PRIME Nov/Dec 2024 issue by IM-Aesthetics

STEP INTO THE NEW ERA WITH ULTHERAPY PRIME

The next generation of hyper-personalised skin lift has arrived. Ultherapy PRIME’s state-of-the-art system is the only FDA-cleared micro-focused ultrasound with real-time visualisation that goes beyond other non-invasive treatments to target the right collagen- and elastin-rich layers of the tissue at multiple depths, delivering consistent and precise energy for a truly personalised lift.

Ultherapy PRIME is an evolution of Ultherapy, which has been recognised by a body of expert physicians as the Gold Standard for non-surgical skin lifting and skin tightening due to its established safety proﬁle of Ultherapy with more than 100 scientiﬁc publications, and over 3 million treatments performed across 80 countries worldwide, with high patient satisfaction of 95% at year 1.1-7

3 Million

Raise the bar with faster and more powerful processing power, elevated ergonomics, and sophisticated design.

References:

1. Ulthera® Instructions for Use.

The new platform provides clearer and larger visualisation to assess each patient’s unique needs in real time with FDA-cleared technology that provides a truly personalised and long-lasting lift.

Ultherapy PRIME builds on the legacy of proven, safe, and e ective results to lift and tighten the neck, submental, and brow, and to improve lines and wrinkles on the décolleté.

2. 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. 2019;18(5):426-432.

3. Park J et al. Customized Treatment Using Microfocused Ultrasound with Visualization for Optimized Patient Outcomes: A Review of Skintightening Energy Technologies and a Pan-Asian Adaptation of the Expert Panel's Gold Standard Consensus. J Clin Aesthet Dermatol. 2021;14(5):E70-E79.

4. Whitney ZB, Zito PM. Anatomy, skin, superﬁcial musculoaponeurotic system (SMAS) fascia. in: StatPearls. Treasure Island, FL: StatPearls Publishing: 2019. https://www.ncbi.n|m.nih.gov/books/NBK519014/ Updated October 27, 2018. Accessed December 9, 2019

5. Suh DH, Choi JH, Lee SJ, Jeong KH, Song KY, Shin MK. Comparative histometric analysis of the e ects of high-intensity focused ultrasound and radiofrequency on skin. J Cosmet Laser Ther 2015:17(5):230-236.

6. Fabi SG, Massaki A, Eimpunth S, Pogoda J, Goldman MP. Evaluation of microfocused ultrasound with visualization for lifting, tightening, and wrinkle reduction of the décolletage. J Am Acad Dermatol. 2013;69 (6) 965-971. 7. Pavicic T, Ballard JR, Bykovskaya T, et al. Microfocused

WELCOME TO THE NOVEMBER/DECEMBER ISSUE OF PRIME

Currently, we are witnessing a shift from merely combating the signs of ageing to a more holistic approach that emphasises longevity and quality of life. This issue takes a look at some of the cutting-edge research and technologies driving this transformation.

We begin with Allergan Aesthetics’ Science of Aging initiative. This platform is dedicated to advancing longevity science within the field of aesthetics by bringing together world-class experts to discuss cellular rejuvenation, AI-driven medicine, and regenerative therapies aimed at addressing the fundamental causes of ageing. Instead of just targeting symptoms, these efforts focus on enhancing overall skin health and resilience, creating a roadmap for the future of aesthetic medicine. You can read the full article on page 10.

As aesthetic treatments gain popularity, safety and efficacy remain of utmost importance. In the Opinion feature, Dr. Vahe Karimyan addresses the rise in fat-dissolving injections and weight-loss drugs, emphasising the need for robust clinical studies and regulatory oversight. His insights highlight the importance of safeguarding patient outcomes as new solutions are introduced to meet the demand for non-surgical options.

Also featured in this issue is an article on the new Ultherapy PRIME and its relevance in clinical practice, which explores the latest advancements in microfocused ultrasound technology. Expert practitioners Joyce Teng Ee Lim, Yanni Xu, and Siew Tuck Wah share their experiences using Ultherapy PRIME on Asian skin types. Their insights reveal how this technology facilitates precise skin lifting with real-time imaging, allowing practitioners to provide tailored treatments with increased safety and comfort. Read the full article on page 16.

Affiliated partners:

An exciting area of longevity research is the anti-ageing potential of GLP-1 analogues. In this issue, Dr. Anish Kotecha and Professor Steve J. Davies examine the benefits of these compounds beyond weight management. Emerging research suggests that GLP-1 analogues may reduce inflammation, enhance mitochondrial function, and protect against age-related diseases, offering a promising approach to extending both lifespan and healthspan.

Other features in this issue include studies on polycaprolactone microspheres for forehead correction, the Asia-Pacific consensus on ELLANSÉ for facial enhancement, and muscle biomodulation techniques that prioritise muscle regeneration over traditional fillers. Together, these articles demonstrate a commitment to natural, effective, and scientifically backed treatments.

Finally, from the team at PRIME, we wish you all happy holidays and a great end to the year.

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

International Journal of Aesthetic and Anti-Ageing Medicine

Informa Australia, Level 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

Digital Marketing Manager 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

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1-2-3 OCTOBER 2025

November/December 2024

NEWS

22 26 36

AI-powered precision in aesthetics: Dr. Uliana Gout’s pioneering approach

8 AMWC Americas 2025 returns to Miami

COMPANY PROFILE

Bold scientific advances inspire a new age of aging

Allergan Aesthetics’ Science of Aging initiative explores groundbreaking research that could transform the future of aesthetic medicine and aging treatments

COMMENTARY

Building trust in weight management treatments: safety measures and clinical studies are essential

As fat-dissolving injections and weight loss drugs gain popularity, Vahe Karimyan, MD, discusses the regulatory challenges and the need for proper oversight and clinical studies to ensure safe and effective use

AESTHETIC FEATURES

16 The new Ultherapy PRIME and its relevance in clinical practice: an Asian experience

Joyce Teng Ee Lim, Yanni Xu and Siew Tuck Wah discussed their early experiences using the latest micro-focused ultrasound with real-time visualisation (MFU-V, Ultherapy PRIME) device for treatments on an all-Asian population

Exploring the anti-ageing potential of GLP-1 analogues

Dr Anish Kotecha and Professor Steve J. Davies explore a promising avenue in longevity research

Injecting polycaprolactone microspheres for forehead correction

A study on 74 female patients reveals that polycaprolactone (PCL) microspheres, provide effective forehead filling with minimal adverse reactions and long-term satisfaction

ELLANSÉ: An Asia-Pacific consensus

Experts from the Asia-Pacific region reach a consensus on the use of ELLANSÉ, a polycaprolactone-based filler, for comprehensive facial enhancement: contouring, volumising, tightening, lifting and skin rejuvenation

CASE REPORT

A new approach for facial volume restoration: muscle biomodulation

Noura Lebbar, MD, discusses a new approach to facial contouring that focuses on muscle regeneration over fillers for natural results

PRIME PROMOTIONS

Reversing the signs of aging with EXOS ANTIAGING

Hyaluronic acid filler injection technique: contouring temporal and under-eyes for Asians

A practical approach to lip filler: considering anatomy and rheology

60 Strategic filler application: a guide to full face rejuvenation and natural-looking results

A round-up of the major industry events happening around the world over the next 12 months 16 14

62 YVOIRE® Y-Solution 720: a paradigm shift in hyaluronic acid filler technology through optimised cohesivity, elasticity, and minimised BDDE crosslinking

EVENTS

news

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

AI-POWERED PRECISION IN AESTHETICS: DR. ULIANA GOUT’S PIONEERING APPROACH

DR. ULIANA GOUT CHAMPIONS AI-DRIVEN 3D IMAGING AT HER LAM CLINIC IN LONDON

In the ever-evolving field of Aesthetic Medicine, technology continues to shape both patient expectations and clinical practices. The aftermath of COVID-19 has accelerated changes in consumer behaviour, where patients now seek not just aesthetic enhancement but overall health and rejuvenation. Dr. Gout, a leading figure in the global industry, shares valuable insights into these shifting trends and the role of advanced diagnostic tools in empowering both clinics and patients.

AI-driven 3D photography improves patient care and speeds communication, focusing on being faster and more effective.

You’ve mentioned ‘SkinXiety’ as a hot global trend which you coined recently. Can you elaborate?

How do personalised diagnostics and smart advertising drive patient recruitment today?

‘Social media and advertising have become staples in our industry. Clinics have to play the game, but it’s important to understand which customers you’re targeting. Are you after quick fixes or gearing towards loyal, long-term premium customers? 3D cameras are key in capturing both segments. They empower clinics to offer a more personalised approach, educating and retaining patients in ways that set them apart from competitors.’

‘Yes, I coined SkinXiety, it’s a global phenomenon that has accelerated since the COVID-19 pandemic, where patients are increasingly concerned about the health and appearance of their skin. It’s no longer about just treating lines or enhancing lips. Today, the focus is on skin quality, homogeneity, and looking less tired. Patients want solutions that make them look healthier and more vibrant, and this is where 3D photography solutions like QuantifiCare’s signature cameras play a crucial role. These tools help patients understand their own skin at a very detailed and quantitative level and provide actionable insights to achieve that energised, healthy look.’

How have you seen patient expectations evolve over the years?

‘Over recent years, especially during and after COVID-19, we’ve witnessed a significant shift in patient expectations. COVID-19 brought with it a significant amount of disruption and exhaustion, both for individuals and businesses. It prompted a moment of reflection for people they asked themselves, “How do I survive?” and this moved to businesses rethinking their value propositions. Patients, too, have endured hardships and are looking for ways to look healthier and less tired. It’s not just about appearance anymore; they want to feel fresh and energised.’

How do you believe 3D imaging is transforming the patient journey in Aesthetic Medicine care?

‘It’s incredibly empowering. When patients see 3D imaging, they feel reassured and more informed. They’re not just taking the practitioner’s word for it they’re seeing the proof and evidence themselves. This allows them to make better decisions about their treatments, and they feel more prepared to accept or deny a treatment based on clear, visual data. These tools can really enhance communication by making it faster and more effective. When you provide patients with data points and visual diagnostics, it’s far more powerful than any qualitative verbal consultation. It’s about turning qualitative consultations into quantitative ones using facts and figures to better guide patient care and decision-making.’

What are your thoughts on integrating AI and facial recognition into Aesthetic Medicine practice?

‘I want the fastest, most advanced technology to improve the quality of my consultations. AI and facial recognition help speed up processes and provide a much deeper level of understanding during consultations. Today, as an industry and specialty, we need to embrace both qualitative and quantitative consultations, meaning we use real numbers and data to guide treatment decisions. This allows for more precise and effective care, which ultimately enhances the patient experience.’

LifeViz Neo

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AMWC AMERICAS 2025 RETURNS TO MIAMI ON FEBRUARY 15-17, 2025

THE 2025 EVENT PROMISES TO EMERGE AS THE EPICENTER OF INNOVATION

Keeping pace with the latest developments in aesthetic and anti-aging medicine is vital in a profession driven by continuous innovation. For physicians, practitioners and practice management specialists, the Aesthetic and Anti-Aging Medicine World Congress (AMWC) is more than just a gathering; it is a gateway to the future of the field. Returning to Miami February 15-17, 2025, at an all-new, luxurious venue the JW Marriott Miami Turnberry Resort & Spa— the 2025 event promises to emerge as the epicenter of innovation and where the future of aesthetic and anti-aging medicine is shaped.

The Global Voice of the Curriculum Curators at the heart of this transformative experience is the Scientific Advisory Board, a world-class team of medical professionals who are leading the way in aesthetic medicine. This board, comprised of leading experts from diverse backgrounds and countries, has played a crucial role in bringing global perspectives and insights to the conference. Their collective expertise ensures that the program is comprehensive and reflective of the latest advancements and challenges faced by practitioners worldwide. By drawing on their vast experience and understanding of global practices, they have created a program that is both innovative and practical, offering medical aesthetic professionals attending AMWC Americas the opportunity to learn from the best in the business and elevate their own practices to new heights.

From global expertise to interactive learning AMWC Americas 2025 is more than just a conference; it is a confluence of global minds, attracting professionals from over 60 countries, each bringing a unique

perspective to the table. ‘The agenda is designed to bridge the gap between groundbreaking research and real-world application, ensuring that attendees leave with actionable knowledge that can be immediately implemented in their practices,’ explained Mark Tager, MD, an anti-aging physician from Rancho Santa Fe, CA. ‘Take, for instance, the sessions on Integrative Aesthetics and Anti-Aging Therapies. Here, the conversation will move beyond the surface, delving into the gut-skin connection – a topic that has garnered increasing attention for its profound implications on skin health,’ added Dr. Tager.

But, AMWC Americas is not just about theoretical knowledge; it is about equipping practitioners with practical skills. The focus on Nonsurgical Profiloplasty and Holistic Facial Rejuvenation exemplifies this, offering a deep dive into techniques that are revolutionizing facial aesthetics. Whether it is mastering the art of nonsurgical facial balancing and harmony an increasingly popular alternative to surgical procedures or understanding the nuances of treating diverse patient demographics and issues, these sessions promise to be invaluable. Special attention will be given to skin of color and male patients, two areas often underserved in aesthetic medicine, ensuring that practitioners are equipped to provide diverse and personalized care across the board.

The agenda is designed to bridge the gap between groundbreaking research and real-world application, ensuring that attendees leave with actionable knowledge that can be immediately implemented in their practices.

New venue to explore the latest trends

This year, the event moves to the luxurious JW Turnberry a venue that perfectly complements the prestige of AMWC Americas. This renowned setting offers a blend of modern elegance and comfort, ensuring that attendees can fully immerse themselves in the conference while enjoying the best that Miami has to offer.

STUDY REVEALS SKIN CONCERNS OF YOUNG PEOPLE

In a study by the Skin Health Alliance that surveyed adults of all ages, 54% reported feeling the most selfconscious about their skin before the age of 25. The period of adolescence and young adulthood can be a difficult time and can be amplified by self-consciousness and skin issues. To better understand the experiences and priorities of young people, the Skin Health Alliance recently surveyed people aged 18-26 to explore their biggest concerns, influences, and skin health priorities.

A surprising finding from the Skin Health Alliance’s most recent survey was the popularity of sunbeds amongst young people. 60% of respondents said they use sunbeds, with 25% of those using them frequently. Although the reason behind this upward trend isn’t entirely clear, social media appears to be a significant factor.

Hashtags like #Sunbed and #Sunbeds have amassed over 100k posts and boasts more than 900 million views, with content ranging from sunbed ‘hacks’ and tanning tips to dramatic before and after videos. Even celebrities, and influencers, like Kim Kardashian publicly share their sunbed use, potentially normalising or even glamourising their use to an impressionable audience. Additionally, Gen Z may have missed out on the majority of prominent public health campaigns warning of sunbed risks, as most were produced many years ago.

Social media’s influence extends to skin care purchases as well. A huge 71% of respondents said they are likely to purchase a skincare product if their favourite influencer recommended it, illustrating the power influencers hold over their followers’ choice. Young people may look to social media and influencers for their skincare advice and if someone popular is advocating for a certain product or behaviour, many young consumers may feel compelled to try it themselves.

Allergan Aesthetics’ Science of Aging initiative explores groundbreaking research that could transform the future of aesthetic medicine and aging treatments

BOLD SCIENTIFIC ADVANCES INSPIRE A NEW AGE OF AGING W

E LIVE IN A ‘NEW AGE OF AGING.’

Anti-aging is out, and the concept of longevity is in. It is not enough to simply live longer; rather, how do we live better and more confidently? Now is the time to better understand these concepts and increase awareness of the early science and emerging regenerative solutions that could help address longevity across the world.

We know that only about 25% of aging is predetermined by genetics1. We also know there are certain hallmarks that influence aging and if we interrupt them, we can maintain our health, enabling us to live longer and better. We’re learning that the rate and ways in which we age are far from fixed, and so the potential to improve and even transform aging as we know it is ours to realize. This potential points to a novel intersection: science and longevity-based approaches are making their way into the world of aesthetics. The intersection of functional medicine and aesthetics brings focus to improving skin longevity, health span and quality of life.

We’re learning that the rate and ways in which we age are far from fixed, and so the potential to improve and even transform aging as we know it is ours to realize.

Efforts to activate that potential and transformation are underway. Targeting cellular rejuvenation, the causes of cutaneous aging, the power of exosomes, AI-driven longevity medicine, regenerative immunotherapy, or vesicle mRNA therapy may sound like the stuff of science fiction, but the early science supporting these ideas is here. Evolving approaches fuel future aesthetic interventions that address the root causes of aging — not just the signs and symptoms.

With this scientific innovation, we can pioneer a new paradigm in aesthetic medicine worldwide. Promising therapies, ongoing investigation and robust collaboration will support providers, empower confidence in patients and enable us to focus less on the years in our life and more on the life in our years.

Advancing The Science of Aging

If you’re looking for a glimpse into the future of longevity and aesthetic medicine, look no further than the Science

of Aging initiative. Science of Aging is a unique platform backed by Allergan Aesthetics, born out of a desire to bring the latest developments from the field of aging to aesthetics. Science of Aging convenes world-class experts within educational forums to discuss the latest early science and research in the field of aging. It aims to stimulate conversations to break new ground in the field, catalyze the exploration of unmet targets, find solutions for unmet patient needs, and the creation of a future blueprint for aesthetic medicine.

Work within the program is expansive and inclusive, going beyond the hallmarks of aging and longevity science to also examine rapidly progressing applications, such as AI and advanced digital technology. Integral to this work are the perspectives of expert faculty. This credentialed network of international academics, physicians and specialists are deeply passionate about their transformative aging-related research.

The Science of Aging’s examination of how our skin ages is rapidly progressing and is now anchored around the fundamental hallmarks of aging (including chronic inflammation, stem cell exhaustion, telomere attrition, and more). Indeed, since 2019, Science of Aging has conducted approximately 10 global events involving dozens of speakers, start-ups, and passionate professionals. Its growth is a testament to the commitment from Allergan Aesthetics to pioneer a new understanding of aesthetic medicine, support customers and empower patient confidence for the next decade and beyond.

Practitioner Perspective

Trends and innovations affecting how we age have a significant impact on practitioners and the people they serve. A targeted aesthetic treatment can do more than improve appearance; it can also help optimize skin function, identify aging factors, target cell regeneration, repair collagen or enrich structural elements beyond the treatment itself.

‘Regenerative aesthetics represents a fundamental shift in our approach to aging,’ says Dr. Saranya Wyles, MD,

DR STEPHANIE MANSON BROWN, Vice President, Head of Clinical Development and Scientific Innovation, Aesthetics Medicine at Allergan Aesthetics and co-founder of The Science of Aging™

PhD, Mayo Clinic, and Science of Aging faculty member.

‘I’m inspired by the myth of Prometheus, who defied Zeus by stealing fire from the gods and giving it to humanity. As punishment, Zeus chained Prometheus to a rock, where an eagle would eat his liver every day; however Prometheus’ liver would regenerate overnight, symbolizing our own innate ability to heal and renew. This illustrates that regenerative medicine taps into the body’s internal power to rejuvenate tissues in response to aging or injury, aligning our health span with our lifespan. In aesthetics, this means moving beyond anti-aging, toward more sustainable, preventive strategies that rebuild skin from within.’

While many across the industry focus on the symptoms and signs of aging, Allergan Aesthetics stands apart for its research and innovation ‘upstream,’ focused on aging’s underlying causes through products that aim to restore youthful tissue and address significant unmet needs. This approach is informed by research supporting more targeted and personalized therapies and inclusive options, representative of a broader, diverse set of patient needs.

‘We must expand the way we examine skin of all colors to ensure we’re looking across the changes and

implications in the dermal anatomy, the epidermal junction and the range of physiological changes we see as skin ages,’ says Professor Rachel Watson, executive director of A*STAR Skin Research Labs and Science of Aging faculty member. ‘That means embedding inclusivity in our research and interventions to help meet the range of unmet needs across patient populations.’

These experts reinforce how we must advocate for investing in and understanding skin health as an important part of a comprehensive approach to good health overall. That means offering personalized aesthetic treatments to meet individual concerns and needs during consultation. While these applications may focus on aesthetic medicine, the work can help society begin to grasp larger complexities in our biology to improve longevity and human health span.

Aesthetics for Longevity

The opportunity to harness science and change perceptions around aging is immense. Greater awareness of early research presented in forums like Science of Aging offers comprehensive, patient-centric scientific exchange and educational outreach, all necessary to prompt transformative innovation in aesthetics medicine. Extending conversations beyond aesthetics can address other health issues. All of this can drive awareness and collaboration to help practitioners grow — and patient outcomes improve.

(Above right) Dr. Saranya Wyles,

This is vital because by 2050, the world’s population of people aged 60 years and older will double (2.1 billion), and the number of persons aged 80 years or older is expected to triple to 426 million2. Scientific developments in the field of aging can translate into meaningful action in the future of aesthetic medicine. Allergan Aesthetics is helping to advance that future and share actionable insights from the field of aging and longevity with the international aesthetics community. By continuing to facilitate discussion among top researchers, physicians, and other innovators, we can explore cutting-edge science and evolve the collective approach to aging, shifting focus from lifespan to health span.

The next Science of Aging symposium will be held at the 2025 Aesthetic and Anti-Aging Medicine World Congress (AMWC) in Monaco in March 2025. Attendance is limited to those registered for the AMWC conference.

To learn more, visit: www.allerganaesthetics.com/ about/our-science

References

(Above left) Professor Rachel Watson, executive director of A*STAR Skin Research Labs and Science of Aging faculty member.

MD, PhD, Mayo Clinic, and Science of Aging faculty member

Science at the core

With a single product, we invented an industry— and our pursuit of new possibilities in medical aesthetics will never stop.

Science is our foundation. That’s why we invest in the research and development behind every innovation and every new idea— because science means quality.

We believe what’s behind our products is just as important as what is in front of them. Because our products are backed by leadingedge science and strengthened by data, our customers can confidently deliver beautiful, safe outcomes that impact patient lives.

And so we continue to evolve our business around the needs of those we serve. United by our shared belief in what we do and a commitment to doing what’s right, we bring our best every day—

To empower confidence.

BUILDING TRUST IN WEIGHT MANAGEMENT TREATMENTS: SAFETY MEASURES AND CLINICAL STUDIES ARE ESSENTIAL

As fat-dissolving injections and weight loss drugs gain popularity, Vahe Karimyan, MD, discusses the regulatory challenges and the need for proper oversight and clinical studies to ensure safe and effective use

DR VAHE KARIMYAN MD, MSC, MS, PHD, Surgeon at King’s College Hospital NHS, CEO and Founder of DrV PRP London, UK

THE LAST FEW YEARS HAVE BEEN A PERIOD OF BREAKTHROUGHS for medications and treatments focused on helping patients tackle excess weight.

Until recently, the average person on the street would not have even been aware of the existence of semaglutide (more commonly known as Ozempic). Now, it is regularly front-page news, offering the promise of ‘miracle’ results that could be a game change for the millions of people in the UK battling obesity.

Celebrities and public figures, including former Prime Minister Boris Johnson, have recounted their experiences with the drug.

However, as with any exciting new product, there has also been plenty of scepticism, from fears over potential side effects and concerns over counterfeit products entering the market to a debate over whether current safeguards are adequately ensuring only those eligible for these drugs are able to take them.

Fat-dissolving injections, a distinct but no less important treatment for excess weight, have faced similar acclaim and criticism. These cosmetic injections work in a different way to the better-known weight loss medications, using a process known as lipolysis that removes localised fat deposits rather than facilitating a reduction in overall body weight.

KEYWORDS Fat-dissolving, semaglutide, Lemon Bottle, injections

In a similar way to semaglutide, fat-dissolving injections like Aqualyx, Kybella and Lemon Bottle have exploded into the public consciousness remarkably quickly, fuelled in part by social media. From my private clinic in Chelsea, I’ve worked with hundreds of patients in recent years using Lemon Bottle in particular, with fantastic results and without the side effects that can occur with other similar treatments, such

as severe swelling and skin necrosis.

But despite this success in the clinic, regulators and the media have shown hostility with questions over the safety and efficacy of these kinds of products and calls to reclassify these cosmetic injections as medical products.

In my view, this is misguided and betrays the inconsistent and illogical approach taken by regulators to products in different jurisdictions.

It’s vital that regulators and patients alike understand the purpose of these kinds of products and have the right expectations about what can be achieved. Fatdissolving injections are cosmetic procedures designed to target localised areas of fat deposits rather than as a general weight loss treatment.

A typical patient would be someone who has tried exercise and/or a strict diet but isn’t seeing progress in the specific areas they would like — perhaps a double chin or in the abdominal area— and is nervous about trying alternative methods like liposuction.

There are steps that the industry could and should be taking to instill confidence in patients. The first thing is to ensure that clinical safety remains the number one priority. I’m firmly of the view that fat-dissolving injections should only ever be administered by medical professionals with the training to do so safely. Self-administering of these injections by someone without a good understanding of human anatomy is a risk that isn’t

Although we are seeing clear evidence of effectiveness every day with patients, our industry is one that relies on robust clinical studies to give us a better picture of exactly what can be achieved.

worth taking.

Counterfeits are also a real issue that need to be addressed. Counterfeit products pose a risk to patients since the ingredients in them can never be guaranteed and often vary significantly. Practitioners should only ever purchase products from licensed pharmacies or certified suppliers. Manufacturers can also play their part by ensuring that their packaging is as secure as possible. Genuine Lemon Bottle products, for example, have a QR code sticker on the packaging that can be scanned to verify the product’s authenticity. Additionally, transparent labelling and marketing regulations can play an essential role in preventing misleading claims and help to guide the safe use of these products.

