Hyperdiluted Calcium Hydroxylapatite 1:2 for Mid and Lower Facial Skin Rejuvenation: Efficacy and Safety

Guided SEFFI and CaHA: A Retrospective Observational Study of an Innovative Protocol for Regenerative Aesthetics

Background/Objectives: This retrospective observational study sought to determine the efficacy and safety of an innovative combined treatment protocol using guided Superficial Enhanced Fluid Fat Injection (SEFFI) and calcium hydroxylapatite (CaHA) in facial rejuvenation. Methods: A total of 158 patients (149 females and 9 males) underwent the combined treatment of guided SEFFI and diluted/hyperdiluted CaHA. The study evaluated treatment outcomes at 30, 90, and 150 days post-treatment using the Global Aesthetic Improvement Scale (GAIS) and three-dimensional photogrammetric analysis. Results: The combined treatment demonstrated consistent enhancement in skin quality and facial volume across temporal, malar, zygomatic, and jawline regions. At 90 days post-treatment, substantial improvements were observed, with the GAIS scores reflecting significant enhancements in both skin quality and volume, which were sustained or slightly improved by 150 days. Minor complications, predominantly ecchymosis at the injection sites, resolved within a week, confirming the treatments' safety. Conclusions: The integration of guided SEFFI and CaHA resulted in significant improvements in skin quality and facial volume with minimal complications. Further research is recommended to consolidate these findings and explore long-term outcomes.

A systematic review of Radiesse® (calcium hydroxylapatite): evidence and recommendations for the body

A filler composed of calcium hydroxylapatite and carboxymethylcellulose gel (CaHA/CMC) has been shown to possess biostimulatory and skin-tightening properties that have been applied not just to the face but also to the body to boost rejuvenation. Recently, evidence and recommendations for CaHA/CMC treatment of the face have been provided, but they are still lacking in terms of body treatment. This article aims to perform a systematic review of the literature on CaHA/CMC applications on the body and provide evidence from the literature. Currently, the only FDA-approved indication on the body is treating the hands and a recent European Union Medical Device Regulation approval has been released for decolletage treatment. The application of hyperdilutions on the neck, feet, arms, thighs, abdomen, and other body parts has been proven to provide a skin-tightening effect. However, despite their wide use with a good safety profile in clinical practice, recent trends and guidelines of diluted and hyperdiluted CaHA/CMC have yet to be supported by randomized controlled trials.

Analysis of the Morphology, Rheology, and Clinical Applicability of a Hybrid Injectable with Hyaluronic Acid and Hydroxyapatite

BACKGROUND

Treating signs of aging requires skeletal restructuring, facial contour redefinition, and sagging skin treatment. Hence, HarmonyCa® was recently introduced in the market, combining hyaluronic acid and hydroxyapatite. However, there are no studies evaluating the physicochemical properties of this material.

PURPOSE

To analyze the morphology, rheology, and clinical applicability of HarmonyCa® over a 180-day follow-up.

METHODS

A morphological analysis with scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS) and rheology measurement with a rheometer. The clinical applicability analysis included a tissue ptosis patient who received the product and was reassessed 30 and 180 days after applying HarmonyCa®.

RESULTS

SEM and EDS analyses showed two distinct morphologies related to hydroxyapatite and hyaluronic acid. The rheological measurements of HarmonyCa® showed G' and G″ of 51.56 and 44.01 Pa, respectively. The tan δ value was 0.8503, and G* was 108.1 Pa. The clinical outcomes were satisfactory.

CONCLUSION

HarmonyCa® presents a good synergy between hyaluronic acid and hydroxyapatite. Also, the rheological analysis showed moderate viscosity for the product, with a clinical indication for subcutaneous application.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hyperdilute Calcium Hydroxylapatite for the Treatment of Perioral Rhytids: A Pilot Study

Background

The perioral region plays a crucial role in facial aesthetics and is susceptible to age-related changes, such as wrinkles and fine lines due to its dynamic nature. Type I collagen is crucial in providing structural integrity and resilience to the skin. Calcium hydroxylapatite (CaHA-CMC) is a widely used dermal filler whose particles stimulate fibroblastic responses within the skin. When diluted, CaHA-CMC has emerged as a useful treatment for collagen stimulation.

