PRIME September/October 2024

INTERNATIONAL JOURNAL OF

THREADS OR FILLERS?

WHICH IS BEST IN 2024

EPIGENETICS AND ANTIAGEING EXPLORING NEW FRONTIERS

TREATING PERIORBITAL HYPERCHROMIA WITH HA AND SUCCINIC ACID

PLLA BASED injectable biostimulators

WELCOME TO THE SEPTEMBER/OCTOBER EDITION OF PRIME

In this issue, we will be looking at, amongst other things, a couple of the major upcoming aesthetic and anti-ageing events taking place around the world.

AMWC Japan 2024 is set to be a major highlight in the aesthetics calendar, taking place in Tokyo during the vibrant autumn season. The congress brings together experts in aesthetic medicine from across the globe, providing a platform for the exchange of knowledge, techniques, and research. As Japan continues to position itself as a leader in aesthetic technology, the event will feature sessions on cutting-edge treatments and innovations, with a focus on natural-looking results, a key trend in the region. Attendees will also have the opportunity to explore the latest in skin boosters, body contouring, and male aesthetics, ensuring that all areas of this dynamic field are thoroughly covered.

Similarly, AMWC China 2024, taking place in Chengdu in October, promises to be an equally impactful event. As the aesthetic industry in China continues to grow rapidly, Chengdu, known for its medical beauty industry, offers the ideal setting for showcasing innovations in both surgical and non-surgical aesthetic treatments. With sessions designed to celebrate innovation and clinical excellence, the congress event is poised to attract a diverse group of professionals eager to explore the latest technological advancements in aesthetic medicine.

One of the key articles featured in this issue is Wendy Lewis’s interview with six top doctors, exploring what excites them most in the current aesthetic landscape. Their collective insights underline the strength of the aesthetic medicine industry as they recommend new topicals, energy-based devices and injectables. You can read the full feature on page 20.

Affiliated partners:

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

Injectable treatments, particularly poly-L-lactic acid-based biostimulators, have been gaining traction in the global aesthetic market. Murat Tsintsadze, MD, and Ellena Lukianchenko, MD, present compelling data from a multicentre study on ELLURE 200, highlighting its efficacy and safety in stimulating collagen production. This innovation underscores the movement toward treatments that provide natural, long-lasting results while maintaining a high safety profile—qualities that are increasingly sought after. Another standout development featured in this issue is the work of Dr. UsHa Hoh on tackling periorbital hyperchromia. Dr. Hoh introduces a combination treatment using succinic acid and hyaluronic acid to address dark eye circles, a notoriously challenging issue, particularly in patients with darker skin tones. This new injectable treatment is showing promise with minimal discomfort and downtime.

Balraj Juttla

Editor, PRIME

balraj.juttla@informa.com

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

1-2-3 OCTOBER 2025

September/October 2024

Aesthetic medicine now recognised by the Royal Society of

Quantificare awarded Best Aesthetic Device at AMWC 2024 EVENT

AMWC Japan: the premier aesthetic congress is back in Tokyo

Explore cutting-edge aesthetics at AMWC Japan 2024 in vibrant Tokyo this autumn 13

AMWC China: celebrating innovation in aesthetic medicine

PRIME previews the upcoming AMWC China congress taking place in Chengdu on October 18–20th 2024

INDUSTRY INSIDER

What aesthetic doctors are excited about right now

Wendy Lewis interviews six top doctors to find out

AESTHETIC FEATURES

20

Poly-L-lactic acid based injectable biostimulators

Murat Tsintsadze, MD and Ellena Lukianchenko, MD, describe the results from a multicentre, 3 month study to assess efficacy and safety of one session of ELLURE 200 in different age groups

The treatment of periorbital hyperchromia with a combination of succinic acid and hyaluronic acid

Tackling dark eye circles has always been a challenge, especially for patients with darker skin tones. Dr UsHa Hoh introduces a new injectable treatment that has shown promise in improving periorbital hyperchromia with minimal discomfort and downtime

Can threads replace fillers?

Aaron Hsieh, MD, explores the use of PDO threads in facial contouring, offering insights into their application for lifting and filling

Epigenetics: a new frontier in anti-ageing medicine

Hidekazu Yamada, MD, PhD, explores the potential of epigenetics in anti-ageing medicine and healthy longevity

fat reduction and lymphatic drainage with

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

news

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

AESTHETIC MEDICINE NOW RECOGNISED BY THE ROYAL SOCIETY OF MEDICINE

AESTHETIC MEDICINE AND SURGERY GAINS STATUS OF MEDICAL SPECIALITY

The Council for The Royal Society of Medicine is establishing a new Section for Aesthetic Medicine and Surgery in October 2024.

This is the first time in 35 years that a new Section has been added to the RSM, and this formally recognises aesthetics as a medical speciality.

Named The RSM Section of Aesthetic Medicine & Surgery (RSM SAMAS), it will be led by its first president, Dr Christopher Rowland Payne, Consultant Dermatologist, and will undertake the following:

■ Promote evidence-based best practice in the field of surgical and non-surgical aesthetics to improve outcomes for patients

■ Provide a forum for scientific debate in the field of aesthetic practice to enhance best patient outcomes

■ Elevate professional standards and safety across the field of aesthetic medicine and surgery

■ Provide regular educational events to support

relevant medical and dental professionals.

Dr Christopher Rowland Payne, Consultant Dermatologist, said: ‘This is a significant and historic moment for the RSM as, for the first time, it recognises aesthetic medicine and surgery as a speciality.

‘Aesthetic medicine and surgery are multi-disciplinary areas and have for decades worked alongside other branches of medicine. As a result, this new section will be pooling expertise and will embrace not only dermatologists but surgeons, physicians, dentists, and other GMC-registered doctors, all of whom have an interest in this growing area. RSM SAMAS will follow the principles of good clinical medicine in a collegiate and inclusive manner.

they want. It should be regarded as any other branch of medicine, where the patient asks a doctor for advice which they can then take or not.’

Professor Gillian Leng CBE, President of the Royal Society of Medicine, said: ‘We are delighted to incorporate this new Section for Aesthetic Medicine and Surgery into the Royal Society of Medicine. This is an important and growing medical field and one that deserves to be recognised in its own right.

‘Aesthetic medicine should not be seen as an industry or a shop where people can ask for what

‘The new Section will be drawing on the support of the world’s leading experts and emerging research evidence in this area. By sharing learning and best practice, it will support the Society’s educational mission of better healthcare for better lives.’

The RSM Section of Aesthetic Medicine & Surgery (RSM SAMAS), will be the RSM’s 56th Section and will formally commence on 1st October 2024.

FACE 2024: PUSHING THE BOUNDARIES OF MEDICAL AESTHETICS

The FACE Conference 2024, held on July 12-13 at the Business Design Centre in London, provided the UK’s aesthetic medicine community with a comprehensive and accessible platform for learning and professional development in aesthetic medicine. With over 2,500 delegates in attendance, an innovative scientific program, and an exhibition bustling at all times, this year’s conference was nothing short of a resounding success.

The 2024 edition of FACE saw the introduction of a thoughtfully redesigned programme that

reflected the evolving needs of the global aesthetic community. The event featured four main agendas — Advanced Injectables, Multispecialty Aesthetics, Industry Workshops, and the newly introduced Aesthetics Open Stage. These agendas covered eight key industry segments, including injectables, skin, regenerative medicine, business and practice management, genital treatments, hair, threads, and medical devices. Scientific sessions and workshops were designed to push the boundaries of aesthetic medicine

and included a wealth of live demonstrations as well as in-depth discussions backed by the latest evidence-based research. Top-tier speakers from across the globe joined the conference to lead these presentations and share their personal expertise.

FACE also made FREE Visitor Passes available for UK and Ireland delegates, providing local professionals across the aesthetic practice spectrum with access to the exhibition area and high-quality educational sessions. Featuring over 100 industry brands presenting their

latest innovations, the exhibition space served as a platform for interaction, where delegates could connect with peers, explore new products, and build long-lasting professional relationships.

Save the date, 26–27 June 2025, as FACE Conference returns to London’s Business Design Centre for its next edition. Building on the momentum gained this year, FACE 2025 will continue to set the standard for excellence in the industry. FACE remains an annual calendar highlight that simply cannot be missed.

10-12 OCTOBER 2024 | 10am-7pm

Jakarta Convention Center (JCC), Indonesia

Organised by: Powered by:

https://linktr.ee/cosmobeauteindonesia

QUANTIFICARE AWARDED BEST AESTHETIC DEVICE AT AMWC 2024

IN RECOGNITION OF ITS LIFEVIZ® MINI PRO 3D CAMERA AND AI SOFTWARE

QuantifiCare, a leader in premium 3D photography systems for aesthetic consultations and research, is proud to announce that it has been honoured with the award for Best Aesthetic Device at The Aesthetic and Anti-Ageing Medicine World Congress (AMWC). This trophy comes on top of the four others received previously and continues to recognise the 3D LifeViz range for its innovative and unique technology, distinguishing itself in the aesthetic world.

QuantifiCare’s flagship product, the LifeViz® Mini Pro, combines a 3D camera with the LifeViz® Neo software, which has gained acclaim for AI integration, ensuring streamlined consultations and making results more visible.

Three dimensional photo documentation plays a crucial role in the consultation process. With the help of the practitioner, patients are able to better understand the ageing process and areas in need of treatments and follow progress over time. However, to fully leverage the 3D system, image capture and preparation should be rapid and straightforward. 3D picture acquisition, uploading, and image generation are automated through AI and

facial recognition, seamlessly associating and organising images directly into patient files.

The LifeViz® Mini Pro allows physicians to achieve impactful before-and-after results and share the 3D pictures with their patients on their mobile, allowing connectivity.

‘As we continue to evolve in a rapidly changing tech world, QuantifiCare remains dedicated to staying at the forefront of innovation,’ stated Jean-Philippe Thirion, CEO and founder of QuantifiCare. ‘We are proud to receive this recognition for our efforts and look forward to continuing to provide industry-leading solutions to the aesthetic community.’

About QuantifiCare

For over twenty years, QuantifiCare has been developing innovative 3D Photography systems for aesthetic consultations and clinical research. With a commitment to delivering accurate and reliable solutions, QuantifiCare empowers physicians with innovative tools to enhance patient care and satisfaction. Headquartered in France, with operations worldwide, the company serves a diverse global clientele.

Three dimensional photo documentation plays a crucial role in the consultation process. With the help of the practitioner, patients are able to better understand the ageing process and areas in need of treatments and follow progress over time.

For more information about QuantifiCare and its products and services, please visit: www.quantificare.com.

PERSANA LAUNCH: A FIRST OF ITS KIND PLATFORM

Persana, the first luxury aesthetic health platform, has officially launched. The company is co-founded by worldrenowned facial plastic surgeon Dr. Babak Azizzadeh and healthtech venture capital firm Initiate Ventures & Studio. A high-end aesthetic service platform, Persana provides customers with timely and personalised access to best-in-class, unparalleled expert physicians and has quickly become a trusted resource for on-demand aesthetic health. With live video calls, chats, and direct booking, Persana facilitates conversations between patients and physicians from the privacy of one’s home, at the click of a button. Persana’s curated, exclusive, network of world-class physicians takes timely research and guesswork out of finding the right specialist. The company’s proprietary matching algorithm immediately and intelligently pairs those seeking specific care and procedures with best-fit expert plastic surgeons or dermatologists based on the individual’s preferences and resources. From decades of experience, Persana physicians know that finding the right physician leads to superior patient outcomes and long term satisfaction. The Persana platform also uniquely presents unbiased, medically accurate information on surgical and non-surgical aesthetic procedures to help people make informed decisions and feel confident with their care.

Every Persana physician is rigorously vetted by Persana’s advisory board of pre-eminent aesthetic practitioners. Persana physicians are not only board-certified in their respective medical specialties but are also selected for exceptional results and reputation. Some noteworthy physicians in the network include: Michelle Henry, Paul Nassif, Rod Rohrich, Doris Day, Mike Nayak, Ben Talei, Amir Karam and Guy Massry.

Discerning consumers who seek unrivalled expertise and experience in aesthetics will benefit from Persana’s guidance and omnichannel access to world-class physicians.

to your patients through results. Connect more visible

AMWC JAPAN

JAPAN’S PREMIER AESTHETIC CONGRESS IS BACK

Explore cutting-edge aesthetics at AMWC Japan 2024 in vibrant Tokyo this autumn

AMWC JAPAN 2024 will be held in the heart of Tokyo, Roppongi, during November, a beautiful season when Tokyo’s autumn foliage can be enjoyed in light long sleeves. This year’s venue is centrally located in Akasaka, Tokyo, an area known for its convenience and accessibility. The venue is close to popular districts such as Roppongi and Shibuya, making it easy for attendees to explore Tokyo’s vibrant culture and attractions, with easy access to public transportation and a variety of restaurants, shops, and hotels nearby. We are excited to feature over three times the number of speakers compared to last year, with a total of 48 International

Speakers from the USA, Europe, the Middle East, South America, and other Asian countries, and 22 Japanese Speakers, making it a total of 70 speakers. Over the course of two days, we will host 44 sessions across four halls, offering a diverse range of topics and insights.

Highlighted sessions include

■ On Day 1, Hall 1: ‘The New Horizon of Male Aesthetics: from Face Treatments to Body Contouring,’ a session that reflects the growing demand for male aesthetics. Dr. Pegah from the Middle East will speak, marking the first time a doctor from this

region will present in Japan, making this a highly anticipated session.

■ On Day 1, Hall 1: ‘Oversea Treatment NOW: Global Perspectives, World Wide Expertise,’ featuring four renowned doctors from the U.S., including Dr. Kay, offering attendees the chance to learn about the latest techniques and innovations from different continents.

■ On Day 2, Hall 1: ‘How to Achieve Natural Looking Results,’ which is always popular in Japan due to the strong preference for natural aesthetics, especially with top-class speakers from overseas.

■ On Day 2, Hall 4: ‘A New Therapeutic Approach with Skin Boosters,’ focusing on the latest advancements in skin boosters that are revolutionising skincare treatments.

All sessions at AMWC Japan will be conducted with simultaneous interpretation in both English and Japanese, making the content accessible to a broad audience. Approximately half of the Japanese speakers will present in English, demonstrating the international nature of the event. Around 20% of attendees will be from overseas, with a significant number coming from fields such as dermatology, plastic surgery, and internal medicine.

The exhibition area consists of three large halls, featuring over 80 companies. Of these, 60% are Japanese companies, and 20% are exhibiting at AMWC Japan for the first time. The majority of exhibitors focus on medical aesthetic devices, dermal fillers, implants, botulinum toxin, and topical skincare and cosmetics, with a notable presence of companies specialising in anti-ageing products.

AMWC Japan will host Luncheon Sessions every day in all halls, organised by partnering companies. In Japan, it is common to enjoy lectures while eating a lunch box, so we have incorporated this tradition into our event. Take this opportunity to learn about the latest technologies while enjoying a Japanese bento box during lunch!

Additionally, there will be a one-hour Tea Time each afternoon. During this period, all Congress Halls will briefly close, providing a chance to enjoy popular matcha sweets and network with exhibitors and speakers in a relaxed setting.

Don’t miss out on the Early Bird Discount, available until the end of September!

We look forward to welcoming you to this exciting event in the heart of Tokyo.

AMWC Japan 2024

ANA Intercontinental Tokyo (at Roppongi) Sunday 10th — Monday 11th November. Congress: 10th 9:20 — 18:00 / Monday 11th 8:40 — 17:10. Registration: Sunday 10th 8:30 — 18:00 / Monday 11th 8:30 — 17:10.