Finally, there currently needs to be more sufficient clinical studies on fat-dissolving injections. Although we are seeing clear evidence of effectiveness every day with patients, our industry is one that relies on robust clinical studies to give us a better picture of exactly

what can be achieved. These studies are critical to validate effectiveness and identify any long-term risks. They can also play an important role in tackling the misinformation we’ve seen spread around these products, particularly on social media, providing customers with a clear and unequivocal understanding of their efficacy and safety. This will be vital not only to build consumer trust and ensure products continue to be used safely but also to support continued development in the sector and bring new generations of treatments to market for the benefit of consumers.

Declaration of

THE NEW ULTHERAPY PRIME AND ITS RELEVANCE IN CLINICAL PRACTICE: AN ASIAN EXPERIENCE

ABSTRACT

Energy-based devices (EBDs) offer effective, non-invasive solutions for skin laxity. Among them, the Ultherapy device has been recognised as the gold standard for non-invasive skin lifting and tightening procedures. Its innovative technology safely targets various skin tones by utilising energy that bypasses melanin absorption, ensuring effective and safe treatments for a diverse range of patients. The micro-focused ultrasound energy with visualisation (MFU-V) feature differentiates Ultherapy from other EBDs through its comprehensive software features, stable thermal characteristics, high-performing transducer acoustics, real-time visualisation capabilities, and extensive evidence-based clinical literature. The new Ultherapy PRIME is an advancement in EBDs that builds upon the legacy of its predecessor, featuring an advanced processor with seamless ultrasound image transition for faster treatments, clearer ultrasound imaging for precise visualisation, a wider screen

THE EMERGENCE OF ENERGY-BASED devices (EBDs) has revolutionised noninvasive treatments for skin laxity1 However, it is crucial to recognise that not all EBDs are equal and appropriate for every individual. Laser- and lightbased devices may pose risks for individuals with Fitzpatrick skin types III to VI due to melanin absorption, potentially leading to complications such as scarring and hyperpigmentation1-3. Recent advancements in these devices allow for the use of energy that is not absorbed by melanin, therefore availing treatment to individuals with darker skin tones1. In light of these innovations, this article will explore micro-focused ultrasound with visualisation (MFU-V), an EBD suitable for all skin types and skin tones, highlighting its unique features compared to other commonly used skin lifting and tightening devices. We also present a series of case

for better real-time visualisation from all angles, and an ergonomic design for enhanced user comfort. An early experience programme for Ultherapy PRIME was launched in Singapore, allowing selected expert physicians and patients to experience the device first-hand. Interim data demonstrated that patients with mild-to-moderate skin sagging showed notable improvements based on physician-GAIS and patient-GAIS scores, as well as 3D photography images taken via Quantificare LifeViz. Expert insights commended Ultherapy PRIME for its intuitive design, ease of use, and system speed and highlighted its superior imaging clarity compared to the legacy Ultherapy device. This innovative system not only enhances the experience for both physicians and patients but also provides effective clinical outcomes and safety. Together with its enhanced system upgrades and high safety standards, Ultherapy PRIME is set to uphold its legacy as the gold standard for non-invasive skin lifting and tightening treatment and is expected to offer even greater potential in the future.

studies and user insights on the new and advanced Ultherapy PRIME system, highlighting clinical outcomes specifically from an Asian demographic, supplemented by testimonials from both users and programme participants.

Ultherapy’s competitive edge against other non-invasive skin lifting and tightening devices

Reduced skin collagen and elastin are associated with increased skin laxity4,5. The superficial musculoaponeurotic system (SMAS), a skin layer rich in collagen and elastin, is an essential target for skin tightening treatments6,7. Many skin lifting and tightening devices deliver a controlled dose of energy into layers of the skin2,6,8-10. Treatments can result in ‘lifting’ through the contraction of the SMAS and the fibro septum connecting the dermis to the SMAS and ‘tightening’

JOYCE TENG EE LIM, FRCPI, FAMS DERMATOLOGY, MBBS, dermatologist in private

practice at Joyce Lim Skin and Laser Clinic, Singapore; YANNI XU, MBBS; founder of The Urban Clinic and Urban Clinic Hair Restoration Center, Singapore; SIEW TUCK WAH, MBBS, medical director and founder of Radium Medical Aesthetics, Singapore.

through the synthesis of collagen and elastin fibres and remodelling these fibres into dense arrangements11

Ultherapy, a non-invasive high-intensity ultrasound device, uses micro-focused ultrasound waves to create microlesions in the skin known as thermal coagulation points (TCPs), offering both skin lifting and tightening capabilities11,12. Results are noticeable a few weeks after treatment and can last up to one year13,14. Different EBDs utilise a range of technologies, each of which can influence treatment outcomes, leading to varying clinical results due to differences in software technology, thermal characteristics, transducer acoustics, and precision of TCPs, including variations in treatment depths6,12,15,16

A recent consensus guideline highlighted the differences in software technology among highintensity focused ultrasound (HIFU) devices12. While common features like touchscreen interaction and adjustable treatment parameters were noted, experts singled out Ultherapy for its technology and standout software capabilities12. Ultherapy’s comprehensive features, including patient and treatment information storage, personalisation, and an access key mechanism, promote continued treatment and enhanced safety12

The thermal properties of EBDs can vary, influencing both safety and clinical outcomes. RF-based devices are recommended to remain below 43°C, while HIFU-based devices’ temperature varies from 55–70°C15,17-22. During a continuous usage test, many HIFU-based devices had excessive increases in temperature, which poses safety concerns as this can increase the risk of superficial skin burns in patients12. Ultherapy was one of the few devices that did not overheat and precisely heats targeted skin layers to 60–70°C to facilitate optimal collagen denaturation, followed by neocollagenesis and elastogenesis4,6,10,12,23,24

Another key technological advancement of Ultherapy is its high-performing transducer acoustics, which experts agree excelled in all three parameters: focal gain, operating frequencies, and beam dimension12 According to the authors, Ultherapy had the highest focal gain, demonstrating the delivery of ultrasound energy at a high intensity; the widest range of operating frequencies, indicating its versatility in targeting deep and superficial layers of the skin; and the smallest average beam dimension, implying a precise delivery of ultrasound energy to the targeted area12 These attributes are key in Ultherapy’s ability to create distinct TCPs that are evenly sized and spaced at three precise skin depths of 1.5, 3.0 and 4.5 mm24. The healthy intervening tissues between TCPs play an important role in the natural wound healing process by promoting adequate space for the proliferation of new fibroblast cells. When TCPs are too close together, as seen in other EBDs25,26, they can fuse and lead to lengthy healing times or even tissue scarring12,23,27

I am very impressed with the after results. The whole process of the treatment was not painful at all. I love it. Thank you doctor for your professionalism and making me look younger and prettier.

Chinese female patient, 50 years of age. Early Experience Programme Participant.

Fast,

convenient, bearable (pain) way to improve sagginess and skin condition.

Chinese female patient, 39 years of age. Early Experience Programme Participant.

My left cheek and jaw felt firmer and more lifted after 1–2 weeks. Within 2 months, my right jaw also improved and the prominent droop below my right lip became less noticeable. Even the wrinkles on my chin have reduced! I am very pleased with the results as before this, I’ve been dreading looking at my haggard, sunken face in the mirror each morning.

Chinese female patient, 62 years of age. Early Experience Programme Participant.

My experience with Ultherapy PRIME has been very positive. It’s very easy to use with an intuitive interface that makes it straightforward to operate. The improved ergonomics has enhanced physician comfort during treatment.

Dr Joyce Lim, Dermatologist

KEYWORDS

MFU-V, Ultherapy, non-surgical skin lift.

Different EBDs offer a range of treatment depths. Lasers, radiofrequency (RF), highintensity facial electromagnetic stimulation (HIFES), and synchronous ultrasound parallel beam technologies target the more superficial skin layers5,19,23, while HIFU-based devices like Ultherapy uses ultrasound energy to penetrate deeper skin structures to the level of the SMAS, with some reaching up to 13 mm in depth2,20 Recently, new devices have combined technologies such as RF with HIFES, RF with HIFU, and micro- and macro-focused ultrasound technology5,20,28. However, accurate and precise targeting of the SMAS layer, which can vary in depth by up to 1.5 mm16, remains difficult in the absence of real-time imaging. A key distinction between Ultherapy and other skin lifting and tightening devices is its real-time visualisation capabilities12. Each ultrasound transducer provides tissue imaging to a depth of 8 mm, allowing physicians to see, plan, and treat exactly where energy should be deposited,

Figure 1 The new Ultherapy PRIME machine

A B C D

Advancing the gold standard: from Ultherapy to Ultherapy PRIME

Since receiving US FDA clearance for lifting of the eyebrow, submental area, and neck as well as to improve lines and wrinkles of the décolleté, Ultherapy has been widely used with over 3 million treatments performed worldwide in more than 80 countries31,32. It has also been backed by extensive clinical research, with over 140 published studies supporting its efficacy, including more than 50 clinical studies4,27. Alongside the aforementioned unique features, these factors contribute to Ultherapy’s recognition as the gold standard device for non-invasive skin lifting and tightening procedures4,27

Building on its success, Merz Aesthetics has developed the all-new Ultherapy PRIME, which boasts an improved design with updated features to elevate the user’s and patient’s experience. Ultherapy PRIME includes a more advanced processor allowing seamless ultrasound image transition for faster treatments, clearer and more vivid ultrasound imaging for stable and precise visualisation, a wider screen for clearer real-time visualisation visible from all angles, and an ergonomic design for greater comfort (Figure 1)31,33

Ultherapy PRIME in action: an early experience programme on Asian patients

The first thing I noticed about the new Ultherapy PRIME was its responsiveness and fast treatment time compared to the previous Ultherapy system. In my opinion, this improved system speed is the most impressive feature by far, which can help enhance the efficiency of procedures. Honestly, it’s a game-changer for myself and my patients!

Dr Siew Tuck Wah, Aesthetic Physician

thereby enabling a personalised treatment plan for each unique individual12,29. Real-time visualisation increases the safety of Ultherapy as it prevents treating critical structures (e.g., bones, nerves, and blood vessels), minimising risk of pain, oedema, vascular damage, and nerve injury30, while also avoiding subcutaneous fat layer treatment (lipolysis) and facilitating good transducer-to-skin coupling to reduce the risk of superficial burns12. Additionally, Ultherapy’s unparalleled real-time visualisation uniquely allows patients to actively participate in their treatment journey by observing and understanding their skin layers. This transparency fosters trust, manages expectations, and enhances patient education on their skin structure and collagen volume.

In July 2024, Merz Aesthetics APAC launched an Ultherapy PRIME early experience programme (EEP) in Singapore where aesthetic experts, each with over 10 years of experience using Ultherapy, were given the opportunity to gain first-hand experience with the new Ultherapy PRIME device. Individuals between 35–65 years with mild-to-severe facial skin sagging of the jawline and neck volume were recruited into this programme. Patients must have a score of 1–3 based on the 5-point Merz Aesthetics Scale, where 0 indicates no sagging and 4 indicates very severe sagging. Each participant underwent dual-depth treatment following the ‘See.Plan. Treat.™’ technique, tailored to their unique anatomical skin distribution. Participants received between 670 and 800 treatment lines, all at energy level 2. Premedication for comfort management was provided. Quantificare LifeViz 3D photography was taken at baseline and at 90 days post-treatment. A 5-point global aesthetic improvement score (GAIS) was recorded by physicians and patients at 90 days post-treatment.

The following interim data shared by one of the expert physicians presents the results of two individuals treated with Ultherapy PRIME, with a follow-up conducted 90 days post-treatment.

Case study #1

A 50-year-old female with level 2-moderate sagging of the neck and jawline, based on the Merz Aesthetics Scale, was treated with 790 lines over 41 minutes. The participant rated a pain score of 4 out of 10. At 90-day follow-up, both the physician-GAIS and patient-GAIS scored ‘3 — very improved.’ Photographs taken 90 days after Ultherapy PRIME treatment revealed overall

Figure 2 Frontal view taken (A) before and (B) 90 days after Ultherapy PRIME treatment session showing a slimmer and lifted face and improvement of skin folds. Photos taken (C) before and (D) 90 days after treatment also showed improvement in submental region and jawline.

improvements, with face lifting and marked reduction of submentum jowls (Figure 2). The nasolabial and marionette folds were less deep.

Case study #2

A 39-year-old female with level 1-mild sagging of the neck and jawline (based on the Merz Aesthetics Scale) was treated with 730 lines over 41 minutes. The participant rated a pain score of 3.5 out of 10. At 90-day follow-up, both physician-GAIS and patient-GAIS were ‘2— improved.’ 90 days after Ultherapy PRIME treatment, photographs revealed an overall lifting and tightening of the face with a marked improvement in skin quality, giving a healthy ‘glow’, improved skin texture, smoothness, and smaller pores (Figure 3).

Treatment times

Treatment times with Ultherapy PRIME were faster compared to the Ultherapy legacy device. The average time to treat the full face (700–800 lines) using Ultherapy PRIME by this physician was 41.50 ± 0.72 minutes, compared with 55.71 ± 11.67 minutes using the Ultherapy legacy device (data from archives of treatment performed between May 2023 and April 2024). This was approximately 25% faster, demonstrating the improved speed and consistency of the new Ultherapy PRIME device.

Ultherapy PRIME: the ultimate user experience

Three Ultherapy experts, comprising one dermatologist and two aesthetic physicians, with close to a cumulative 40 years of experience with the legacy Ultherapy device, took part in the Ultherapy PRIME EEP. In total, they treated 30 individuals and provided the following feedback.

Sleek design with improved user interface

The EEP experts found Ultherapy PRIME to be ‘very easy’ to use and had no problems with the device. They described the device as ‘extremely intuitive’, encountering minimal confusion or difficulties during procedures. The experts praised the sophisticated design of Ultherapy PRIME, calling it ‘sleek’, ‘beautiful’, and ‘very attractive’. Furthermore, all experts rated the ergonomic design as ‘excellent’ or ‘good’, highlighting its comfort and user-friendliness. These results suggest that Ultherapy PRIME’s design and user interface substantially enhance the overall user experience.

Faster system speed exemplified by the seamless ultrasound image transition

The EEP experts were ‘satisfied’ or ‘very satisfied’ with the speed and responsiveness of Ultherapy PRIME. Comparing the speed of Ultherapy PRIME with the legacy Ultherapy device, the experts cited an up to 20% increase in speed, demonstrating a marked improvement in performance. These results reflect a positive reception on the overall efficiency of treatment using Ultherapy PRIME.

A

C

E

B

D

F

Better ultrasound imaging clarity

The EEP experts agreed that the new Ultherapy PRIME offered ‘much better’ visualisation capabilities compared to the legacy Ultherapy device. They described the improvements as ‘clearer’, ‘brighter’,

I enjoyed using Ultherapy PRIME! Its ergonomic design made it incredibly comfortable to use and the user-friendly interface made procedures feel seamless. The improvements to the visualisation have made imaging clearer, brighter, and more detailed compared to the previous model. I’m excited to see how this innovative technology will enhance patient care in the future.

Dr Yanni Xu, Aesthetic Physician

Figure 3 Frontal view (A, C) before and (B, D) 90 days after Ultherapy PRIME treatment showing a slimmer and lifted face with improved skin quality. Photos taken (E) before and (F) 90 days treatment also showed improvement of jawline and submentum.

Ultherapy PRIME reduces treatment times, averaging just 41.50 ± 0.72 minutes for the full face (700–800 lines), compared to 55.71 ± 11.67 minutes with the legacy device—25% faster— underscoring the enhanced speed and consistency of the Ultherapy PRIME.

and ‘easier to visualise’ patient skin layers. This feedback highlights Ultherapy PRIME’s improved imaging capabilities, which contribute to increased user satisfaction and a more effective, personalised treatment.

Conclusion

With the rising demand for non-invasive skin lifting and tightening procedures, Ultherapy has solidified its reputation as the gold standard, distinguished by its unique mechanism, real-time visualisation, and over a decade of robust clinical data demonstrating proven results. The introduction of Ultherapy PRIME marks a significant leap in energy-based devices for skin lifting and tightening, building on the renowned legacy of its predecessor. Powered by an upgraded processor, Ultherapy PRIME boasts improved treatment speed, while its larger screen and enhanced clarity empower practitioners with vivid real-time visualisation, enabling them to deliver tailored, long-lasting results customised for each patient, thereby enhancing satisfaction for both physicians and patients. Interim results from the early experience programme revealed that Ultherapy PRIME not only maintains its status as the gold standard for noninvasive skin lifting and tightening but also demonstrates proven efficacy and safety. With its advanced system

References

1. Sanyal RD, Fabi SG. Energy-Based Devices for the Treatment of Facial Skin Conditions in Skin of Color. J Clin Aesthet Dermatol. 2024;17(6):22-32.

2. Suh DH, Choi JH, Lee SJ, Jeong KH, Song KY, Shin MK. Comparative histometric analysis of the effects of high-intensity focused ultrasound and radiofrequency on skin. J Cosmet Laser Ther. 2015;17(5):230-6.

3. Harnchoowong S, Vachiramon V, Jurairattanaporn N. Cosmetic Considerations in Dark-Skinned Patients. Clin Cosmet Investig Dermatol. 2024;17:259-77.

4. 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. 2019;18(5):426-32.

5. Kent DE, Fritz K, Salavastru C, Jarosova R, Bernardy J. First Evidence of Cutaneous Remodelling Induced by Synchronized Radiofrequency Aided by High-Intensity Facial Muscle Stimulation: Porcine Animal Model. Dermatol Surg. 2024;50(2):178-81.

6. Haney B. Nonsurgical Facial Skin Tightening. Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology. Cham: Springer International Publishing; 2024. p. 241-9.

7. White WM, Makin IRS, Barthe PG, Slayton MH, Gliklich RE. Selective Creation of Thermal Injury Zones in the Superficial Musculoaponeurotic System Using Intense Ultrasound Therapy. Archives of Facial Plastic Surgery. 2007;9(1):22-9.

8. Shome D, Vadera S, Ram MS, Khare S, Kapoor R. Use of Micro-focused Ultrasound for Skin Tightening of Mid and Lower Face. Plast Reconstr Surg Glob Open. 2019;7(12):e2498.

9. Bonjorno AR, Gomes TB, Pereira MC, de Carvalho CM, Gabardo MCL, Kaizer MR, et al. Radiofrequency

Key points

Ultherapy PRIME, the latest iteration of the Ultherapy device, offers faster treatment times, clearer imaging, and a more ergonomic design, all contributing to a more efficient user and patient treatment experience.

updates, Ultherapy PRIME is poised to unlock even greater potential, revolutionising patient expectations for skin lifting and tightening procedures while setting new heights in aesthetic industry standards.

An early experience programme conducted in Singapore revealed high satisfaction among aesthetic experts with the new Ultherapy PRIME device, with positive clinical outcomes particularly in improving skin laxity and skin quality.

therapy in esthetic dermatology: A review of clinical evidences. J Cosmet Dermatol. 2020;19(2):278-81.

10. Hantash BM, Ubeid AA, Chang H, Kafi R, Renton B. Bipolar fractional radiofrequency treatment induces neoelastogenesis and neocollagenesis. Lasers Surg Med. 2009;41(1):1-9.

11. Casabona G, Kaye K. Facial Skin Tightening With Microfocused Ultrasound and Dermal Fillers: Considerations for Patient Selection and Outcomes. J Drugs Dermatol. 2019;18(11):1075-82.

12. Pavicic T, Ballard JR, Bykovskaya T, Corduff N, Hirano C, Park JY, et al. Microfocused ultrasound with visualization: Consensus on safety and review of energy-based devices. J Cosmet Dermatol. 2022;21(2):636-47.

13. Sasaki G, Gorssman J, Misell L. 2018. Stimulation of collagen synthesis in human skin following Ultherapy. 2018. Available at: https://thebodyworkclinic.co.uk/wp-content/uploads/collagen-synthesisstimulation-with-ultherapy.pdf. Accessed on 26 September 2024.

14. Werschler WP, Werschler PS. Long-term Efficacy of Micro-focused Ultrasound with Visualization for Lifting and Tightening Lax Facial and Neck Skin Using a Customized Vectoring Treatment Method. J Clin Aesthet Dermatol. 2016;9(2):27-33.

15. Fritz K, Salavastru C. Ways of Noninvasive Facial Skin Tightening and Fat Reduction. Facial Plast Surg. 2016;32(3):276-82.

16. Wood E, Gonzalez A, Almukhtar R, Fletcher L, Fabi S. Comparing the Safety and Effectiveness of Microfocused Ultrasound: Standard vs Targeted Tissue Protocol in Lifting and Tightening the Lower Face and Upper Neck. J Drugs Dermatol. 2024;23(4):249-54.

17. Duncan DI, Kreindel M. Basic Radiofrequency: Physics and Safety and Application to Aesthetic Medicine. In: Lapidoth M, Halachmi S, editors.

Declaration of interest The Ultherapy PRIME Early Experience Programme was sponsored by Merz Aesthetics. All authors declared that they have received an honorarium and have been engaged as consultants for the company.

Radiofrequency in Cosmetic Dermatology. 2: S.Karger AG; 2014. p. 0.

18. Sun Y, Chen WL, Lin SJ, Jee SH, Chen YF, Lin LC, et al. Investigating Mechanisms of Collagen Thermal Denaturation by High Resolution Second-Harmonic Generation Imaging. Biophysical Journal. 2006;91(7):2620-5.

19. Hongcharu W, Boonchoo K, Gold MH. The efficacy and safety of the high-intensity parallel beam ultrasound device at the depth of 1.5 mm for skin tightening. Journal of Cosmetic Dermatology. 2023;22(5):1488-94.

20. Classy’s. Ultraformer III. 2022. Available at: https:// ultraformer.com/marketing-kit/. Accessed on 26 September 2024.

21. Hironic. Doublo treatment with HIFU. 2022. Available at: https://hironic-us.com/Doublo. Accessed on 11 October 2024.

22. Asterasys. Liftera 2. 2024. Available at: https:// www.liftera.co.kr/. Accessed on 11 October 2024.

23. Dobke MK, Hitchcock T, Misell L, Sasaki GH. Tissue restructuring by energy-based surgical tools. Clin Plast Surg. 2012;39(4):399-408.

24. White WM, Makin IRS, Slayton MH, Barthe PG, Gliklich R. Selective transcutaneous delivery of energy to porcine soft tissues using intense ultrasound (IUS). Lasers in Surgery and Medicine. 2008;40(2):67-75.

25. Gold MH. Update on tissue tightening. J Clin Aesthet Dermatol. 2010;3(5):36-41.

26. Laubach HJ, Makin IRS, Barthe PG, Slayton MH, Manstein D. Intense Focused Ultrasound: Evaluation of a New Treatment Modality for Precise Microcoagulation within the Skin. Dermatologic Surgery. 2008;34(5):727-34.

27. Park JY, Lin F, Suwanchinda A, Wanitphakdeedecha R, Yu J, Lim TS, et al. Customized Treatment Using Microfocused Ultrasound with

Visualization for Optimized Patient Outcomes: A Review of Skin-tightening Energy Technologies and a Pan-Asian Adaptation of the Expert Panel’s Gold Standard Consensus. J Clin Aesthet Dermatol. 2021;14(5):E70-e9.

28. Hironic. MFU & RF synergy technology for skin rejuvination. 2024. Available at: https:// hironicnewdoublo.webflow.io/. Accessed on 26 September 2024.

29. Merz Aesthetics. Ulthera® System Instructions for Use Featuring DeepSEE® Technology for Ultherapy®. 2021. Available at: https://ultherapy.com/ifu. Accessed on 1 October 2024.

30. Vachiramon V, Iamsumang W, Chanasumon N, Thadanipon K, Triyangkulsri K. A study of efficacy and safety of high-intensity focused ultrasound for the treatment of melasma in Asians: A single-blinded, randomized, split-face, pilot study. Journal of Cosmetic Dermatology. 2020;19(2):375-81.

31. Merz Aesthetics. Intructions for use for Ultherapy PRIME. 2024. Available at: https://ultherapy.com/app/ themes/ultherapy2020/pdfs/1015390IFU-Rev-01-USUltherapy-Prime.pdf. Accessed on 26 September 2024.

32. Merz Aesthetics. Frequently asked questions. 2024. Available at: https://ultherapy.com/ frequently-asked-questions. Accessed on 26 September 2024.

33. Merz Aesthetics. Merz Aesthetics announces the launch of Ultherapy PRIME platform as the next generation of nonsurgical skin lifting treatments. 2024. Available at: https://merzaesthetics.com/news/ merz-aesthetics-announces-the-launch-of-ultherapyprime-platform-as-the-next-generation-ofnonsurgical-skin-lifting-treatments/. Accessed on 26 September 2024.

