BURGER Melinda - South Africa

Dr. CHACUR Roberto - Brazil

Dr. CLEMMENSEN Dorte - Denmark

Ms. FERRAZ Elizabeth - Brazil

Dr. KARAIVANSKA Olga - Ukraine

Dr. KARATAS Gizem - Turkey

Dr. KENNINGHAM Maeve - UK

Dr. KIVERLING Nadia - Argentina

Dr. KOVACHEVA Irena - UK

Dr. LIMA Adma - Brazil

Dr. LÓPEZ TALLAJ Luis - Spain

Dr. MALIKOVA Tarana - USA

Dr. MAZZEO Francesca - Italy

Dr. MONCADA BUSTAMANTE Ivan - Spain

Dr. NARAGHI Mohsen - USA

Ms. NAZEM Maryam - Denmark

Mrs. PEREZ WILLIS Kateryn Michelle - Peru

Dr. RHOBAYE Dean - UK

Dr. SILIKOVICH Fernando - Argentina

Dr. VITALE Massimo - Italy

Dr. YASSINE Hussein - Lebanon

Dr. YI Kyu-Ho - South Korea

Dr. YU Arthur - USA

NON-SURGICAL FACIAL REJUVENATION

Dr. BELCIU KERNS Roxana - USA

DR. BURGER Melinda - South Africa

Dr. CHIEPPE DE SÁ Juliana - Brazil

Dr. CLEMMENSEN Dorte - Denmark

Ms. DUAN Yan - USA

Dr. ENJALBERT Bruno - France

Dr. FRANCESCHELLI Antonella - Italy

Dr. GARORI Maris - Italy

Dr. JALALI Arash - Canada

Dr. KANNAIAH Thallapally - India

Dr. KARAIVANSKA Olga - Ukraine

Dr. KENNINGHAM Maeve - UK

Ms. KHARINA Tatiana - USA

Dr. KIVERLING Nadia - Argentina

Mrs. MARTINS Taynara - Brazil

Dr. MONCADA Ivan - Spain

Dr. PEREZ WILLIS Kateryn Michelle - Peru

Dr. RAMIREZ Sylvia - Singapore

Dr. RHOBAYE Dean - UK

Dr. RUPEKA Jason - USA

Dr. SAMBACHE Katherin - Ecuador

Dr. SIDDIQI Ayah - UK

Dr. SIEW Tuck Wah - Singapore

Ms. SINGH Manisha - Australia

Dr. TORRES Sebastian - Chile

Dr. TREACY Patrick - Ireland

Dr. TSAI Jenghaw - Taiwan

Dr. TSIVTSIVADZE Mariam - Georgia

Dr. UTEPKALIYEV Khakim - Kazakhstan

Dr. VITALE Massimo - Italy

Dr. YI Kyu-Ho - South Korea

Dr. YU Arthur - USA

SKIN ENHANCEMENT & SCAR TREATMENT

DR. BURGER Melinda - South Africa

Dr. FRANCESCHELLI Antonella - Italy

Dr. GONZALEZ ISAZA Pablo - Colombia

Dr. HALIM Azza - USA

Dr. HERRERA Arturo - Mexico

Dr. KARAIVANSKA Olga - Ukraine

Dr. LLANO Francisco - Mexico

Dr. MADANAGOBALANE Shraddha - India

Prof. MANUSKIATTI Woraphong - Thailand

Dr. RAMIREZ Sylvia - Singapore

Dr. SOMSUP Sarittha - France

Dr. TSAI Jenghaw - Taiwan

Dr. VITALE Massimo - Italy

Dr. YU Arthur - USA

Dr. ZATEZALO Chad - USA

SURGICAL BODY SHAPING

Prof. Dr. GENTILE Pietro - Italy

Dr. MAZZEO Francesca - Italy

Dr. TORRES Sebastian - Chile

Dr. YU Arthur - USA

SURGICAL FACIAL REJUVENATION

Dr. HALIM Azza - USA

Dr. MCGINNISS Vincent - USA

Dr. NARAGHI Mohsen - USA

Prof. Dr. SADYKOV Rasul - Uzbekistan

Dr. SALEH Sabreyah - Kuwait

Dr. TORRES Sebastian - Chile

Dr. YU Arthur - USA

THREADS TREATMENT

Dr. BELCIU KERNS Roxana - USA

DR. BURGER Melinda - South Africa

Dr. HALIM Azza - USA

Dr. KENNINGHAM Maeve - UK

Dr. NARAGHI Mohsen - USA

Dr. TSIVTSIVADZE Mariam - Georgia

Dr. YU Arthur - USA

EUROPE

30 MARCH – 1 APRIL 2023

AMWC 2023

Monte Carlo, Monaco www.euromedicom.com

12–13 MAY 2023

AFA 2023

Leiden and Amsterdam Netherlands, UK www.euromedicom.com

18–20 MAY 2023

EADV Symposium

Seville, Spain

eadvsymposium2023.org

25–27 MAY 2023

33RD EURAPS Annual Meeting

Stockholm, Sweden

www.euraps.org

Industry events in 2023 for the aesthetic and anti-ageing market

1–3 JUNE 2023

Beauty through Science

Stockholm, Sweden

www.btsstockholm.com

1–4 JUNE 2023

5-CC Word Congress

Lisbon, Portugal www.5-cc.com

30 JUNE – 1 JULY 2023

FACE 2023

London, UK

www.euromedicom.com

31 AUGUST – 2 SEPTEMBER 2023

ISAPS Olympiad Athens World Congress 2023

Athens, Greece

www.isapsathens2023.com

REST OF WORLD NORTH AMERICA

7–10 JUNE 2023

Vegas Cosmetic Surgery 2023

Las Vegas, NV www.vegascosmeticsurgery.com

17–21 MAY 2023

18th Annual Music City SCALE Nashville, TN www.scalemusiccity.com

6–9 JULY 2023

The Aesthetic Show

Online and Las Vegas, NV www.aestheticshow.com

5–7 MAY 2023

AMWC Asia 2023

Taipei, Taiwan

www.euromedicom.com

15–16 SEPTEMBER 2023

AMWC India

Mumbai, India

www.euromedicom.com

7–8 OCTOBER 2023

FACE ASEAN

Bali, Indonesia

www.euromedicom.com

MONTE-CARLO,

MARCH

APRIL 1, 2023

30-31

MONACO GRIMALDI FORUM

Under the High Patronage of H.S.H. Prince Albert II of Monaco

Under the scientific supervision of the Aesthetic Multispecialty Society (AMS)