For more information: www.amwc-japan.com/

ACM23

2nd

AESTHETIC CLINIC MARKETING

With over 25 years of experience in medical aesthetics, Lewis shares her deep understanding of the challenges aesthetic clinics face to effectively market their products and services, manage patients, and increase profits. This updated text is the definitive expert user’s guide written specifically for healthcare professionals and medical spa managers to present best practices and actionable strategies for mastering digital marketing, social media, branding, and the advent of AI. It is a must-read for aesthetic practitioners to keep up with the latest developments they need to manage their businesses effectively in this highly competitive field. April 2024 • Hb: 9780367405656 • Pb: 9780367405182 • eBook: 9780429356742 www.routledge.com/9780367405182

on hot topics you need to know

tips, charts, tables, and resources

AMWC CHINA CELEBRATING INNOVATION IN AESTHETIC MEDICINE

PRIME previews the upcoming AMWC China congress taking place in Chengdu on October 18–20th 2024

AIn addition, AMWC China is set to host a series of competitions and masterclasses, each

MWC CHINA, NOW IN ITS 4th edition, has quickly become the second largest Aesthetic and Anti-Aging Medicine World Congress (AMWC) conference globally. The AMWC is renowned for being at the forefront in the field of medical aesthetics, providing a global stage for professionals to discuss, learn, and innovate. This year, AMWC China 2024 will gather over 180 distinguished experts in anti-ageing medicine, cosmetic surgery, and dermatology from both domestic and international fields. Together, they will discuss global trends in the medical aesthetics industry, share innovative products and practical cases from both domestic and international medical aesthetics technology, and deeply analyse current hot topics in medical aesthetics.

designed to foster professional growth, showcase cutting-edge advancements, and facilitate the exchange of knowledge among the best in the industry. From the prestigious Face Rejuvenation Case Competition, the Young Physicians Medical Research Elite Competition, and the practical Injection Masterclass, each segment of the event aims to enhance the skills and understanding of delegates.

AMWC Face Rejuvenation Case Competition

This authoritative and creative competition aims to bring together experts in global medical beauty to explore the latest technology and concepts of facial rejuvenation. Doctors will have the opportunity to

demonstrate their skills and unique insights in the field of facial rejuvenation, as well as discuss the latest trends and developments in facial rejuvenation by sharing their latest achievements in surgical techniques, nonsurgical therapies, and personalised treatments.

The AMWC Facial Rejuvenation Case Competition is a comprehensive display of aesthetic medicine technology and an important promotion of the developments taking place in the aesthetic medicine industry. By holding the competition, we hope to inspire more doctors and promote the continuous innovation and progress of facial rejuvenation technology to bring more safe and effective

treatment programmes to patients.

AMWC Young Physicians Medical Research Elite Competition

The aim of the competition is to discover and commend outstanding young doctors and researchers in aesthetic medicine and promote the innovation and progress of the aesthetic medicine industry. The competition will pay special attention to the latest research progress in the fields of ‘basic research’ and ‘clinical research’ related to aesthetic medicine.

We encourage young medical researchers to think eclectically and incorporate inspiration from different fields into their research. Through this competition, we hope to provide

INTERVIEW: DR HANG WANG

To learn more about the medical aesthetics industry in China, PRIME took the opportunity to speak to the executive director of AMWC China’s Scientific Committee, Dr Hang Wang

AFTER GRADUATING FROM THE TOP dental hospital in China, Dr Wang joined the clinical faculty at West China School of Stomatology, Sichuan University, specialising in Facial Plastic Surgery. Alongside her academic endeavours, Dr Wang has been practising facial cosmetic and plastic surgery for over two decades, with a particular focus on filler and toxin treatments for facial rejuvenation and emotional beauty. Her extensive experience includes over 20 years of expertise in injection techniques. Her main scientific research focuses on the clinical application of adipose tissue and adipose stem cells, basic research on biomaterials and stem cells, and hyaluronic acid microplastic surgery. Dr Wang has published over 60 articles in international journals, further highlighting her commitment to advancing research in the field.

What is the market scale and trends of China’s medical aesthetics industry?

From RMB 36,000 (around 6000usd) per capita urban disposable income in 2017, to RMB 49,000 (around 7000USD) in 2022, the consumption capacity of Chinese people has been steadily increasing year on year, and the willingness to consume medical aesthetics is also gradually increasing. Following the continuous implementation of a series of policies to expand domestic demand, and driven by consumption restoration and growth in demand for medical aesthetics post pandemic; the medical aesthetics market is expected to achieve a growth rate of 20% in 2023 and maintain a compound annual growth rate of around 15% in the following four years. The industry is expected to develop steadily based on the potential and resilience of the Chinese economy and the vitality and momentum of China’s medical aesthetics market.

China’s medical aesthetics industry is developing rapidly. Compared with Japan, the United States and South Korea, the penetration rate of medical aesthetics services in China is relatively low, and there is a huge opportunity for future growth. The market size is expected to exceed 200 billion yuan by 2023 and reach 507.1 billion yuan by 2028.

Who are the major brand players in the Chinese market?

At present, products in China’s medical aesthetics market are mainly imported brands, as well as several local brands. Imported companies and brands include Allergan (Juvederm, Botox, CoolSculpting), Galderma (Restylane, Dysport),

Sinclair (Ellense S), Hugel (Letybo), Merz (Belotero), Princess, FILLMED, LG Chem (Yvoire), Cynosure, Candela, Fotona, Thermage, and Canfield (Visia). Local companies and brands include Bloomage Biotech (Agualauna, Biohyalux), SinoBiom (Loviselle, PLLA), Jinbo (Weiyimei, Recombinant Humanized Type III Collagen), Giant Biogene (Comfy), Juyou Bio-tech, Lanzhou Institute of Biological Products (Hengli), and Botanee (Winona). At present, there are more than 30 brands of hyaluronic acid products registered in China, as well as four brands of botulinum toxin; other products include PLLA and PCL. At present, the Chinese medical aesthetics market is vast, and some products of foreign brands, such as Teoxane have also started clinical trials in China.

What are some current popular treatment methods in China?

Relevant surveys show that in 2022, 70% of respondents who have undertaken medical aesthetics treatments chose skin aesthetic-related services. Compared with the survey data from 2020, consumer awareness of anti-ageing has increased considerably, and firming and anti-ageing surpassed whitening and brightening. Another interesting finding was that about 60% of medical aesthetics customers chose facial adjustment treatments. With the popularity of light medical aesthetics services and the fact that beauty seekers are paying more attention to anti-ageing, medical aesthetics services that were popular in 2020, such as rhinoplasty, eye canthus opening and other plastic surgery treatments are gradually being replaced by wrinkle removal, apple skin and dark circle removal and other non-

surgical facial rejuvenation therapies. About 40% of medical aesthetics customers have undergone body shaping treatments, among which underarm odour and underarm hair removal were extremely popular. Based on the pursuit of the S-shaped body, treatments such as partial body liposuction/ fat melting, breast enhancement, and buttock enhancement are also popular.

Why is the industry still not very well regulated when there are regulatory policies in place?

In order to promote a standardised and healthy development of the industry, in recent years, the state has stepped up supervision and enacted a series of policies and regulations involving product research and development, production, sales, promotion, and services within the medical aesthetics industry. In the first half of 2023, a total of 13 policies and regulations were announced, targeted at rectifying the irregularities in the industry and promoting a more sustainable and healthy development for medical aesthetics in China.

Take the ‘Guiding Opinions on Further Strengthening the Supervision of the Medical Aesthetics Industry’ policy, promulgated by the State Administration for Market Regulation and 11 departments, released on May 4th 2023, as an example. The state’s supervision of the industry is more detailed and comprehensive. Clear provisions have been made in terms of access management, comprehensive supervision during and after the event, and supervision of related fields and industries. Specific requirements have also been put forward for the operational compliance of institutions.

China’s medical aesthetics industry and systems are gradually moving towards more standardisation, with greater transparency of information, thereby boosting the safety for Chinese consumers. In the long run, grey areas such as ‘black medical

a broad platform for young physicians so that they have the opportunity to interact and exchange with outstanding medical researchers and experts at home and abroad and promote academic cooperation and professional development. Participants have the opportunity to showcase their outstanding achievements, share their research results and medical insights, and promote cross-industry exchanges and cooperation.

AMWC Injection Masterclass

The AMWC China 2024 Injection Masterclass is a significant event at the conference, providing a unique platform for practitioners in the medical aesthetics industry to exchange ideas, interact,

aesthetics’, ‘black injections’ and ‘violation of regulations and counterfeiting’ within the industry will definitely be abolished. Leading medical and aesthetics companies with comprehensive licenses, strong research and development, and mature and compliant products are expected to benefit from rigorous industry supervision. With the cooperation of various national departments, medical aesthetics product companies, medical aesthetics service institutes, and consumers, China’s medical aesthetics industry chain will be more regulated and ready to promote sustainable market expansion.

Who can perform treatments, and how is product safety judged and implemented?

In China, if a doctor wants to practice in the medical aesthetics industry, in addition to obtaining a medical practitioner license and a licensed physician registration certificate, they also have to obtain a medical aesthetics attending physician license. Medical aesthetics attending physician majors include aesthetics surgery, aesthetics dentistry, skin beauty and TCM aesthetics.

Product safety mainly depends on national supervision, including pre-market and post-market supervision, as well as consumer supervision.

Pre-market supervision of products before a product hits the market, it has to undergo multiple stringent and mandatory clinical trials spread across three phases. Only after successful qualification of the safety trials, can it be permitted to enter the market.

Post-market supervision of the product in the past two years, the Chinese government has intensified its supervision of the medical aesthetics industry, enacting a large number of laws and regulations to prevent irregular products and institutions from disrupting the market, thus promoting the healthy development of the industry.

and practice hands-on skills. The masterclass will bring together several Asian experts who have a deep background and extensive knowledge of injection technology and clinical operation experience. These experts will share their exclusive clinical skills and hands-on experience, including how to assess patient needs, develop an effective facial rejuvenation injection solution that is personalised and in line with Asian trends, and deal with problems that may arise

Consumer supervision through constant consumer education by the government, associations, and manufacturers, consumers are now more aware and are paying greater attention to product compliance. Consumers can check the authenticity of products through product anticounterfeiting measures and other methods to protect their own rights and interests.

What is your view on the future of China’s aesthetics industry and its impact on world medical aesthetics?

The academic level of Chinese aesthetic doctors has been recognised internationally, especially doctors working in university hospitals, who play a leading academic role.

China has a large base of beauty aspirants, and there is a rapidly growing pool of doctors in private hospitals who have rich experience in clinical treatment. With regard to the use of medical beauty products, more experience and consensus suitable for Asians can be put forward.

The development of Chinese medical aesthetics is also facing some difficulties. Some of these challenges include the administrative access to medical aesthetic drugs, materials, and equipment by the National Medical Products Administration (NMPA), which is very strict, and the cycle is long. There are higher thresholds, resulting in fewer products that can enter clinical practice. Some technologies that have been popularised internationally are currently difficult to implement here in China. Another difficulty is that irregularities in medical aesthetics in China still exist. Although the situation has improved in the past few years, it may take some more time to completely eliminate them. Also, the exchange between Chinese doctors and their international peers is still relatively limited, with language being a major barrier. I believe that AMWC China (Chengdu) will be a very good stage and window for our Chinese doctors to communicate with the world.

Photos courtesy of

WHAT AESTHETIC DOCTORS ARE EXCITED ABOUT RIGHT NOW

Wendy Lewis interviews six top doctors to find out

WENDY LEWIS is Founder/ President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy since 1997, author of 13 books, and frequent presenter on the international stage. Her first textbook, Aesthetic Clinic Marketing in the Digital Age (CRC Press) debuted a second edition in 2024.

email: wl@wendylewisco.com

I

T HAS BEEN AN EXCITING YEAR IN AESTHETICS AND WE certainly witnessed many captivating launches. From unique pairings of widely used technology plus new injectables from Asia, a plethora of medical innovations, the formidable impact of weight loss drugs, an emphasis on devices to address acne, and a lot of interest around exosomes.

In addition, we saw an abundance of acquisitions from medspas to practices across robust specialties, high-growth and high-priced skincare lines, and a consolidation of some longstanding device companies. I can’t wait to see what 2025 will bring!

Natalie

Barton, MD Plastic

Surgeon

Dallas, TX, USA

ZO SKIN HEALTH

The ZO Complexion Clarifying Serum is an exciting, new water-based salicylic acid that allows for better control of sebum production. Studies have shown that the product reduces redness, decongests the skin, and allows for a reduction in visible pore size just 6 weeks after application. The product is delivered via a unique dropper that automatically fills to the appropriate amount for ease of use. It is easy to pair with any protocol that addresses redness and excess oil production, such as acne, rosacea, and melasma. I have also added the serum as part of my post-procedure bundle after facial resurfacing procedures. For example, the ZO Controlled Depth Peel and Sciton Erbium laser is a combination treatment modality that I offer for facial rejuvenation.

The ZO Complexion Clarifying Serum is an exciting, new water-based salicylic acid that allows for better control of sebum production.

Natalie Barton, MD

ZO Complexion Clarifying Serum

With the proper patient selection, the treatment may be safely tailored for a range of skin conditions, including acne, textural differences, pigmentation, rhytids, and scarring. Once the skin has re-epithelialised, the patient will resume their pre-procedure regimen with the addition of the Complexion Clarifying Serum for better control of the post-inflammatory erythema.

The Complexion Clarifying Serum layers very well given its lightweight profile, which is especially important for acne-prone patients with poor tolerance for excessively heavy products. Patients love how the serum is gentle and effective, without irritation or discomfort, and easy to use. Patient compliance is notably high with this product.

In my practice, the ZO Complexion Clarifying Serum is considered a foundational staple for the majority of my patient protocols for all skin types.

Mark H. Schwartz, MD, FACS Board-Certified Plastic Surgeon

New York City, NY, USA

RENUVION

Renuvion is a device that utilises a unique combination of radiofrequency and helium plasma to tighten skin and underlying tissues. It is a minimally invasive procedure where a wand is placed under the skin of the area to be treated and delivers two forms of energy: radiofrequency and cold helium plasma. The best candidates for Renuvion have moderate skin laxity, are in good physical and emotional health, and want to improve the appearance of their neck and jawline, as well as areas of their body.

It can be performed with a local anaesthetic with or without oral pain medication; however, most patients choose to have some sedation type of anaesthesia.

Another welcome advantage in my practice is that Renuvion can be performed as a standalone procedure or combined with liposuction for additional skin tightening. Although this is not a delegatable procedure in my practice, there is a short learning curve to safely achieve noticeable results. It can be used for the skin of the body and the submental region. The system is safe for all

Fitzpatrick phototypes, which is important when treating the diverse patient population in New York, as well as our out-of-town patients from the sun-belt who are perpetually tan.

We have found this technology to be especially useful for ‘in-between’ cases where the skin may be too loose for liposuction alone. For these patients, Renuvion is an ideal adjunct. I can confidently perform liposuction in areas with borderline skin laxity, as well as for patients who desire skin tightening. We also see a plethora of patients who have embraced weight loss drugs and request this procedure. However, some of these patients

Another welcome advantage in my practice is that Renuvion can be performed as a standalone procedure or combined with liposuction for additional skin tightening.

Mark H. Schwartz, MD, FACS Renuvion, Apyx Medical

are not ideal candidates, as many of them have lost so much weight that their skin is too loose for it.

Renuvion can be an excellent ‘bridge’ procedure for patients who are not ready or cannot afford a surgical procedure, such as those who present with a small amount of neck laxity. With this device, we have a nonsurgical option that is safe, effective, and delivers great results.

Adam J. Rubinstein, MD, FACS Board-Certified Plastic Surgeon Aventura, FL, USA

AVÉLI

One of the most exciting things right now in my practice is Avéli, an advance in the treatment of cellulite. Nearly all women (80-90%) suffer with cellulite. For years we have struggled with mediocre options that provided hit-or-miss results for our patients. Most technology used to treat cellulite has gone the way of the dodo. Avéli has transformed cellulite treatment in my

Avéli has transformed cellulite treatment in my practice.

Adam J. Rubinstein, MD, FACS Avéli

practice. Treatments are done under local anaesthesia through 5mm incisions in the infragluteal folds and are completed in about an hour. The results are fantastic. However, Avéli is designed to treat dimpled cellulite. It is not meant for wavy skin and will not improve that issue.