Figure 1–3 © Merz Aesthetics

EXPLORING THE ANTI-AGEING POTENTIAL OF GLP-1 ANALOGUES

Dr Anish Kotecha and Professor Steve J. Davies explore a promising avenue in longevity research

ANISH KOTECHA, FRCGP, FAcadMEd, GPwERLM, MBBCh, BSc, General Practitioner and Programme Lead for Postgraduate Certificate in Anti-Ageing Medicine, Learna & University of South Wales, UK; Steve J. Davies, MD, FCRP, Consultant Endocrinologist and Director of Postgraduate Programmes, Learna & University of South Wales, UK

KEYWORDS

GLP-1 Analogues, Glucagon-like peptide-1, insulin secretion, inflammation, glycaemic control

ABSTRACT

Glucagon-like peptide-1 (GLP-1) analogues are gaining recognition, not only for their use in managing type 2 diabetes and obesity, but also for their broader potential in anti-ageing and longevity therapies. This article explores how GLP-1 analogues, such as liraglutide, semaglutide and tirzepatide, may offer multifaceted benefits beyond weight loss,

GLUCAGON-LIKE PEPTIDE-1 (GLP-1) analogues have garnered significant attention for their therapeutic benefits in managing type 2 diabetes mellitus and obesity1. However, emerging research suggests that these molecules may hold promise beyond their primary indications, offering exciting potential in the realm of anti-ageing and longevity. As humans continue to make advances in science and medicine, lifespan expectancy continues to rise. However, increased longevity does not necessarily equate to increased health span — the number of years spent in good health. Research now suggests that along with extending our life expectancy, targeted interventions may help compress morbidity, delaying the onset of age-related diseases and disorders, allowing us to not just live longer but also healthily2. One key intervention supported by mounting evidence is intentional weight loss, particularly in those carrying excess adiposity.

GLP-1 analogues, weight loss and anti-ageing

Obesity is considered a state of chronic, low-grade systemic inflammation3. This inflammation is implicated in cellular ageing via increased oxidative stress and telomere attrition4. Consequently, excess adiposity significantly increases the risk of developing numerous

including anti-inflammatory properties, improved mitochondrial function, and neuroprotection. Emerging studies suggest their potential role in modulating ageing processes, delaying the onset of age-related diseases, and extending both lifespan and healthspan. However, more research is needed to fully understand their long-term effects and optimal application in longevity-focused interventions

chronic diseases that predominantly afflict older populations.

With respect to interventions, animal studies reveal that calorie restriction is one of the few interventions associated with reduced mortality and longevity5. Whilst these studies are not entirely translatable to humans, epidemiological data reveal healthy longevity in communities where calorie restriction is common practice6. More recently, however, the emergence of GLP-1 analogues has heralded a new paradigm in not just glycaemic control but also weight loss and mortality7 Glucagon-like peptide-1 (GLP-1) is a hormone released by the small intestine and, as well as regulating insulin secretion, GLP-1 also acts centrally in appetite regulation. However, physiological GLP-1 is short-acting, yet GLP-1 analogues such as liraglutide, semaglutide and tirzepatide have a much longer duration of action. They are associated with improved glycaemic control and weight loss8. Whilst studies reveal that GLP-1 analogues are associated with improved glycaemic control and weight loss in subjects with type 2 diabetes, treatment is also associated with reduced cardiovascular risk9. Beyond diabetes, the 10-20% weight loss seen with GLP-1 analogues is also associated with reduced cardiovascular risk in non-diabetic, obese and overweight subjects10. Side effects are predominantly gastrointestinal but usually in the initiation or dose escalation phase. They are transient and usually tolerable11. The latter observation is

COVER STORY

Studies reveal that GLP-1 analogues can improve mitochondrial biogenesis, reduce reactive oxygen species production, and upregulate antioxidant defence. These actions may contribute to the preservation of cellular integrity and functionality, potentially counteracting age-related deterioration.

remarkable in obesity and so offers the intriguing potential of longevity in association with GLP-1 analogue therapy through modulation of several age and obesityrelated mechanisms.

Mitigating age-related inflammation with GLP-1 analogues

GLP-1 analogues exhibit anti-inflammatory properties, which could mitigate age-related inflammatory processes implicated in chronic diseases12. Chronic low-grade inflammation is a hallmark of ageing and is associated with an increased risk of age-related diseases, such as cardiovascular disorders, neurodegenerative diseases, and certain cancers13. By modulating inflammatory signalling pathways and regulating immune cell function, GLP-1 analogues may play a role in reducing the detrimental effects of inflammation on ageing14. Similarly, a progressive decline in mitochondrial function, leading to increased oxidative stress, inflammation and cellular damage, is associated with accelerated ageing15. Studies reveal that GLP-1 analogues can improve mitochondrial biogenesis, reduce reactive oxygen species production, and upregulate antioxidant defence16. These actions may contribute to the preservation of cellular integrity and functionality, potentially counteracting age-related deterioration.

Neuroprotection and cognitive health

In consequence, GLP-1 analogue therapy appears to have roles beyond weight loss and diabetes. Studies reveal potential for neuroprotection, with preclinical studies showing enhanced neuronal survival, synaptic plasticity and reduced neuroinflammation17. Liraglutide improved cognitive function and reduced neuroinflammation in a mouse model of Alzheimer’s disease, potentially by modulating histone acetylation and deacetylase expression18 and has been shown to improve non-motor symptoms, mobility, and quality of life in Parkinson’s disease patients19. With respect to the latter, treatment with the GLP-1 analogue, lixisenatide, has been shown to attenuate motor deterioration in subjects with early Parkinson’s disease versus placebo20. There are also ongoing clinical trials evaluating the effects of semaglutide as a treatment option in Alzheimer’s disease and Parkinson’s disease21. Such observations pave the way for further exploration of GLP-1 analogues in the prevention and management of age-related cognitive impairment and neurodegenerative disorders.

Reducing morbidity and extending healthspan

In addition to their cellular and molecular effects, GLP-1 analogues may contribute to reduced morbidity, a key concept in longevity research. By targeting obesity and its associated comorbidities, these molecules could potentially delay the onset of age-related diseases and disorders such as arthritis, hypertension and diabetes, allowing individuals to spend more years in good health. Intentional weight loss, particularly using GLP-1 analogues, has been shown to modulate cellular ageing processes23, reduce the risk of chronic diseases, preserve physical function, and potentially impact longevity24. However, it should also be appreciated that data regarding the long-term effects of

References

1. Williams DM, Staff M, Bain SC, Min T. Glucagon-like Peptide-1 Receptor Analogues for the Treatment of Obesity. TouchREVIEWS in endocrinology. 2022 Mar; 18 (1): 43–8

2. Crimmins EM. Lifespan and Healthspan: Past, Present, and Promise. Gerontologist. 2015 Dec; 55 (6): 901–11

3. Khanna D, Khanna S, Khanna P, Kahar P, Patel BM. Obesity: A Chronic Low-Grade Inflammation and Its Markers. Cureus. 2022 Feb; 14 (2): e22711

4. Guo J, Huang X, Dou L, Yan M, Shen T, Tang W, et al. Aging and aging-related diseases: from molecular mechanisms to interventions and treatments. Signal Transduct Target Ther. 2022 Dec; 7 (1): 391

5. López-Lluch G, Navas P. Calorie restriction as an intervention in ageing. J Physiol. 2016 Apr; 594 (8): 2043–60

6. Flanagan EW, Most J, Mey JT, Redman LM. Calorie Restriction and Aging in Humans. Annu Rev Nutr. 2020 Sep; 40: 105–33

7. Lincoff AM, Brown-Frandsen K, Colhoun HM, Deanfield J, Emerson SS, Esbjerg S, et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. New England Journal of Medicine. 2023 Dec; 389 (24): 2221–32

8. Müller TD, Blüher M, Tschöp MH, DiMarchi RD. Anti-obesity drug discovery: advances and challenges. Nat Rev Drug Discov. 2022 Mar; 21 (3): 201–23

9. Lincoff AM, Brown-Frandsen K, Colhoun HM, Deanfield J, Emerson SS, Esbjerg S, et al. Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes. New England Journal of Medicine. 2023 Dec; 389 (24): 2221–32

10. Popoviciu MS, Păduraru L, Yahya G, Metwally K, Cavalu S. Emerging Role of GLP-1 Agonists in Obesity: A Comprehensive Review of Randomised Controlled Trials. Int J Mol Sci. 2023 Jun; 24 (13)

11. Ghusn W, Hurtado MD. Glucagon-like Receptor-1 agonists for obesity: Weight loss outcomes, tolerability, side effects, and risks. Obesity Pillars. 2024 Dec; 12:1 00127

12. Peng W, Zhou R, Sun ZF, Long JW, Gong YQ. Novel Insights into the Roles and Mechanisms of GLP-1 Receptor Agonists against Aging-Related Diseases. Aging Dis. 2022 Apr; 13 (2): 468–90

13. Baechle JJ, Chen N, Makhijani P, Winer S, Furman D, Winer DA. Chronic inflammation and the hallmarks

GLP-1 analogues is scant and current recommendations suggest only up to 2 years of therapy. Consequently, pharmacologically assisted weight loss should also be complemented with lifestyle modifications. Indeed, physical activity and lifestyle behavioural change should potentiate the benefits of GLP-1 analogues in the context of longevity. We await data relating to GLP-1 analogues and a well-appreciated surrogate marker of biological ageing, such as epigenetic clocks25

Conclusion

While further research is warranted to elucidate the specific mechanisms and translate these findings into clinical applications, the emerging evidence highlights the promising potential of GLP-1 analogues in the quest for healthspan extension and the pursuit of longevity. By targeting multiple aspects of ageing, including cellular senescence, inflammation, cognitive function, telomere length and obesity-related comorbidities, these molecules may offer a multifaceted approach to promoting healthy ageing and potentially extending lifespan.

Declaration of interest None

Figure 1 Adapted from Kalra, S., Das, AK, Sahay, RK, et al. Consensus Recommendations on GLP-1 RA Use in the Management of Type 2 Diabetes Mellitus: South Asian Task Force. Diabetes Ther 10, 1645–1717 (2019).

of aging. Mol Metab. 2023 Aug; 74: 101755

14. Lee YS, Jun HS. Anti-Inflammatory Effects of GLP-1-Based Therapies beyond Glucose Control. Mediators Inflamm. 2016; 2016: 3094642

15. Maldonado E, Morales-Pison S, Urbina F, Solari A. Aging Hallmarks and the Role of Oxidative Stress. Antioxidants (Basel). 2023 Mar; 12(3)

16. Oh YS, Jun HS. Effects of Glucagon-Like Peptide-1 on Oxidative Stress and Nrf2 Signaling. Int J Mol Sci. 2017 Dec; 19(1)

17. Reich N, Hölscher C. The neuroprotective effects of glucagon-like peptide 1 in Alzheimer’s and Parkinson’s disease: An in-depth review. Front Neurosci. 2022; 16: 970925

18. Carranza-Naval MJ, Del Marco A, Hierro-Bujalance C, Alves-Martinez P, Infante-Garcia C, Vargas-Soria M, et al. Liraglutide Reduces Vascular Damage, Neuronal Loss, and Cognitive Impairment in a Mixed Murine Model of Alzheimer’s Disease and Type 2 Diabetes. Front Aging Neurosci. 2021; 13: 741923

19. Hogg E, Wu T, Bresee C, Wertheimer J, Malatt C, Tan E, et al. A Phase II, Randomized, Double-Blinded, Placebo-Controlled Trial of Liraglutide in Parkinson’s Disease. SSRN Electronic Journal. 2022

20. Meissner WG, Remy P, Giordana C, Maltête D, Derkinderen P, Houéto JL, et al. Trial of Lixisenatide in Early Parkinson’s Disease. New England Journal of Medicine. 2024 Apr; 390 (13): 1176–85

21. Kopp KO, Glotfelty EJ, Li Y, Greig NH. Glucagon-like peptide-1 (GLP-1) receptor agonists and neuroinflammation: Implications for neurodegenerative disease treatment. Pharmacol Res. 2022 Dec; 186: 106550

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Figure 1 Mechanisms by which GLP-1 agonists may exert beneficial effects

GLP-1

Combining existing clinical experience, our team discussed and studied the safety and effectiveness of PCL microspheres in frontal injection to provide treatment suggestions and data support for this emerging field of treatment.

INJECTING POLYCAPROLACTONE MICROSPHERES FOR FOREHEAD CORRECTION

ABSTRACT

Objective: To investigate the safety and effectiveness of polycaprolactone (PCL) microspheres for forehead injection and filling. Method: Seventy-four (74) female patients with dents and defects in their forehead soft tissue were injected with a PCL microsphere facial filler (ELLANSÉ®). Follow-up visits were conducted 7 days, 1 month, 3 months, 6 months, and 12 months after injection. Clinical effects were observed through the Sloping Forehead Assessment Scale, Global Aesthetic Improvement Scale (GAIS) grading assessment, satisfaction assessment, and adverse reaction assessment. Results: Sloping Forehead Assessment Scale and GAIS grading assessment: The subjects and researchers showed significant improvement immediately after treatment, with the highest satisfaction grading. There was a decrease in satisfaction at 1~3 months after treatment, and the satisfaction increased again from 6~12 months after treatment. Adverse reaction assessment: Swelling proved to be the most prominent adverse reaction, with the highest grading. The swelling subsided within 2~4 days. Other adverse reactions such as erythema, bruising and pain were not obvious, with low grading, all of which are normal reactions after injection within the acceptable range of subjects. No long-term adverse reactions were observed. Conclusion: The PCL microspheres (ELLANSÉ®) can be effectively and safely applied to forehead depressions for defect improvement and aesthetic modification.

KEYWORDS

Polycaprolactone microsphere, forehead, aesthetic modification

A study on 74 female patients reveals that polycaprolactone (PCL) microspheres provide effective forehead filling with minimal adverse reactions and long-term satisfaction

AS SOCIETY PROGRESSES, AESTHETIC medicine continues to advance rapidly. There is increasing use of injectable fillers to treat various facial issues such as volume defects, relaxation, deformity, and atrophy. Rich in fat and mimetic muscles that support diverse expressions, the middle face and lower face expressively convey people’s facial emotions and feelings and are more prone to atrophy and sagging during ageing. They, therefore, often attract more attention from aesthetic practitioners and raise more discussions on injection techniques. However, the forehead, located at the upper one-third of the face, bears therapeutic significance in frontal bony structure and frontotemporal transitional aesthetics, playing an equally important role in facial contouring and rejuvenation. Touching firm and hard, the forehead is characterised by obvious bony support, small volumes of fat in the soft tissue, dense tissue hierarchy, and low skin mobility. The challenge lies in choosing the right filler for treating depression or atrophy of soft tissue in the forehead. Currently, there are few

YU XIANG, MD, Department of Aesthetic Surgery, Yunyan Ruiyaruimei

Medical Beauty Clinic, Guiyang, China

DU ZHENNAN, MD, Department of Aesthetic Surgery, Yunyan Ruiyaruimei

Medical Beauty Clinic, Guiyang, China

LONG YU, MD, Department of Aesthetic Surgery, Yunyan Ruiyaruimei

Medical Beauty Clinic, Guiyang, China

comprehensive reports on forehead injections in and outside of China, and more clinical research is needed to verify the treatment mode, product selection, injection layer, and aesthetic characteristics. Combining existing clinical experience, our team discussed and studied the safety and effectiveness of PCL microspheres in frontal injection to provide treatment reference suggestions and data support for this emerging field of treatment.

Materials and methods

Clinic subjects:

A group of 74 female patients, aged 29~47 (37.12 on average), took part in the study.

Inclusion criteria:

■ Suffering from different degrees of forehead soft tissue depression

■ Congenital bone volume hypoplasia in the forehead

■ Promising not to accept other injection products for treatment on the same site within one year after receiving PCL microsphere injection.

Exclusion criteria:

■ Patients whose forehead received an injection of

LI XIA, MD, Department of Microinvasive Surgery, Chengdu Huamei Zixin

Medical Aesthetic Hospital, Chengdu, China

DONG JIE, MD, Department of Aesthetic Surgery, Yunyan Ruiyaruimei

Medical Beauty Clinic, Guiyang, China

WANG

XIAOYANG, MD, Department of Aesthetic Surgery, Shanghai Yanfan

Medical Beauty Clinic, Shanghai, China

SHI BING, MD, Department of Aesthetic Surgery, Beijing Milan Bravou Lidu

Medical Aesthetic Hospital, Beijing 100101, China

unknown materials that cannot be naturally degraded

■ Patients whose forehead is in the acute infection stage or suffer soft tissue defects with exposure trauma

■ Pregnant patients or patients who are complicated with serious systemic diseases related to their liver, kidney, cardiovascular system and endocrine system

■ Patients with autoimmune diseases

■ Patients who suffer coagulation dysfunction or who take anticoagulant drugs such as aspirin orally for the long term but stop administrating for less than two weeks

■ Patients with mental illness or imperfect mental state

■ Patients with a hypersensitive constitution. This study was performed in line with the principles of the Declaration of Helsinki. All subjects have good communication skills and have signed an informed consent form.

Figure 2 Sloping Forehead Assessment Scale.

Materials used

PCL microsphere facial filler (trade name: ELLANSÉ®), 1 ml/syringe; ingredients: polycaprolactone (PCL) evenly suspended in a gel carrier prepared with a phosphate buffer solution (European Pharmacopoeia), glycerinum (United States Pharmacopeia) and carboxymethyl cellulose (CMC) (United States Pharmacopeia), a sterile, latex-free and heat-free bioabsorbable PCL microsphere gel; type: ELLANSÉ®-s; manufacturer: AQTIS Medical B.V., agent: Sinclair Aesthetics (Shanghai) Medical Technology Co., Ltd.; medical device registration certificate number: GXZJ 20213130100. Lidocaine hydrochloride injection, adrenaline hydrochloride injection, 23G cannula, 27G needle.

Injection techniques

Pre-treatment aesthetic assessment

The aesthetic unit of the face and subunits are determined considering both the aesthetic design and anatomical principles of plastic surgery in principle1-2

The forehead occupies one-third of the face, four boundaries of which are defined as follows:

■ Upper boundary: frontal hairline

■ Lower boundary: horizontally from the upper margin line of the eyebrows to the sideburns of the head

■ Left and right boundary: 1.0cm within the hairlines of both temples3, which links and overlaps with the temporal region to a certain extent.

Considering the bony structure of the frontal bone, there should be two bilaterally symmetrical frontal protuberances in the upper third of the forehead, and the frontal bone should reach the superior temporal septum when it extends left and right. Therefore, the forehead is divided into five aesthetic units based on its arc characteristics (Figure 1):

Central forehead (F1): the cross-section between the perpendicular line of the medial line of bilateral frontal protuberances and the frontal area.

Bilateral para frontals (F2a, F2b): the cross-section between the perpendicular line of the medial line of bilateral frontal protuberances, the superior temporal septum and the frontal area.

Bilateral frontotemporal junction areas (F3a, F3b): the cross-section between the lateral surface of the superior temporal septum and the frontal range.

A: Optimal Forehead Volume; B: Mild Sloping Forehead; C: Moderate Sloping Forehead; D: Severe Sloping Forehead; E: Extremely Severe Sloping Forehead. A B C D E

The lateral plane was rated with the Sloping Forehead Assessment Scale before treatment (Figure. 2)4. According to the forehead injection techniques, the frontal plane can be divided laterally into three equal parts: upper

Figure 1 Forehead aesthetic unit. a.a‘: midpoint of the frontal protuberances; F1: central forehead; F2a: Left frontal area; F2b: Right frontal area; F3a: Left frontotemporal junctional area; F3b: Right frontotemporal junctional area

forehead (Fu), middle forehead (Fm) and lower forehead (Fl) (Figure 3).

Pre-treatment preparations

Involves comprehensively assessing patients’ forehead condition, age, skin tightness, requirements on frontal aesthetics, personality, and preferences; conducting preoperative routine examinations; inquiring about their medical history to be clear whether there are surgical contraindications, whether they are pregnant or suffer severe cardiovascular diseases, whether there is a history of infection or mental illness, trauma history, bone defects, drug allergies, immune tissue diseases or functional declines; assessing whether the patients can be treated with PCL microsphere facial fillers.

The second stage focuses on accurately evaluating patients’ psychological conditions to identify if their expectations are excessively high or unrealistic.

The third stage involves finding out whether there is an acute or chronic infection at the site to be injected, whether there are abnormal bulges such as fibroma and connective tissue hyperplasia, and whether there is an injection history of unknown injection materials.

The next stage involves taking photos of the treatment area before and after the procedure, ensuring good lighting for accurate comparison. The skin on various parts of the forehead should be carefully examined and palpated. Injection techniques will be designed, and the injection points will be marked. Finally, patients will be organised to sign an informed consent form.

Injection techniques

Injections were performed based on the aesthetic units of the face and the layout of the injection points, which were determined by areas of depression and volume loss. Considering these depressions and the varying aesthetic needs, injection points were selected along the upper, middle, and lower forehead. The injections were carried out from the central forehead, moving outward to the para-frontal and frontotemporal junction areas. Fillers were injected into the periosteal layer using a cannula, following the designated points labeled as a-a’, b-b’, c-c’, and e-d-d’. Please refer to Figure 4 for the markings of the injection points.

To minimise pain for the patient during injections, each 1 ml syringe of PCL microsphere facial filler was mixed with 0.2 ml of 2.0% lidocaine hydrochloride prior to injection. This preparation method does not alter the physical properties or safety of the injected materials5 The procedure begins with disinfecting the entire face and hairline with iodophor three times. A 2.0% lidocaine hydrochloride solution is then applied for supraorbital

Figure 4 Marking of injection points. a’, a: midpoint of frontal protuberances; b’, b: boundary point between the perpendicular line of the left and right superciliary arches and the midline of the forehead length; c’, c: 1cm perpendicular line on the left and right superciliary arches; d’, d: the junctional point between the left and right zygomatic arches and the hairline; e: 1.0–1.5 cm between the midline of the forehead and the hairline

Figure 3 Forehead injection unit. Fu: Upper forehead; Fm: middle forehead; Fl: lower forehead

Table 1 Sloping Forehead Assessment Scale

GRADE SLOPING FOREHEAD ASSESSMENT

0 Optimal forehead volume, protruding and full

1 Mild sloping forehead, protruding and slight sloping

2 Moderate sloping forehead, flat forehead and moderate sloping

3 Severe sloping forehead, concave forehead and severe sloping

4 Extremely severe sloping forehead, concave forehead and extremely severe sloping

Table 2 Global Aesthetic Improvement Scale

GLOBAL AESTHETIC IMPROVEMENT SCORE

nerve block anaesthesia. Following this, a 23G 50 mm cannula was used to inject at various points after infiltration anaesthesia with 2% lidocaine. During the injection process, the filler was administered into the periosteal layer to avoid damaging the supratrochlear arteries, supraorbital arteries, and the frontal branches of the superficial temporal arteries. When the tip of the cannula reached the edge of the injection site, it was withdrawn for dosage, allowing for the injection of 0.1 to 0.15 ml of PCL microsphere facial filler per stripping tunnel. A fanning injection technique was utilised in the periosteal layer, focusing on areas around the injection points to prevent unnecessary stripping and multiple doses in the same location.

It was important to inject gently and slowly, ensuring a smooth and even distribution of the filler to avoid multiple dosing in a single area. The injector monitored for surface tension and skin colour changes to prevent issues such as circulatory disturbances, mottled skin, and potential embolisms caused by excessive dosage at a single point. In the process, injectors gently pressed to smooth the area. Throughout the procedure, gentle pressure was applied to smooth the area. If any noticeable swelling occurred due to overdosing, that section could be gently stripped multiple times and pressed back to a flat state. The injection should be halted once the result meets the desired proportion to prevent overdosing.

Post-treatment management

After injection, the injector checks whether the aesthetic goals have been met and observes for any changes in skin colour. An erythromycin eye ointment is then applied to the injection points and dressed with cotton balls, which can be removed 6 hours later. An elastic bandage may be used to dress the injection, applying gentle compression for about 4 to 6 hours each day for 2 to 3 days to relieve swelling. Alternatively, surgical bandages can be applied to the injection points on the forehead to minimise tension and further alleviate swelling. No oral antibiotics are required for infection prevention. It is advised to avoid drinking alcohol and smoking for 72 hours, refrain from massaging the injection site, and steer clear of allergy-inducing foods for

7 days. Additionally, it is recommended not to undergo photoelectrical therapy in the injection area for 3 months and to avoid taking hormones or immunosuppressive

appointments at 1 month, 3 months, 6 months, and 12 months after treatment, during which their facial images were collected. The conditions for taking the posttreatment images were consistent with those taken

before treatment, including the same black background, equipment, and parameter settings. A third-party researcher with the title of attending physician, who was not involved in the treatment covered in this study, conducted the Sloping Forehead Assessment Scale (SFAS)4 assessment based on images of subjects before treatment, 3 months, 6 months and 12 months after treatment as a blind study researcher. The blind study researcher explained the assessment and grading standards of the Global Aesthetic Improvement Scale (GAIS)6 to the subjects. The subjects themselves and the blind study researcher scored them respectively at 1 month, 3 months, 6 months and 12 months after treatment. Subjects’ satisfaction assessment scale and adverse events7-8 were designed by the blind study researchers.

Sloping Forehead Assessment Scale (SFAS)

The forehead lateral amplitude of the subjects was evaluated using the Sloping Forehead Assessment Scale, which consists of five grades (Table 1). A higher score indicates a greater degree of forehead sloping. After treatment, a reduction of one grade compared to the pretreatment score is considered effective, while a reduction of more than two grades is deemed significantly effective.

Global Aesthetic Improvement Scale (GAIS)

GAIS was used to assess the improvement in facial aesthetics before and after treatment (Table 2). The evaluation was divided into five grades, with corresponding scores ranging from 5 to 1. A higher score indicates a more significant improvement.

Satisfaction assessment

The researcher evaluated the therapeutic effects based on four dimensions of satisfaction:

■ Satisfaction with treatment effects before and after the injection

■ Feelings and willingness to continue with a second treatment during the injection process

■ Tolerance of pain during the treatment

■ Maintenance of forehead improvement effects, assessed through a self-prepared satisfaction scale. Satisfaction with the treatment effects was categorised into five grades:

■ Grade 1: Very satisfied

■ Grade 2: Satisfactory

■ Grade 3: Neutral

■ Grade 4: Dissatisfied

■ Grade 5: Very bad.