Objectives

The objective of the study is to evaluate the efficacy and safety of hyperdilute CaHA-CMC at a 1:3 ratio, specifically administered in the perioral area, to assess its impact on deep rhytids and overall skin quality.

Methods

Females aged 40 to 70 years with moderate-to-severe wrinkles in the perioral region based on a validated wrinkle scale were injected with hyperdilute CaHA-CMC throughout the perioral region at 2 separate injection intervals (Weeks 1 and 8). This was followed by an injection of hyaluronic acid (CPM-HA22.5) into the perioral region at Week 16. The primary endpoint was a ≥1-point improvement from baseline on the wrinkle grading scale.

Results

Twelve female participants were treated. Investigator and patient ratings based on the 5-point Merz perioral/lip wrinkle grading scale showed at least 1 grade improvement in 83% of the patients with a P-value of .0156. A majority of both investigators and patients rated their lip wrinkles as improved in appearance compared with their baseline.

Conclusions

Hyperdilute CaHa-CMC at a 1:3 dilution may be a safe and effective treatment for improving the depth and overall appearance of perioral rhytids.

Level of Evidence 4

A systematic review of Radiesse/calcium hydroxylapatite and carboxymethylcellulose: evidence and recommendations for treatment of the face

Radiesse® is a filler composed of calcium hydroxylapatite microspheres suspended in a carboxymethylcellulose gel (CaHA/CMC). It has robust rheological properties that have been associated with its versatility. CaHA/CMC is employed for both on-label indications of filling wrinkles or lines, volumizing, and contouring of areas as well as off-label indications aiming at biostimulation and skin tightening. However, despite the expanding use of CaHA/CMC, overall evidence and recommendations for treatment are currently lacking. This paper aims to provide an up-to-date overview of CaHA/CMC clinical applications, together with a level of evidence of supporting literature, focusing on the face. Based on the data, CaHA/CMC may be considered a safe and effective treatment option for cheeks, jawline, HIV-related facial lipoatrophy, and nasolabial folds. Treatment of marionette lines, chin, pre-jowl, and corner of the mouth also tends to respond with a high degree of efficacy. Despite the recent trend, guidelines, and safety profile of diluted and hyperdiluted Radiesse® , no randomized controlled trials have been published.

Neurotoxin in the Lower Third of the Face

Botulinum toxin A (BT) is the most required treatment in face rejuvenation. However, applications of BT on the lower third are off-label and specific tips for the treatment of this area should be taken into account to achieve best results. In the current study, literature concerning BT treatment of lower face has been revised and summarized according to anatomy and indications, tips, and complications. BT treatment of the lower face has been reported to be effective and safe when performed with adequate knowledge of anatomy and techniques.

Starting Point for Protocols on the Use of Hyperdiluted Calcium Hydroxylapatite (Radiesse®) for Optimizing Age-Related Biostimulation and Rejuvenation of Face, Neck, Décolletage and Hands: A Case Series Report

Radiesse® is a dermal filler made of calcium hydroxylapatite, a natural component of the human body, which, in diluted and hyperdiluted forms, promotes, unlike other fillers, neocollagenesis, neoelastinogenesis, fibroblast proliferation, and angiogenesis, leading to a long-term improved skin quality, elasticity, tightening, and firmness. This case series examined the use of Radiesse® (Merz, Frankfurt, Germany) for skin rejuvenation and regeneration through a long-lasting action of collagen biostimulation. The report explored for the first time the use of different dilution ratios of Radiesse® in 50 patients of varying ages and skin needs. By combining microboluses, tunneling, and/or fanning techniques, Radiesse® was superficially injected in different body regions, including the full-face, neck, décolletage, and hands. The treatment was effective in improving skin thickness, laxity, and wrinkles in 95% of 30-40 year-olds, 80% of 40-60 year-olds, and 70% of >60 year-olds, with an average improvement of 81.6% for the general population. The treatment was well-tolerated with no significant adverse effects reported. The report also describes specific cases and includes pictures comparing the baseline condition to the changes obtained after different months and Radiesse® sessions. The patients reported a clear improvement in skin firmness and brightness, as well as a visible improvement in wrinkles' appearance. This report found that diluting and hyperdiluting Radiesse® with flexible dilution ratios favoured a treatment's individualization, providing improved skin quality, elasticity, tightening, and firmness, without volume augmentation. In conclusion, it highlights the versatility and flexibility of Radiesse® and emphasizes its efficacy and safety in skin rejuvenation and regeneration.