The device utilises a small retractable hook at the end of a thin shaft connected to a comfortable plastic handle. The hook has a thin, protected blade that can be exposed with the push of a button on the handle. The procedure is easy to perform. All dimples on the buttocks and thighs are marked, and the area is anaesthetised with local anaesthesia. The patient is treated in the prone position. Typically, small incisions are made in the infragluteal folds and sometimes in the intergluteal crease as needed to reach all the dimples. The device enters the skin and remains in the subcutaneous layer just beneath the dermis. A red light at the tip of the device just past the hook shines through the surface of the skin as a guide to ensure the tip remains superficial and to help position the hook around the dimples. Cellulite dimples are caused by septal bands pulling the skin inward, thereby creating an indentation. The hook is positioned to grab around these bands and cut them once the blade is exposed by pressing a button. Avéli is very effective at cutting all the bands causing dimpled cellulite.

Treatments can be performed in treatment rooms, procedure rooms, and even an exam room with a bed that lays flat. The procedure can be delegated to welltrained extenders who are comfortable with minimally invasive procedures.

Recovery is easily tolerable with swelling and bruising that lasts 1–2 weeks on average. Results can be seen immediately and get better as swelling and bruising resolve. Patients love their results. The ability to wear a bikini with renewed confidence is a big deal in Miami!

Avéli is a game changer for 85% of women who have dimpled cellulite.

Bob Khanna, BDS President of the International Academy of Advanced Facial Aesthetics (IAAFA) London, UK

PLURYAL

DENSIFY

Pluryal Densify is a unique injectable that sets itself apart from other products on the market through several key features. It is formulated with a combination of high-purity polynucleotides and hyaluronic acid stabilised with mannitol. The synergy between these ingredients has been shown to be more effective in biostimulating the skin than each component alone.

An ex-vivo study* conducted by an independent laboratory in France demonstrated that Pluryal Densify effectively stimulates the production of collagen I, collagen III, elastin, and HAS-1 in the skin. It can be used on the face, neck, and décolletage, as well as on body

areas to treat stretch marks and scars, offering a comprehensive approach to skin rejuvenation.

This product features a powerhouse of a material thanks to its superior composition. The result is a product that has a significant effect of regenerating collagen and elastin, as well as enhancing the extracellular matrix. This is one of my favourite products from the Pluryal range, and I use it on virtually every patient, in multiple regions of the face and neck, as well as the body. In my practice, it meets the growing demand for natural-looking outcomes that enhance skin texture without appearing overdone.

*Evaluation of the anti-ageing effects of two products on living human skin living explants ex-vivo.

This is one of my favourite products from the Pluryal range, and I use it on virtually every patient, in multiple regions of the face and neck, as well as the body.

Bob Khanna, BDS Pluryal Densify

Arthur W. Perry, MD, FACS

ROHRER AESTHETICS

I have been combining the Rohrer Aesthetics Phoenix Fractionated CO2 laser with a syringe of Restylane Refyne and a syringe of Restylane Defyne in the same session. Together, these two modalities rejuvenate the face far better than either alone.

I have found that I can achieve the best results when I apply the fillers first and then the laser treatment. Before the procedure, topical EMLA cream is applied, and I perform infraorbital and mental blocks with 2% lidocaine with epinephrine and inject around the angular vessels. This makes injections painless for the patient, and vasoconstriction decreases the chance of inadvertent

intravascular injection.

I sterilely inject microdroplets of Refyne into the lipstick bleed lines, vermilion border, philtral ridges, and the Cupid’s Bow. I create convexities of the lips without increasing their size and also fill curved cheek wrinkles and acne or chicken pox scars as needed. Then I plump shrivelled earlobes so that stud earrings can lie flat once again. Finally, I fill the neck horizontal lines.

I have been combining the Rohrer Aesthetics Phoenix

Fractionated CO2 laser with a syringe of Restylane Refyne and a syringe of Restylane Defyne in the same session.

Arthur W. Perry, MD, FACS Rohrer Aesthetics

I then use Defyne to fill the nasolabial folds, using a 25 g CosmoFrance microcannula for safety. I fill the marionette lines and the sulcus between the chin and the jowl. In some cases, I may augment cheekbones and chin with Restylane Lyft, Voluma, or Radiesse (calcium hydroxylapatite). This procedure takes an hour and involves more than 500 separate microinjections. I protect the eyes with steel contact lenses or goggles and laser the face from the hairline to the jaw. I perform one pass at 10 mj with 35% density using the fractionated CO2 laser from Rohrer Aesthetics. Finally, I will apply 0.1% triamcinolone following the procedure and offer iced gel packs to the patient.

nails via direct messaging to nailproducing cells for a smoother and stronger nail plate.

It is infused with a powerful collection of high-performing ingredients for a comprehensive nail rejuvenation approach, including tara tree fruit extract, niacinamide, biotin, squalene, pentanol, and methionine. This advanced formula protects nails and acts as an anti-inflammatory and soothing complex. In addition, it was shown to be effective in an independent, third-party clinical study.

In our practice, our patients have seen visible improvements, including healthier nails and the overall improvement of the nails, nail root skin, and skin around the nails. Their nails have shown an increase in strength, smoothness, and hydration, with less fragility of the skin around the nails. They also report that their nails seem to grow faster.

The DefenAge Nail Root Serum is the only currently available nail serum that stimulates the nail matrix, which produces the nail plate and improves the actual nail quality from its origin, creating a ‘new, fresh nail’. The new 360-Rejuvenation Nail Root Serum is designed to help revitalise nails via direct messaging to nail-producing cells.

This combination of procedures has minimal downtime, and makeup can be applied the next day. Peeling occurs at about 3–4 days and the result is a fresher, more vital and less wrinkled appearance. In the same session, I will often rejuvenate the patient’s hands with the laser and Radiesse filler. We have found that our female patients look refreshed with minimal downtime and almost no risk.

Natalie M. Curcio, MD, MPH, MMHC Dermatologist Nashville,

TN, USA

DEFENAGE 360-REJUVENATION NAIL ROOT SERUM

The newest product from the DefenAge range is the DefenAge Nail Root Serum. This innovative product contains a serum-high level of Defensin-molecules that specifically target nail-producing cells. It was designed to help revitalise

In

our practice, our patients have seen visible improvements, including healthier nails and the overall improvement of the nails, nail root skin, and skin around the nails.

Natalie M. Curcio, MD, MPH, MMHC Defenage 360-Rejuvenation Nail Root Serum

The protocol is simple for patients to maintain. We suggest that they use this product twice daily, in the morning and evening. It comes with a built-in brush, so they can easily apply 1–2 pumps of serum on all the nails and the skin around the nails on both hands. We recommend that they release a pump of the serum on top of the brush, distribute the serum across all the nails by starting with the first phalange, and then brush the serum toward the nail end. For best results, we recommend leaving the serum on for a minimum of 30 minutes, or overnight. It is fine to use on fingernails and toenails, with or without nail polish. This product is equally effective for women and girls as well as men.

We recommend the DefenAge Nail Root Serum for any patient with slow-growing or damaged nails from repetitive manicures/pedicures and anyone who wants to improve the overall condition of their nails and skin around the nails.

POLY-L-LACTIC ACID BASED INJECTABLE BIOSTIMULATORS

Murat Tsintsadze, MD, and Ellena Lukianchenko, MD, describe the results from a multicentre, 3 month study to assess efficacy and safety of one session of ELLURE 200 in different age groups

MURAT TSINTSADZE, MD, Total Charm, Tbilisi, Georgia; ELLENA LUKIANCHENKO, MD, Medical Cosmetology Center

GMG, Donetsk, Ukraine

ABSTRACT

With the rising demand for non-invasive skin rejuvenation techniques, the aim of this study is to evaluate the efficacy and safety of ELLURE new poly-L-lactic acid-based biostimulators (PLLA) in combination with carboxymethylcellulose (CMC) and hyaluronic acid (HA). This study focuses on the effects of these formulations on collagen synthesis, skin hydration, and biocompatibility across different age groups.

Methods: This clinical study included 76 female patients aged 35 to 72 years with involutive skin changes. Patients were divided into two treatment Groups: Group 1 (ELLURE PLLA/CMC) and Group 2 (ELLURE PLLA/HA). The study measured the efficacy of each treatment using dynamic evaluations of skin elasticity and hydration. Additionally, possible adverse events such as redness, swelling, and

THE NUMBER OF PATIENTS SEEKING nonsurgical rejuvenation of the face and body continues to increase due to a growing ageing population concerned with physical appearance. This demand has resulted in a rise in the use of injectable fillers, with recent developments introducing new fillers whose safety and efficacy are validated by research. Numerous fillers are now commonly used in cosmetic and medical practice1,2.

In addition to fillers, the value of skin boosters and skin quality improvement treatments has gained significant recognition in aesthetic medicine. Skin boosters, which typically involve microinjections of hyaluronic acid (HA) and other bioactive compounds, target the dermal layers to improve skin hydration, elasticity, and overall quality. These treatments are particularly effective in addressing the early signs of ageing by enhancing skin texture, reducing fine lines, and providing a subtle, natural-looking rejuvenation3-5

pain were monitored over three months.

Results: The ELLURE PLLA/CMC and ELLURE PLLA/HA formulations demonstrated significant improvements in skin hydration and elasticity during 3 months of observation. The safety profile was favourable, with minor adverse events such as temporary redness and swelling, which resolved within a few days.

Conclusion: ELLURE polylactic acid-based biostimulators are effective for non-invasive skin rejuvenation, enhancing skin quality, collagen synthesis and skin hydration while maintaining a high safety profile. These findings support the continued use of PLLAbased biostimulators as a robust option for non-surgical aesthetic treatments, providing both mechanical lifting and long-term skin improvement. Further clinical trials are recommended to validate these benefits across broader patient demographics.

physiological process that leads to thin, dry skin, fine wrinkles, and gradual dermal atrophy. In contrast, extrinsic ageing is driven by external environmental factors such as air pollution, smoking, poor nutrition, and sun exposure, which result in coarse wrinkles, loss of elasticity, skin laxity, and a rough-textured appearance. This differentiation is essential in tailoring treatment approaches, as it allows for more personalised and effective interventions6,7

Poly-L-lactic acid (PLLA)

KEYWORDS

ELLURE, poly-L-lactic acid-based biostimulators, PLLA,

Ageing is influenced by a combination of intrinsic and extrinsic factors. Intrinsic ageing is a natural

Advances in technology have established Poly-L-lactic acid (PLLA) as a safe and effective treatment for addressing the volume loss that contributes to a sagging or deflated appearance, a key characteristic of facial ageing8,9. PLLA is a biocompatible, biodegradable, synthetic polymer known for stimulating collagen synthesis, leading to gradual volume restoration. Upon injection, PLLA microparticles induce a subclinical inflammatory response, which is crucial for their mechanism of action. This response leads to the recruitment and activation of macrophages and

Advances in technology have established Poly-L-lactic acid (PLLA) as a safe and effective treatment for addressing the volume loss that contributes to a sagging or deflated appearance, a key characteristic of facial ageing.

fibroblasts at the site of injection.

Macrophages play a pivotal role by phagocytosing the PLLA particles and releasing cytokines, such as transforming growth factor-beta (TGF-β), which in turn stimulates fibroblasts. The activated fibroblasts then differentiate into myofibroblasts and begin synthesising extracellular matrix components, particularly collagen types I and III2. This collagen production is essential for the volumising effect of PLLA fillers, as it leads to the formation of new tissue that provides structural support and volume enhancement10–13

Over time, the PLLA microparticles degrade into lactic acid monomers, which are metabolised and excreted by the body. The degradation process is gradual, allowing for a sustained stimulatory effect on collagen production. This results in a progressive and long-lasting augmentation of the treated area, with effects that can persist for several years14,15

Larger PLLA microparticles are more likely to

aggregate under certain conditions, such as during sterilisation, while smaller particles, particularly nanoparticles, do not exhibit the same tendency to aggregate in human blood or with platelets. This differential behaviour is likely due to the distinct physicochemical interactions of particles of different sizes with biological systems16-19

With over 20 years of experience in invasive techniques and a deep understanding of the complex mechanisms of skin ageing, we identified the primary objective for achieving effective lifting: restoring collagen integrity in the skin, which deteriorates with age, leading to laxity, dryness, wrinkle formation, and sagging. To address these objectives, we conducted a clinical study on the innovative injectable product, ELLURE, based on poly-L-lactic acid with two PLLA with carboxymethylcellulose (CMC) and PLLA with hyaluronic acid (HA). ELLURE with CMC is comprised of 80% pure poly-L-lactic acid (160 mg) and 20% CMC (40 mg), which functions as a stabiliser to prevent the rapid aggregation of PLLA microparticles, while ELLURE with HA is comprised of 85% pure poly-L-lactic acid (170 mg) and 15% non-crosslinked HA (30 mg).

Along with PLLA, ELLURE’s compound is CMC, an FDA-approved, water-soluble polysaccharide derived from cellulose20. Available in high-purity forms, CMC is favoured for biomedical applications due to its biocompatibility and low cost. Its plant-based origin reduces the likelihood of immune responses compared to animal-derived fillers like collagen and hyaluronic acid21-22

In another formulation, ELLURE proposes a combination of PLLA with non-crosslinked hyaluronic acid. Non-crosslinked hyaluronic acid is known for its ability to enhance skin hydration and elasticity without creating the volumising effects typically associated with crosslinked HA. This form of HA integrates smoothly into the dermal matrix, providing immediate hydration and supporting collagen production without altering the natural contours of the face and body23–26

PLLA in ELLURE differs from similar products on the market by its active ingredient concentration, the unique morphology of its microspheres, and microsphere sizes and distribution range, which allow the product to be more effectively dispersed in tissue, providing the uniform stimulation of fibroblasts. The above properties lead to enhanced collagen synthesis, which results in more consistent skin rejuvenation and volumisation. The narrow range (20–30 µm) of particle

Table 2 Distribution of patients by morphotypes of ageing

Table 1 Distribution of patients by groups and sub-groups

size distribution minimises the risk of particle aggregation, ensuring a smooth and even distribution in the tissue, which reduces the likelihood of complications such as nodules or granulomas. The combination of smooth and porous microspheres in a particular ratio also promotes controlled biodegradation, leading to sustained effects over time while maintaining a high safety profile25

Materials and methods

The clinical data was collected from two research centres. In total, 76 patients aged 35 to 72 years with involutive skin changes were involved in this clinical study. The patients with the following key inclusion criteria were enrolled: Involutive skin changes (including fine lines, wrinkles, and skin laxity); exhibited age-related volume loss in soft tissues of the face and neck; Stable medical conditions as confirmed by a complete medical history and laboratory evaluations (e.g., normal levels of complete blood count, bilirubin, liver enzymes, C-reactive protein, and creatinine).

The clinical data was collected from two research centres. In total, 76 patients aged 35 to 72 years with involutive skin changes were involved in this clinical study.

Patients were excluded from the study if they had a known hypersensitivity to any components of the study products, including poly-L-lactic acid, carboxymethylcellulose, or hyaluronic acid. Additional exclusion criteria included a history of autoimmune diseases, bleeding disorders, or the use of anticoagulants. Patients who were pregnant, breastfeeding, or planning to become pregnant during the study period were also excluded. Other exclusion factors included recent participation in other skin treatments such as deep chemical peels, dermabrasion, or laser therapy within one month prior to enrollment, as well as the presence of active skin diseases such as purulent skin lesions, acne or herpes at the site of the product administration. All subjects gave their written informed consent before taking part in the study. The study was carried out in accordance with the guidelines laid down in the Declaration of Helsinki.

Eligible subjects were split into two groups: Group 1 treated with ELLURE PLLA with CMC and Group 2 treated with ELLURE PLLA with HA. Forty-five female patients were included in Group 1 and 31 in Group 2. The patients were divided into four age sub-groups in each group, as shown in Table 1:

■ First sub-group: 35-40 years. In Group 1, 8 patients were included, while Group 2 had 7 patients.

■ Second sub-group: 40-45 years. In Group 1, 10 patients were included, while Group 2 had 9 patients.