Adverse events

The time, place, cause, detailed content, and severity of adverse events were observed and recorded. The relationship between technical operations and injected products was analysed, and solutions were documented.

Statistical method

SPSS 26.0 was applied for analysis. The measurement data was expressed by x±s. A comparison of the same

Table 3 Grading of Sloping Forehead Assessment Scale for subjects

Table 4 GAIS scores of subjects

Table 5 GAIS scores by research

Table 6 Subject satisfaction assessment

The forehead lateral amplitude of the subjects was evaluated using the Sloping Forehead Assessment Scale,

A B C D E

subject before and after treatment was made using a paired sample t-test. The enumeration data was expressed by n (%). The chi-squared test indicated that p<0.05, suggesting that the results are statistically significant.

Results

General conditions

A total of 74 female patients were selected for the study. Patients aged 29~47, 37.12 on average. Among them, 24 patients aged 30~35 (32.4%), 38 patients aged 36~40 (51.4%), and others aged 41~45 (16.2%). All patients were followed up for 12 months after treatment, with details recorded. Three patients were followed up for up to 24 months.

SFAS assessment

The SFAS grading of patients before and after treatment is shown in Table 3. Compared with data before treatment, 5 patients (6.8%) were moved down the scale by 1 grade, 68 patients (91.9%) by 2 grades and 1 patient (1.3%) by 3 grades immediately after treatment, indicating an improvement in forehead volume and a reduction in sloping. 20 patients were moved up by 1 grade 1 month after treatment, implying a decreased curative effect. 13 patients were moved down by 1 grade again 3 months after treatment, and 6 patients were moved down the scale by 1 grade again 6 months after treatment. Their conditions kept consistent with those 6 months and 12 months after treatment.

GAIS scoring

After treatment, all subjects believed that the aesthetic

A: Before treatment;

B: 1 month after treatment;

C: 3 months after treatment;

D: 6 months after treatment;

E: 12 months after treatment

appearance of their foreheads had been significantly improved. The whole course of treatment was scored five separate times: immediately after treatment, 1 month after treatment, 3 months after treatment, 6 months after treatment, and 12 months after treatment. The grading and scores for the subjects and the researcher are displayed in Table 4 and Table 5, respectively. Scores immediately after treatment and 1 month after treatment were significantly different, showing a direct proportion to SFAS assessment. After PCL microspheres are injected into the human body, CMC is rapidly metabolised, allowing the PCL microspheres to stimulate collagen production within 2 to 4 weeks. It typically takes 2 to 3 months to achieve and maintain the best results. The difference in scores measured immediately after treatment and 12 months later showed no statistical significance (t = -1.000, p = 0.321). This indicates that the improvement in the forehead area of the subjects can be sustained in good condition for 12 months following the treatment.

Satisfaction assessment

The satisfaction assessment is shown in Table 6. In the immediate post-treatment satisfaction assessment, 69 patients (93.2%) reported feeling very satisfied with the results of their treatment. They noted that it involved only slight and minimal pain and a significant improvement that met their expectations. In the immediate post-treatment satisfaction assessment, 69 patients (93.2%) were very satisfied with the curative effect, believing that the treatment featured slight and little pain and obvious improvement that is in line with their expectations. 4 patients (5.4%) were satisfied with

Figure 5 Female subject, 30 years old, showed significant improvement in frontal appearance after injection of PCL microspheres into the upper forehead and middle forehead.

the curative effect, and 1 patient (1.4%) kept neutral due to fear of the treatment process. The total satisfaction reached 98.6%. 73 subjects expressed their willingness to receive secondary treatment, accounting for 98.6%. One month after treatment, the satisfaction decreased as the curative effect declined, and the total satisfaction was 97.3%. 6 and 12 months after treatment, 73 patients (98.6%) were very satisfied, and 1 patient (1.4%) was satisfied with the curative effect, and the total satisfaction was 100%.

Adverse events

In the collection of adverse events, mild swelling proved to be the most commonly reported, occurring in 25 subjects. The swelling typically subsided within 2~4 days, having a directly proportional relationship to the injection dose, all of which are normal reactions after injection within the acceptable range of subjects. No other adverse reactions, such as erythema, bruising and pain, were significantly reported, and no long-term adverse reactions, such as infection, granuloma, nodules and other complications, were observed.

Discussion

The forehead depression is mainly caused by congenital underdevelopment of bone tissues or congenital/acquired soft tissue insufficiency, so it can be seen among people of all ages. For young patients, forehead depression is characterised by uncoordinated facial proportions but excellent soft tissue elasticity. For elderly patients, it is characterised by low skin elasticity, sagging skin, and wrinkles caused by the decrease of bone tissue capacity, soft tissue atrophy, decreased collagen synthesis and loss of support due to ageing. Besides the depression, the aesthetic form and transition amplitude of the forehead should also be considered during treatment. It is particularly important to fill each aesthetic unit with a certain transition amplitude while retaining the bony protruding structures, such as frontal protuberances, to enhance the beauty of the forehead instead of simply rounding it into a semicircle. We found that it is more natural to fill a small amount at the transitional junction between the frontal protuberance and the superior temporal septum while keeping a certain transition amplitude. Moreover, a slight vertical depression at the central forehead below the frontal protuberance makes the forehead appear more natural. Many materials have been applied to the forehead clinically, including silicone rubber, expanded polytetrafluoroethylene, hyaluronic acid, collagen, autologous fat, etc. Prosthetic materials have proven to

In practice, the injection of hyaluronic acid brings a favourable and long-acting filling effect, but some shortcomings appear over time, including sagging skin, reduced skin elasticity, loosening soft tissue of the skin, and failure in maintaining flat skin after multiple treatments.

be less accepted by patients due to a huge pool of adverse reactions in forehead augmentation9. There was a time when the authors would once fill the forehead with hyaluronic acid, autologous fat and collagen. In practice, the injection of hyaluronic acid brings a favourable and long-acting filling effect, but some shortcomings appear over time, including sagging skin, reduced skin elasticity, loosening soft tissue of the skin, and failure in maintaining flat skin after multiple treatments. Autologous fat filling can be beneficial in the early stages of treatment. However, there are certain limitations. The operator often cannot accurately determine the relationship between the injection dosage and the survival of the fat cells. This may lead to hypercorrection. Additionally, complications such as induration, calcification, infection, and necrosis may occur.

For some time, collagen injections have been considered a favourable option for treating forehead depression. This method provides immediate results, helps improve soft tissue loss, reduces wrinkles, and enhances the skin’s texture. After several treatments, patients often notice a significant improvement in skin smoothness and experience less sagging. However, the difficulty of injection is positively correlated with the increase in injection time, as the increase of tension of the forehead soft tissues shortens the acting time of the curative effect. Therefore, there are also some limitations.

The PCL microsphere facial filler (Ellansé-S) is comprised of 66.9% carboxymethyl cellulose (CMC) and 33.1% PCL, with the PCL microspheres uniformly suspended in the CMC gel carrier10. PCL is a biocompatible, biodegradable, and bioabsorbable polymer with stable safety and effectiveness, which has been proven in multiple studies11-12. After being injected into the human body, CMC is rapidly absorbed within 2~4 weeks and uniformly suspended PCL microspheres stimulate collagen proliferation through a nonbacterial inflammatory reaction13

According to the assessment of the effectiveness and safety of PCL microsphere injection in the forehead performed in this study, the subjects’ forehead sloping significantly improved after treatment, and the SFAS grading was significantly lower than before treatment. All subjects achieved effective or significantly effective treatment results immediately after treatment, and the curative effect decreased 1 month after treatment as CMC was rapidly absorbed during this period. The curative effect was improved again 3~12 months after treatment. It can be observed from the images that the curative effect on all subjects remained for at least 12 months. After treatment, the subjects and the blind study researcher observed that the GAIS score was ≥4 during follow-ups throughout the cycle, with a grading of ‘extremely obvious improvement’ or ‘obvious improvement’. The total number of subjects with a score of 5 was greater than that of subjects with a score of 4,

objectively indicating an excellent curative effect. In the satisfaction assessment, the lowest satisfaction rate was 97.3% in the follow-up 1 month after treatment. The satisfaction rate reached 100% in follow-ups 3~12 months after treatment. Subjects were satisfied with the treatment process and acting effect, and no obvious complications were found 12 months after treatment.

The literature review revealed that there has been little to no discussion regarding the injection of PCL microspheres into the forehead in China. In 2016, Byunggi Bae14 and a team from South Korea examined the effectiveness and safety of PCL microsphere injections in the forehead. They assessed the effects by administering PCL microspheres one week after a botulinum toxin injection. In the paper, GAIS assessment was used as the only criterion for efficacy and safety assessment. On this basis, SFAS assessment, satisfaction assessment and adverse events were introduced to further improve and discuss the frontal aesthetic unit, selection of unit-based treatment, as well as selection of injection layers and points, ultimately leading to better methods for injecting PCL microspheres into the forehead. The forehead

injection of PCL microsphere facial filler produced satisfactory treatment results not only for the forehead fullness that met the aesthetic requirements but also provided immediate results that aligned with the effects of collagen stimulation over time. Additionally, the high elastic modulus10 of the product offers improved bony support and plasticity, contributing positively to the formation of aesthetic angles and transition planes that cannot be achieved with other materials. Currently, a more real vertical structure can be obtained through needle injection in the periosteal layer, and suitable

volume supplementary and proportion can be achieved through the combination with cannula injection in the subcutaneous layer. The skin tightness improves as PCL microspheres gradually stimulate collagen production over time, effectively reducing wrinkles and alleviating skin laxity. Its effect has been validated and confirmed by improved volume and smoothness of skin. No related complications were found during follow-up observations.

Complications and mitigating risks

However, it does not mean that the injection of PCL microsphere facial filler brings no complications. It is reported in the literature that there may be common filler complications such as bruising, hematoma and delayed oedema during injection8, which are commonly related to the operation, the anatomical knowledge and expertise of the injector, and whether the patient takes aspirin, warfarin and other drugs. There may also be longterm complications such as nodules and skin discolouration, which are related to whether the operator ensures effective aseptic operation and targets the correct layer during injection, whether there was excessive dosage in a single point, and whether the injection point was injected with other microsphere fillers prior to treatment. This raises the requirements for the operator’s knowledge of anatomy and technical skills. When PCL microsphere facial filler is injected, its fault tolerance decreases because it cannot be immediately dissolved by lytic enzymes like hyaluronic acid fillers can after injection. According to existing studies, collagen stimulators can be used for the targeted dissolution of nodules with collagenase15, which effectively reduces the probability of nodules. Forehead injections typically require a linear, flat technique. However, uneven injections can lead to insufficient flatness and lower nodule formation probability. Therefore, it is crucial to focus on the uniformity and technique of the injections.

During injection, the following tips must be kept in mind. When performing injections in the forehead, it is essential to prioritise safety. To ensure a successful procedure, it’s important to have a thorough understanding of the injection layers and the pathways of vital blood vessels and nerves in the forehead. Key structures to be aware of include the supratrochlear arteries, supraorbital arteries, and the frontal branches of the superficial temporal arteries16. The blood vessels most likely to be embolised in the forehead area are the supratrochlear arteries and supraorbital arteries17. If the filler is injected into a blood vessel mistakenly during the treatment, it may cause serious eye complications or embolic skin necrosis.

To mitigate these risks, it is advisable to perform subcutaneous injections, as the supraorbital arteries travel vertically through the SMAS layer after originating from the supraorbital foramen or notch, gradually emerging in the forehead region. The same applies to the supratrochlear arteries. When injecting in the periosteal layer, it’s important for the operator to effectively pull back the needle and operate gently, even when using a cannula. This approach helps avoid rupturing blood vessels that can occur from the cutting action of a forcefully handled cannula. The authors once injected tumescent fluid mixed with lidocaine and adrenaline in advance to form an injection tunnel and shrink the vessels to effectively avoid vascular injury and embolism formation.

However, this practice increased the pain during injection, and skin colour changes could not be observed due to the white skin in treatment. As a result, this approach was abandoned. Currently, it is recommended to give patients a better and more comfortable experience through nerve blocking. Additionally, when injecting PCL microsphere facial filler into the forehead, the maximum dosage for a single needle injection should not exceed 0.05 ml. In case of excessive single-point dosage, it may create a smooth appearance immediately due to swelling but can lead to the formation of nodules that become noticeable once the swelling subsides. In cases of cannula injection, the single-tunnel dosage should be between 0.1~0.15 ml18 to effectively reduce the formation of nodules or lumps caused by excessive inflammatory stimulation due to the over-accumulation of filler in the

References

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2. Claude,Muresan,Helen,et al.Forehead Reconstruction with Microvascular Flaps: Utility of Aesthetic Subunits[J].Journal of Reconstructive Microsurgery, 2012. DOI:10.1055/s-0032-1311690.

3. Liu Ping, Liu Yi, Li Shilong, et al. Significance of forehead aesthetic unit in forehead augmentation with granular fat transplantation [J]. Chinese Journal of Aesthetic and Plastic Surgery, 2015,26(11).

4. Yu Chao YY, Chhabra C, Corduff N, et al. Validation of a Photonumeric Assessment Scale for Grading the Slope of the Asian Forehead. Dermatol Surg. 2019 Aug;45

Key points

Polycaprolactone (PCL) microspheres (ELLANSÉ®) were found to be effective in treating forehead depressions, improving facial aesthetics by increasing volume and reducing sloping.

The treatment showed immediate results, with observed 6 to 12 months post-treatment.

The most common adverse reaction was mild swelling, which subsided within 2 to 4 days. Other adverse reactions, such as erythema and pain, were minimal and within an acceptable range. No long-term adverse effects were reported.

PCL microspheres stimulate collagen production and contribute to long-term improvements in skin texture and volume. This process helps maintain the aesthetic results for at least 12 months, with continued improvement after the initial treatment period.

same location, thus avoiding post-injection complications. Moreover, when cannula injection is applied, the filler may accumulate around the injection point, as in the case of the fanning technique, so repeated dosage must be avoided around injection points. During the injection process, the frontal bone has an uneven surface, which makes it difficult to guarantee that the filler is distributed evenly in the periosteal layer if the cannula reaches the far end upon entry. Therefore, it is advisable to inject from multiple points and to use the entire length of the cannula to ensure consistent injection layers. This approach promotes an even appearance and allows for better control of flatness after the treatment. Additionally, it’s important to avoid hypercorrection to prevent an abnormal protrusion of the forehead in the future.

Conclusion

Follow-up observations indicate that injecting PCL microsphere facial filler into the forehead can effectively address congenital or acquired defects resulting from depression and poor shape. This method demonstrates satisfactory and long-lasting treatment effects. Importantly, no complications were reported during follow-up observations. The procedure involves minimal trauma, allows for faster recovery, and shows no significant difference between immediate results and those observed later. Overall, it is a safe and efficient option for improving facial contours, resulting in high patient satisfaction.

However, it is worth noting that the low fault tolerance and poor solubility of the filler in the short term necessitate strict adherence to sterile procedures, precise injection techniques, accurate injection points, and careful dosage considerations. The operator must be mindful of these factors to ensure the best outcomes.

In summary, the PCL microsphere facial filler demonstrates a safe and effective therapeutic effect with few complications for treating forehead depression and enhancing aesthetics, making it a valuable option for clinical application.

Figure 1-5 © Retained by the authors

Suppl 1:S38-S45. doi: 10.1097/ DSS.0000000000001997. PMID: 31246870.

5. de Melo F, Marijnissen-Hofsté J. Investigation of physical properties of a polycaprolactone dermal filler when mixed with lidocaine and lidocaine/epinephrine. Dermatol Ther (Heidelb). 2012 Dec;2(1):13.

6. Sasaki GH, Tevez A. Microfocused ultrasound for nonablative skin and subdermal tightening to the periorbitum and body sites: preliminary report on eighty-two patients [J]. Journal of Cosmetics, Dermatological Sciences and Applications, 2012,2(2):108-116.

7. Expert Consensus Working Group of Ellansé. Expert consensus on material characteristics and nasolabial fold filling of Ellansé [J]. China Medical Cosmetology, 2022,103(3):1-7.

8. Lin SL, Christen MO. Polycaprolactonebased dermal filler complications: A retrospective study of 1111 treatments. J Cosmet Dermatol. 2020 Aug;19(8):19071914.

9. Zhang Xiao, Wu Bin, Peng Sanmei, et al. Application of autologous fat transplantation in frontotemporal depression filling and analysis of its complications [J]. Chinese Journal of Aesthetic Medicine, 2017, 26(12):5-8.

10. Christen MO, Vercesi F. Polycaprolactone: How a Well-Known and Futuristic Polymer Has Become an Innovative Collagen-Stimulator in Esthetics. Clin Cosmet Investig Dermatol. 2020 Jan 20;13:31-48.

11. Nicolau PJ. Long-lasting and permanent fillers: biomaterial influence over host tissue

response. Plast Reconstr Surg. 2007; 119: 2271- 2286.

12. Laeschke K. Biocompatibility of microparticles into soft tissue fillers. Semin Cutan Med Surg. 2004; 23: 214- 217.

13. Gunailake PA, Adhikari R. Biodegradable synthetic polymers for tissue engineering. Eur Cell Mater. 2003;5:1-16.

14. Bae B, Lee G, Oh S, Hong K. Safety and Long-Term Efficacy of Forehead Contouring With a Polycaprolactone-Based Dermal Filler. Dermatol Surg. 2016 Nov;42(11):12561260. doi: 10.1097/ DSS.0000000000000913. PMID: 27662054.

15. Tian Hongwei, Shi Bing, Chen Jintian, et al. Expert consensus on collagenase treatment of nodular complications after collagen (stimulant) implantation [J]. China

Medical Cosmetology, 2024,14(2):1-7. DOI:10.19593/j.issn.2095-0721.2024.02.001. 16. Cong L Y , Phothong W , Lee S H ,et al. Topographic Analysis of the Supratrochlear Artery and the Supraorbital Artery: Implication for Improving the Safety of Forehead Augmentation[J].Plastic and Reconstructive Surgery, 2017, 139(3):620e-627e.

17. Scheuer JF,Sieber DA,Pezeshk RA,et al. Anatomy of the Facial Danger Zones: Maximlzing Safety during Soft-Tissue Filler Injections[J].Plast Reconstr Surg,2017,139(1):50e-58e.

18. Lin SL. Polycaprolactone facial volume restoration of a 46-year-old Asian women: A case report[J]. Cosmet Dermatol. 2018 Jun;17(3):328-332.

ELLANSÉ AN ASIA-PACIFIC CONSENSUS

ABSTRACT

ELLANSÉ, a dermal filler based on polycaprolactone (PCL), distinguishes itself by providing both instant volumising effects and long-lasting collagen stimulation. Developed through patented STAT technology, ELLANSÉ’s biocompatible microspheres ensure minimal inflammatory response, smooth integration, and a natural aesthetic outcome. Based on a combination of clinical experience, research findings, and fundamental study data, Asia-Pacific experts have formulated a tailored consensus to address the unique needs of Asian aesthetic seekers. This consensus emphasises that ELLANSÉ, when administered using injection techniques specifically tailored to Asian facial structures and ageing patterns, provides the following five significant benefits contouring: it enhances

bony support, thereby increasing facial three-dimensionality and definition; volumising: it addresses volume loss and improves the smoothness of facial contours; tightening: it reduces soft tissue laxity through collagen neo-generation scaffold; lifting: it improves sagging through techniques such as ligament lifting and contour fixation; and skin rejuvenation: it enhances skin texture and boosts elasticity.

IN THE EXPANSIVE FIELD OF MEDICAL aesthetic research, injectable treatments have emerged as a focal point of in-depth exploration due to their dual scientific objectives — aesthetic enhancement and anti-ageing. For younger Asian patients, injectable treatments aim to precisely adjust facial proportions, optimise structural features, and correct potential deficiencies, reflecting a profound understanding and scientific application of human aesthetics. For older Asian patients, these treatments focus on maintaining facial structure stability and volume while effectively alleviating age-related wrinkles and skin laxity, thus addressing the visible signs of ageing from a scientific perspective1.

The distinct facial features of Asian populations, along with the diversification of contemporary aesthetic concepts, have made the selection and application of injectable fillers one of the key focuses of academic research. The advantages of injectable treatments lie in the rapid advancements in material science and aesthetic medical technologies. The safety, biocompatibility, and efficacy of facial fillers have been validated through scientific research and clinical practice. In particular, ELLANSÉ, a facial filler based on polycaprolactone (PCL) microspheres, has demonstrated exceptional value in promoting collagen regeneration and restoring youthful appearance.

Aesthetic experts from the Asia-Pacific region, with their strong academic foundation and extensive clinical experience, have continuously driven innovation and breakthroughs in this domain, striving to develop safer, more effective, and personalised treatment solutions. This expert consensus is proposed within this academic context, providing a comprehensive review and scientific summary of the applications of ELLANSÉ in medical aesthetics. The goal is to offer a scientific, systematic, and personalised treatment guide to better serve those seeking aesthetic improvements and to foster the healthy development of the medical aesthetic industry.

Material properties and advantages of ELLANSÉ

ELLANSÉ obtained the European Conformity (CE) mark approval in 2009. Due to its outstanding efficacy and safety profile, ELLANSÉ has received registration certification or marketing access in more than 70 countries or regions overseas, and in April 2021, ELLANSÉ received marketing approval and the Medical Device Registration Certificate from the National Medical Products Administration (NMPA), making it the only imported PCL-based regenerative facial filler product licensed by NMPA in China2. The core components of ELLANSÉ are 70% carboxymethyl cellulose (CMC) gel carrier and 30% PCL microspheres. This unique blend provides a dual benefit of immediate restoration of volume and long-lasting collagen regeneration.

CMC is a natural material derived from cellulose and designated by the FDA as a substance Generally Recognised As Safe (GRAS), widely used in food and pharmaceutical products. The degradation end products of CMC gel are β-glucose, carbon dioxide, and water3. PCL is a highly biocompatible, biodegradable, and bioresorbable polymer

ROY YA-HARN CHANG, Ellansé Asia Expert, Hangzhou No.6 BeauCare Hospital, China

TONG FENG, Ellansé China Training Instructor, Sichuan Xichan Plastic and Aesthetic Hospital Co., Ltd., China

YONGSHU WANG, Ellansé Asia Expert, Nanjing Victoria Plastic Surgery Hospital, China

SHENGJUN ZHU, Ellansé Asia Expert, Wuhan Yestar Medical Cosmetic Hospital, China

ELLANSÉ Asia-Pacific Consensus Board

GUANGYU CHEN, Professor, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, China

E GAO, Ellansé Asia Expert, Qingdao Dr.U Medical aesthetic hospital, China

MINLIANG CHEN, Professor, The Fourth Medical Center of Chinese PLA General Hospital, China

KYUNGKOOK HONG, Sinclair International Training Instructor, Sinclair Global Advisory Board member, Clinique hus,hu Korea

ISAAC WONG, Sinclair International Training Instructor, The Artisan Clinic, Singapore

SHOUCHAO ZHU, Ellansé Asia Expert, Aesthetic Surgery Department, Suwang Medical Beauty Group, China

LARRY WU, Sinclair International Training Instructor, Icare medical and wellness clinic, Singapore

HSIANG-I CHU

Ellansé Asia Expert, Shanghai Juanya Aesthetic Clinic, China

SHANGLI LIN, Sinclair International Training Instructor, Sinclair Global Advisory Board member, Shangli Aesthetics Derm Clinic, Taiwan, China

YAKUN ZHANG, Ellansé China Training Instructor, Beijing KSME Medical Aesthetic Clinic, China

PAI-NIEN CHU, Ellansé Global Expert, Arsmo Aesthetic Hospital China

SHENGKANG LUO, Professor, TGuangdong Second Provincial General Hospital, China

MENGJIE ZHU, Ellansé Asia Expert, Ningbo JustHer Plastic Surgery Hospital, China

Authors are sorted by the initial letter of their last name

KEYWORDS ELLANSÉ, PCL, Collagen stimulator

formed through the ring-opening polymerisation of ε-caprolactone, with dual FDA and CE certification. It is widely applied in drug delivery systems and medical devices3. The degradation of PCL in the body occurs through bulk degradation: in the first stage, hydrolysis of the ester bonds of PCL microspheres results in a decrease in

molecular weight, which allows for the volume of particles to be maintained for a longer time and delays the trigger of phagocytosis, reducing the intensity of the inflammatory reaction. In the second stage, PCL microspheres are degraded via an intracellular mechanism once the molecular weight is reduced to 3000 Da or less. The degradation end products (CO2 and H2O) are eliminated from the body via the kidneys4

ELLANSÉ has significantly higher elasticity (G’ value around 1000 Pa) than traditional cross-linked hyaluronic acid, indicating superior moldability. The dynamic viscosity (η) of ELLANSÉ is around 1 x 106 cP, exhibiting pseudoplastic fluid characteristics. Shear-thinning behaviour is observed, where the apparent viscosity decreases with an increasing shear rate, allowing for easy injection and precision during the procedure, while under low shear rates, its viscosity increases sharply, preventing displacement after injection into the skin5,6. Furthermore, the manufacturing process of ELLANSÉ does not involve cross-linking and does not use BDDE cross-linking agents.