Ultrasonographic Patterns of Calcium Hydroxyapatite According to Dilution and Mix With Hyaluronic Acid

OBJECTIVES

To assess the ultrasonographic patterns of different calcium hydroxyapatite (CaHA) formulations, including the undiluted, diluted, and mixed with hyaluronic acid (HA) compounds.

METHODS

To review the ultrasonographic images of patients ≥18 years with confirmed injections of CaHA clinically and ultrasonographically, and without different concomitant types of fillers in the same region or other systemic or localized cutaneous diseases.

RESULTS

Twenty-one patients met the criteria (90% female; 10% male; mean age: 52 years ± 12.8). Of these, 33.3% have been injected with an undiluted formulation, 33.3% with diluted, and 33.3% with a mixed formulation. All cases were studied with devices presenting frequencies that ranged from 18 to 24 MHz. Twelve cases (57%) were also studied with the 70 MHz. The ultrasonographic patterns of CaHA presented differences in the presence and intensity of PAS and the degree of inflammation according to the dilution and mix with HA. Diluted formulations show a milder intensity posterior acoustic shadowing (PAS) artifact than undiluted at 18-24 MHz. In mixed formulations, 57% showed mild PAS, and 43% demonstrated no PAS artifact at 18-24 MHz, besides fewer inflammatory changes in the periphery of the deposits.

CONCLUSIONS

The ultrasonographic patterns of CaHA show differences in the presence and intensity of PAS and the degree of inflammation according to the dilution and mix with HA. Awareness of these ultrasonographic variations can support better discrimination of CaHA.

Guided Superficial Enhanced Fluid Fat Injection (SEFFI) Procedures for Facial Rejuvenation: An Italian Multicenter Retrospective Case Report

BACKGROUND

The aging process starts in the center of the face, in the periocular region and around the mouth, with a combination of volume loss, tissue descent, deepened wrinkles, and the loss of skin structure and quality. Recently, several studies have demonstrated the efficacy of therapies based on autologous adipose tissue grafting, which leverages the properties of stromal vascular fraction (SVF) and adipose-derived mesenchymal stem cells (ADSCs) to accelerate the regenerative processes of the skin. This study aims to verify the ability of guided superficial enhanced fluid fat injection (SEFFI) in the facial area to correct volume loss and skin aging, proving that this standardized procedure has a very low rate of complications.

METHODS

We retrospectively collected data from 2365 procedures performed in Italian centers between 2019 and 2021. Guided SEFFI was performed alone or combined with cosmetic treatments, including the use of hyaluronic acid filler, suspension threads, synthetic calcium hydroxylapatite, botulin toxin, and microneedling.

RESULTS

guided SEFFI was used alone in more than 60% of the patients and in all facial areas. In about one-tenth of the patients, guided SEFFI was combined with a botulin toxin treatment or hyaluronic acid filling. Other procedures were used more rarely. Ecchymosis in the donor or injection sites was the most frequent adverse event but was only observed in 14.2% and 38.6% of the patients, respectively.

CONCLUSIONS

The guided SEFFI technique is standardized and minimally invasive, leading to very few complications. It constitutes a promising antiaging medical treatment that combines effectiveness, safety, and simplicity.

Skin regeneration-related mechanisms of Calcium Hydroxylapatite (CaHA): a systematic review

Introduction

Calcium Hydroxylapatite (CaHA) is a common dermal filler used in aesthetic medicine for volumizing and contouring. Understanding mechanisms of actions of CaHA can help improve our understanding of its clinical applications.