■ Third sub-group: 45–55 years. This sub-group had the largest number of study participants, with 15 in Group 1 and 9 in Group 2.

Figure 1 Average values of elasticity and hydration

Change in percentages across

the sub-groups on different timepoints (1 month and 3 months) for Group 1

Change in percentages across the sub-groups on different timepoints (1 month and 3 months) for Group 2

■ Fourth sub-group: over 55 years. In Group 1, 12 patients were included, while 6 patients were included in Group 2.

The third age sub-group (45–55 years) was the most numerous, comprising 15 patients and accounting for 33.3% of the total participants. The second largest group was the 55–75 years age group, consisting of 12 patients, which represented 26.7% of the total. The 40–45 years age group followed with 10 patients, making up 22.2% of the participants. Lastly, the 35–40 years age group had

Table 3 Group 1 and 2 ICC scores

ICC score calculated to determine absolute agreement between physician and patient responses on GAIS scale questionnaire. The scores were calculated on at different timepoints (1 month and 3 month). GROUP

Figure 2 Average values of elasticity and hydration

8 patients, accounting for 17.8% of the total participants. When assessing the morphotypes of ageing, it was found that patients with a combined type of ageing predominated, accounting for 49% (n=22) of patients in Group 1 and 54.8% (n=17) in Group 2. The next most common morphotype was the deformation type, comprising 33.3% (n=15) of patients in Group 1 and 25.8% (n=8) in Group 2. Lastly, the fine-wrinkled type was observed in 17.7% (n=8) of patients in Group 1 and 19.4% (n=6) in Group 2, as shown in Table 2

All patients in both Groups received a single injection of ELLURE 200 in the face and neck areas to correct age-related changes. Comprehensive clinical, instrumental, and laboratory examinations were conducted to ensure patient eligibility, focusing on exclusion criteria. Patients were excluded if they had abnormal levels in complete blood count, bilirubin and its fractions, alanine and aspartate aminotransferase, C-reactive protein, total protein, albumin, urea, uric acid, creatinine, and gamma-glutamyltranspeptidase. Additionally, patients were consulted by a General Practitioner to identify comorbidities and provide necessary treatment.

The results were evaluated using the Multi Skin Test Center MC 900 VisioFace Quik diagnostic complex (manufactured by Courage, Khazaka Electronic GmbH, Germany). The following skin parameters were analysed:

■ Elasticity

■ Hydration.

Assessment of aesthetic improvement was assessed by both physicians and patients using the Global Aesthetic Assessment Scale (GAIS).

All parameters were evaluated dynamically before the procedure, 1 month and 3 months after.

Possible adverse events (hematomas, redness, swelling, infection, itching, peeling, pain after injection, papules, granulomas)1 were also assessed on the first day, the third, seventh, fourteenth days, and 3 months. Patients were examined for any other adverse events during the above-mentioned time points.

Data analysis was performed using statistical software R Core Team (2021)27 Version 2024.04.2+764 statistical software, with the packages ‘irr’ and ‘psych’ (Gamer et al., 2019; Revelle, 2024)28,29. For the graphic, we used the package ‘ggplot2’ (Wickham, 2016)30. Physician and patient responses through the GAIS questionnaire were assessed using interclass relationship ICC scores based on the

Figure 3 Pie-donut chart illustrates incidence of reported adverse events for Group 1

Figure 4 Pie-donut chart illustrates incidence of reported adverse events for Group 2

calculation according to Terry K. Koo and Mae Y. Li, 201631. All other data were analysed using descriptive statistics and percentages.

Procedure methodology

The preparation of the basic solution of ELLURE 200 (both variants of ELLURE — PLLA/CMC and PLLA/HA) involved dissolving the contents of the vial (200 mg of dry substance) in 9 ml of sterile water for injection, followed by the addition of 1 ml of articaine anaesthetic (20 mg/ml) without epinephrine to obtain a 10 ml working solution.

Before administering the drug, markings were done. A homogeneous suspension of 1–2 ml was injected into the subcutaneous fat in each of the following anatomical zones: face (cheekbone, parotid, mental, submental) and neck areas. For the neck, an additional dilution with injection water in a 1:1 ratio was used.

For the injection, 22G x 70 mm and 25G x 50 mm cannulas were used, depending on the anatomical zone. The fan technique was employed, and the average consumption of the drug was 0.2 ml per pass.

During the injection, it was crucial to avoid areas of mimetic activity, inject the suspension as evenly as possible into the subcutaneous fat layer, and avoid injecting the drug within 1.0 cm from the cannula entry point to prevent the solution from entering the dermis.

After the procedure, a 5-minute massage was performed with the post-procedure cream-gel Recowell to ensure even distribution of the injected product. Patients were also advised to perform massages at home for 5 days, 5 minutes each session, several times a day.

Results

The analysis of the biophysical parameters of the skin and possible adverse events after the administration of ELLURE 200 polylactic acid injections showed the following results.

When examining the change in skin hydration and elasticity over time, the Group 1 results revealed that after 1 month, improvements in elasticity were observed across all sub-groups, ranging from an 8% increase in sub-group 1 to a 17% increase in sub-group 4. By the 3-month mark, the highest increase in elasticity was in sub-group 4 (21%) and the lowest in sub-group 1 (11%). Hydration levels after 1 month increased significantly across all sub-groups, with sub-group 1 showing a 25% increase and sub-group 4 showing a 19% increase. After 3 months, the hydration levels remained stable or slightly decreased in some sub-groups, with sub-group 1 still exhibiting a 24% increase and sub-group 4 maintaining a 19% increase.

Group 2 results showed the elasticity improvements after 1 month were somewhat lower than in Group 1, with increases ranging from 9% in sub-group 2 to 14% in sub-group 4. After 3 months, the improvements in elasticity were more pronounced, with sub-group 4 showing the highest increase of 23%, followed by subgroup 3 with an 18% increase. Hydration levels in Group 2 increased similarly across all sub-groups after 1 month,

Assessment of aesthetic improvement was assessed by both physicians and patients using the Global Aesthetic Assessment Scale (GAIS).

ranging from 22% in sub-group 4 to 27% in sub-group 1. After 3 months, the hydration levels decreased slightly compared to the 1-month results, with sub-group 1 maintaining a 23% increase, while sub-group 4 saw a slight improvement, ending with a 21% increase.

For visualisation of total effectiveness, Figure 1 and Figure 2 charts illustrate all percentages separately for each Group per age sub-group.

At 1 month post-treatment, physician-assessed Global Aesthetic Improvement (GAIS) scores in Group 1 indicated that the majority of participants across subgroups were rated as ‘Much Improved’ (50%-60%), with fewer participants assessed as ‘Very Much Improved’ or ‘Improved.’ Group 2 followed a similar pattern, with most participants rated as ‘Much Improved’ (50%-

Figure 5 Patient A, 46 years old, before (A, C, E) and 3 months after ELLURE 200 injections (B, D, F)

66.7%). By Month 3, Group 1 experienced an increase in ‘Much Improved’ ratings (50%–66.7%), while Group 2 showed a notable shift toward higher ‘Very Much Improved’ scores.

Patient-assessed improvements at Month 1 mirrored these findings, with most participants in Group 1 rating themselves as ‘Much Improved’ (40%-66.7%), while 55.5%–71.4% of Group 2 self-assessed similarly. By Month 3, Group 1 showed a further increase in selfassessed ‘Much Improved’ ratings (62.5%–83.3%), while Group 2 exhibited a rise in ‘Very Much Improved’ ratings (26.6%–44.5%), with ‘Much Improved’ ratings remaining stable across sub-groups.

A B E F C D

The Intraclass Correlation Coefficient (ICC) was calculated to determine absolute agreement with the results presented in Table 3, which showed statistically significant absolute agreement between physician and patient responses. This means that the results of the treatment are highly noticeable both for doctors and patients.

The analysis of adverse events after injections of ELLURE 200 polylactic acid was performed based on data collected from medical examination, patientreported complaints and photography images. In Group 1 across the four sub-groups, hematoma incidence was low. No hematomas were reported in sub-group 1 subjects, while sub-group 2 and 3 subjects had 1 case each. Sub-group 4 subjects reported the highest incidence with only 2 cases of hematoma. Redness was the most frequently reported adverse event. The highest occurrence was in sub-group 3, where 7 participants experienced redness. Sub-group 1 and 2 subjects reported 5 and 6 cases of redness, respectively, while sub-group 4 reported 4 cases. Swelling was moderate across the sub-groups. Sub-groups 3 and 4 had the highest incidence, with 4 and 6 cases, respectively. Both sub-groups 1 and 2 reported 2 cases each. Mild pain was a common adverse event, reported consistently across the sub-groups. Sub-group 1 experienced 3 cases of pain, while sub-groups 2 and 4 had 5 cases each. Sub-group 3 reported 4 cases.

In Group 2 patients, hematoma occurrence was minimal. There were no cases reported in sub-groups 1 and 3, while sub-groups 2 and 4 reported 1 case each. Redness was observed in all sub-groups but at lower rates compared to Group 1. Sub-groups 1 and 3 reported 2 cases each, while sub-groups 2 and 4 reported 1 case each. Swelling was also less frequent in Group 2. Subgroups 1 and 2 each reported 1 case of swelling, while Sub-group 3 had 2 cases. Sub-group 4 reported only 1 case of swelling. Pain occurred less frequently in Group 2 than in Group 1. Sub-group 1 subjects did not report any cases of pain, while Sub-group 2 subjects reported 1 case. Sub-group 3 and 4 subjects both had 2 cases of pain each.

Both groups experienced typical post-treatment adverse events, with Group 1 showing a generally higher incidence across most categories.

All adverse events were mild and resolved within 3 days after the procedure in both Groups.

Such adverse events as inflammation, itching, peeling, papules, and granulomas were not recorded in any patient during the entire 3-month observation period.

The results of observed adverse events for Group 1 and Group 2 are presented in Figures 3–4

Clinically, all patients in all age groups observed a gradual and increasing improvement in facial skin tone, skin radiance, smoothing of its relief, reduction in the depth of superficial wrinkles, nasolacrimal and nasolabial folds, increased skin firmness, and reduction of skin excess in areas of gravitational changes. Visual results are presented in photos before and three months after the injection of

Figure 6 Patient B, 65 years old (A, C, E) and 3 months after ELLURE 200 injections (B, D, F)

ELLURE — polylactic acid-based biostimulators in different age groups (Figures 5–6).

Conclusions

Both groups experienced increases in skin elasticity and hydration after 1 month, with greater improvements observed by the 3-month timepoint, particularly in elasticity.

Group 1 delivered slightly higher and more consistent improvements in elasticity compared to Group 2.

In both groups, hydration increased more rapidly after 1 month but slightly decreased by 3 months, though improvements were still present compared to baseline.

This study confirms the efficacy and safety of ELLURE polylactic acid-based biostimulators in

Both groups experienced increases in skin elasticity and hydration after 1 month, with greater improvements observed by the 3-month timepoint, particularly in elasticity.

enhancing skin hydration, elasticity, overall skin quality and aesthetic improvement across different age groups. Both ELLURE — PLLA/CMC and ELLURE — PLLA/HA formulations demonstrated significant improvements in skin parameters, particularly in older patients, offering sustained skin rejuvenation. Overall, the data suggest that the interventions used in these groups were effective in improving skin elasticity and hydration, with the effects being more sustained in elasticity over time.

The treatments were well-tolerated, with only mild, transient adverse events such as redness and swelling, which resolved without further issues. These findings

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Declaration of interest None

Figures 5-6 © Dr. Ellena Lukianchenko

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13. Vleggaar D, Fitzgerald R, Lorenc ZP. The history behind the use of injectable poly-L-lactic acid for facial and nonfacial volumization: the positive impact of evolving methodology. J Drugs Dermatol. 2014;13(4 Suppl):s2–s7.

14. Vleggaar D;Fitzgerald R;Lorenc ZP. (2014). Composition and mechanism of action of poly-L-lactic acid in soft tissue augmentation. Journal of Drugs in Dermatology : JDD, 13(4 Suppl).

15. Stein, P., Vitavska, O., Kind, P., Hoppe, W., Wieczorek, H., & Schürer, N. Y. (2015). The biological basis for poly-l-lactic acid-induced augmentation. Journal of Dermatological Science, 78(1), 26–33.

16. Fitzgerald, R., Bass, L. M., Goldberg, D. J., Graivier, M. H., & Z Paul Lorenc. (2018). Physiochemical Characteristics of Poly-L-Lactic Acid (PLLA). Aesthetic Surgery Journal, 38(suppl_1), S13–S17. https://doi.org/10.1093/asj/sjy012

17. Choi, Y., Sang Yoon Kim, Moon, M.-H., Sun Hee Kim, Lee, K.-S., & Byun, Y. (2001). Poly(ethylene glycol)–poly(l-lactide) diblock copolymer prevents aggregation of poly(l-lactide) microspheres during ethylene oxide gas sterilization. Biomaterials, 22(9), 995–1004.

18. Bakhaidar, R., Green, J., Khaled Alfahad, Shazia Samanani, Nabeehah Moollan, O’Neill, S., & Zebunnissa Ramtoola. (2019). Effect of Size and Concentration of PLGA-PEG Nanoparticles on Activation and Aggregation of Washed Human Platelets. Pharmaceutics, 11(10), 514–514.

19. Vibhu Kanchan, & Panda, A. K. (2007). Interactions of antigen-loaded polylactide particles with macrophages and their correlation with the immune response. Biomaterials, 28(35), 5344–5357.

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carboxymethylcellulose for biomedical applications. J Biosci Bioeng. 2007;104(1):30–33.

21. Alijotas-Reig J, Garcia-Gimenez V. Delayed immune-mediated adverse effects related to hyaluronic acid and acrylic hydrogel dermal fillers: clinical findings, long-term follow-up and review of the literature. J Eur Acad Dermatol Venereol. 2008;22(2):150–161.

22. Manna F, Dentini M, Desideri P, De Pità O, Mortilla E, Maras B. Comparative chemical evaluation of two commercially available derivatives of hyaluronic acid (hylaform from rooster combs and restylane from streptococcus) used for soft tissue augmentation. J Eur Acad Dermatol Venereol. 1999;13(3):183–192.

23. Bertucci, V., & Lynde, C. B. (2015). Current Concepts in the Use of Small-Particle Hyaluronic Acid. Plastic & Reconstructive Surgery, 136, 132S138S.

24. Andre, P. (2004). Hyaluronic acid and its use as a “rejuvenation” agent in cosmetic dermatology. Seminars in Cutaneous Medicine and Surgery, 23(4), 218–222.

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treatment of facial wrinkles and folds. Clin Interv Aging. 2008;3(4):629–634.

27. H. Wickham. ggplot2: Elegant Graphics for Data Analysis. Springer-Verlag New York, 2016.

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THE TREATMENT OF PERIORBITAL HYPERCHROMIA WITH A COMBINATION

OF SUCCINIC ACID AND HYALURONIC ACID

Tackling dark eye circles has always been a challenge, especially for patients with darker skin tones. Dr UsHa Hoh introduces a new injectable treatment that has shown promise in improving periorbital hyperchromia with minimal discomfort and downtime

USHA HOH, MBBS,MRCS,MAFP, FRACGP,DIPDERM, is the CEO & Senior Medical Director of MX Clinic, Key Opinion Leader and International Speaker for Hyalual, Merz Aesthetics, BTL Aesthetics, Elogio Asia & Babor.

KEYWORDS

Periorbital hyperchromia, POH, succinic acid, hyaluronic acid

ABSTRACT

Periorbital hyperchromia (POH), commonly referred to as dark eye circles, is a prevalent aesthetic concern affecting patients of various ages and skin types. Characterised by bilateral, circular, hyperpigmented patches primarily on the lower eyelids, POH can extend to the upper eyelids and surrounding facial regions. The multifactorial aetiology of POH, including dermal melanin deposition, superficial vasculature, and skin laxity, complicates its treatment. This article explores the potential of a novel injectable treatment, Electri,

PERIORBITAL HYPERCHROMIA (POH), also known as dark eye circles or periocular hyperpigmentation, is a common encounter in aesthetic practice in both young and older patients of any skin type. The definition of periorbital hyperchromia is bilateral, circular, homogeneous, hyperpigmented macules or patches mainly involving the lower eyelids but, in some cases, may extend over the upper eyelids, eyebrows, malar regions, temporal regions and lateral nasal root1.