The patented STAT technology of ELLANSÉ ensures that uniformly sized, smooth, spherical PCL microspheres are stably suspended in the CMC gel carrier6. Research indicates that the shape and size of regenerative materials correlate with the degree of inflammation and collagen production. Macrophages will rapidly phagocytose microspheres with particles smaller than 20 μm in diameter, which do not provide sustained collagen stimulation. In comparison, those larger than 150 μm tend to induce inflammation and are difficult to inject through fine needles. Additionally, if the filler exhibits irregular morphology or a rough surface, macrophages will promptly adhere to its surface, leading to severe foreign body reactions, prolonged inflammation, and an increased risk of granuloma formation7,8. ELLANSÉ’s PCL microspheres are smooth, uniform spheres with particle diameters ranging from 25 to 50 μm, providing a large specific surface area (SSA), improved biocompatibility, and strong fibroblast adhesion, thereby enhancing collagen stimulation. ELLANSÉ 2.0 has enhanced its production technique to achieve a more precise differentiation of PCL microsphere sizes, thereby better aligning with the material requirements for injectable treatments across various facial layers.

ELLANSÉ mechanism of action

The action of ELLANSÉ occurs in two stages, providing a dual effect: immediate restoration of volume by CMC gel and gradual, long-lasting collagen regeneration by PCL microspheres.

Immediately after injection, the CMC component provides temporary volume. The high elasticity and rheological properties of the CMC gel help form a 3D structure, ensuring an even distribution of PCL microspheres and preventing their migration9. Over the course of 2–3 months post-injection, as the CMC gel gradually diminishes, the PCL microspheres become progressively more exposed. Activated fibroblasts migrate onto the 3D network scaffold created by the PCL microspheres, generating and depositing more persistent type I collagen around each microsphere, ultimately resulting in the encapsulation of each

Research indicates that the shape and size of regenerative materials correlate with the degree of inflammation and collagen production.

microsphere by collagen fibres4. The cellular process, known as mechanotransduction, converts mechanical forces into intracellular signals and biological responses that further stimulate collagen production3. Additionally, the crosstalk between fibroblasts and keratinocytes enhances the synthesis of collagen fibres, elastic fibres, and extracellular matrix, improving skin texture and increasing skin elasticity10. Animal studies have shown that different sizes of microspheres induce distinct collagen features11 Large microspheres generate a larger 3D collagen scaffold with thicker collagen fibres, making them suitable for periosteal injection to provide robust support for shaping. Medium-sized microspheres form a 3D collagen scaffold between the sizes of the large and small microspheres, making them ideal for fascia layer injection to stabilise contours and provide lifting effects. Small microspheres are better suited for the subcutaneous fat layer, where they form natural, orderly collagen structures similar to fat compartments.

Comparative Analysis of ELLANSÉ and Other Filler Materials

ELLANSÉ, poly-D,L-lactic acid (PDLLA), poly-L-lactic acid (PLLA), and calcium hydroxylapatite (CaHA) are currently common regenerative filler materials, each exhibiting distinct effects and safety profiles due to differences in composition and mechanisms (Table 1). ELLANSÉ is used directly in treatment, eliminating the complicated steps of mixing and maintaining sterile conditions, thus offering greater convenience and safety in operation. From a clinical efficacy perspective, ELLANSÉ provides immediate restoration of volume and achieves progressive improvement, lasting for at least 12 months. ELLANSÉ shows a relatively lower risk of triggering inflammatory reactions and nodule formation, demonstrating a higher safety profile.

Facial aesthetic characteristics in Asians

Aesthetic research is gradually shifting from subjective morphological evaluations to quantitative and data-driven assessments. It has been found that there are more than 42 golden ratio points on the human body’s surface structure, with 28 located on the face, accounting for 66.7% of the total29

For frontal facial aesthetics, ‘Three Forehead heights and Five Eyes’ width’ remains a commonly used standard both domestically and internationally for assessing facial contours and the distribution of facial features30. The face is divided vertically into three roughly equal parts: forehead hairline to eyebrow bone, eyebrow bone to columellar, and from columellar to the chin menton. For facial width, it is horizontally divided into five eyes’ width. The measurement from left to right: the helical fold to the lateral canthus of the eye equates to one-fifth of the face, then the width of the left eye is one-fifth, the intercanthal distance equates to the width of an eye (one-fifth), the right eye width as one fifth and the distance from right lateral canthus to helical fold as one-fifth. Additionally, in 1964, Seghers et al. systematically

Table 1 Comparative analysis of common regenerative fillers

MATERIAL COMPOSITION

MICROSPHERES

ELLANSÉ PDLLA PLLA

PCL microspheres and CMC gel

The PCL microspheres have a 25-50 μm particle diameter and are smooth, spherical particles. For different therapeutic needs, anatomical locations, and tissue layers, varying microsphere sizes can be selected, enabling personalized and precise treatment.

Lyophilized powder composed of PDLLA microspheres and CMC

AestheFill: Microspheres with a particle diameter of 30-70 μm, porous structure, and wide particle size range.

Lyophilized powder composed of PLLA microspheres, mannitol, and CMC

Löviselle: 20-50μm, microspheres

Sculptra: irregular shape, non-microsphere

CaHA

Powder: HYDROXYAPATITE BIOCERAMICS

Radiesse: CaHA microspheres + CMC gel

Feilinpuli 20-71μm microspheres; HYALUMATRIX CLOUD 10-35μm microspheres; Radiesse: 25-45μm microspheres.

Microspheres with a particle diameter <20μm can be directly phagocytosed by immune cells, leading to a strong inflammatory response and posing a risk of in vivo migration.7, 8

PHYSICOCHEMICAL PROPERTIES

The elastic modulus (G’) is approximately 1000 Pa, 3 to 5 times higher than hyaluronic acid, and the dynamic viscosity (η) is about 1x106 cP, 10 times higher than hyaluronic acid. Its pseudoplastic fluid characteristics facilitate precise injection and prevent displacement. The product contains no cross-linking agents and is non-hydrophilic.

DEGRADATION AND METABOLISM

The material undergoes natural metabolism, with water and carbon dioxide degradation products. The bulk degradation of PCL ensures uniform microsphere size and a smooth surface throughout the process, minimizing long-term inflammatory reactions and enabling sustained collagen regeneration. 3

PRODUCT APPLICATION ELLANSÉ is ready for injection without any reconstitution required. Its excellent component stability makes it more convenient for application. The high elasticity and rheological properties of the CMC gel ensure a uniform distribution of microspheres without aggregation. 3

The viscoelasticity varies based on the reconstitution ratio of sterile water. When PDLLA filler is diluted with 3 ml of sterile water and 1 ml of lidocaine, its elastic modulus and dynamic viscosity are significantly lower compared to ELLANSÉ.

The viscoelasticity varies depending on the reconstitution ratio.

The viscoelasticity varies depending on different HA/ CMC carriers.

The material undergoes complete metabolism, with water and carbon dioxide degradation products.12 PDLLA’s intermediate degradation product, D-lactic acid, poses mild harm to the human body.13 As a noncrystalline polymer, PDLLA degrades more efficiently and is metabolized faster than PLLA.12, 14, 15

It is reconstituted with sterile water. PDLLA materials are prone to hydrolysis and must be stored in powder form.18 Thorough preparation and control of microsphere concentration per unit volume are required to prevent microsphere aggregation after reconstitution.16

PRODUCT EFFICACY Immediate filling with long-lasting results. No immediate effect; a waiting period is required for the long-term stimulation of collagen regeneration.19

The material undergoes complete metabolism, with water and carbon dioxide degradation products. During degradation into oligomers, an increase in lactic acid concentration is observed,16, 17 which alters the local pH and may trigger a more intense inflammatory response.17

Reconstituted with saline. The material is prone to hydrolysis and must be stored in powder form to ensure the material aggregates properly after reconstitution. Adequate preparation is essential, and the concentration of microspheres per unit volume needs to be controlled.

No immediate effect; multiple treatments are required. Long-term collagen stimulation and regenerative effects vary among individuals. 20

CaHA is degraded into Ca2+ and phosphate ions and excreted from the body.

Powder: Must be advanced prepared before use, often employing HA as a carrier.

Radiesse can be used directly.

Uniform distribution of the microspheres cannot be guaranteed, and there is a risk of cross-linking agent residues.

Powder: Immediate effects are primarily due to HA, while CaHA promotes long-term collagen stimulation. However, the metabolic rate of HA remains uncertain, as does the duration of microsphere exposure.

Radiesse: Immediate effects with long-term collagen stimulation, but CaHA microspheres degrade relatively quickly in tissues, leading to a shorter regenerative effect. 21

DURATION OF EFFECT ELLANSÉ-S microspheres stimulate collagen production until they are fully degraded. , and the effect duration exceeds 12 months. 22, 23

RISK OF INFLAMMATORY REACTION

PROBABILITY OF AGGREGATION

Low.

9-24 months.12, 14, 15

The faster the microspheres degrade, the more likely they are to cause noticeable inflammatory reactions. As degradation progresses towards oligomers, the increasing concentration of lactic acid alters the local pH, potentially triggering a stronger inflammatory response.13, 17

12-24 months; detectable at 18 months, fully degraded by 2 years, though the collagen production and regenerative effects differ from person to person. 20

During the degradation of PLLA into oligomers, lactic acid concentration increases, altering the local pH, which may provoke a stronger inflammatory reaction.16, 17

6-19 months; CaHA activates significantly fewer fibroblasts compared to PCL. 24

Both excessively large and small microspheres increase the risk of inflammation and migration.7, 8 There are also reports of ectopic ossification, characterized by pain, fever, swelling, and the formation of osteoblasts and bone tissue in soft tissue. 25, 26

Low. ELLANSÉ 1.0 includes 0.2 ml lidocaine, and after 15 injections and thorough mixing, the microspheres distribute evenly without aggregation. 27 ELLANSÉ

2.0, with small microspheres diluted in a 1:1 ratio of saline/lidocaine, shows no microsphere damage or aggregation even after more than 30 injections, with no aggregation observed within 30 minutes.11

PROBABILITY OF NODULE FORMATION

Low.

A complex reconstitution process and preparation time are required to dissolve CMC and avoid PDLLA aggregation.18, 28

Microsphere aggregation increases the risk of postinjection complications, such as nodules. 28

described the golden ratio (approximately 1.618) as a key characteristic of beautiful facial structures, which aesthetic researchers have widely referenced31

Building on this work, Marquardt designed the aesthetically significant golden mask (Phi mask) in two dimensions, composed primarily of decagons and supplemented by other polygons, to represent facial aesthetic proportions32

For the profile view, aesthetics suggests that the facial profile should exhibit a ‘four high peaks and three low troughs’ structure, where the forehead, nasal tip, philtrum, and chin pogonion form the ‘four high peaks,’ and the nasal

The reconstitution process is complex and requires significant preparation time. Post-injection massage is necessary to prevent granuloma formation caused by microsphere aggregation.

Aggregation may increase the risk of complications such as nodules and granulomas after injection.

For the profile view, aesthetics suggests that the facial profile should exhibit a ‘four high peaks and three low troughs’ structure.

Powder materials are prone to aggregation.

Aggregation increases the risk of complications such as papules and nodules after injection.

radix, philtrum groove, and labiomental fold create the ‘three lows.’ This undulating profile is considered one of the key standards for evaluating facial dimensionality and attractiveness in Asian facial aesthetics33. In addition, Chinese aesthetics amalgamates elements of classical aesthetic standards. The Ricketts lower face aesthetic plane described in 1968 described the lower facial aesthetic plane, where a harmonious lower face is indicated by the alignment of the chin pogonion, lower lip margin, and nasal tip in a straight line. The deviation of the chin pogonion from this line may indicate chin retrognathia or prognathia if the pogonion is behind the plane or anterior to the plane,

respectively34. In 2000, Little, drawing inspiration from late 13th-century Gothic architecture, vividly described the curve from the highest point of the malar fat pad to the cheek interface and down to the mandibular border as resembling an ‘S’ shape, conforming to the Fibonacci golden curve. This curve was named the Ogee plasty or Ogee curve and continues to be used today35. A flattened Ogee curve suggests malar fat pad atrophy and descent, while an overly rounded Ogee curve, forming a ‘C’ shape, indicates an overly full midface. An uneven Ogee curve, with irregularities in height, disrupts facial contour smoothness. As aesthetic standards and methods continue to evolve with changing trends and preferences, the criteria for facial aesthetic assessments are still being explored and refined.

In general, the facial features of Asians tend to be rounder, with wider zygomatic bones and prominent zygomatic arches, lacking smooth contours and facial

dimensionality. However, Asian skin is typically finer in texture, with good elasticity36,37. Regarding facial contours, modern Han Chinese women’s facial shapes are categorised into eight types: round, oval, diamond, rectangular, square, triangular, inverted triangle, and trapezoidal, with ‘inverted triangle’ and ‘oval’ faces considered the most attractive38. A facial aesthetic survey conducted on a Chinese population included 1,417 respondents (599 men and 818 women), revealing that the most preferred facial shape was oval (39.94%, characterised by a long, slender face with a pointed chin), followed by heart-shaped (24.06%, inverted triangle) faces39. Asians’ aesthetic trends favour smooth, refined facial contours with soft transitions, a gentle jawline, and a slightly pointed chin. In addition to anti-ageing facial treatments, cosmetic demands focus on contour sculpting to enhance facial dimensionality and structure.

Facial ageing in Asians

Facial ageing is a comprehensive and interconnected process involving the remodelling of facial bones, atrophy and displacement of fat pads, changes in muscle thickness, skin laxity, and the formation of wrinkles. This process manifests as follows:

At age 30, the midface begins to show signs of ageing, with hollowness around the orbital area, maxilla, and oral commissures. The nasolabial folds deepen slightly, and skin texture changes along with pigmentation begin to appear.

At age 40, the forehead begins to recede, the temples hollow, eyebrows droop, and the skin of the upper eyelids becomes lax. Tear troughs deepen, the infraorbital rim becomes more exposed, the midface contour flattens and starts to descend, cheeks sag, nasolabial folds deepen, perioral and marionette lines become prominent, and the jawline becomes less well-defined.

At age 50 and above, forehead changes become more pronounced, with noticeable hollowness in the glabella and temporal areas. Upper eyelid ptosis worsens, and the nose elongates and broadens with a drooping nasal tip. The stability of the midface structure declines significantly, and in cases of tooth loss, cheeks may become sunken, and the nasolabial folds become more prominent. The lower face exhibits a downward and posterior sagging tendency, the jawline loses its tightness, and the skin becomes thinner, less elastic, and visibly more sagging37,40,41

Application of ELLANSÉ

Basic injection techniques for

ELLANSÉ

According to literature reports and the ELLANSÉ Expert’s Guide, the injection layers include the subcutaneous layer, the fascial layer, deep fat compartments, and the periosteum. Injection sites include the forehead, eyebrows, temples, zygomatic area, preauricular area, cheeks, nose, mandibular, nasolabial folds, marionette lines, and chin. Injection techniques include bolus injection, linear threading, fanning injection, and cross-hatching techniques (Figure 1). The treatment sequence is from top to bottom, from the outside to the inside, and from the deep to the superficial. Detailed operational methods and recommended doses for each area can be found in the Expert’s Guide42

Figure

Therapeutic goals of ELLANSÉ

Targeting the aesthetic and ageing characteristics of the Asian population, ELLANSÉ injections at different anatomical layers and sites can achieve the following:

■ Contouring: enhance bony support to increase facial three-dimensionality and folding degree

■ Volumising: address volume loss and improve contour smoothness

■ Tightening: mitigating soft tissue laxity through collagen neo-generation scaffold

■ Lifting: improve sagging by ligament lifting and contour fixation

■ Skin rejuvenation: improve skin texture and increase elasticity.

Contouring

Sites: Forehead, brow area, nose, zygoma and chin.

Objective: Enhance bony support to increase facial threedimensional projection and contouring.

Rationale: Innate insufficient bony support: compared with Caucasian faces, the Asian face demonstrates a weaker facial bony support, which is manifested in innate facial traits such as a retruded forehead, a flat maxilla, and a retruded chin (Table 2)43-45

Age-associated bone resorption and displacement in the facial skeleton: facial bones undergo selective resorption with age, resulting in bony retrusion. Simultaneously, there is a displacement of the facial ligaments and muscles closely adhered to the periosteum, leading to a decrease in support and an ageing appearance (Table 2)46-49

Forehead contouring

A study on aesthetic parameters and proportions assessed forehead aesthetics in 86 patients with an average age of 27.17±3.54 years. According to the study, a ‘beautiful’ forehead in Chinese aesthetics is characterised by a complete shape with a gently forward-projecting curve. The difference between the forehead length (linear distance) and the arc length (curved distance) is 19.66±4.35 mm (measured from the temporal ridges on both sides)50. The ideal ratio of forehead height to total facial height for Chinese women is approximately 0.3251

The long-term efficacy and safety of ELLANSÉ in forehead contouring was confirmed in a 2016 study by Bae et al52. The study involved 58 Asians seeking contouring treatment for suboptimal or recessed forehead profiles. All participants received 3 to 4 ml of ELLANSÉ injection treatment as well as type A botulinum toxin to relax the frontalis muscle two weeks before the injection. Results showed that 1 month after ELLANSÉ injection, participants achieved a Global Aesthetic Improvement Scale (GAIS) score of 2 or higher (indicating noticeable improvement), with scores significantly increasing at 6 months and maintaining this improvement at 12 and 24 months (GAIS scores at 1, 3, 6, 12, and 24 months were 2.14±0.95, 2.38±0.77, 2.50±0.76, 2.45±0.52, and 2.33±0.50, respectively). Throughout the study, no serious adverse events or complications were reported. The study demonstrates that ELLANSÉ is an excellent option for forehead contouring, providing safe and long-lasting aesthetic results by stimulating collagen production.

Table 2 Skeletal features and ageing manifestations in Asians* 37, 49

UPPER FACE

Asians typically exhibit a retruded forehead and broad temporal bones, resulting in a wide and flat forehead appearance.

Ageing: Retrogression of the frontal bone and resorption of the orbital bone tissue (superior medial and lateral) lead to frontal depression and outer canthal droop.

MIDFACE Asians generally possess relatively broad zygomatic bones, which visually widen the midface. The retrogression of the maxilla and the posterior displacement of the piriform aperture contribute to midfacial hollowing and the deepening of nasolabial folds. Additionally, the incomplete development of the nasion and the nasal septal cartilage, as well as the insufficient height and posterior displacement of the nasal columella, lead to a relatively flat and short nasal appearance.

Ageing: Resorption and flattening of the maxilla and enlargement of the piriform aperture exacerbate the deepening of the nasolabial folds and midfacial hollowing, resulting in widening at the base of the nasal ala and drooping of the nasal tip.

LOWER FACE Asians often have a broad but underdeveloped mandible, frequently associated with chin retrusion.

Ageing: Resorption and downward and backward displacement of the mandible lead to an blunting of gonial angle and loss of chin projection leading to the development of a double chin.

*Compared to Caucasians

T-zone reshaping

According to the literature, the ideal starting point of the medial eyebrow is from a vertical line that intersects the inner canthus and lateral extent of the alar cartilage53. From this point, the eyebrow ascends slightly above the midpoint connecting the lateral canthus and the lateral margin of the cornea. The distance between the pupil’s midline and the lower edge of the eyebrow is approximately 2.5 cm, and the distance between the upper edge of the eyebrow and the frontal hairline is about 5 cm. The distance between the medial heads of the eyebrows on both sides is the same as the distance from the alar base to the cheek junction. The highest point of the female eyebrow is typically about 1 cm above the superior orbital rim between the lateral canthus and the corneal edge. In contrast, male eyebrows are usually positioned lower and have a flatter shape30,53

According to a survey on facial aesthetics in the Asian population, most respondents (42.27%) prefer a nose with a straight and pronounced bridge, while the second preference (29.64%) is for a nose with a slightly downwardarched nasal root and a slightly upward-tilted tip39. The aesthetic indicators for the nose include: the nasofrontal angle (the angle formed between the line from the tip of the nose to the nasal root and the line from the glabella to the nasal root), with an ideal angle of 115° to 130°; the nasofacial angle (the angle between the vertical plane of the face and the line of the nasal dorsum), with an ideal angle of 30° to 40°; the nasomental angle (the angle formed between the line from the tip of the nose to the menton and the line of the nasal dorsum), with an ideal angle of 120° to 130°; the nasolabial angle (the angle between the line from the base of the nasal columella to the nasal tip and the line from the base of the nasal columella to the midpoint of the upper lip), with an ideal angle of 90° to 120° 36

ELLANSÉ enhances bony support, thereby augmenting facial threedimensionality and definition.

The efficacy and safety of ELLANSÉ for T-zone shaping has been confirmed in many studies involving Asian patients54,55. In a review published in 2024, a 28-year-old female sought injection treatment to improve facial appearance due to a flat nose, collapsed nasal bridge, facial sagging, and an unclear chin contour. ELLANSÉ injections were administered to the eyebrow and nose regions, as well as to the cheeks, perioral area, and chin, yielding highly satisfactory outcomes. Following the treatment, there was not only a marked enhancement in facial contouring but

also a notable improvement in sagging and fatigue, ultimately leading to facial rejuvenation55

In the study published in 2024, a 35-year-old female whose previous hyaluronic acid filler had worn off sought facial shaping treatment. ELLANSÉ was used for nasal shaping, eyebrow lifting, and cheek augmentation. Results showed that by the third month after ELLANSÉ injection, there were noticeable improvements in eyebrow and nasal elevation54

Another study conducted on a Chinese population included 30 patients who underwent aesthetic injections for eyebrow ridge and nasal enhancements. In the ELLANSÉ treatment group (n=15), at 1, 3, and 6 months post-surgery, the eyebrow peak angle, the distance between the eyebrows, the angle between the outer edge of the nasal root and the eyebrow, and the distance between the highest point of the double eyelid line and the eyebrow were all significantly better than those in the hyaluronic acid (HA) control group (P<0.05). Compared to traditional HA fillers, ELLANSÉ demonstrated definite efficacy in eyebrow ridge and nasal adjustments, exhibiting superior contouring ability and durability56

Chin contouring

In terms of morphology of the chin, Asian women tend to prefer a narrow and slightly pointed chin. In contrast, Asian men favour a narrow and slightly rounded chin39. The Gonzalez-Ulloa line is a vertical line extending from the nasal root to the Frankfurt plane. An ideal chin is expected to intersect this line57

The efficacy, safety, and high satisfaction rate of ELLANSÉ for chin shaping have been validated in studies involving the Asian population58. In a study published in 2023, a total of 120 participants with either wide or recessed mandibular contours were enrolled. These participants were allocated to receive either a combination of ELLANSÉ and hyaluronic acid (60 individuals) or hyaluronic acid alone (60 individuals) for chin shaping. The results showed that the ELLANSÉ combined with hyaluronic acid treatment significantly reduced the chin angle and lower facial width, with no serious adverse events reported. Notably, the satisfaction rate among those treated with the ELLANSÉ and hyaluronic acid combination was remarkably high, reaching 96.67%, which was significantly greater than the 83.33%

A study published in 2023 showed that 17 patients with moderate to severe nasolabial folds experienced significant midand lower-face soft tissue lifting following ELLANSÉ outer contour injections. The improvement in nasolabial folds showed an immediate efficacy rate of 64.7%, maintained at 58.8% after 3 months, with no significant complications observed.

satisfaction rate observed in the hyaluronic acid-only group. ELLANSÉ exhibits the capacity to stimulate the body’s fibroblasts to produce collagen, thereby minimising the risk of displacement and offering more stable shaping outcomes with prolonged effects, ultimately leading to higher patient satisfaction59

Summary of ELLANSÉ Advantages

ELLANSÉ’s large microspheres exhibit notable advantages in contouring the forehead, T-zone, and chin regions. Administration of ELLANSÉ large microspheres has proven effective in addressing congenital deficiencies in bony contours and significantly ameliorating depressions, fat atrophy, and skin ageing issues that arise from bone resorption and displacement associated with ageing. Preclinical animal studies have validated the efficacy and safety of ELLANSÉ when injected on the periosteum, demonstrating robust collagen production without the formation of ectopic bone11. A distinctive advantage of ELLANSÉ lies in its capacity to stimulate the synthesis of endogenous collagen. The newly synthesised collagen integrates seamlessly with the skin’s optimal state, preserving an ideal level of fullness without imparting a stiff sensation due to overgrowth. Furthermore, it avoids the soft, foamy texture that can result from filler degradation and prevents displacement, thereby achieving a highly natural appearance. These attributes underscore ELLANSÉ’s potential as a valuable option for aesthetic enhancement.

Volumising

Sites: Mid-face, nasolabial folds, hands.

Objective: Address volume loss and improve contour smoothness.

Rationale: Congenital bony support deficiency: the position and shape of the maxilla significantly impact facial contours. A retrognathic maxilla or recessed nasal base can lead to insufficient bony support, making the mid-face flat and accentuating the nasolabial folds43

Fat atrophy: Fat distribution in the mid-face is crucial for contour shaping and maintaining a youthful appearance. Specifically, superficial fat comprises approximately 56% and deep fat about 44% of the total fat in the mid-face, collectively maintaining its fullness60. With ageing, both deep and superficial fats experience atrophy, with a relatively higher proportion of profound fat loss. Consequently, superficial fat appears to ‘increase’ relatively, leading to a ‘pseudo-sagging’ effect and deepening of the nasolabial folds.