Methods

We performed a systematic review to summarize the skin-regeneration related mechanisms of CaHA. Five bibliographic databases were searched for English-language publications that evaluated CaHA in skin regeneration outcomes including neocollagenesis, cell proliferation and growth factors, angiogenesis, vascular dynamic and inflammatory markers, among others. Methodological rigor of included studies was assessed.

Results

Of 2,935 identified citations, 12 studies were included for final analysis. Collagen production was reported by nine studies, cell proliferation by four, elastic fibers and/or elastin by four, and three studies on angiogenesis, while limited studies were available on the other outcomes. Six were clinical/observational studies. Only seven studies had a control group. Overall, studies showed CaHA resulted in increased cell proliferation, increased collagen production and angiogenesis, as well as in higher elastic fiber and elastin formation. Limited and inconclusive evidence was available on the other mechanisms. The majority of the studies had methodological limitations.

Discussion

Current evidence is limited but indicates several mechanisms through which CaHA could lead to skin regeneration, volume enhancement, and contouring.

Systematic review registration

https://doi.org/10.17605/OSF.IO/WY49V.

Laser Treatment Monitoring with Reflectance Confocal Microscopy

Laser treatments have become popular in Dermatology. In parallel to technologic development enabling the availability of different laser wavelengths, non-invasive skin imaging techniques, such as reflectance confocal microscopy (RCM), have been used to explore morphologic and qualitative skin characteristics. Specifically, RCM can be applied to cosmetically sensitive skin areas such as the face, without the need for skin biopsies. For these reasons, apart from its current use in skin cancer diagnosis, our systematic review reveals how RCM can be employed in the field of laser treatment monitoring, being particularly suitable for the evaluation of variations in epidermis and dermis, and pigmentary and vascular characteristics of the skin. This systematic review article aims to provide an overview on current applications of RCM laser treatment monitoring, while describing RCM features identified for different applications. Studies on human subjects treated with laser treatments, monitored with RCM, were included in the current systematic review. Five groups of treatments were identified and described: skin rejuvenation, scar tissue, pigmentary disorders, vascular disorders and other. Interestingly, RCM can assist treatments with lasers targeting all chromophores in the skin and exploiting laser induced optical breakdown. Treatment monitoring encompasses assessment at baseline and examination of changes after treatment, therefore revealing details in morphologic alterations underlying different skin conditions and mechanisms of actions of laser therapy, as well as objectify results after treatment.

Hyperdiluted calcium hydroxylapatite for the treatment of skin laxity of the neck

Despite being a common concern, there are very few minimally invasive treatments targeting neck skin laxity (NSL) reported in the literature. To assess the efficacy of hyperdiluted calcium hydroxyapatite (hy-CaHA) for the treatment of NSL, according to the NSL scale, and to estimate safety. Twenty patients showing NSL were treated with hy-CaHA 1:2. To evaluate the efficacy of hy-CaHA treatment for NSL, pictures of treated subjects were collected before and 3 months after treatment and graded according to the NSL scale, and T-student's test was applied to estimate differences. Hy-CaHA for the neck was effective according to the previously unreported NSL scale (p < 0.001) and safe. There were no major adverse events reported. This study supports the efficacy (according to the NSL scale) and safety of hy-CaHA (1:2) for NSL. Our results also highlight the utility of the newly developed NSL scale, being a useful tool to evaluate the level of NSL before treatment and to measure the outcome.

Reflectance Confocal Microscopy of Aging Skin and Skin Cancer

Skin aging is a complex process that causes morphologic variations. Some of these variations have been hypothesized to be involved in skin cancer development. This paper reviews current knowledge of the features of aged skin as seen with reflectance confocal microscopy (RCM). Basic principles of the technique are described, and the RCM features of healthy skin and skin cancer are briefly discussed. Moreover, the RCM features at different layers of young and elderly skin are described, as are the variations that occur with passing years and in relation to sun exposure that contribute to photoaging and the development of skin cancer. RCM enables the noninvasive evaluation, at quasi-histologic resolution, of aging-related skin changes, some of which are shared with skin cancer; this ability helps avoid skin biopsy. Further research is needed to understand the relation between skin aging and skin cancer development.