The data on the incidence and prevalence of POH is scarce due to its transitory nature and lack of reasonable aetiological

which combines high molecular weight hyaluronic acid (HMW HA) and succinic acid. Through case studies involving three women with varying degrees of POH, the treatment demonstrated significant clinical improvement after just three sessions. The treatment’s efficacy in reducing pigmentation and improving skin quality is highlighted, along with its potential to enhance periorbital aesthetics safely and effectively. The article suggests that Electri may offer a promising new approach for managing POH, particularly in patients with darker skin tones.

explanation. POH, although easily diagnosed, can be quite challenging to treat because of the underlying multifactorial aetiology, difficult to approach deep facial anatomy, soft tissue changes and contributions from the skin. Often familial, POH is frequently found in individuals of Mediterranean ancestry. POH is mainly caused by dermal melanin deposition, post-inflammatory hyperpigmentation secondary to atopic dermatitis (allergic shiners) or allergic contact dermatitis, periorbital oedema, superficial location of the vasculature, shadowing due to skin laxity, or drug-induced2

As more interactions move online, individuals are becoming more conscious of their appearance on camera, especially of the periorbital regions, leading to a rise in interest in aesthetics-related treatments and procedures.

An individual’s age and degree of fatigue may often be misperceived based on periorbital aesthetics. Throughout multiple cultures, societal perceptions are usually very similar in that POH contributes to a tired, aged,

and even sad appearance3. Even though there are no published studies on the effect of POH on quality of life, it is undeniable that it does have psychological implications on young adults, especially those with darker skin tones.

The ‘social media zoom boom’ refers to the phenomenon where people are increasingly using video conferencing platforms like Zoom for work, education, socialising and even aesthetic enhancements. As more interactions move online, individuals are becoming more conscious of their appearance on camera, especially of the periorbital regions, leading to a rise in interest in aesthetics-related treatments and procedures. Social media platforms like Instagram and TikTok play a significant role in shaping makeup trends. On average, a woman in the United States spends $300,000 (USD) in her lifetime on facial cosmetics, including cosmeceuticals and makeup. Of this, a large percentage of it is spent on periorbital rejuvenation and under-eye concealers4. This expenditure occurs worldwide, with the global cosmetics market size valued at $374.18 billion in 2023 and projected to grow from $393.75 billion in 2024 to $758.05 billion by 20325

The approach to periorbital hyperchromia

As for all cases, the principles of aesthetic care always begin with good history-taking and rapportbuilding with the patient. Identifying the main

causative factor and eliminating other predisposing factors will remain the mainstay of the treatment approach for POH. Examination of the periorbital area must be performed in a well-lit environment with the patient in a seated position. When examining the lower eyelid component, the proximal boundary is the tarsal plate of the lower eyelid, and the most distal boundary is at the tear trough deformity. In a patient with skin of colour, the indentation of the tear trough may be the only area of concavity visible in the face and can be portrayed as an early sign of ageing6

This shadowing is often perceived as a dark eye circle. Anatomical consideration is critical for the correction of the tear trough component of POH. Laxity of the lid-cheek junction with age, accompanied by the herniation periorbital fat pads, involutional descent of the midface, and bone and fat atrophy with ageing may further contribute to the loss of soft tissue support and descent of the cheek that deepens the tear trough7 Concave surfaces replacing convex surfaces is the hallmark of facial ageing, and our aesthetic efforts should focus on restoring the convexity of the facial structures when improving POH. If the POH is caused by volume loss in the tear trough area along with increased skin hyperpigmentation or laxity, the treatment approach has to be multimodal so the causative factors of volume loss are dealt with simultaneously with the initiation of treatment that will target the hyperchromia and laxity. It is imperative for us as physicians to be able to convey the history and examination findings to the patients in order for them to fully comprehend the underlying causative factors and how the recommended treatment will be able to target those issues so that the end result will be up to their expectations.

Consequences of inflammaging

Ageing is a time-dependent progressive accumulation of significant cellular and tissue changes, including physiological, structural, and functional changes. Skin ageing is a process accompanied by changes that alter the local microenvironment, such as the weakening of the skin barrier and the accumulation of stressed and senescent cells8. The consequences of such an altered microenvironment include compromised tissue renewal and function, increased pigmentation, altered cellular interactions9 and chronic low-grade inflammation10. This sterile inflammatory state, termed inflammaging, develops with advanced age and is associated with persistent inflammation that ultimately exhausts the skin’s defence system. The gatekeepers of tissue homeostasis and integrity are macrophages, constituting primary inflammatory cytokine producers, as well as initiators and regulators of inflammation, and represent one of the leading cellular players in adaptive immunity exacerbation

Figure 1 Case 1 was an Indian woman who came in with the main concern of darkened periorbital region. With a coinciding melasma, monotherapy with Electri was initiated with superficial dermal injections points mainly focused on the periorbital region extending into the temporal and malar melasma region. Before (A, C, E) and after (B, D, F) the subject completed 3 sessions 3-4 weeks apart

Succinic

and exhaustion during ageing11,12. Proinflammatory macrophages can contribute to melanogenesis in conditions of chronic inflammation through the production of reactive oxygen species (ROS) and the reinforcement of oxidative stress13

Hyaluronic acid

The most frequently used substance to achieve rapid skin hydration and quality improvement is noncrosslinked hyaluronic acid (HA). Evidenced by its hygroscopic properties and multiple stimulating effects both on dermal cellular fibroblasts and extracellular components by enhancing neocollagenesis, mimicking the healing process, elastin production and expression or release of growth factors that help restore skin hydration and structure respectively, hyaluronic acid still tops the chart for skin boosters14 Yang et al., in their studies, found that dermal thickening was dependent on the hyaluronic acid’s molecular weight. It was found that with the introduction of hyaluronic acid, existing collagen fibres are stretched, which induces mechanical tension of the surrounding fibroblasts, leading to increased collagen production. There was a statistically significant increase in procollagen, tissue inhibitors of metalloproteinase (TIMP-1) and gene expression of procollagen type 1 and 3 approximately 1 month after injection15

With so many hyaluronic acid-based products in the market, it is pertinent for physicians to understand the characteristics of the specific hyaluronic acid used to provide the best clinical outcome, depending on the treatment area. The higher the concentration of HA, the larger the volume of fluid trapped will be, with more downtime and pain at the injection site induced by the tissue stretching. In some investigations, it was shown that high molecular weight hyaluronic acid (HMWHA) displays anti-inflammatory properties, whereas low molecular weight hyaluronic acid (LMWHA) could cause inflammation through macrophage activation and stimulation of cytokines production. Another benefit related to HMWHA is the antioxidant effect of activation pathways involved in the regulation of cellular redox balance16. There were no significant differences in the skin layers’ thickness depending on different concentrations of HA in the products that were used. Therefore, subdermal injection of noncrosslinked HA, mainly low concentration of HMWHA including other anti-inflammatory and antioxidant elements in the final composition, could stimulate the reorganisation of the ECM, which is proven to increase skin thickness (redermalisation).

Hyaluronic acid

Succinic acid and SUCNR1 receptor

In periorbital hyperchromia, it was found that most of the melanin deposition was dermal17, which clinically correlates with the difficulty in treating this disorder and the observed resistance of POH to respond to

topical treatments18. With only a handful of treatment options available, skin irritation and unintended postinflammatory hyperpigmentation can be evident after treatment with a topical or energy-based device.

Succinic acid or butanedioic acid, a symmetrical, four-carbon, dicarboxylic acid, which forms colourless, odourless crystals, was first isolated in 1546 as a distillate from amber by Georgius Agricola19

Succinate plays a significant role in intermediary metabolism, mainly in the TCA cycle for cell energy production. During a hypoxic state, succinate acts as an important metabolic intermediate, leading to adenosine triphosphate (ATP) generation as a result of a shift from oxidative phosphorylation to glycolysis20 Succinate also functions as an extracellular metabolic stress signal sensed by the mainly Gicoupled succinate receptor SUCNR1, functioning as an autocrine and paracrine sensor to mediate cell signalling transduction21. Exogenous succinate mimics cell signal, causing a ‘pseudohypoxia’ condition to enhance the proliferation of mesenchymal cells through activation of SUCNR1 receptors22

The most frequently used substance to achieve rapid skin hydration and quality improvement is non-crosslinked hyaluronic acid

Succinate-dependent mechanisms of the succinate SUCNR1 receptor were detected in the skin, and the presence of the succinate receptor SUCNR1 was highlighted in fibroblasts, keratinocytes, endotheliocytes, mast cells, and macrophages. The succinate receptor, SUCNR1 (also known as GPR91), is a G proteincoupled receptor which is also expressed in a variety of other tissues, including blood cells, adipose tissue, liver, retina and kidney. In these tissues, this receptor and its ligand succinate have recently emerged as novel mediators in local stress situations, including ischemia, hypoxia, toxicity and hyperglycemia23. Among others, the succinate receptor is also involved in the recruitment of immune cells to transplanted tissues. SuccinateSUCNR1 signalling can act as a chemotactic factor for dendritic cells and synergises with toll-like receptors 3 or 7 to promote dendritic cell activation and migration to draining lymph nodes, resulting in antigen-specific T-cell activation24. In recent years, the involvement of SUCNR1 in multiple pathophysiological processes and its potential as a drug target due to its affinity for succinic acid have become increasingly evident25

Significantly, in primary anti-inflammatory human M2 macrophages, in which SUCNR1 is highly expressed, it is demonstrated that physiological concentrations of extracellular succinate act through SUCNR1-activated Gq signalling to efficiently regulate transcription of immune function genes in a manner that hyperpolarises the M2 versus the proinflammatory M1 phenotype26. Therefore, perceiving stress-induced extracellular succinate by SUCNR1 is an important transcriptional regulator in human M2 macrophages

2 Case 2 was an Indian woman presenting with POH along with post inflammatory hyperpigmentation post laser done in another setting for underlying melasma. In this patient, monotherapy with Electri was performed in the periorbital region extending to the post inflammatory hyperpigmentation area over the temple and malar eminence. In her, additional lymphatic drainage technique was performed to improve the periorbital puffiness. However, due to the extensive area of involvement, 2 syringes (each with 1.5mls) were required for the treatment each session. Before (A, C, E) and after (B, D, F) the subject completed 3 sessions 3-4 weeks apart

through Gq signalling to reduce the cellular inflammation that contributes to cellular ageing.

In the study by Dr Alexander Turkevych and his team in 2020 on improving skin quality with hyaluronic and succinic acid, it was found that the conjugate induction of the succinate receptor SUCNR1/GPR91 and all the studied growth factors (VEGF, FGF2, TGFb1) in the samples injected with succinate-containing preparations (HA plus Na succinate 1.6% formula ) was found to be effective and safe and was accompanied by an increase in the number of fibroblasts, the density of the vascular network and the density of collagen fibres27. In this study, the highest level of SUCNR1 expression was found in macrophages, which made it possible to consider them as the main target of exposure in order to stimulate the regeneration of the skin. As macrophages are also key factors that contribute to melanogenesis in conditions of chronic inflammation through the production of reactive oxygen species (ROS) and the reinforcement of oxidative stress, targeting this cell signal plays a major role in reverting the process28,29

Electrifying the skin

I was introduced to ELECTRI in early September 2023, an injectable based on succinic acid and noncrosslinked HMW hyaluronic acid 0.55% designed for targeting periorbital hyperchromia and intensive skin restoration. Panda eyes, especially in Asian darker skin types, have always been a challenge for me as a clinician. Commencing peels, skin lightening agents or energy-based devices in the periorbital area has always been a concern to avoid paradoxical hyperpigmentation or post inflammatory hyperpigmentation that may worsen the existing condition. Without intervention, POH usually progresses over time, so early intervention and management are important. Before incorporating this new modality into my clinical armamentarium, even though I did a lot of personal research, I was initially sceptical about whether it would produce the promised results, as succinic acid is a new tool for me to work with.

As a clinician who prefers a multimodality approach when it comes to periorbital hyperchromia, especially in a darker skin tone patient, I wanted to explore if monotherapy would show any clear advantages in targeting multiple underlying pathophysiology.

The ELECTRI containing HMW hyaluronic acid solution (0.55 mg/ml) and succinic acid (16 mg/ml) was recommended to be injected in the superficial dermis in a papular technique mainly over the upper and lower eyelid area every 2-3 weeks for 3-5 sessions.

My first subject (Case 1) was an Indian woman who came in with the main concern of a darkened periorbital region. With a coinciding melasma, monotherapy with Electri was initiated with superficial dermal injection points mainly focused on the periorbital region extending into the temporal and malar melasma region.

The second subject (Case 2) was also an Indian woman presenting with POH along with postinflammatory hyperpigmentation post-laser performed in another setting for underlying melasma. In this patient, monotherapy with Electri was performed in the periorbital region extending to the post-inflammatory hyperpigmentation area over the temple and malar eminence. With this patient, an additional lymphatic drainage technique was performed to improve the periorbital puffiness. However, due to the extensive area of involvement, two syringes (each with 1.5mls) were required for the treatment each session.

The third subject (Case 3), presented with a complaint of POH with uneven skin tone. Initial treatment with Electri was commenced for the periorbital region and full-face (with two syringes) and the patient was so convinced with the results after the first session that she then proceeded to treat her underarm and inner groin area (not consented for image sharing).

Owing to the physiological concentration of HMW hyaluronic acid, injection points were less painful, and

Figure

the papules disappeared within 4 hours, which is ideal for those who are looking for single-procedure skin rejuvenation without a long rehabilitation period. All the subjects completed three sessions 3-4 weeks apart, and the clinical outcome of this procedure using a monotherapy combination of HA and succinic acid was significant.

The result was clinically visible even after a single session. Not only was the POH issue addressed, but the patient also had a clinically visible improvement in skin quality because of the redermalization potential delivered by the product. By combining with the specific lymph draining technique, the periorbital oedematous component was reduced by promoting lymphatic drainage and improved microcirculation.

The result was clinically visible even after a single session. Not only was the POH issue addressed, but the patient also had a clinically visible improvement in skin quality.

Successful outcomes may be punctuated with chronic recurrences. With that in mind, Electri is certainly a promising treatment for POH on the horizon. As this may be a chronic and relapsing condition, preventive and maintenance regimens that involve UV protection and patient education should be integrated into the treatment plan for a longer-lasting improvement in clinical outcomes.

HMW hyaluronic acid, in combination with succinic acid, is definitely an exciting new innovation that is still very new to my clinical practice. I have yet to explore the endless possibilities that this product may deliver to my patient’s expectations and clinical outcomes. However, with the current trend of how the product is making an impact on my patients, I am very confident that, over

References

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5. Cosmetic market size, share and analysis, by category (haircare, skincare, makeup and others), by gender (men and women), by distribution channel (speciality stores, hypermarket / supermarket, online channels and others) and regional forecast 2024-2032. https:// www.fortunebusinessinsights.com/ cosmetics-market-102614

6. Aesthetic and Cosmetic Surgery for Darker Skin Types. Grimes, PE. 2007 Lippincott.

7. Clinical analysis and Classification of dark eye circle. Huang YL, Chang SL, Ma L, Lee MC, Hu S. Int J Dermatol. 2014 Feb 53(2) 164-70.