The Hinderer line, defined as a line extending from the nasal wing groove to the ear tragus and from the outer canthus to the corner of the mouth, serves as a valuable tool for describing and evaluating the mid-face61. Notably, Caucasians perceive high cheekbones as indicative of a youthful, oval face, and they regard the upper outer segment of the Hinderer line as the most prominent and attractive feature. Conversely, Asian faces tend to be broader with more prominent cheekbones, leading Asian beauty standards to often favour the inner portion of the Hinderer line as aesthetically more pleasing.

ELLANSÉ’s long-term effectiveness and safety in

volumising have been confirmed in multiple studies. In a multicentre, randomised controlled trial involving 80 Chinese patients with moderate to severe nasolabial folds, ELLANSÉ was again compared to hyaluronic acid This study reported a significantly higher efficacy rate for ELLANSÉ at 12 months post-injection (88.8% vs. 23.8% for hyaluronic acid, P<0.001). WSRS improvements persisted for 12 months in the ELLANSÉ group, whereas improvements in the hyaluronic acid group began to decline from 3 months post-treatment. Similarly, sustained GAIS improvement was observed for 12 months with ELLANSÉ but started to decrease from 6 months post-treatment in the hyaluronic acid group. Both treatments were well-tolerated, with no new safety concerns identified. These results further affirm ELLANSÉ’s long-lasting and safe treatment effect for nasolabial folds in the Chinese population.

In a Korean randomised, participant- and evaluator-blinded, matched-pair prospective study comparing the safety and efficacy of the newly developed polycaprolactone (PCL)-based filler, SYB filler® (SF-01) (Samyang Biopharmaceuticals Corporation, Korea), with the widely utilised PCL-based filler, Ellansé-M® (Sinclair Pharma, UK), for the correction of moderate-to-severe nasolabial folds, both treatments demonstrated statistically significant improvements in key efficacy measures, including the Wrinkle Severity Rating Scale (WSRS), Global Aesthetic Improvement Scale (GAIS), and three-dimensional (3D) scanner assessments, at 12-month follow-up. Notably, while SF-01 was found to be non-inferior to Ellansé-M® based on predefined criteria, the established safety profile and proven track record of Ellansé-M® in clinical practice, coupled with its comparable efficacy outcomes in this study, continue to support its status as a reliable and effective option for the treatment of nasolabial folds63

demonstrates a notable absence of water absorption, mitigating the risks of swelling or puffiness that can arise from such absorption. Additionally, its stability against facial muscle movement ensures more predictable and sustained injection outcomes. The remarkable regenerative properties of ELLANSÉ contribute to the extended durability of post-injection results, making it a superior choice in the realm of aesthetic medicine.

Tightening

Sites: The ELLANSÉ dual-lifting technique includes the temples, malar regions, cheeks, nasolabial folds, and marionette lines.

Objective: Mitigating soft tissue laxity through collagen neo-generation scaffold.

A study published in 2023 reported that ELLANSÉ treatment was administered to 5 patients with Hand Grading Scale (HGS) 3–4 scores (severe fat loss with visible veins and tendons). Both self-assessment and investigator assessment showed a 100% GAIS improvement rate, with 90% achieving very significant improvement. Patient satisfaction and willingness for retreatment were 82% and 88%, respectively64 ELLANSÉ not only achieved natural volume enhancement but also demonstrated a non-shifting advantage, eventually due to the neocollagenesis process anchoring the microspheres, even in highly mobile hands.

Summary of ELLANSÉ Advantages

ELLANSÉ exhibits superior biocompatibility through its mechanism of stimulating endogenous collagen regeneration, effectively filling depressed areas while avoiding the formation of voids. This attribute is pivotal in preserving the natural mobility of facial muscles, thereby circumventing stiffness and an unnatural aesthetic appearance, which are essential for maintaining facial smoothness and a natural look. Furthermore, ELLANSÉ

The subcutaneous fat compartments of the face are delimited by intricate fibrous septa, which originate from the compact connective tissue of the superficial fascia and extend vertically to the dermal layer, serving as a ‘structural framework’ for the facial fat.

Rationale: Diminished collagen fibre integrity and facial fat compartment morphology. The subcutaneous fat compartments of the face are delimited by intricate fibrous septa, which originate from the compact connective tissue of the superficial fascia and extend vertically to the dermal layer, serving as a ‘structural framework’ for the facial fat. This framework offers both support and suspension, functioning as a scaffold for the soft tissues of the face65. As ageing progresses, collagen fibres undergo structural alterations, including curling, wrinkling, and fragmentation, which compromise the support and stability of the soft tissues66. Consequently, the morphology of the fat compartments is altered, manifesting as a reduction in the cranial aspect and an augmentation in the caudal aspect. The increased shear forces between contiguous fat compartments exacerbate the misalignment of facial soft tissues, ultimately contributing to a sagging facial appearance. Notably, the nasolabial folds, tear troughs, and marionette lines coincide with the locations of these septa within the fat compartments67

Degeneration and laxity of the fascial layer: The fascia plays a pivotal role in anchoring facial soft tissues to the periosteum or deep fascial layers of the skeleton, thereby preserving skin tautness and facilitating the proper functioning of facial muscles68. The superficial facial fascia resides beneath the subcutaneous fat, whereas the deep fascia is positioned superficial to the deep fat, consisting of white fibrous bands embedded within the connective tissue69. With advancing age, the initially robust fibrous tissue undergoes degenerative changes, leading to the progressive thinning and laxity of the fascial layer. This impairment in fascial support results in the descent of the cheeks and skin, as well as the emergence of wrinkles60,70

Numerous studies have confirmed the efficacy and safety of ELLANSÉ for facial tightening. A study published in 2018 reported on a 46-year-old Asian woman who presented with facial soft tissue sagging and expressed a desire for a product that provides immediate filling and sustained effect for over a year71. Given ELLANSÉ’s immediate volumising effect and long-lasting collagen regeneration tightening characteristics, Dr. Lin opted for ELLANSÉ for a comprehensive full-face injection treatment. The treatment regimen encompassed injections administered to the

temples, periorbital region, and additional areas, which not only recontoured the facial features but also achieved a lifting effect and markedly diminished upper eyelid puffiness. Furthermore, injections targeting the suborbicularis oculi fat (SOOF), deep medial cheek fat (DMCF), buccal fat pad, and perioral region, in conjunction with the periosteum layer, led to the attenuation of tear troughs, nasolabial folds, and marionette lines. This comprehensive approach also substantially ameliorated cheek sagging, optimised the contour of the lateral cheeks, and ultimately achieved overall facial tightening. At the 12week follow-up, the patient’s facial profile exhibited a more youthful and aesthetically desirable inverted triangle configuration71

A study published in 2022 focusing on the Chinese population enrolled 30 female participants with mid-face sagging. The study administered ELLANSÉ at eight pivotal facial sites, employing the ‘Double S’ injection technique, which integrates injections into both the subcutaneous fat layer and the periosteum layer72. The immediate posttreatment wrinkle improvement and overall facial uplift were most notable, with patient satisfaction reaching 100%. Immediate postoperative improvements were observed in the midcheek groove, nasolabial folds, and marionette lines, with these effects persisting at the 6-month follow-up, achieving a 100% efficacy rate. No severe adverse events were observed during the study72

Another study published in 2024 evaluated the efficacy of ELLANSÉ on the midface, involving 120 Chinese patients73

The physician administered injections in the nasolabial fold area, using a fanning approach with gradual retraction and slow injection, targeting the nasolabial folds and marionette lines and covering the entire mid-face region. Post-treatment, significant improvement was observed in the mid-face, with tightness and elevation of the skin, enhanced jawline contour, and a natural effect without excessive stretching or stiffness. Patient satisfaction reached 96.66% at the 1-month follow-up73

Summary of ELLANSÉ Advantages

The application of ELLANSÉ small microspheres in the establishment of a rejuvenated collagen network has exhibited considerable benefits in facial tightening. Animal studies have revealed that, upon implantation of ELLANSÉ into the subcutaneous fat layer, there is a substantial increase in new collagen deposition and encapsulation of collagen fibres around the microspheres, accompanied by thickening of the fat septa11. These findings suggest that ELLANSÉ possesses a remarkable capacity to stimulate collagen fibre regeneration and augment soft tissue support, thereby enhancing facial tightening and mitigating sagging.

The small microspheres of ELLANSÉ demonstrate excellent injectability, making them wellsuited for linear or fanning facial

ELLANSÉ

provides improved structural support and firmness to the skin. This dual mechanism of action results in a smoother and more refined skin surface, imparting a fuller, firmer, and more vibrant appearance that is indicative of youth.

treatments. In comparison to powdered filler materials that require reconstitution prior to injection, the small microspheres of ELLANSÉ anchor effectively to fat septa and fascia, facilitating the regeneration of a reticular collagen scaffold and reducing interstitial spaces. This process mechanism achieves multi-dimensional tightening of superficial soft tissues, providing a more comprehensive and long-lasting facial tightening effect.

Lifting

Sites: The ELLANSÉ pentagram ligament lifting technique includes the anterior temporal, zygomatic protuberance, zygomatic arch, intersection of the oral commissure line and mandibular border, and mandibular angle. The outer contour fixation lifting technique includes the temporal area, preauricular area, and mandibular border.

Objective: Improve sagging by ligament lifting and contour fixation.

Rationale: Ligament ageing changes and lifting mechanism. With ageing, facial bones undergo resorption, leading to weakened bony support and resulting in soft tissue sagging. Since ligaments firmly connect soft tissues to bones, support ligaments also experience sagging and deformation as part of ageing74-76. At the same time, the amount of type I collagen within ligaments decreases, and the structure becomes sparse with reduced elastic strength77, which leads to the sagging of the soft tissues they support, manifesting as deepening grooves and other signs of facial ageing. Based on the changes in ligament support strength with ageing, the anchoring effect of the periosteal ligament origin can be utilised by placing a filler with a high G’ value at the ligament base. This directly tightens the ligament and indirectly lifts the SMAS layer through a ‘cantilever’ effect, restoring the ligaments’ support function78-82. Contour fixation mechanism: soft tissue sagging due to gravity is one of the most fundamental changes in facial ageing. A fuller appearance is achieved by enhancing the support of the fascia and ligaments in the outer contour areas. The contour fixation approach lifts the entire midfacial tissue upwards, improving sagging83, thus achieving contour fixation and vector lifting84

The ELLANSÉ pentagram ligament lifting technique emphasises precision targeting of ligaments and bony structures with minimal volume enhancement. Utilising the high G’ prime strength of Ellanse and its capacity to stimulate secondary collagen production, this approach achieves a highly natural facial appearance post-treatment, particularly for Asian patients. By precisely injecting large microspheres into five pivotal ligament points — the anterior temporal fusion, zygomatic eminence, zygomatic arch, intersection of the oral commissure and mandibular border, and posterior mandibular angle — this technique addresses facial sagging effectively. This technique leverages multiple facial ligaments for contour lifting, particularly suited for those with rounded facial contours showing initial ageing signs. The outer contour fixation technique focuses on the temporal, cheek, and mandibular regions, lifting soft tissues and improving volume distribution. Combining these

techniques provides a comprehensive, personalised facial rejuvenation approach, addressing diverse aesthetic needs. Multiple studies conducted on Chinese populations have established the long-term efficacy and safety of ELLANSÉ for facial lifting. A study published in 2023 showed that 17 patients with moderate to severe nasolabial folds experienced significant mid- and lower-face soft tissue lifting following ELLANSÉ outer contour injections. The improvement in nasolabial folds showed an immediate efficacy rate of 64.7%, maintained at 58.8% after 3 months, with no significant complications observed84

Another study published in 2024 involving 126 patients with facial laxity treated with ELLANSÉ contour fixation in the temporal, posterior temporal, preauricular, and postauricular (fossa triangularis and cymba conchae) areas showed improvement in facial skin sagging after 1–3 months, as assessed by a third-party evaluation. All patients exhibited an improvement in lower facial skin tightening, reduced cheek wrinkles, smoothed forehead depressions, softened tear troughs, and firmed cheeks. The technique also effectively filled temples, resolved oral commissure depressions, and reduced neck wrinkles. Patient satisfaction was as high as 91.27% three months post-injection85

Summary of ELLANSÉ Advantages

ELLANSÉ possesses rheological properties that contribute to its excellent lifting effects. ELLANSÉ effectively restores ligament positioning and resists gravitational forces by providing robust support. Whether applied to the masticatory muscle area of the outer contour or at true facial ligament points, ELLANSÉ maintains its cohesive properties under external pressure, demonstrating strong support. Furthermore, animal studies have shown that ELLANSÉ has a notable ligament-nourishing effect. It induces new collagen formation in ligaments, significantly enhances their mechanical properties, and restores the ligament structure in aged rats to a more youthful state. ELLANSÉ 2.0 also offers a refined, layered treatment approach, utilising large microspheres for injection at the ligament roots and medium microspheres in the fascial layer. This layered treatment approach allows ELLANSÉ to nourish better and strengthen the facial supporting ligaments and fascial system, resulting in effective lifting outcomes.

ELLANSÉ, characterised by its high cohesiveness, exhibits unique rheological attributes that underlie its exceptional lifting capabilities. This filler is adept at restoring ligament positioning and counteracting the effects of gravity, providing robust structural support. Whether administered to the masticatory muscle region of the facial outline or directly at the points of facial ligament attachment, ELLANSÉ retains its cohesive integrity under external pressure, thereby ensuring sustained support. Studies conducted on animal models have revealed that ELLANSÉ exerts a pronounced ligament-nourishing effect. Specifically, it stimulates the synthesis of new collagen within ligaments, leading to significant enhancements in their mechanical properties. In aged rats, ELLANSÉ has been shown to rejuvenate ligament structure, restoring it to a more youthful state11

The ELLANSÉ 2.0 formulation further refines the treatment approach by incorporating a stratified treatment concept. Large microspheres are utilised for injection at the ligament roots, while medium microspheres are employed in the fascial layer. This stratified application strategy enables ELLANSÉ to more effectively nourish and strengthen the facial supporting ligaments and fascial system, ultimately resulting in superior lifting outcomes. This comprehensive approach underscores the scientific rigour and innovative design of ELLANSÉ as a leading facial filler option.

Skin rejuvenation

Layer: Skin.

Objective: Improve skin texture and increase skin elasticity. Rationale: Endogenous skin ageing: This process involves a reduction in the extracellular matrix (ECM), collagen, and elastic fibres within the dermis, as well as collagen fragmentation and degradation of the elastic fibre network. Clinically, this results in thinning skin, increased wrinkles, dryness, and deteriorated skin quality86. Exogenous skin ageing is caused by damaging external environmental factors, such as ultraviolet radiation (UVR), which penetrates the epidermis and damages the DNA in dermal fibroblasts. This leads to the synthesis and release of cytokines and matrix metalloproteinases (MMPs), causing the breakdown of elastin and collagen, promoting the generation of reactive oxygen species (ROS), and accelerating skin ageing87 Manifestations include increased and irregular pigment distribution, changes in epidermal thickness, decreased and fragmented collagen, inflammation, and vascular dilation88-90

ELLANSÉ injection techniques such as ligament lifting and contour fixation are employed to improve sagging.

The long-term efficacy and safety of ELLANSÉ in improving skin quality have been well-established in multiple studies. A 2019 study reported that 13 patients with moderate to severe facial wrinkles were treated with ELLANSÉ bio-stimulation therapy. After mixing 0.5 cc of PCL filler, 0.5 cc of lidocaine, and 2 cc of saline, the injection led to significant improvements. Post-treatment skin biopsies revealed fibroblast migration and proliferation around PCL microspheres, with new capillaries, collagen, and elastic fibres forming. This effectively improved skin atrophy, with an average increase in skin thickness of 21.31%, and no severe adverse reactions were observed throughout the treatment10

Another study published in 2022 involved 7 patients with enlarged pores who received deep dermal injections of ELLANSÉ (full-face total volume of 2 ml with 0.01–0.05 ml volume per injection). Results showed a significant reduction in pore size, with an improvement rate of up to 48.09%. The effect was more pronounced in patients with moderate to severe pore enlargement, with no adverse reactions such as lump formation, erythema, or bleeding reported during the treatment, and no severe adverse events were noted during follow-up91

Additionally, skin quality improvements were observed during ELLANSÉ treatment for the subcutaneous fat layer and

periosteum. PCL promotes skin cell renewal and increases metabolic rate, improving skin surface colour and texture85

Summary of ELLANSÉ Advantages

Skin ageing is intricately associated with the integrity and function of collagen, collagen fibres, elastic fibres, and ECM. To counteract skin ageing caused by both endogenous and exogenous factors, an ideal material should stimulate the synthesis of these key components, thereby improving skin texture and increasing elasticity. Animal studies show ELLANSÉ exhibits a pronounced capacity to promote skin health and maintain a youthful appearance. Specifically, ELLANSÉ effectively stimulates the biosynthesis of collagen and elastin fibres, thereby significantly enhancing the skin’s resilience and elasticity11. By augmenting dermal thickness, ELLANSÉ provides improved structural support and firmness to the skin. This dual mechanism of action results in a smoother and more refined skin surface, imparting a fuller, firmer, and more vibrant appearance that is indicative of youth.

Complications and prevention principles

Complications and prevention principles of PCL microspheres in facial rejuvenation treatments:

Complications

■ Swelling: A common temporary reaction postinjection, typically resolving within a few days

■ Nodules: these may be related to improper injection techniques, such as shallow or rapid injection speed

■ Induration: similar to nodules, possibly due to technical issues during injection

■ Inflammation/Infection: Less common, potentially related to inadequate preoperative disinfection or non-standard injection practices

■ Bruising/Hematoma: Caused by vascular damage during the injection process.

Prevention principles

■ Strict sterile technique: essential to prevent infection, including thorough preoperative disinfection and adherence to sterile practices

Key points

ELLANSÉ, a polycaprolactone (PCL) filler, provides dual benefits of immediate volumizing and sustained collagen regeneration, making it ideal for long-term aesthetic enhancement.

Experts from Asia-Pacific highlight ELLANSÉ’s unique suitability for facial injectable treatments, providing customised treatments for contouring, volumising, tightening, lifting, and skin rejuvenation.

ELLANSÉ’s innovative STAT technology and biocompatible properties offer safe, natural-looking results that maintain facial harmony over time.

instructions, including avoiding vigorous exercise, keeping the injection site clean and dry, and informing patients about potential temporary swelling or bruising.

Postoperative care

Immediate post-injection care

■ Ice packs: Apply ice packs to the treatment area immediately after injection to reduce swelling and discomfort, typically for 15 minutes

■ Cleaning: Keep the injection area clean, avoiding water exposure or contact with coloured cosmetics to prevent infection.

Short-term care (within 24 hours)

■ Avoid makeup: Do not apply makeup to the injection site within 24 hours

■ Avoid touching: Refrain from touching or pressing the injection area to prevent displacement of the filler.

Mid-term care (days to 1 week)

■ Avoid vigorous exercise: Avoid intense physical activity in the initial days post-treatment to minimise swelling and bruising

■ Dietary considerations: Avoid alcohol and spicy or allergenic foods for one week after the procedure.

■ Moderate injection volume: Avoid excessive injection to reduce the risk of swelling and nodules

■ Layered correction: Choose the appropriate injection layer based on the treatment area, which is generally recommended to be subcutaneous or above the periosteum

■ Slow injection: Administer injections slowly and evenly to avoid excessive local pressure

■ Avoid high-risk areas: avoid injecting in areas prone to vascular damage, such as the lips, glabella, and eyelids

■ Pain management: Pre-mixing with less than 0.2 ml 2% Lidocaine per syringe. When diluted with normal saline at a ratio greater than 1:1, it can impact the skin texture improvement

■ Postoperative care: Provide clear postoperative care

The combination of ELLANSÉ with other cosmetic treatments holds promise for achieving more comprehensive and synergistic rejuvenation effects.

Long-term care

Avoid prolonged use of hormones or immunosuppressants: For 6 months posttreatment, avoid long-term use of medications that could affect collagen regeneration

Regular follow-ups: Schedule follow-up visits as per the physician’s recommendations to monitor treatment results and detect any potential complications early.

Handling special situations

For swelling or bruising, consider using antiinflammatory medications or cold compresses under medical guidance.

For any abnormal reactions or severe pain, contact a physician immediately and seek professional help.

Adhering to these postoperative care guidelines helps maximise treatment outcomes, minimise the risk of complications, and ensure patient comfort and satisfaction.

Summary and outlook

ELLANSÉ, a collagen stimulant formulated with PCL, has exhibited remarkable efficacy in aesthetic medicine by achieving contouring, volumising, tightening, lifting, and skin rejuvenation. Its unique mechanism offers both immediate and sustained collagen regeneration, enabling tailored solutions for intricate facial treatments.

As clinical data continues to accumulate and aesthetic technology progresses, ELLANSÉ is poised to assume a more prominent role in personalised treatment plans. This is particularly evident in precise applications targeting various facial and body regions, where its potential for refinement and enhancement warrants further

investigation. Moreover, the combination of ELLANSÉ with other cosmetic treatments holds promise for achieving more comprehensive and synergistic rejuvenation effects. Such combinations could potentially advance the field of facial rejuvenation by offering innovative approaches that address multiple aspects of ageing simultaneously. Therefore, further research into the synergistic potential of ELLANSÉ with other cosmetic modalities is anticipated, with the aim of optimising treatment outcomes and advancing the state of aesthetic medicine.

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Acknowledgements

This consensus was discussed at the ELLANSÉ Asia Pacific Summit in October 2024 in Barcelona and approved by all members of the expert consensus board. This consensus was prepared by Chang Chen.

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43. Liew S, Wu WT, Chan HH, et al. Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty. Aesthetic Plast Surg. 2016;40(2):193-201.

44. Gu Y, McNamara JA, Jr., Sigler LM, et al. Comparison of craniofacial characteristics of typical Chinese and Caucasian young adults. Eur J Orthod. 2011;33(2):205-211.

45. Le TT, Farkas LG, Ngim RC, et al. Proportionality in Asian and North American Caucasian faces using neoclassical facial canons as criteria. Aesthetic Plast Surg. 2002;26(1):64-69.

46. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106(2):479-488; discussion 489-490.

47. Albert AM, Ricanek K, Jr., Patterson E. A review of the literature on the aging adult skull and face: implications for forensic science research and applications. Forensic Sci Int. 2007;172(1):1-9.

48. Kahn DM, Shaw RB. Overview of current thoughts on facial volume and aging. Facial Plast Surg. 2010;26(5):350355.

49. Mendelson B, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36(4):753-760.

50. Hong WJ, Liao ZF, Zeng L, et al. Tomography of the Forehead Arteries and Tailored Filler Injection for Forehead Volumizing and Contouring. Dermatol Surg. 2020;46(12):1615-1620.

51. Jung SG, Wu X, Hwang K, et al. Anthropometric analysis of the faces of Chinese beauty pageant winners, from the early 20th century to the present. J Craniofac Surg. 2024.

52. Bae B, Lee G, Oh S, et al. Safety and Long-Term Efficacy of Forehead Contouring With a Polycaprolactone-Based Dermal Filler. Dermatol Surg. 2016;42(11):1256-1260.

53. Truswell WHt. Aging changes of the periorbita, cheeks, and midface. Facial Plast Surg. 2013;29(1):3-12.

54. Wu L, Rohilla S, Jain A. Levobupivacaine as a substitute for lignocaine during reconstitution of Ellanse M. Journal of Cosmetic Medicine. 2024;8(1):58-61.

55. Chen Q, Wang Y. Ellanse: Advanced Technology and Advantageous Selection of New Collagen Stimulating Agents for Face Rejuvenation. Aesthetic Plast Surg. 2024;48(10):1977-1984.

56. Li S. Improvement Effect of Different Fillers on the Face in the Adjustment of Eyebrow Arch, Double C and Nose (in Chinese). Journal of Medical Aesthetice and Cosmetology. 2024(13):74-77.

57. Vanaman Wilson MJ, Jones IT, Butterwick K, et al. Role of Nonsurgical Chin Augmentation in Full Face

Rejuvenation: A Review and Our Experience. Dermatol Surg. 2018;44(7):985-993.

58. Guo SH. Cosmetic Effect of Polycaprolactone Gel for Injection Combined with Chin Injection Filled with Hyaluronic Acid of Micro Plastic Surgery in Female Maxillofacial Contour Remodeling (in Chinese). Journal of Medical Aesthetice and Cosmetology. 2023;32(22):44-47.

59. Oh H, Lee S, Na J, et al. Comparative Evaluation of Physical Characteristics and Preclinical Data of a Novel Monodisperse Polycaprolactone Microspheres Filler. Aesthetic Plast Surg. 2022;46(1):429-436.

60. Raskin E, Latrenta GS. Why do we age in our cheeks? Aesthet Surg J. 2007;27(1):19-28.

61. Naini FB. Facial aesthetics: concepts and clinical diagnosis.: John Wiley & Sons 2011.

62. Zhao H, Ren R, Bao S, et al. Efficacy and Safety of Polycaprolactone in Treating Nasolabial Folds: A Prospective, Multicenter, and Randomized Controlled Trial. Facial Plast Surg. 2023;39(3):300-306.

63. Park JW, Choi SY, Kim KR, et al. A randomized, participant- and evaluator-blinded, matched-pair prospective study to compare the safety and efficacy between polycaprolactonebased fillers in the correction of nasolabial folds. Dermatol Ther. 2022;35(7):e15508.

64. Figueiredo VM. A five-patient prospective pilot study of a polycaprolactone based dermal filler for hand rejuvenation. J Cosmet Dermatol. 2013;12(1):73-77.

65. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219-2227.

66. Li Z, Wang S, Liu S, et al. New insights into aging-associated characteristics of female subcutaneous adipose tissue through integrative analysis of multi-omics data. Bioengineered. 2022;13(2):2044-2057.