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Figure 3 Case 3 presented with a complaint of POH with uneven skin tone. Initial treatment with Electri was commenced for the periorbital region and full-face approach (with 2 syringes) and patient was very convinced with the results within the first session that she then proceeded to treat her underarm and inner groin area (not consented for image sharing). Before (A, C, E) and after (B, D, F) the subject completed 3 sessions 3-4 weeks apart

13. Role of Macrophages in Age-Related Oxidative Stress and Lipofuscin Accumulation in Mice. Vida C., de Toda I.M., Cruces J., Garrido A., GonzalezSanchez M., De la Fuente M. Redox Biol. 2017; 12:423–437. doi: 10.1016/j. redox.2017.03.005. [PubMed]

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15. A Low Molecular Weight Hyaluronic Acid Derivative Accelerates Excisional Wound Healing by Modulating Pro-Inflammation, Promoting Epithelialization and Neovascularization,and Remodeling Collagen. Gao Y, Sun Y, Yang H, et alInt J Mol Sci. 2019;20(15):3722. [PubMed]

16. Hybrid Complexes of High and Low Molecular Weight Hyaluronans Highly Enhance HASCs Differentiation: Implication for Facial Bioremodelling. Stellavato A, La Noce M, Corsuto L, et al. Cell Physiol Biochem. 2017;44(3):1078–1092. [PubMed] [Google Scholar] [Ref list]

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18. Cutaneous idiopathic hyperchromia of

time, I will be able to share more clinical indications and techniques to battle not just pigmentary disorders but also renormalisation and repair of the skin.

Declaration of interest Dr UsHa Hoh is a Key Opinion Leader and international speaker for Hyalual

Figures 1–3 © Dr. UsHa Hoh

the orbital region (CIHOR): A histopathological study. Graziosi AC, Quaresma MR, Michalany NS, Ferreira LM. Aesthetic Plast Surg. 2013 Apr;37(2):434-8. doi: 10.1007/s00266-012-0048-2.

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22. Succinate Supplement Elicited “Pseudohypoxia” Condition to Promote Proliferation, Migration, and Osteogenesis of Periodontal Ligament Cells. Huimin Mao, Andi Yang, Yunhe Zhao, Lang Lei. 23. Anatomical profiling of G protein-coupled receptor expression. Jean B Regard 1, Isaac T Sato, Shaun R Coughlin Cell. 2008 Oct 31;135(3):561-71. doi: 10.1016/j.cell.2008.08.040. PMID: 18984166 PMCID: PMC2590943 DOI:

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25. The succinate receptor as a novel therapeutic target for oxidative and metabolic stress-related conditions. Front. Endocrinol, 6 (3) (2012), p. 22, 10.3389/ fendo.2012.00022.Z. Xie, J. Dai, L. Dai 26. Succinate: A metabolic signal in inflammation. Trends Cell Biol., 24 (5) (2014), pp. 313-320, 10.1016/j. tcb.2013.11.008. A.C. Ariza, P.M. Deen, J.H. Robben

27. Improving skin quality with hyaluronic acid and succinic acid. Article Jan 2020 Alexander Turkevych, Natalia Derkach, Anna Kupriyanova, Leila Zubair, Marta Turkevych, Danylo Turkevych.

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CAN THREADS REPLACE FILLERS?

Aaron Hsieh, MD, explores the use of PDO threads in facial contouring, offering insights into their application for lifting and filling

ABSTRACT

Objective: fillers have been widely used for volume loss for many years, but complications like vessel obstruction and facial overfilled syndrome are also reported frequently. This study discusses whether threads can replace fillers to avoid these complications.

Research design and methods: three groups of patients were reviewed for this study: the forehead, cheek, and nose group. Each group has two patients.

FILLERS HAVE BEEN WIDELY USED FOR

facial volume loss for many years. There are many types of fillers, such as hyaluronic acid, poly-L-lactic acid, and polycaprolactone, all of which can demonstrate significant improvement to areas of depression in the face, as well as provide a lifting effect due to the volume support under the skin. However, due to the prevalence of fillers, a greater number of complications have been reported1. Among the complications, vessel obstruction and facial overfilled syndrome are the most severe.

On the other hand, threads, especially PDO cog threads, have also been popular for years. The lifting effects of cog threads are well documented, but the filling effect is still under debate. There are several papers discussing the impact of threads for collagen bio-stimulation2, forehead augmentation3, cheek augmentation4, and nasal augmentation5. The complications with the use of threads include thread migration, protrusion, dimple, infection, and hematoma. However, the occurrence of vessel obstruction and facial overfilled syndrome is rarer when compared to fillers. If threads can totally or partially replace fillers, we can prevent many irreversible complications caused by using fillers. In this study, we discuss the filling effect of threads.

Patients and methods

We divided the study into three groups: forehead, cheek, and nose. Two female patients were enrolled in each group, respectively. There are three kinds of threads used in the study, which are all PDO barbed threads (Meteora thread, Diamond Biotechnology Co., Ltd., Taiwan.) with USP 1 and 3-0 in diameter, 17 cm and 45 cm in length.

For the forehead group, we used two pieces of the USP 1, 17 cm PDO thread on each side. We inserted the thread in a V-pattern at the peak of the eyebrow and at the intersection point of the eyebrow and the midline of the pupil (Figure 1). The V-shape has two wings, each 5 cm in length, with all the cogs open downward, which gives the thread a strong fixation force to prevent the migration of the thread.

For the first patient in the cheek group, we inserted three pieces of USP 1, 45 cm PDO thread on each side in a U-pattern. We created a strong fixation down to the deep fascia in the temporal area, with both wings then inserted again from the entry point to the nasolabial fold. Both wings are kept parallel to each other. In this way, we inserted three pieces of thread from the hairline of the temporal area to the nasolabial fold with

Results: the results showed significant improvement in volume loss after treatment.

Conclusions: the thread treatment demonstrated significant improvement in facial volume loss on the forehead, cheek, and nose. Compared to fillers, the effect is more natural, with fewer vessel obstructions and overfill complications. Further studies will be needed to determine the longevity.

a U-pattern (Figure 2).

For the second patient, we inserted 10 pieces of USP 3-0, 17 cm PDO threads on each side. The threads were inserted from the hairline to the nasolabial fold and cheek (Figure 3).

For the nasal group, we have two patients, each receiving eight pieces of USP 1, 17 cm PDO threads on the nasion, nasal bridge, and columella (Figure 4).

Results

The first case in the forehead group showed the eyebrow lift after thread lifting and the volume increase to the forehead. The result can last for 7 months.

The second case of the forehead group also showed the same result, which lasted more than 4 months.

The first case of the cheek group received a total of six pieces of thread on both sides of the face and showed an improvement in the volume deficiency on both cheeks 1 month after treatment.

email: jasonwilliamsmvp@ gmail.com

There are several papers discussing the impact of threads for collagen bio-stimulation, forehead augmentation, cheek augmentation, and nasal augmentation.

The second case, which received 20 pieces of thinner (USP 3-0) PDO threads on both sides, also showed significant improvement after 1 month (Figure 5). We can see the fullness of the bilateral cheeks without any filler injection.

Finally, for the two patients in the nose group, we

KEYWORDS

Threads, fillers, vessel obstruction, overfilled syndrome

AARON CHIA-HSIEN HSIEH, MD, is a Dermatologist, Taipei City Hospital, Taipei, Taiwan

Figure 1 We inserted the thread from the peak of the eyebrow and the intersection point of the eyebrow and the midline of the pupil with a V patten. The angle between both wings is 30~45 degree. After insertion the thread with the V pattern, we cut the remanent part which is mostly smooth.

Eyebrow peak point

Midpoint of the eyebrow

Trim off excess thread to reverse threading

Figure 2 We inserted the thread from point 1 to 2 to make a strong fixation on the deep fascia, then re-insert every wing from the insertion point to the nasal labial fold and penetrate through point 5 and 6, respectively. Then we pulled the skin up from the nasolabial fold to the temporal area and cut the remaining part of the thread. The same procedure was performed again from point 2 and 3 to point 6 and 7 and then from point 3 and 4 to point 7 and 8.

Figure 3 Pieces of 3-0, 17 cm PDO bi-directional barbed threads were inserted on each side. The first insertion point was on the intersection point of the hairline and the extension line of the eyebrow. The thread was inserted from the point 1 to the lower jawline (point 2 to 6). The second insertion point was 1 cm in front of the upper part of the ear auricle (point 7). Then the thread was inserted from the entry point to the nasolabial fold (point 8 to 12). After the threads were inserted and fixed, the remaining part was cut.

Figure 4 (A) There were 2 USP 1, 17 cm PDO bi-directional barbed threads inserted from the medial eyebrow to the nasal bone to raise the nasion, 4 pieces inserted from the nasal tip to the frontal bone to raise the nasal bridge, and (B) 2 from the nasal tip down to the maxillary bone for the columella.

used eight pieces of USP 1, 17 cm threads for the nasion, nasal bridge, and columella. After the treatment, we followed up for 7 months and noted the persistence of the result (Figure 6–7).

Discussion

For the first study group, the thread not only lifts the eyebrow but also acts as a solid filler3 for the forehead. Although there were only two threads inserted on each side, the thread still has volume itself and can stimulate collagen production2. Also, the filling effect may come from the fat transposition of the forehead. We also noticed that the forehead wrinkle improved after treatment, possibly due to the threads’ muscle suppression effect.

For the second study group, the sunken cheek of the first case improved after thread lifting. The volume on the buccal fat area decreased, and the lateral cheek area was filled, which indicates the fat transposition happened after the treatment. The second case showed the same result. The thread not only lifted the face but also filled the cheek. In addition, the skin texture improved after treatment due to collagen stimulation2. Compared to the fillers, the filling effect on the cheek is not direct but more natural. The duration of the result is a problem, so combined with longlasting fillers might be a solution.

The third study used the thread to perform a nasal elevation. The threads were placed from the medial eyebrow or nasal tip to treat the nasion, nasal bridge, and columella. The barbs on the thread now act as fixation rather than lifting, which keeps the thread from migrating after being inserted. The elevation effect was prominent immediately after treatment. Also, we followed up with the patient for 7 months and saw that some effects persisted. However, the greatest advantage of nasal filling with thread over filler is that the vessel compression or obstruction rate is very low. This indicates that the thread might be a safer option for minimal invasive nasal elevation. However, some complications remain, such as thread migration, protrusion, swelling, pain, and bleeding, but all are reversible.

Conclusion

The filling effect of the threads differs from injectable fillers in three main ways: more natural, less overfilled, and safer for blood vessels. However, the effects last for a shorter period, and the treatment is associated with more pain than the injectable fillers. Other complications have also been reported, including thread migration, protrusion, dimpling, infection, and hair loss. Therefore, threads are also not the best choice for use alone. The combination therapy of threads and fillers may attenuate the effect and decrease the complications of both. We believe combination therapy will be the future of minimally invasive surgery.

Declaration of interest None

Figures 1–7 © Aaron Hsieh

Figure 5 The case received 20 pieces of thinner(USP 3-0) PDO threads on both sides. Not only the shape of the face changed from square to oval but also the improvement of depression on both cheeks and skin texture. (a) before treatment. (b) 1month after treatment.

There are several papers discussing the impact of threads for collagen bio-stimulation, forehead augmentation, cheek augmentation, and nasal augmentation.

References

1. Haneke E. Managing Complications of Fillers: Rare and Not-So-Rare. J Cutan Aesthet Surg. 2015 Oct-Dec;8(4):198-210. doi: 10.4103/0974-2077.172191. PMID: 26865784; PMCID: PMC4728901.

2. Kwon, Tae-Rin & Han, Sung & Yeo, In & Kim, Jae-Min & Hong, Ji Yeon & Lee, Byung Chul & Lee, Sung Eun & Moon, Ho & Kwon, Han & Kim, Beom. (2019). Biostimulatory effects of polydioxanone, poly-d, l lactic acid, and polycaprolactone fillers in mouse model. Journal of Cosmetic Dermatology. 18. 10.1111/ jocd.12950.

3. Seung Hoon Kang MD, Seok Hoon Moon MD, Bong-Il Rho MD, Seong Jae Youn MD, Hei Sung Kim MD, PhD.

5. Lee HY, Yang HJ. Rhinoplasty with Barbed Threads. Plast Reconstr Surg Glob Open. 2018 Nov 13;6(11):e1967. doi: 10.1097/GOX.0000000000001967. PMID: 30881784; PMCID: PMC6414097 A A C D B A B B

Wedge-shaped polydioxanone threads in a folded configuration (“Solid fillers”): A treatment option for deep static wrinkles on the upper face. J Cosmet Dermatol. 2019;18:65–70. 4. El-Mesidy, M.S., Alaklouk, W.T. & Azzam, O.A. Nasolabial fold correction through cheek volume loss restoration versus thread lifting: a comparative study. Arch Dermatol Res 312, 473–480 (2020).

Figure 6 The colour image analysis shows the elevation of the nasion and nasal bridge. (A) before treatment, (B) immediately after treatment, (C) 1 month after treatment, (D) 3 months after treatment

C D E

Figure 7 Photographs of a 28-year-old woman who underwent thread minimal invasive nasal augmentation on the nasion, nasal bridge, and nasal columella. The color image analysis showed the elevation of the nasion and nasal bridge. (A) before treatment, (B)immediately after treatment, (C) 1 month after treatment, (D) 3 months after treatment. (E) 6 months after treatment.

EPIGENETICS A NEW FRONTIER IN ANTI-AGEING MEDICINE

Hidekazu Yamada, MD, PhD, explores the potential of epigenetics in anti-ageing medicine and healthy longevity

ABSTRACT

This paper explores the transformative potential of epigenetics in anti-ageing medicine and health sciences. It covers fundamental mechanisms such as DNA methylation, histone modifications, and non-coding RNAs and discusses the use of epigenetic clocks, the information theory of ageing, and advanced therapeutic approaches. The impact of lifestyle and environmental factors on the epigenome is examined alongside applications in personalised medicine, ethical considerations, and future directions. The concept of ‘wellbeing capital’ is also introduced, emphasising how biological age can serve as an indicator of overall health and wellbeing, influencing individual and societal approaches to healthcare and longevity.

HEALTH AND LONGEVITY HAVE BEEN eternal themes of human pursuit.

Epigenetics, the study of mechanisms that control gene expression without altering the DNA sequence, holds the potential to revolutionise anti-ageing medicine and health sciences1. This paper provides a comprehensive overview of epigenetics, from basic concepts to the latest research findings and its potential applications in these fields.

Fundamentals of epigenetics

Epigenetics encompasses dynamic modifications that control gene expression2. The main epigenetic modifications include DNA methylation, histone modifications, and non-coding RNAs (Figure 1). DNA methylation involves adding methyl groups to DNA molecules. Its effects are complex and context-dependent. Recent research has identified diverse methylation patterns, including hypermethylated domains (HMDs), partially methylated domains (PMDs), low methylated regions (LMRs), and unmethylated regions (UMRs)3

In histone modifications, chemical modifications of histone proteins alter chromatin structure and control gene access4

Non-coding RNAs are RNA molecules that do not code proteins but regulate gene expression5. Environmental factors and lifestyle habits influence these modifications and change with age6

Epigenetic clocks: validated indicators of biological age

Epigenetic clocks are innovative tools that estimate biological age based on DNA methylation patterns (Table 1)1,7,8. These clocks analyse specific DNA methylation sites that change with age and use machine learning algorithms to calculate biological age1. Various clocks have been developed, including the Horvath clock, Hannum clock, PhenoAge, GrimAge, and DunedinPACE7,9. For clinical applications and validation, a study involving 4,568 participants validated 12 major clocks, demonstrating their applicability across age, gender, and race. GrimAge and DunedinPACE, in particular, showed strong associations with mortality and age-related health indicators7

Epigenetics, the study of mechanisms that control gene expression without altering the DNA sequence, holds the potential to revolutionise anti-ageing medicine and health sciences.

Epigenetics and the mechanisms of ageing: the information theory of ageing

David Sinclair’s Information Theory of Aging proposes that ageing results from losing epigenetic information10 This theory emphasises:

■ Accumulation of epigenetic alterations over time

■ Loss of cell-specific identity and function

■ The role of longevity genes like sirtuins in maintaining epigenetic information

■ Potential reversibility of ageing through epigenetic landscape restoration.