67. Gierloff M, Stohring C, Buder T, et al. The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides. J Plast Reconstr Aesthet Surg. 2012;65(10):1292-1297.

68. Bryan M, Wong C-H. Anatomy of the aging face. Plastic surgery. 2013;2:78-92.

69. Kapoor KM, Saputra DI, Porter CE, et al. Treating Aging Changes of Facial Anatomical Layers with Hyaluronic Acid Fillers. Clin Cosmet Investig Dermatol. 2021;14:1105-1118.

70. Okuda I, Yoshioka N, Shirakabe Y, et al. Basic analysis of facial ageing: The relationship between the superficial musculoaponeurotic system and age. Exp Dermatol. 2019;28 Suppl 1:38-42.

71. Lin SL. Polycaprolactone facial volume restoration of a 46-year-old Asian women: A case report. J Cosmet Dermatol. 2018;17(3):328-332.

72. Yin M, Yin S, Liu X, et al. The Specific Application of Polycaprolactone Microspheres in the “Double S” Injection Technique and Its Therapeutic Effect (in Chinese). China Medical Cosmetology. 2022;12(11):14-20.

73. Zhu SC, Ye T, Li PJ, et al. Improvement of the midface with polycaprolactone microsphere injectable facial filler (in Chinese). Journal of Medical Aesthetics and Cosmetology. 2024;33(14):46-48.

74. Kim BJ, Choi JH, Lee Y. Development of Facial Rejuvenation Procedures: Thirty Years of Clinical Experience with Face Lifts. Arch Plast Surg. 2015;42(5):521-531.

75. Schaverien MV, Pessa JE, Rohrich RJ. Vascularized membranes determine the anatomical boundaries of the

subcutaneous fat compartments. Plast Reconstr Surg. 2009;123(2):695-700.

76. Alghoul M, Codner MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J. 2013;33(6):769-782.

77. Zhang YL, Chen Y, Sun ZS, et al. Retrospective Study of Vascular Complications Caused by Hyaluronic Acid Injection. Aesthetic Plast Surg. 2023;47(6):2745-2753.

78. Papadopoulos T. Commentary on: Injectable Filler Technique for Face Lifting Based on Dissection of True Facial Ligaments. Aesthet Surg J. 2021;41(11):NP1584-NP1588.

79. Peter H. The True Lift Technique™: facial ligament retightening, an anatomical approach. The PMFA Journal. 2018;5.5:2-3.

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

81. Cong LY, Duan J, Luo CE, et al. Injectable Filler Technique for Face Lifting Based on Dissection of True Facial Ligaments. Aesthet Surg J. 2021;41(11):NP1571-NP1583.

82. Casabona G, Bernardini FP, Skippen B, et al. How to best utilize the line of ligaments and the surface volume coefficient in facial soft tissue filler injections. J Cosmet Dermatol. 2020;19(2):303-311.

83. Haidar R, Freytag MDD, Frank K, et al. Quantitative Analysis of the Lifting Effect of Facial Soft-Tissue Filler Injections. Plast Reconstr Surg. 2021;147(5):765e-776e.

84. Cong LY, Zhang SY, Zhao JJ, et al. Analysis of the effect of multisite combined multilevel injection of Ellansé in the external facial contour to improve nasolabial folds (in Chinese). China Medical Cosmetology. 2023;13(10):1-6.

85. Zhang EJ, Gu YC, Shen HR, et al. The effects of injectable polycaprolactone microsphere soft tissue filler on improving facial contours (in Chinese). Journal of Medical Aesthetics and Cosmetology. 2024;33(7):69-71.

86. 86. Kohl E, Steinbauer J, Landthaler M, et al. Skin ageing. J Eur Acad Dermatol Venereol. 2011;25(8):873-884.

87. Yaar M, Gilchrest BA. Photoageing: mechanism, prevention and therapy. Br J Dermatol. 2007;157(5):874-887.

88. Flament F, Bazin R, Laquieze S, et al. Effect of the sun on visible clinical signs of aging in Caucasian skin. Clin Cosmet Investig Dermatol. 2013;6:221-232.

89. Longo C, Casari A, Beretti F, et al. Skin aging: in vivo microscopic assessment of epidermal and dermal changes by means of confocal microscopy. J Am Acad Dermatol. 2013;68(3):e73-82.

90. Guida S, Pellacani G, Ciardo S, et al. Reflectance Confocal Microscopy of Aging Skin and Skin Cancer. Dermatol Pract Concept. 2021;11(3):e2021068.

91. Marefat A, Dadkhahfar S, Tahvildari A, et al. The efficacy of polycaprolactone filler injection on enlarged facial pores. Dermatol Ther. 2022;35(8):e15600.

A NEW APPROACH FOR FACIAL VOLUME RESTORATION MUSCLE BIOMODULATION

Noura Lebbar, MD, discusses a new approach to facial contouring that focuses on muscle regeneration over fillers for natural results

NOURA LEBBAR, MD, Cosmetic

Surgeon, Professor at the University of Genoa Milan, Italy

email dott.noura.lebbar@gmail.com

FOR YEARS, FACIAL AESTHETIC MEDICINE HAS FOCUSED ON volumizing the face using fillers; however, the more we fill, increasing the volume of the zygomatic area and middle cheek, the more the face is lifted. The result is overfilled patients, commonly known as pillow face, that we often see even in celebrities.

The current trend is to slow the ageing process with autologous regenerative medicine. Most energy-based devices are designed to target the dermis or fat layers, but what about aging muscles? The only injectable that specifically affects muscles is botulinum toxin. While it has been used for many years, one of its consequences is muscle atrophy, particularly in the frontalis muscle, which is the primary lifting muscle in the upper face. This atrophy can lead to increased wrinkles and noticeable eyebrow drooping.

Restoring facial muscles

The facial structure is composed of approximately 60% muscles, 20% skin, 10% fat, and 10% bone1. Therefore, restoring the facial muscles is the most important anti-ageing procedure.

Working on facial muscles has become a new trend in facial contouring. For the past three years, I have been using a technique called diathermocontraction, which combines bipolar radiofrequency with deep muscle contraction simultaneously. By thoroughly understanding the anatomy of the facial muscles, I can specifically target the lifting muscles and supportive ligaments when using diathermocontraction.

KEYWORDS Diathermocontraction, muscle stimulation

I have been using a new energy-based treatment that helps restore muscle and fat loss in the face. The treatment was performed on two female patients: one aged 60 (Figure 1) and the other aged 55 (Figure 2). The technique I used is called FaceStim, which is based on a technology called RF Diathermocontraction. For both patients, I conducted three treatment sessions, each lasting 20

I have been using a technique called diathermocontraction, which combines bipolar radiofrequency with deep muscle contraction simultaneously.

minutes, once a week. During each session, I used the following parameters: Diathermy level 3, Contraction level 3, and Frequency level 3. After just three sessions, the patients experienced noticeable improvements, including a midface lift, enhanced jawline definition, and a more pronounced V shape in their facial structure.

RF diathermy treatment helps to reduce wrinkles and signs of skin aging by targeting the deeper layers of the dermis and subdermis. Additionally, muscle contraction can lead to a 20% increase in the thickness of the zygomatic major muscle, along with improvements in how individuals perceive their facial features related to ageing2

When combined, the effects of diathermy and muscle contraction in the FaceStim technique can stimulate the activation of satellite cells. These cells help regenerate and strengthen existing muscle fibers through a process known as differentiation. This technique also promotes the release of Heat Shock Proteins (HSP), which are signaling molecules that encourage muscle protein synthesis and growth.

The benefits of radiofrequency treatment are wellestablished and include improved blood microcirculation, which enhances tissue oxygenation. This process also stimulates the release of insulin-like growth factors (IGF), fibroblast growth factor (FGF), and vascular endothelial growth factor (VEGF), all of which play essential roles in tissue health and regeneration3

The main muscles responsible for lifting the face include the occipitofrontalis, temporalis, masseter,

Muscle biomodulation through diathermocontraction offers a valid alternative to traditional fillers for facial volumisation and lifting. This innovative method is regenerative and conservative, enhancing muscle volume without the use of external injectable substances.

buccinator, and the zygomaticus major and minor. During our treatment, we will focus on these lifting muscles, tailoring our approach to each patient’s needs. For instance, if a patient desires a more defined jawline, we will concentrate on the masseter and buccinator muscles. Conversely, to lift the eyebrows, we will target the temporalis and frontalis muscles.

Using diathermocontraction, we can also counteract the actions of the depressor muscles, such as the lateral pterygoid, which depresses the zygomatic area, as well as the levator labii superioris alaeque nasi and the levator labii superioris. These muscles can contribute significantly to the deepening of the nasolabial folds that occur with ageing. Furthermore, we will address the powerful depressor muscle of the lower face: the platysma.

Muscle biomodulation through diathermocontraction

A A B B References

offers a valid alternative to traditional fillers for facial volumization and lifting. This innovative method is regenerative and conservative, enhancing muscle volume without the use of external injectable substances. Diathermocontraction preserves the natural harmony of the facial muscles, focusing solely on pure muscle regeneration and volume enhancement.

The ability to place electrodes on each targeted lifting muscle and adapt the treatment dynamically is essential for personalizing the experience according to each patient’s needs. Diathermocontraction represents the new technique for achieving the highly sought-after V-shaped face in a conservative manner.

Declaration of interest None

1. Marur T, Tuna Y, Demirci S. Facial anatomy. Clin Dermatol. 2014 Jan-Feb;32(1):14-23. doi: 10.1016/j. clindermatol.2013.05.022. PMID: 24314374.

2. Kavanagh S, Newell J, Hennessy M, Sadick N. Use of a neuromuscular electrical stimulation device for facial muscle toning: a randomized, controlled trial. Cosmet Dermatol. 2012 Dec; 11 (4): 261-6 doi: 10.1111/jocd.12007

3. Alvarez N, Ortiz L, Vicente V, Alcaraz M, Sánchez-Pedreño P. The effects of radiofrequency on skin: experimental study. Lasers Surg Med. 2008 Feb;40(2):76-82. doi: 10.1002/lsm.20594. PMID: 18306157.

Figure 1 (A) Before and (B) after treatment

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

REVERSING THE SIGNS OF AGING WITH EXOS ANTIAGING

Drs Eleni Delimpalta, Magda Manoli and Carlos Aznar present two successful cases where EXOS ANTIAGING from Simildiet Laboratories significantly improved facial skin quality, addressing wrinkles, sagging, and enlarged pores through advanced exosome-based treatments

Case one: mesotherapy technique

Dr Eleni Delimpalta is a dermatologist-venereologist specialising in aesthetic dermatology at Dermaone Clinic in Thessaloniki, Greece. She is a member of the Hellenic Society of Dermatology and Venereology, the Hellenic Society of Dermatologic Surgery, and the European Academy of Dermatology and Venereology.

A 56-year-old patient presented with wrinkles on the forehead, periorbital, and perioral areas, along with enlarged pores. An accurate diagnosis is key to selecting the appropriate treatment. For this patient, EXOS ANTIAGING from Simildiet Laboratories was used. This product contains exosomes with seven growth factors and cytokines that stimulate collagen and hyaluronic acid production, in addition to possessing antioxidant and anti-inflammatory properties that help reduce signs of ageing. The diluent, which includes seven biomimetic peptides, DMAE, hyaluronic acid, magnesium, copper, and zinc, complements the anti-ageing therapy.

Technique

Before applying the treatment, it is important to properly prepare the Simildiet EXOS ANTIAGING product by introducing the entire content of the diluent vial (pink vial, 5 ml) into the lyophilised vial (black vial). Once

ELENI DELIMPALTA, MD, is a dermatologist-venereologist specialising in aesthetic dermatology at Dermaone Clinic, Thessaloniki, Greece; MAGDA MANOLI, MD, is a dermatologist-venereologist with extensive experience in clinical dermatology, aesthetic treatments, and dermatoscopy at Dermocosmetica Clinic, Thessaloniki, Greece; CARLOS AZNAR SÁNCHEZ, MD, Master in Aesthetic medicine by L’Union International de Médecine Esthétique, General Manager of Simildiet Laboratorios

Figure 1 Male patient (A) before, (B) after second treatment, and (C) after fourth treatment

the powder is diluted, the product is ready for use. The protocol, based on the recommendations of Dr. Carlos Aznar, involved administering between 2 and 2.5 ml per session. The technique used was classic mesotherapy, with one session every 15 days for a total of four sessions over a two-month period.

Results

The patient's overall appearance improved significantly, with visible smoothing of wrinkles across the face, increased skin firmness, reduced pore size, and enhanced skin luminosity. These results underscore the effectiveness of EXOS ANTIAGING in improving facial quality and combating the signs of ageing.

Case two: microneedling technique

Dr Magda Manoli is a dermatologist-venereologist with extensive experience in clinical dermatology, aesthetic treatments, and dermatoscopy. She is recognised as the lead dermatologist at Dermocosmetica Clinic in Thessaloniki, Greece. In addition to her clinical practice, Dr Magda is active in the scientific field: she is a reviewer and author of dermatological articles in international scientific journals, a speaker at dermatology conferences, and a member of eight scientific societies.

In this case, a 68-year-old patient presented with multiple aesthetic concerns, including forehead wrinkles, sagging skin, enlarged pores, and a scar located under the chin. These signs are common in elderly patients and reflect the need for a treatment that not only

“After completing the protocol, the patient demonstrated a marked improvement in skin quality, with significant smoothing of fine lines and wrinkles, resulting in a facial tightening effect and a more youthful appearance.”

improves the appearance of wrinkles but also enhances overall skin quality. The EXOS ANTIAGING formula contains seven growth factors, all derived from plant exosomes. While HGF and bFGF are highlighted for their roles in stimulating skin regeneration and healing and aFGF for its comprehensive anti-ageing effects, there are additional growth factors in the formula that further contribute to its rejuvenating properties.

Technique

The microneedling technique was utilised to target the signs of facial ageing in the patient, with 2.5 ml administered per session. Sessions were scheduled every 2 weeks, with a total of four sessions over a period of 2 months. This frequency enables sufficient recovery and maximises results throughout the treatment.

Results

After completing the protocol, the patient demonstrated a marked

improvement in skin quality, with significant smoothing of fine lines and wrinkles, resulting in a facial tightening effect and a more youthful appearance. Additionally, there was a slight brightening of the skin, improvement in the scar under the chin, and a reduction in pore size, contributing to a more even and healthy skin texture. This product and treatment stand out for their minimally invasive nature and the ability to address multiple dermatological concerns with a single product.

Find out more at: simildiet.com

Figure 2 Female patient (A) before, (B) after second treatment, and (C) after fourth treatment

HYALURONIC ACID FILLER INJECTION TECHNIQUE: CONTOURING TEMPORAL AND UNDER-EYES FOR ASIANS

Truong Ngoc Minh, MD, explores how precise HA filler techniques can restore volume in Asian patients, achieving natural and rejuvenated results

FACIAL AGEING IN THE Asian population commonly manifests through temporal hollowing and tear trough deformities, often contributing to a tired, sunken appearance1. These changes are largely driven by volume loss in subcutaneous fat and surrounding soft tissues, particularly as the fat pads descend with age. These conditions are exacerbated by certain anatomical predispositions in Asian populations, including shallower facial bone structure, making these areas particularly vulnerable to signs of premature ageing.

Temple volumisation

Hollowing temples may either be a congenital feature or caused by the loss of temporal volume with ageing or weight loss. In Asian patients, the combination of a

thinner dermis and the presence of less robust fatty tissue can lead to more prominent hollowing, even at relatively younger ages. The temples begin to take on a concave appearance, contributing to the perception of skeletal ageing2 Superficial cannula injection of HA filler can be attempted with careful observation of cannula position3. The cannula is introduced between the superficial temporal fascia and the deep temporal fascia, targeting the intermediate fat layer or into the superficial fat compartment, just beneath the skin. A fanning technique is employed, wherein the cannula is introduced at a single-entry point, and filler is dispersed in a fanning motion across the hollowed region. This allows for an even distribution of the product and minimises the risk of lumpiness. It should be noted that superficial injections may lead to surface irregularities that require massage over the

ensuing days3

General treatment material and method:

■ Volumisation of the temples can be achieved using S100 or S300

■ Needle (27G) or cannula (23G/27G)

■ Amount of HA filler: 1-2ml per side

■ Target area: medial part of the temporal depression for smoothening the orbital rim contour and Lateral part for the oval face line.

Case study: temporal filler injection

A 39-year-old female presented with moderate bilateral temporal hollowness, contributing to an aged and skeletal appearance. The patient reported dissatisfaction with the disproportionate concavity of her temples, which had become more pronounced due to the natural ageing process and soft tissue atrophy.

The decision was made to restore volume using a combination of e.p.t.q.® Lidocaine S300 and S100 (manufactured by JETEMA, Co., Ltd., Republic of Korea). A total of 3cc of filler was used (2cc of S300 and 1cc of S100) to provide structure and smooth contouring.

Injection technique

The filler was administered using a combination of straight needle and cannula techniques:

■ The needle technique is ideal for deeper temporal hollows. It

TRUONG NGOC MINH, MD, is a board-certified dermatologist at Aura Beauty Clinic, Ho Chi Minh City, Vietnam Figure 1

(A) Before, (B) After 3 ml of e.p.t.q.® Lidocaine filler for temporal volumisation

allows for the precise placement of the filler into the deeper compartments, enhancing volume and contour and effective volume restoration.

■ The cannula technique is advantageous for superficial temporal hollows. Avoid deep needle injections into the lower or posterior fossa above the zygomatic arch, as internal maxillary branches are present, with a risk of palate necrosis. Superficial cannula injection may be attempted with careful observation of cannula position. A 23G cannula was employed to minimise the risk of vascular injury and ensure an even distribution of the product.

Filler e.p.t.q.® Lidocaine S300 was primarily injected at the deeper layers to provide the necessary volume and structural support, while S100 was used for superficial contouring and refinement.

Results and outcomes

Post-treatment evaluation showed immediate improvement in the concavity of the temples, restoring a youthful and harmonious appearance to the patient’s face.

After 2 weeks, the filler blended well with the surrounding tissues, and no significant complications were reported. The patient expressed high satisfaction with the

result, particularly the naturallooking outcome.

“In Asian patients, the combination of a thinner dermis and the presence of less robust fatty tissue can lead to more prominent hollowing, even at relatively younger ages. The temples begin to take on a concave appearance, contributing to the perception of skeletal ageing.”

Follow-up at 1 month demonstrated sustained results, with no signs of migration, overcorrection, or other adverse effects.

Inferior orbital hollowness volumisation

Inferior orbital hollowness consists of three components: the tear trough in the medial aspect, the central infraorbital hollow in the central aspect, and the palpebromalar groove in the lateral aspect4

Under-eye discolouration, colloquially referred to as ‘dark circles,’ is a multifactorial problem resulting from the thinning of the orbital septum, which allows fat pads to prolapse and create a sunken, dark appearance beneath the eyes. This condition is often accompanied by skin pigmentation issues. It is frequently observed in Asian patients due to the relatively lower volume of subcutaneous fat in the periorbital region compared to other ethnic groups.

General treatment material and method:

■ e.p.t.q.® Lidocaine S100 is preferred for injecting the delicate infraorbital area

■ Needle vs. Cannula: 27G x 50mm cannula for the subdermal layer; 23G x 50mm cannula for the

“Under-eye discolouration, colloquially referred to as ‘dark circles,’ is a multifactorial problem resulting from the thinning of the orbital septum, which allows fat pads to prolapse and create a sunken, dark appearance beneath the eyes.”

Figure 2 Infraorbital hollowness consists of three parts depending on the location, namely the tear trough on the medial aspect, the central infraorbital hollow on the central aspect, and the palpebromalar groove on the lateral aspect

deep submuscular layer (preseptal layer)

■ Amount of HA filler: 0.3–0.5 mL per side

■ To minimise bruising and avoid damage to the extensive vasculature contained in the periorbital region, it is important to insert the needle slowly with the bevel facing downwards. In the event of any vascular damage, firm compression (with an ice bag if available) should be applied to the area for at least 3 minutes to stop the bleeding4

Case study: central inferior orbital hollow filler injection

A 28-year-old female presented with a central infraorbital hollow in the central aspect. She reported feeling self-conscious about her tired appearance, which was not

Central infraorbital hollow

Palpebromalar groove

Tear trough

HYALURONIC ACID FILLER INJECTION

TECHNIQUE: CONTOURING TEMPORAL AND UNDER-EYES FOR ASIANS (continued)

alleviated by adequate sleep or topical treatments.

1 ml filler e.p.t.q.® Lidocaine (S100) treatment was deemed appropriate to restore volume and reduce the shadowing effect.

Injection technique

A 23G cannula was used to inject the filler in a subperiosteal plane close to the bone to provide subtle volume restoration without overfilling.

Filler Placement: 0.3ml of S100 was injected into each under-eye hollowness for a total of 0.6ml. Total Volume: 0.6ml (0.3ml per side).

Results and outcomes

The patient experienced immediate improvement in the appearance of her central orbital hollow, with a reduction in the shadowing effect that had contributed to her dark circles. The use of e.p.t.q.® Lidocaine S100 allowed for smooth integration into the delicate periorbital tissue, avoiding the risks of lumpiness or unevenness commonly associated with filler treatment in this area.

After 1 month follow-up, the patient continued to express satisfaction with her results. The filler remained well-integrated, with no signs of

“The use of e.p.t.q.® Lidocaine, in addressing temporal hollowing and inferior orbital hollowness in Asian patients, offers a safe and effective solution for volume restoration. ”

Conclusion

The use of e.p.t.q.® Lidocaine, in addressing temporal hollowing and inferior orbital hollowness in Asian patients, offers a safe and effective solution for volume restoration. In both cases, the patients experienced significant aesthetic improvements without complications, highlighting the versatility of e.p.t.q.® Lidocaine for different anatomical regions and concerns. The combination of appropriate filler selection and precise injection techniques, including the use of cannulas, contributed to the successful outcomes.

e.p.t.q.® Lidocaine fillers are particularly well-suited for the Asian population, given their ability to provide natural-looking results with minimal downtime. As aesthetic demand continues to grow in Vietnam, the role of HA fillers, especially e.p.t.q.® Lidocaine, is expected to expand, offering patients a reliable option for facial rejuvenation.

For more information, contact global@jetema.com

Samizadeh, Souphiyeh. “Facial ageing in east Asians.” Non-surgical rejuvenation of Asian faces (2022): 97-106.

Coleman, Sydney R., and Rajiv Grover. “The anatomy of the aging face: volume loss and changes in 3-dimensional topography.” Aesthetic

3. De Maio M, Swift A, Signorini M, Fagien S. Facial assessment and injection guide for botulinum toxin and injectable

Seo KK. Facial Volumization with Fillers. Springer; 2021.

Figure 3 (A) Before, (B) After under-eyes hollowness injection

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Under the scientific supervision of the Aesthetic Multispecialty Society (AMS)

A PRACTICAL APPROACH TO LIP FILLER: CONSIDERING ANATOMY AND RHEOLOGY

Kang Nien How, MBBS, explains why lip augmentation requires a deep understanding of anatomy and filler properties

long-lasting results

LIP AUGMENTATION has gained significant popularity in recent years. Although the procedure may appear straightforward, it is far more complicated than it seems. Achieving optimal results requires a thorough understanding of both facial anatomy and the rheological properties of the filler materials1 Each individual’s face and lips are unique, necessitating a tailored approach for every patient2. This article aims to present my practical approach to lip augmentation, focusing on how anatomical knowledge and an understanding of rheology inform every step of my clinical practice

Understanding lip anatomy: the blueprint for success

A comprehensive understanding of lip anatomy is fundamental to performing safe and effective

to achieve natural,

aesthetic procedures. The lips, while seemingly simple, are anatomically complex and central to facial expressions.

Key anatomical landmarks, as illustrated in Figure 1. Enhancing these cosmetic units can lead to a well-defined lip shape; however, overcorrection can result in unnatural outcomes, such as the ‘duck lips’ effect. Youthful lips are typically characterised by a well-defined border, volume, smoothness, symmetry, and projection. However, the ideal lips are fully dependent on cultural and ethnic background2. It is essential to recognise that each patient has a unique ideal lip shape, and a one-size-fits-all approach should be avoided.

The orbicularis oris muscle, responsible for lip movement, is a frequent cause of filler migration. To minimise the risk of complications, such as migration,

higher cohesivity fillers should be selected, and superficial and excessive volume injections should be avoided3

Another important consideration is the lip’s vascular network (Figure 2). The superior and inferior labial arteries run adjacent to the vermillion border, predominantly travelling intramuscularly or submucosally. For this reason, the optimal plane for injection is the subcutaneous plane, specifically within the wet-dry mucosal area. A deep understanding of this anatomy helps to mitigate the risk of vascular occlusion4,5

While anatomical knowledge is crucial, the selection of an appropriate filler is equally important. Rheology, the study of how materials flow, plays a pivotal role in this decision. Products with higher elasticity (G’) offer greater structural support, making them ideal for enhancing the vermillion border. In contrast, fillers with a lower G’ are softer and more flexible, which is preferable for the body of the lips, as it allows for natural movement with minimal interference3,6

Rheology, in particular cohesivity, is another critical factor to consider. It had been found that less cohesive gels may modify faster in the dynamic lip area7. More viscous fillers are beneficial for adding volume, but overly thick fillers may not integrate smoothly with the surrounding tissue. A cohesive filler is necessary to ensure uniform

DR. KANG NIEN HOW, MBBS, is a board-certified dermatologist, Head of the Dermatology Unit, Hospital Sultan Abdul Aziz Shah, UPM, and Co-Founder and Consultant Dermatologist of Central Dermatology Specialist Clinic, Malaysia.