Age-related epigenetic changes include alterations in DNA methylation, histone modifications, chromatin structure, and non-coding RNA expression11,12

Cutting-edge epigenetic therapies

Advances in epigenetics research have led to the development of new therapeutic approaches, such as DNA methylation and histone deacetylase inhibitors, which are now included in pharmacological approaches13 and cellular rejuvenation using Yamanaka factors14,15 in

reprogramming techniques.

Exosomes are a type of extracellular vesicle emerging as important mediators of intercellular communication. Stem cell-derived exosomes show great potential in regulating recipient cell behaviour and promoting tissue repair and regeneration17. Small extracellular vesicles (sEV) are treated in exosome therapy using sEV derived from young plasma16

Lifestyle and epigenetics

Daily lifestyle habits have a significant impact on the epigenome (Figure 2)18

Exercise

Regular exercise promotes beneficial epigenetic changes. Physical activity induces favourable changes in DNA methylation and histone modification patterns, promoting gene expression profiles associated with health and longevity19

Nutrition

Specific nutrients and dietary patterns (e.g.,

HIDEKAZU YAMADA MD, PHD, Kindai University, Anti-Aging Center, Osaka, Japan

Mediterranean diet) positively influence the epigenome.

Nutrients such as folate, vitamin B12, and polyphenols modify DNA methylation and histone acetylation, affecting gene expression and metabolic health20. Calorie restriction and intermittent fasting are also associated with beneficial epigenetic changes that may slow the ageing process21

Stress management and sleep

Chronic stress and sleep deprivation can induce harmful

Biological age can be viewed as a new form of ‘capital’ representing an individual’s health status.

Mechanisms that regulate gene expression; acquired regulatory mechanisms that are regulated without affecting the DNA sequence.

The aim of antiageing medicine is to extend healthy life expectancy by regularly measuring biological age and by slowing the rate of ageing through these interventions. All of the interventions involve epigenetics.

epigenetic changes. Mental health and sleep quality are crucial elements in epigenetic regulation22

Environmental factors and epigenetics

The environment also significantly influences the epigenome. With environmental pollution, exposure to air pollution and chemicals can induce harmful epigenetic changes. Pollutants such as PM2.5 and CO2 cause detrimental epigenetic alterations, increasing the risk of respiratory and cardiovascular diseases23

Strong social networks are associated with healthy epigenetic profiles. The traditional Okinawan practice of ‘moai’ forms lifelong social networks, providing mutual support and friendship. These strong social bonds are associated with the exceptional longevity observed in Okinawan communities24

Epigenetics and personalised medicine

Epigenetics research is significantly contributing to the realisation of personalised medicine.

Epigenetic profiling involves analysing an individual’s epigenetic state to assess health risks, enabling early identification of potential health issues and preventive interventions25

For tailored preventive medicine and treatment, they are developing personalised intervention strategies based on epigenetic profiles. Clinicians can use epigenetic clocks to individualise treatment plans based on a person’s biological age26

Clinical applications

Epigenetic clocks have various potential clinical applications:

■ Early diagnosis and risk assessment

■ Monitoring treatment effects

■ Applications in preventive medicine.

Biological age as wellbeing capital

Biological age can be viewed as a new form of ‘capital’ representing an individual’s health status27. This concept is important from the perspectives of health investment indicators, socioeconomic impact, individual empowerment, and corporate health management. Epigenetics research suggests that changes in appearance have a profound biological basis, not just superficial phenomena. However, this interpretation requires careful handling.

Ethical considerations

The advancement of epigenetics research raises several ethical challenges28:

■ Handling of epigenetic information and privacy protection

■ Ethical boundaries of epigenetic manipulation

■ Social impacts (e.g., discrimination in insurance and employment).

These challenges require the establishment of appropriate regulations and guidelines, as well as social consensus.

Figure 1 Epigenetics

Figure 2 Prevention medicine and treatment for anti-ageing medicine

Future prospects

Epigenetics research is rapidly progressing, with the following developments expected:

■ Development of more comprehensive ageing biomarkers

■ Acceleration of research through initiatives like the XPRIZE challenge

■ Establishment of new treatment and prevention strategies considering epigenetics

■ Elucidation of epigenetic patterns and development of prediction models using AI and extensive data analysis.

These advancements are expected to lead to more precise and personalised anti-ageing medicine. Epigenome assessment will form wellbeing capital.

Conclusion

Epigenetics research holds the potential to revolutionise anti-ageing medicine. It may lead to accurate measurement of biological age, development of personalised intervention strategies, and healthy lifespan extension. Clinicians must stay informed about developments in this field and incorporate new findings into clinical practice.

Epigenetics is opening new horizons in realising health and longevity. However, its application requires careful ethical consideration. It is necessary to utilise epigenetic knowledge while respecting individual diversity and maintaining a holistic view of health.

Continued investment in epigenetics research, interdisciplinary cooperation, and comprehensive approaches will be vital in promoting the advancement of epigenetic therapies and paving the way for a healthier, more vibrant future. By continuing to explore this new frontier of knowledge, we can move step by step closer to realising the human dream of healthy longevity.

Declaration of interest None

Figures 1–2 © Hidekazu Yamada

References

1. Horvath, S. & Raj, K. DNA methylation-based biomarkers and the epigenetic clock theory of ageing. Nat. Rev. Genet. 19, 371–384 (2018).

2. Vatiwutipong, P., Vachmanus, S., Noraset, T. & Tuarob, S. Artificial Intelligence in Cosmetic Dermatology: A Systematic Literature Review. IEEE Access 11, 71407–71425 (2023).

3. Greenberg, M. V. C. & Bourc’his, D. The diverse roles of DNA methylation in mammalian development and disease. Nat. Rev. Mol. Cell Biol. 20, 590–607 (2019).

4. Alaskhar Alhamwe, B. et al. Histone modifications and their role in epigenetics of atopy and allergic diseases. Allergy Asthma Clin. Immunol. 14, 39 (2018).

5. Frías-Lasserre, D. & Villagra, C. A. The importance of ncRNAs as epigenetic mechanisms in phenotypic variation and organic evolution. Front. Microbiol. 8, 2483 (2017).

Table 1 DNA methylation clocks

Measure DNA methylation to predict age. It can predict the timing of disease development and life expectancy.

GENERATION CLOCK NAME MAIN FEATURES USE

Horvath's clock

Hannum’s clock

PhenoAge

GrimAge

EpiTOC

● Chronological age and DNA methylation patterns

● Used to estimate biological age

● DNA methylation patterns and disease risk and life prognosis

● EpiTOC specializes in assessing the risk and progression of cancer

DunedinPACE DunedinPoAm

CausalAge AdaptAge DamAge H3K27me3 clock

● Longitudinal data, the rate of change in DNA methylation with aging is used to predict the rate of aging and aging rate

● Used to assess the rate of aging progression of an individual

● Focusing on specific biological processes associated with ageing, such as DNA repair, cellular stress response, cellular senescence, and epigenetic regulation

● We aim to elucidate the mechanism of ageing by capturing changes in DNA methylation and histone modification related to the process

● Estimation of biological age

● Assessment of health status

● Predicting disease risk

● Prediction of life prognosis

● Assessing the risk and progression of cancer (EpiTOC)

● Predicting the rate of ageing

● Assessment of the rate of ageing progression in individuals

● Elucidation of the ageing mechanism

● Understanding Age-Related Biological Processes

7. Moqri, M. et al. Validation of biomarkers of aging. Nat. Med. 30, 360–372 (2024).

8. Lu, A. T. et al. Universal DNA methylation age across mammalian tissues. Nat Aging (2023) doi:10.1038/ s43587-023-00462-6.

9. Oblak, L., van der Zaag, J., Higgins-Chen, A. T., Levine, M. E. & Boks, M. P. A systematic review of biological, social and environmental factors associated with epigenetic clock acceleration. Ageing Res. Rev. 69, 101348 (2021).

10. Lu, Y. R., Tian, X. & Sinclair, D. A. The Information Theory of Aging. Nat Aging 3, 1486–1499 (2023).

11. López-Otín, C., Blasco, M. A., Partridge, L., Serrano, M. & Kroemer, G. Hallmarks of aging: An expanding universe. Cell 186, 243–278 (2023).

12. Ocampo, A. et al. In Vivo Amelioration

6. Booth, L. N. & Brunet, A. The aging epigenome. Mol. Cell 62, 728–744 (2016).

of Age-Associated Hallmarks by Partial Reprogramming. Cell vol. 167 1719-1733.e12 (2016).

13. Ganesan, A., Arimondo, P. B., Rots, M. G., Jeronimo, C. & Berdasco, M. The timeline of epigenetic drug discovery: from reality to dreams. Clin. Epigenetics 11, 174 (2019).

14. Yang, J.-H. et al. Chemically induced reprogramming to reverse cellular aging. Aging 15, 5966–5989 (2023).

15. Paine, P. T., Nguyen, A. & Ocampo, A. Partial cellular reprogramming: A deep dive into an emerging rejuvenation technology. Aging Cell e14039 (2023).

16. Chen, X. et al. Small extracellular vesicles from young plasma reverse age-related functional declines by improving mitochondrial energy metabolism. Nat Aging (2024) doi:10.1038/ s43587-024-00612-4.

17. Dimik, M., Abeysinghe, P., Logan, J. & Mitchell, M. The exosome: a review of

current therapeutic roles and capabilities in human reproduction. Drug Deliv. Transl. Res. 13, 473–502 (2023).

18. Franzago, M., Pilenzi, L., Di Rado, S., Vitacolonna, E. & Stuppia, L. The epigenetic aging, obesity, and lifestyle. Front Cell Dev Biol 10, 985274 (2022).

19. Światowy, W. J. et al. Physical activity and DNA methylation in humans. Int. J. Mol. Sci. 22, 12989 (2021).

20. Tiffon, C. The Impact of Nutrition and Environmental Epigenetics on Human Health and Disease. Int. J. Mol. Sci. 19, (2018).

21. Waziry, R. et al. Effect of long-term caloric restriction on DNA methylation measures of biological aging in healthy adults from the CALERIE trial. Nature Aging 1–10 (2023).

22. Wu, Z., Qu, J., Zhang, W. & Liu, G.-H. Stress, epigenetics, and aging: Unraveling the intricate crosstalk. Mol. Cell 84, 34–54 (2024).

23. Rider, C. F. & Carlsten, C. Air pollution and DNA methylation: effects of exposure in humans. Clinical Epigenetics vol. 11 Preprint at https://doi.org/10.1186/ s13148-019-0713-2 (2019).

24. Cockerham, W. C. & Yamori, Y. Okinawa: an exception to the social gradient of life expectancy in Japan. Asia Pac. J. Clin. Nutr. 10, 154–158 (2001).

25. Wang, K. et al. Epigenetic regulation of aging: implications for interventions of aging and diseases. Signal Transduct Target Ther 7, 374 (2022).

26. Bell, C. G. et al. DNA methylation aging clocks: challenges and recommendations. Genome Biol. 20, 249 (2019).

27. Jylhävä, J., Pedersen, N. L. & Hägg, S. Biological Age Predictors. EBioMedicine vol. 21 29–36 Preprint at https://doi. org/10.1016/j.ebiom.2017.03.046 (2017).

28. Dyke, S. O. M. et al. Points-to-consider on the return of results in epigenetic research. Genome Med. 11, 31 (2019).

NAVIGATING DERMAL FILLER COMPLICATIONS: EXPERT GUIDANCE AND SUPPORT FROM E-FILLERS

IN RECENT YEARS, DERMAL fillers have become a staple in aesthetic medicine, offering a minimally invasive way to restore volume, smooth wrinkles, and enhance facial contours. While these treatments are generally safe when performed by experienced professionals, complications can occur, even in the best hands. As the popularity of dermal fillers continues to rise, so does the need for accessible expert advice when things don’t go as planned. This is where e-FILLERS comes into play, offering a unique solution to aesthetic practitioners worldwide.

Understanding dermal filler complications

Dermal filler complications can range from mild, transient issues to more serious concerns requiring immediate intervention. Common complications include bruising, swelling, and lumpiness, which typically resolve on their own or with minimal treatment. However, more serious complications, such as vascular occlusion, infections, and allergic reactions, demand prompt and knowledgeable management to prevent long-term damage. For practitioners, handling these complications effectively is crucial not only for patient safety but also for maintaining trust and reputation. Unfortunately, even seasoned professionals may encounter cases that are challenging or outside their typical scope of experience.

Introducing e-FILLERS’ Medical Advice service

Recognizing the need for expert support, e-FILLERS.com, a worldwide distributor of dermal fillers and other medical aesthetic products, has launched a Medical Advice service—a game-changing resource available exclusively to their registered members. This service connects aesthetic practitioners with Dr. Spyros Vlachos, a renowned Plastic Surgeon and e-FILLERS’ Medical Advisor. Registered members can book a 20-minute session with Dr. Vlachos to discuss any

concerns, complications, or questions related to dermal filler treatments.

Whether you’re dealing with a challenging case or simply seeking a second opinion, this service offers invaluable guidance—and the best part? It’s completely free for registered e-FILLERS members. For those who prefer not to book a session, e-FILLERS also allows members to send in their questions via WhatsApp, ensuring that help is always at hand.

Why e-FILLERS is the go-to platform for aesthetic professionals

Beyond their Medical Advice service, e-FILLERS has built a reputation as a trusted partner for aesthetic practitioners. They offer an extensive selection of premium dermal fillers at some of the best prices in the industry, ensuring that you never have to compromise on quality. Whether you’re stocking up on favourites like Juvederm®, Stylage®, Restylane®, Teosyal®, and Radiesse® or exploring new options like Exosome and Polynucleotides Treatments, e-FILLERS make it easy to find exactly what you need.

The shopping experience at e-FILLERS is streamlined and efficient, with an easy-to-use website that allows for quick navigation and secure transactions. For those who prefer a more personalized approach, e-FILLERS offers a Personal Shopping Assistant service. You can place orders via phone or WhatsApp, receive exclusive offers, and even pay securely through a link sent directly from the bank.

Why expert support matters

In the rapidly evolving field of aesthetic medicine, having access to expert advice is more important than ever. Complications, though rare, can occur, and the ability to

manage them effectively is what separates good practitioners from great ones. e-FILLERS’ Medical Advice service provides the peace of mind that comes from knowing you have a seasoned expert in your corner, ready to assist whenever needed.

Ready to elevate your practice?

e-FILLERS is more than just a supplier—it’s a comprehensive support system designed to help aesthetic practitioners succeed. Whether you’re looking for the best prices on top-tier dermal fillers, an easy and secure shopping experience, or expert guidance when dealing with complications, e-FILLERS has you covered.

Join the e-FILLERS community today and take advantage of everything this platform has to offer. Register now to unlock exclusive benefits, including access to the Medical Advice service, and elevate your practice to new heights.

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LOCAL FAT REDUCTION AND LYMPHATIC DRAINAGE WITH CELLBOOSTER® SHAPE

Timur

Taskesen, MD, PhD, presents

an

innovative solution for local fat reduction and lymphatic drainage based on the CHAC technology by Suisselle

TIMUR TASKESEN, MD, PHD, is a board-certified dermatologist based in Switzerland

CELLBOOSTER® SHAPE

is a Class III medical device (CE0373), developed and fully produced by Suisselle, a leading medical aesthetic company based at Yverdon-les-Bains in Switzerland (certified ISO 22716, ISO 13485 and ISO 9001). This injectable device is designed to reduce local fat accumulation or deposits. It reduces water retention and diminishes puffiness by improving microcirculation and hydration. The uniqueness of this product is the hyaluronic acid reshaping complex thanks to the CHAC technology, which consists of stabilised hyaluronic acid (HA) with L-carnitine, vitamin C, and other active ingredients. HA hydrates the skin and supports tissue structure, while L-carnitine and vitamin C are critical components in fat metabolism, skin health, and lymphatic function.