Figure 1 The surface anatomy of the lips

Figure 2 The intricate vascular network supplying the lips

“My advice is to prioritise precision over speed, under-correct when necessary, and use smaller volumes in the initial session, with the option to reassess and perform touch-ups two weeks later.”

results and prevent lump formation3

Practical techniques: tailoring to the patient

There is no universal technique when it comes to lip filler injections. Multiple different techniques were previously described7,8. My approach is highly individualised, depending on the patient’s anatomy and aesthetic goals.

Needle

vs. cannula

The debate over whether to use a needle or cannula in lip augmentation is ongoing. Different practitioners will have different preferences, and each produces wonderful results8,9. In my practice, I often prefer using a cannula for deeper injections, as it reduces the risk of vascular injury. However, in

cases requiring greater precision, such as defining the Cupid’s bow, I opt for a needle. When using a needle, it is best to inject perpendicular to the blood vessels and at the subdermal layer to minimise the risk of intravascular complications.

Injection

techniques

Various injection techniques yield different results, and I select my approach based on the patient’s desired outcome6-9. The linear threading method is effective for volumising the lip body, while the tenting technique works well for enhancing definition, particularly along the vermillion border and Cupid’s bow. This technique involves small, vertical filler deposits along the lip’s edge, producing subtle yet precise results.

“While anatomical knowledge is crucial, the selection of an appropriate filler is equally important. Rheology, the study of how materials flow, plays a pivotal role in this decision.”

The lips are highly sensitive and prone to swelling. While a slow injection technique can minimise complications, the trauma from the injection itself may still induce swelling, which can make it challenging for novice injectors to gauge the appropriate filler volume. My advice is to prioritise precision over speed, under-correct when necessary, and use smaller volumes in the initial session, with the option to reassess and perform touch-ups two weeks later.

A 32-year-old gentleman presented with thin lips (Figure 3). Upon assessment, the vermillion border and Cupid’s bow were present and prominent, but the central tubercle of the upper lip was absent. Additionally, the lateral body of the upper lip was nearly non-existent. Given that the patient is male, our goal was to subtly enhance the central tubercle and add volume to the lateral upper lip by augmenting it with a mediumviscosity e.p.t.q.® Lidocaine S300 (manufactured by JETEMA, Co., Ltd., Republic of Korea). Care was taken to avoid feminising the overall

Figure 3 (A) Baseline, (B) Immediately postprocedure, and (C) 10 days after treatment

A PRACTICAL APPROACH TO LIP FILLER: CONSIDERING ANATOMY

AND RHEOLOGY (continued)

appearance. The treatment plan is outlined in Figure 6

A total of 0.8 cc was injected into the lips. The immediate posttreatment results revealed a more defined central tubercle and increased volume in the lateral upper lip (Figure 3B). The final results (Figure 3C) demonstrated a fuller upper lip with a less prominent lip line. The lips

appeared more hydrated, too. Treating male lips can be rewarding and satisfying and should be offered to improve overall acceptance of the treatment, as demonstrated in previous publications10

Conclusion

Achieving an optimal outcome in lip augmentation requires a balance

“Achieving an optimal outcome in lip augmentation requires a balance between artistic vision and scientific knowledge. Understanding anatomy provides a critical foundation, while rheology guides the selection of appropriate filler materials. .”

STRATEGIC FILLER APPLICATION:

A GUIDE TO FULL FACE REJUVENATION AND NATURAL-LOOKING RESULTS

Dr.

Shilpi Bhadani, MBBS

, discusses the beauty triangle technique for balanced facial rejuvenation and contouring

DR.

BHADANI, MBBS, MS, MRCS, MCH(PLASTIC SURGERY),

board-certified

FACIAL AGEING IS caused by atrophy of the fat pads, ultimately leading to facial tissue sagging. A network of superficial and deep facial fat compartments is discretely partitioned into multiple independent units by fascial barriers1.

The superficial fat compartment can be categorised into nasolabial, medial, middle and lateral in the mid-face area. The deep facial fat pad is located below the SMAS. They enable sliding during animation and mastication and, above all, support the overlying subcutaneous fat. These include sub–orbicularis oculi medial and lateral, buccal fat pads, deep medial cheek fat, and lateral deep cheek compartment2

The most prominent age-related change on the face is the inferior migration of the midfacial fat compartments3. In addition, a

decrease in volume in the cephalad portions of the nasolabial and deep medial cheek compartments worsens the appearance of the tear trough, nasojugal fold, and palpebromalar groove.

Key concept

Volume loss in the deep medial cheek fat gives rise to the appearance of a saggy mid-cheek (Figure 1). This also makes the nasolabial folds more pronounced. The deep medial cheek fat is the support on which the mid-face rests, and it is overlapped by the superficial fat pads. Key concepts of mid-face rejuvenation include volume restoration of specific compartments and face contouring. Deep cheek fat augmentation leads to volume restoration, improved anterior projection, decreased nasolabial fold, and corrected V-deformity, tear trough, and nasojugal fold. There is

also more control on augmentation. Deep medial cheek compartment volume augmentation is the most important component of facial rejuvenation, followed by the superficial, middle and lateral cheek compartments (Figure 1).

The beauty triangle

Focusing on the beauty triangle, this case study aims to highlight the three most powerful points of definition that can rejuvenate almost all faces. These are the mid/lateral cheek point, the chin, and the jawline (Figure 2). A multilayering technique is used to achieve the desired changes4. This method also aims to draw attention to the careful placement of fillers in relevant planes so that filler volume is optimally used, thereby preventing the overfilled look. We need to recognise the importance of various modalities of non-invasive aesthetics and their importance instead of trying to push all rejuvenation with one method. Sustained rejuvenation

SHILPI

is a

plastic surgeon specialising in body contouring, breast reduction, facelift, fat grafting of the face and Founder, Director of SB Aesthetics, Gurugram, India.

Figure 1 Volume loss of deep medial cheek fat

Figure 2 The Beauty triangle

Figure 3 Treatment plan

of the face requires a comprehensive plan that includes HA fillers and skin boosters for volume loss, skin care and energy-based treatments for improving skin quality, and threads for lifting.

Case study

A 41-year-old female presented with concern regarding facial ageing changes and desired rejuvenation. A plan for comprehensive rejuvenation of the face with HA fillers was made. The lateral mid-face projection was missing, and the chin and jawline definition could be made better (Figure 5–6). A full face combination injection of e.p.t.q.® LidocaineS500 and S300 (manufactured by JETEMA, Co., Ltd., Republic of Korea) 2 ml each was planned for her. A combination of cannula and needle method was used. A 25G and 27G needle were used for the supraperiosteal placement, and a 23G cannula was used for deep subcutaneous filler placement.

e.p.t.q.® Lidocaine S500 2.4 ml:

■ 0.6 ml = 0.3 ml x2 (deep medial cheek fat pad, cannula)

■ 0.8 ml = 0.4 ml chin (supraperiosteal, needle)

■ 1.0 ml = 0.5 ml x2 angle (supraperiosteal, needle)

e.p.t.q.® LidocaineS300 2 ml:

■ 1.0 ml = 0.5ml x2 (labiomental fold) (subcutaneous cannula)

Conclusion

The application of the triangle technique utilising a dual-plane approach has demonstrated significant efficacy in achieving comprehensive facial rejuvenation. This method not only enhances midfacial lifting but also effectively reduces nasolabial folds, elongates the chin, and opens up the lower face. Additionally, it contributes to an increased jawline length by accentuating the angle of the jaw. For practitioners seeking to address multiple areas, the dual plane technique can be effectively extended to the angle of the jaw through strategic subcutaneous filler placement. Furthermore, for patients requiring targeted treatment in the tear-trough region, direct intervention can be seamlessly integrated into the treatment plan. A notable advantage of this approach is the minimal product requirement in the central facial region, thereby reducing the risk of an overfilled appearance. Overall, this technique offers a balanced, aesthetic outcome while prioritising patient satisfaction and natural results.

For more information, contact global@jetema.com

“Focusing on the beauty triangle, this case study aims to highlight the three most powerful points of definition that can rejuvenate almost all faces.”

3. Ramanadham SR, Rohrich RJ. Newer understanding of specific anatomic targets in the aging face as applied to injectables: Superficial and deep facial fat compartments–An evolving target for site-specific facial augmentation. PlastReconstr Surg. 2015;136:49S–55S.

4. Trévidic P, .Trévidic T, Imanilov A et al. Midface Multilayering Filler Injection Technique:Understanding of the Dynamic Facial Anatomy Through a “Smiling Cadavers” Anatomical Stud. Plast Reconstr Surg 2021; 149: 1326-1336

Figure 4 Comparison of before and after and how the proportions have changed with the filler placement.

Figure 5 Improvement of prominent jawline

Figure 6 Amelioration of uneven facial line

PROMOTION

YVOIRE® Y-SOLUTION 720: A PARADIGM SHIFT IN HYALURONIC ACID FILLER TECHNOLOGY THROUGH

OPTIMISED COHESIVITY, ELASTICITY, AND MINIMISED BDDE CROSS-LINKING

Erica W. Jang, MD, PhD, and Ji Young Lee discuss how YVOIRE®

Y-Solution 720 redefines hyaluronic acid fillers by blending cohesivity

and elasticity for natural, long-lasting results

THE LANDSCAPE OF aesthetic dermatology is constantly evolving, driven by the relentless pursuit of superior clinical outcomes and enhanced patient safety.

Hyaluronic acid (HA) fillers, a cornerstone of minimally invasive cosmetic procedures, have undergone significant advancements in recent years. Among these advancements, YVOIRE® Y-Solution 720 stands out as a prime example of a well-balanced filler that expertly combines high cohesivity and elasticity while minimising the use of cross-linking agents. This innovative approach directly addresses the limitations of previous filler generations and significantly reduces the risk of adverse events associated with excessive use of cross-linking agents, resulting in enhanced efficacy, longevity, and patient safety.

The interplay of cohesivity and elasticity in dermal fillers

There are many factors which can describe the characteristics of hyaluronic acid dermal fillers, such as storage modulus, cohesivity, complex viscosity, concentration, damping factor, and particle size. Among the rheological properties of fillers, elasticity and cohesivity are the most crucial.

■ Cohesivity refers to the filler’s ability to remain cohesive and resist shear forces, preventing dispersion and ensuring long-lasting results with minimal migration. High cohesivity translates to longer-lasting volume and a reduced risk of undesirable filler migration or lumpiness.

■ Elasticity refers to the filler’s ability to return to its original shape after being

subjected to external forces, such as facial movements. A highly elastic filler offers immediate lifting and smoothing effects, creating a natural and aesthetically pleasing outcome. This contributes to a smoother, more natural appearance and allows the filler to adapt to the dynamic movements of the face. Typically, fillers with high elasticity or storage modulus are classified as biphasic, while those with high cohesivity are considered monophasic. However, this method of classification is not scientifically accurate. Technically, all hyaluronic acid dermal fillers have biphasic properties since they consist of both cross-linked (solid) and non-cross-linked (fluid) HA. Therefore, labelling HA fillers strictly as biphasic or monophasic is misleading. Despite this, for simplicity, it is often said that biphasic fillers typically emphasise elasticity, whereas monophasic fillers tend to focus on cohesivity. Monophasic fillers possess particles with lower individual strength but achieve a lifting effect through the cohesive force of the particles binding together. In contrast, biphasic fillers have particles that are inherently firm, providing a lifting effect through their rigidity. Y-phasic fillers combine firmness and cohesivity, resulting in a more pronounced lifting effect on the tissue (Figure 1).

To achieve optimal clinical results, it is essential to consider both elasticity and cohesivity of dermal fillers simultaneously rather than separately. When both of these properties are enhanced, the filler demonstrates a superior ability to maintain its shape. A product that exhibits high levels of both cohesivity and elasticity can be described as a well-balanced filler product. For a filler to withstand various physical

stresses once injected into the body, it must possess both high cohesivity and high elasticity. If a filler product can return to the initial shape even after dynamic shearing forces and dynamic compression forces, it can endure dynamic facial expressions while providing its projection/lifting effect. If a filler were to endure those dynamic forces, it needs to have high cohesivity as well as high elasticity. When a filler is both cohesive and elastic, it can be considered wellbalanced, ensuring it delivers the best possible clinical outcomes by maintaining its intended shape and functionality over time.

YVOIRE® Y-Solution:

A well-balanced product

LG Chem’s YVOIRE® Y-solution achieves a superior balance of both cohesivity and elasticity, providing immediate lifting and long-lasting volume retention. This optimal combination results in a more natural appearance, minimised migration, and enhanced longevity, maximising patient satisfaction and clinician confidence.

LG Chem’s YVOIRE® Y-solution exemplifies a well-balanced product in the realm of dermal fillers, thanks to its innovative approach to combining high cohesiveness and elasticity. Developed to address the common shortcoming of lower cohesiveness in biphasic fillers, YVOIRE® Y-solution leverages the advanced S-HICE™ (Stable High Concentration Equalized) cross-linking technology. This cutting-edge technology surpasses traditional HICE™ methods by using sophisticated particle processes to enhance sustainability and cohesivity in the form of small, tightly bound particles. This technological advancement allows YVOIRE® Y-solution to

function as a Y-phasic filler, successfully merging the high cohesiveness typical of monophasic fillers with the impressive elasticity of biphasic fillers, thereby greatly enhancing lifting capacity.

Introduced in Korea in 2018, the YVOIRE® Y-solution lineup includes Y-solution 360, Y-solution 540, and notably, Y-solution 720, each product containing lidocaine and presenting varying HA concentrations 12mg, 20 mg, and 20 mg, respectively. YVOIRE® Y-solution 720 stands out as a testament to the ideal balance of cohesiveness and elasticity, offering superior performance for aesthetic applications by ensuring durability and effective lifting, thereby delivering optimised clinical outcomes.

To explore the features of a well-balanced product, the rheological properties of YVOIRE® Y-solution 720 and its similar commercially available products were compared (Table 1). The elasticity and cohesivity of these fillers are determined by manufacturing parameters such as crosslinking conditions, particle size reduction methods, and HA concentration. Variations in these parameters account for the differences in elasticity and cohesivity observed across different brands.

YVOIRE® Y-solution 720 demonstrates a superior balance of elasticity and cohesivity compared to its competitors, achieving a high lift capacity while using a relatively low

amount of cross-linking agent (BDDE). As shown in Table 1, YVOIRE® Y-solution 720 exhibits significantly higher lift capacity (71064) than other products in its class despite having the lowest MoD of many of its competitors. This exceptional lift capacity is a result of its well-balanced formulation, which simultaneously optimises both elasticity and cohesivity. The data clearly indicate that YVOIRE® Y-solution 720 achieves high performance without compromising on the amount of crosslinking agent, demonstrating efficient utilisation of the cross-linking technology to enhance both the filler’s elastic and cohesive properties. This unique combination contributes to its superior clinical outcome, offering excellent longlasting results.

Minimising BDDE:

A safety-focused approach

Conventional manufacturing methods often rely on high concentrations of BDDE (butanediol diglycidyl ether), a cross-linking agent, to achieve high cohesivity and elasticity. However, this approach is associated with several risks, including granuloma formation, inflammatory responses, delayed adverse events, tissue necrosis, and allergic reactions1–4. Incomplete BDDE degradation can lead to the formation of granulomas, localised accumulations of immune cells that manifest as unsightly

lumps or nodules. Excessive BDDE can trigger significant inflammatory responses, resulting in redness, swelling, pain, and prolonged healing times. Although relatively rare, allergic reactions to BDDE are possible. The effects of excessive BDDE may not be immediately apparent; delayed reactions, such as inflammation or granuloma formation, can occur weeks or even months after the procedure. In severe cases, excessive BDDE can lead to tissue necrosis (tissue death).

A critical aspect differentiating YVOIRE® Y-Solution 720 is its significantly reduced reliance on BDDE, a commonly used cross-linking agent. Excessive BDDE can lead to several adverse clinical events, primarily due to its potential for incomplete degradation and its consequent inflammatory effects. Table 1 provides a compelling comparison, illustrating that YVOIRE® Y-Solution 720 achieves a substantially higher lift capacity (71064) compared to competitor products yet boasts a considerably lower MoD (Modification Degree, a direct indicator of BDDE concentration) of 3.3 mole%. This reduction in BDDE concentration demonstrates a commitment to patient safety without compromising on the efficacy and long-lasting effects of the filler. By significantly reducing BDDE usage while maintaining superior performance, YVOIRE® Y-Solution 720 directly mitigates

Figure 1 Characteristics of monophasic, biphasic, and Y-phasic fillers

YVOIRE® Y-SOLUTION 720:

SHIFT IN HYALURONIC ACID FILLER

THROUGH

COHESIVITY,

AND MINIMISED BDDE CROSSLINKING (continued)

Table 1 Test result of hyaluronic acid dermal fillers

Table 2. Test result of hyaluronic acid dermal fillers

*Lift Capacity = Storage modulus(G') x Tack test(gf)

these risks, enhancing patient safety and minimising the potential for complications.

YVOIRE Y-Solution 720 and S-HICE cross-linking technology

By achieving a superior balance of cohesivity and elasticity while significantly reducing BDDE usage, YVOIRE® Y-Solution 720 delivers demonstrably superior clinical outcomes. The higher lift capacity, coupled with the lower MoD, indicates a more efficient and safer cross-linking process that leads to enhanced longevity and reduced risk of adverse events. This combination of high performance and enhanced safety underscores YVOIRE® Y-Solution 720’s position as a leader in HA filler technology, offering practitioners a powerful and reliable tool to achieve optimal aesthetic results while prioritising patient well-being.

How does it work? The answer is its crosslinking technology. This innovation was enabled by S-HICE cross-linking technology.

*Lift Capacity = Storage modulus (G') x Tack test (gf)

This superior performance is directly attributed to LG Chem’s innovative S-HICE (Stable High-Concentration Equalized) cross-linking technology. Conventional cross-linking methods often rely on high concentrations of BDDE (butanediol diglycidyl ether) to achieve the desired properties. However, high BDDE levels are associated with several potential adverse events, including granuloma formation, inflammatory responses, and delayed adverse reactions.

S-HICE technology offers a solution by employing sophisticated particle engineering techniques. This results in smaller, uniformly sized HA particles that exhibit enhanced inter-particle interactions, leading to superior cohesivity.

Simultaneously, the precisely controlled cross-linking process ensures the desired elasticity for immediate lifting. The net effect is a remarkable balance of cohesivity and elasticity achieved with significantly reduced

BDDE usage. This translates to superior clinical results, a minimised risk of adverse events, and an enhanced safety profile for patients.

The clinical implications of YVOIRE Y-Solution 720’s superior rheological properties and reduced BDDE usage are substantial: enhanced lifting and volumising, prolonged duration of results, improved patient safety, versatility across diverse applications, and potentially improved cost-effectiveness compared to traditional fillers. This combination makes YVOIRE Y-Solution 720 a powerful tool for practitioners seeking both optimal aesthetic results and enhanced patient safety. It establishes a new standard for HA filler technology, effectively redefining the expectations for performance, safety, and patient experience.

Biphasic fillers typically involve milling hyaluronic acid (HA) to a specific size, followed by sieving. This results in larger base particles compared to monophasic fillers, which utilise a finer grinding process. Imagine the biphasic filler as a structure similar to bricks stacked together. While exhibiting high elasticity and resilience to external forces even with lower BDDE usage, biphasic fillers demonstrate lower inter-particle cohesiveness.

In contrast, monophasic fillers employ a finer grinding process, resulting in significantly smaller base HA particles. To continue the analogy, monophasic fillers resemble clay-like consistency. While less elastic than biphasic fillers, their increased surface area and stronger inter-particle forces contribute to higher cohesiveness. However, achieving comparable elasticity in monophasic fillers necessitates a relatively larger amount of cross-linking agent. Although less elastic, the superior cohesiveness of monophasic fillers promotes excellent tissue integration, leading to smooth and natural-looking results.

While increasing the cross-linking agent

concentration or HA concentration could partially address the limitations of these traditional manufacturing processes, increasing the cross-linking agent concentration presents significant safety concerns, a factor that is not aligned with LG Chem’s product development philosophy. Similarly, increasing HA density, while enhancing firmness, can lead to excessive stiffness and various undesirable side effects.

LG Chem’s Y-Solution fillers utilise a refined biphasic process. Following an initial sieving, the particles undergo a second sieving through a finer mesh, resulting in smaller, more uniform particles. This approach minimises the need for increased cross-linking agent usage while simultaneously achieving both the elasticity of biphasic fillers and the high cohesiveness and tissue integration characteristic of monophasic fillers.

Consequently, Y-solution fillers exhibit a superior balance of elasticity and cohesiveness, resulting in exceptional shape retention and resistance to spreading. This optimised manufacturing process allows for the creation of a filler material with an ideal balance of both key properties.

Clinical implications:

Optimised performance and enhanced patient outcomes

The superior balance of cohesivity and elasticity, achieved through S-HICE technology, translates into a series of clinical advantages for YVOIRE Y-Solution 720.

■ Enhanced lifting and volumising effects: The immediate lifting and volumising effects are superior to those observed with traditional fillers. The well-balanced properties ensure a natural and aesthetically pleasing outcome, with minimal migration or distortion. These benefits have several advantages in various areas, including cheek augmentation, where its balanced properties allow for both subtle volume

“

“YVOIRE Y-Solution 720 represents a significant advancement in the field of HA dermal fillers. Its superior balance of cohesivity and elasticity and minimised BDDE usage, enabled by the innovative S-HICE™ technology, delivers superior clinical results with improved safety.”

restoration and effective lifting, resulting in a more youthful and natural appearance.

■ Prolonged duration of results: The high cohesivity ensures that the filler remains in place for an extended period, resulting in longer-lasting aesthetic results with reduced need for touch-up treatments.

■ Improved patient safety: The reduced BDDE concentration significantly lowers the risk of adverse events associated with high concentrations of this crosslinking agent.

■ Versatility and adaptability: YVOIRE Y-Solution 720’s exceptional properties make it suitable for a wide range of applications, including cheek augmentation, lip augmentation, nasal reshaping, and more. The text suggests specific injection techniques that can enhance the clinical results even further.

■ Cost-effectiveness: Due to the reduced amount required for effective treatment, compared to fillers that rely on higher BDDE concentrations for higher lifting capacity, YVOIRE Y-Solution 720 can lead to cost savings for both practitioners and patients, making premium aesthetic treatments more accessible.

In summary, YVOIRE Y-Solution 720 represents a significant advancement in the field of HA dermal fillers. Its superior balance of cohesivity and elasticity and minimised BDDE usage, enabled by the innovative S-HICE technology, delivers superior clinical results with improved safety. This advanced filler offers practitioners a reliable and powerful tool to achieve optimal aesthetic results while prioritising patient safety and satisfaction.

LG aesthetics

LG Chem began its R&D in hyaluronic acid in 1990. Its non-animal origin HA has been marketed in various medical fields since 1995, such as injections for ophthalmic surgery and osteoarthritis. In 2010, LG Chem acquired KFDA approval as the first

Korean pharmaceutical company in Korea with YVOIRE® Classic.

YVOIRE® is produced with LG Chem’s proprietary HICE™† cross-linking technology, which is the mechanics optimised for making biphasic hyaluronic acid filler. Also, HICE™ cross-linking technology is characterised by cross-linking the high molecular weight HA with a low degree of BDDE, leaving the gel less modified and improving its safety. Thanks to these features, YVOIRE® has sold more than 10 million syringes in over 40 countries since its launch in 2010.

Based on its accumulated knowledge of HA, LG Chem released a new line up of YVOIRE® in 2018 which is called YVOIRE Y-Solution®. YVOIRE Y-Solution® was developed with S-HICE™‡ cross-linking technology, which brings the advantages of both biphasic and monophasic filler, enhancing the elasticity and the cohesivity in sync. With this S-HICE™ cross-linking technology, YVOIRE Y-Solution® presents a unique rheological property called Y-Phasic that features high elasticity and relatively high cohesivity simultaneously.

† High concentrated equalised, ‡ Stable-high concentrated equalized

For more information, visit global.lgyvoire.com/yvoire.jsp

Further

Reading

1. Choi SC, Yoo MA, Lee SY, Lee HJ, Son DH, Jung J, Noh I, Kim CW. Modulation of biomechanical properties of hyaluronic acid hydrogels by crosslinking agents. J Biomed Mater Res A. 2015 Sep;103(9):3072-80. doi: 10.1002/ jbm.a.35437.

2. Jeong CH, Kim DH, Yune JH, Kwon HC, Shin DM, Sohn H, Lee KH, Choi B, Kim ES, Kang JH, Kim EK, Han SG. In vitro toxicity assessment of crosslinking agents used in hyaluronic acid dermal filler. Toxicol In Vitro. 2021 Feb;70:105034. doi: 10.1016/j.tiv.2020.105034.

3. Schiraldi, C., La Gatta, A., De Rosa, M. Biotechnological Production and Application of Hyaluronan. Available at: https://www.semanticscholar.org/reader/32dc63da57979817 17996d4201a4685f0c74c6d5. Accessed 25 June 2024.

4. Fundarò, S. P., Salti, G., Malgapo, D. M. H., Innocenti, S. The Rheology and Physicochemical Characteristics of Hyaluronic Acid Fillers: Their Clinical Implications. Int J Mol Sci 2022;23.