CELLBOOSTER® SHAPE complex stabilised with CHAC technology

CELLBOOSTER® SHAPE utilises CHAC technology, a patented process designed to stabilise HA without the use of chemical binding agents, resulting in long-lasting effects. The stabilisation is achieved through a three-step process:

■ Formation of an HA matrix: High pressure and shear deformation are applied to the HA, leading to the unfolding and restructuring of its molecular chains. This step increases the HA’s interaction

with other components, enhancing its ability to form an initial stable and robust matrix

■ Cross-linking: The HA molecules are then cross-linked without any chemical agents using physical methods like controlled pressure and deformation are used. This creates a stable structure while maintaining the HA’s biological properties

■ Final stabilisation: The whole structure is strongly stabilised in solution to provide long-term efficacy when injected into the skin.

Overall, the in-house innovation available in the CELLBOOSTER® SHAPE helps to achieve the clinical benefits of an advanced skin booster: effective fat reduction and skin reshaping made possible by a gradual and optimal release of the nutrients and HA into the injected area.

Materials and methods

The CELLBOOSTER® SHAPE formulation consists of noncrosslinked hyaluronic acid (18 mg/6 ml) combined with L-carnitine and vitamin C. Studies have shown that L-carnitine plays a significant role in fat metabolism by facilitating the transport of fatty acids into the mitochondria for energy production, thus aiding in fat reduction1. Additionally, vitamin C, a potent antioxidant, supports collagen synthesis and strengthens the skin’s extracellular matrix, which can improve skin elasticity and overall appearance2

CELLBOOSTER® SHAPE Complex stabilised with CHAC technology

Local fat reduction and lymphatic drainage mechanisms

As we age, the natural fat-burning and lymphatic drainage mechanisms in our skin tend to decrease in efficiency. However, these processes can be revitalised by stimulating mitochondrial activity, the energy powerhouse of our cells. Mitochondria play a crucial role in fat burning through the beta-oxidation process. Fatty acids are broken down into acetyl-CoA, which then enters the Krebs cycle, a series of chemical reactions that generate ATP (adenosine triphosphate) the cell’s energy currency. This energy fuels various cellular functions, including the maintenance of metabolic processes that are essential for fat reduction. Additionally, efficient mitochondrial function supports the lymphatic system, which is responsible for removing waste and excess fluid from tissues. The enhancement of mitochondrial activity can, therefore, lead to improved lymphatic drainage, reducing water retention and contributing to a leaner appearance.

By boosting these natural mechanisms, interventions such as CELLBOOSTER® SHAPE can help counteract the effects of ageing, promoting both localised fat reduction and enhanced lymphatic drainage.

Results

Clinical observations indicate that treatments using CELLBOOSTER® SHAPE result in a noticeable reduction in local fat deposits and improved skin tone. L-carnitine’s ability to dilate subcutaneous arteries enhances blood flow and nutrient delivery to tissues, promoting healthier, more resilient skin3. Moreover, vitamin C’s role in stimulating elastin and collagen production contributes to the reduction of stretch marks and skin sagging, which are common concerns in areas with fat accumulation2

Conclusion

CELLBOOSTER® SHAPE effectively combines HA, L-carnitine, and vitamin C to target local fat deposits while promoting lymphatic drainage and improving skin health. The synergistic effects of these ingredients enhances the cosmetic appearance by reducing puffiness and fat and supports the structural integrity and elasticity of the skin, making it a valuable tool for treatments focused on body contouring and rejuvenation.

Safety and efficacy profile of L-carnitine

Minimised side effects

L-carnitine has a lower incidence of side effects when compared to phosphatidylcholine (PPC) and deoxycholic acid (DC). Injections of PPC and DC have been associated with adverse reactions such as inflammation, pain, and scarring at the injection site.

Inherent Metabolic Pathway:

In contrast to PPC and DC, L-Carnitine operates within the body’s innate metabolic pathways by facilitating the transport of fatty acids into mitochondria for energy conversion. Its mode of action does not interfere with product safety and biocompatibility.

Alignment with skin health

L-carnitine’s inclusion in formulations aimed at enhancing skin health is a testament to its beneficial properties. Its antioxidant activity and potential role in supporting cellular energy metabolism can contribute to skin rejuvenation and overall skin health. This alignment with skin health provides additional advantages beyond its primary function of reducing fat deposits.

Boosted energy production

By facilitating the transport of long-chain fatty acids into mitochondria, L-carnitine has the potential to enhance energy production. This could yield benefits beyond fat reduction alone, such as improved exercise performance or increased overall energy levels. Such effects may not be readily achievable with PPC or DC injections, which do not directly influence energy metabolism.

Application versatility

L-carnitine’s versatility extends beyond fat reduction treatments. Its role in supporting energy metabolism and skin health makes it a valuable ingredient in various cosmetic formulations. This flexibility allows L-carnitine to be included in products addressing diverse cosmetic concerns, such as cellulite reduction or skin rejuvenation.

“CELLBOOSTER® SHAPE effectively combines HA, L-carnitine, and vitamin C to target local fat deposits while promoting lymphatic drainage and improving skin health.”

References

1. Alizadeh Z, Halabchi F, Mazaheri R, et al. Review of the Mechanisms and Effects of Noninvasive Body Contouring Devices on Cellulite and Subcutaneous Fat. Int J Endocrinol Metab. 2016; 14 (4):e36727. doi: 10.5812/ijem.36727. PMID: 28123436

2. Pullar JM, Carr AC, Vissers MCM. The Roles of Vitamin C in Skin Health. Nutrients. 2017; 9(8):866. https://doi.org/10.3390/nu9080866

3. Cipolla, Marilyn J. et al. Propionyl-L-carnitine dilates human subcutaneous arteries. Journal of Vascular Surgery, Volume 29, Issue 6, 1097–1103

ANTI-AGEING EFFECTS AND DERMAL REGENERATION OF SIMILDIET EXOSOMES

Exploring the rejuvenating potential of Melissa spp.-derived exosomes in skin regeneration and anti-ageing therapies

Efficacy of Melissa spp. derived exosomes in necrotic wound repair: a bioactive approach

Materials and Methods

Study Design

The primary objective was to assess the potential of these exosomes to counteract infection and minimise scar tissue formation. The study enrolled a 30-year-old male participant who developed necrotic wounds subsequent to undergoing

laser-assisted liposuction in the double chin region.

Materials

The exosome preparation used in the study was supplied by Simildiet Laboratorios, Spain. The preparation consists of two phases:

■ Phase One: Melissa spp.-derived exosomes 18 mg (15 x 109). The active ingredients within the exosomes include hepatocyte growth factor (HGF), vascular

endothelial growth factor (VEGF), acidic fibroblast growth factor (aFGF), basic fibroblast growth factor (bFGF), keratinocyte growth factor (KGF), insulin-like growth factor 1 (IGF-1), and cytokines.

Phase two: Exosome diluent (5 ml) containing active ingredients such as dimethylaminoethanol tartrate, sodium hyaluronate, acetyl octapeptide-3, hexapeptide-10, pentapeptide-18, hydrolysed DNA and RNA, magnesium aspartate, copper and zinc, acetyl hexapeptide-30, acetyl hexapeptide-8, acetylarginyltryptophyl diphenylglycine, N-prolyl palmitoyl tripeptide-56 acetate, and mannan.

Since Phase One is in a lyophilised powder form, it is dissolved by mixing with the exosome diluent to prepare it for injection.

SABUHI ABILOV, MD, Board Certified Maxillo-Facial Plastic Surgeon, Azerbaijan; AYTAN MIRZALIYEVA, MD, Surgeon, Cosmetologist, Aesthetic Doctor in Medline Aesthetic Clinic, Azerbaijan; CARLOS AZNAR SÁNCHEZ, MD, Master in Aesthetic medicine by L’Union International de Médecine Esthétique, General Manager of Simildiet Laboratorios; HELENA SOKOLOVSKAIA, MD, Pharmacologist, Ukraine; ANNA BOHACHOVA, MD, Dermatologist, Ukraine

Figure 1 (A) Necrotic wound (B) after treatment with exosomes

Treatment protocol

To accelerate the healing of the wound and enhance the reparative potential of the tissue, an injection of Melissa spp.-derived exosomes (15x 109 exosome particles/5ml) was administered both into and around the wound area.

For treatment, the wound and the surrounding area were cleansed according to aseptic principles, and this procedure was repeated at every visit.

The diluted exosome preparation was injected into and around the wound area every three days for 1 week, using Dr. Sabuhi Abilov's specific technique for this clinical case: 0.5 ml per injection. The distance between injection points was 2–3 mm, and the injection depth was 2–4 mm.

Results

The outcome of this study was that we observed the healing of necrotic wounds within a week of initiating treatment with Melissa spp.-derived exosomes. The area of the wound rapidly progressed through all phases of healing, culminating in the formation of minimal scar tissue.

Innovative anti-ageing therapies: case studies and

results

Treatment Protocol

Sokolovskaia Helena developed an innovative anti-ageing therapy utilising Simildiet Antiaging Exos, a powerful product designed to combat the signs of ageing. A 45-year-old patient underwent this treatment, which consisted of two sessions where 2.5 ml of Simildiet Antiaging Exos was administered each time, with a 15-day interval between sessions. The injections,

“The results were highly satisfactory, showing a significant reduction in pronounced wrinkles in the treated areas. This outcome highlights the efficacy of Simildiet Antiaging Exos in visibly reducing the signs of ageing in middle-aged patients.”

using the micro-papular technique, were targeted around the eyes and the corners of the mouth, areas most prone to wrinkles and fine lines. The results were highly satisfactory, showing a significant reduction in pronounced wrinkles in the treated areas. This outcome highlights the efficacy of Simildiet Antiaging Exos in visibly reducing the signs of ageing in middle-aged patients.

Treatment protocol

Dr. Bohachova Anna, a qualified dermatologist, has implemented an antiaging therapy protocol using Simildiet Antiaging Exos. A 35-yearold patient who presented with fine

wrinkles and dehydrated skin was selected for this advanced treatment, which consisted of two sessions where 5 ml of Simildiet Antiaging Exos was administered in each, with a 15-day interval between sessions. The injections, using the micropapular technique, were applied to the face and neck.

The results of the treatment were impressive, showing rapid skin recovery and a reduction in wrinkles. This protocol highlights the effectiveness of the micro-papular technique in addressing fine wrinkles and improving skin hydration in younger patients.

Find out more at: simildiet.com

Figure 2 (A) Wrinkles evident around the eyes, (B) after two sessions of exosome injections

Figure 3 (A) Patient with fine wrinkles and dehydrated skin, (B) after two exosome treatments

EXOBALM: OPTIMISED REGENERATIVE SKINCARE

Diane Duncan, MD, and Prof. Kwi-Young Park, describe the novel use of exosomes to treat pain and severe radiation burns post radiotherapy

URGENT

SITUATIONS

can stimulate the birth of innovative solutions when the standard care is not working. Four years ago, a patient with a burn showed up in my office because the emergency room declined to care for her. It was the peak of the COVID-19 epidemic, and only critical care was available.

This patient had undergone chemotherapy and aggressive radiation for metastatic breast cancer. She had a severe radiation burn as well as pulmonary impairment from the radiation. The standard care, silver sulfadiazine, was not working. The patient was in excruciating pain, was short of breath, and felt that her current care plan was falling short.

I had been treating my resurfacing patients with topical exosomes for a post-care solution with great success. After educating the patient about the regenerative and healing potential of exosomes,

we applied the lyophilised exosome and HA based diluent mixture to her burns. She noted immediate relief the moment the solution touched her skin ( Figure 1 ). The challenge was the need for continuing application, as the solution dries when placed upon the skin. Four vials a day were needed, and the interval between applications was challenging for the patient. A clear need for ongoing pain relief was evident.

In a recent clinical study conducted by Prof. Kwi-Young Park on patients undergoing radiotherapy, ExoBalm™ demonstrated a 68% reduction in pain, a statistically significant outcome that further highlights its therapeutic value. A visual representation of this pain reduction has been included in the form of a figure in the study ( Figure 2 ). The findings of the study align with my experience, as within 5 days of use, the patient’s burns had healed and, by day 9, the majority of redness had

diminished. This underscores the effectiveness of ExoBalm™ as a post-care solution.

The first edition of Exobalm combined Aquaphor, essential lipids, squalane, and two vials of lyophilised exosomes reconstituted with diluent. The concept of ongoing pain relief was eagerly accepted by the patient. She used the compounded mixture 4–6 times a day.

Within 5 days of use, her burns were healed. At 9 days, the majority of redness was gone. The value of topical exosomes was clear to me. I continue to use Exobalm on a daily basis with outstanding results.

It can be challenging to choose the right exosome for use in your clinic because there are so many to choose from. The FDA does not allow injection of exosomes; there is no current indication. FDA jurisdiction does not extend to topical cosmetic use. Even so, impure formulations or lack of proper preservation can cause

DIANE DUNCAN, MD, FACS, is a board-certified plastic surgeon, Fort Collins, CO, USA, PROF. KWI-YOUNG PARK, Seoul, Korea

Figure 1 A 56 year old with severe radiation burn. (A) Patient before Exobalm, (B) 5 days later (C) 9 days later

patient problems. Occasionally, pink-coloured conditioned media is sold as ‘exosomes’. Because most fluids contain exosomes, many brands of cosmetics claim them as an ingredient, though they may be few in number and not therapeutic. It is important to choose an exosome source that is produced in a cGMP facility and from a lab that is routinely FDA-inspected. Donor screening of the exosome source is very important. Isolation and purification techniques should be top quality, and exosomes should not contain ‘filler’ or other substances. Lyophilisation is a great way to ensure stability. Most exosome formulations require freezing or refrigeration until use. Exobalm can be kept in a refrigerator from 2–8 degrees centigrade after mixing the powder with the cream.

ExoCoBio has created a unique product that combines a regenerative, soothing base with a lyophilised exosome powder for use after clinical procedures as a post-care product. The product recently won the AMWC Award in Monaco for the Best New Cosmetic product.

The best use of Exobalm is periprocedural, particularly as part of the ExoPriming™ protocol, although it is also a wonderful balm for daily facial use. ExoPriming™ involves prepping the skin before any resurfacing procedure by applying Exobalm morning and night for 1-2 weeks. This will optimise the skin’s moisture content, enhancing the effect of energybased devices. Exobalm is perfect for immediate application right after a procedure, ensuring continued skin hydration and care.

Figure 2

ExoBalm™ demonstrated a 68% reduction in pain, a statistically significant outcome that further highlights its therapeutic value

“Within 5 days of use, her burns were healed. At 9 days, the majority of redness was gone. The value of topical exosomes was clear to me. I continue to use Exobalm on a daily basis with outstanding results.”

Industry events in 2024/25 for the aesthetic and anti-ageing market

EUROPE

3–5 OCTOBER 2024

Agorà 2024 Milan, Italy

www.congressomedicinaestetica.it/

28–30 NOVEMBER 2024

State of the Art in Plastic Surgery (SOAP) 2024 Bremen, Germany www.soap-meeting-bremen.de

14–15 MARCH 2025

Aesthetics Conference and Exhibition London, UK www.aestheticsconference.com

27–29 MARCH 2025

AMWC Monaco 2025 Monte Carlo, Monaco www.amwc-conference.com

29–31 MAY 2025

5-CC World Congress Lisbon, Portugal www.5-cc.com

29–31 MAY 2025

EURAPS 2025

Palma de Mallorca, Spain www.euraps.org

12–14 JUNE 2025

Beauty Through Science Stockholm, Sweden www.btsstockholm.com/

18–21 JUNE 2025

International Congress Of Dermatology Rome, Italy www.icd2025rome.org/

REST OF WORLD NORTH AMERICA

17–20 OCTOBER 2024

ASDS Annual Meeting Orlando, Florida www.asds.net

23–27 OCTOBER 2024

American Dermatological Association Meeting Seattle, Washington ada1.org/

6–8 FEBRUARY 2024

South Beach Symposium Miami, Florida www.southbeachsymposium.org

18–20 OCTOBER 2024

AMWC China Chengdu, China en.amwcchina.com/

10–11 NOVEMBER 2024

AMWC Japan Tokyo, Japan www.amwc-japan.com/en

21–23 NOVEMBER 2024

AMWC Southeast Asia Bangkok, Thailand www.amwc-southeastasia.com