A plea for standardization of confocal microscopy and optical coherence tomography parameters to evaluate physiological and para-physiological skin conditions in cosmetic science

Non-invasive reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) have been extended to the dermo-cosmetic field, for skin pathophysiology understanding and therapeutics monitoring. However, standardized methodology and parameters to interpret structures and changes in these settings are still lacking. Present study aimed to propose a validated standard methodology and a list of defined parameters for objective non-pathological skin assessments in the cosmetically sensitive cheekbone area of the face. OCT and RCM quantitative, semi-quantitative and qualitative features were considered for assessments. Validation process included 50 sets of images divided into two age groups. Inter-rater reliability was explored to assess the influence of the proposed methodology. Quantitative OCT parameters of "epidermal thickness," "density and attenuation coefficients" and "vascular density" were considered and calculated. Severity scales were developed for semi-quantitative OCT features of "disruption of collagen" and "vascular asset," while extent scales were produced for semi-quantitative RCM "irregular honeycomb," "mottled pigmentation" and "polycyclic papillary contours." Qualitative assessment was obtained for RCM type of collagen, and comparison between age groups was performed for all features considered. Severity visual scales assistance proved excellent inter-rater agreement across all semi-quantitative and qualitative domains. The assistance of shareable software systems allows for objective OCT quantitative parameters measurement. The use of standard reference scales, within a defined assessment methodology, offers high inter-rater reliability and thus reproducibility for semi-quantitative and qualitative OCT and RCM parameters. Taken together, our results may represent a starting point for a standardized application of RCM and OCT in dermo-cosmetic research and practice.

Clinical Applications of In Vivo and Ex Vivo Confocal Microscopy

Confocal laser scanning microscopy (CLSM) has been introduced in clinical settings as a tool enabling a quasi-histologic view of a given tissue, without performing a biopsy. It has been applied to many fields of medicine mainly to the skin and to the analysis of skin cancers for both in vivo and ex vivo CLSM. In vivo CLSM involves reflectance mode, which is based on refractive index of cell structures serving as endogenous chromophores, reaching a depth of exploration of 200 μm. It has been proven to increase the diagnostic accuracy of skin cancers, both melanoma and non-melanoma. While histopathologic examination is the gold standard for diagnosis, in vivo CLSM alone and in addition to dermoscopy, contributes to the reduction of the number of excised lesions to exclude a melanoma, and to improve margin recognition in lentigo maligna, enabling tissue sparing for excisions. Ex vivo CLSM can be performed in reflectance and fluorescent mode. Fluorescence confocal microscopy is applied for “real-time” pathological examination of freshly excised specimens for diagnostic purposes and for the evaluation of margin clearance after excision in Mohs surgery. Further prospective interventional studies using CLSM might contribute to increase the knowledge about its application, reproducing real-life settings.

Hyperdiluted calcium hydroxylapatite for skin laxity and cellulite of the skin above the knee: A pilot study

Despite an increasing request for skin rejuvenation above the knee, very few treatment options have been reported in literature. To evaluate the efficacy and safety of 1:4 hyperdiluted calcium hydroxylapatite (CaHA) in the treatment of skin laxity and dimples of the skin above the knees. A retrospective evaluation of hyperdiluted CaHA treatment for skin laxity and dimples above the knee was performed. Efficacy was classified as blinded evaluation of pre (T0) and 3-month post-treatment (T1) photographs by three investigators according to the validated knee cellulite severity score (KCSS) and patient satisfaction. Safety was evaluated through pain scores and adverse events evaluation. A significant reduction of KCSS at T1, as compared to T0, mainly in subjects with lower KCSS at T0, was observed (P < .05). All blinded assessments resulted in a correct identification of T0 and T1 pictures and evaluations of all investigators were found to be consistent and reliable. All patients were satisfied. Only minor adverse events (swelling, erythema, bruising, and skin irregularities) were reported, lasting 2 to 3 weeks after treatment. Our preliminary results highlight the efficacy and safety of hyperdiluted CaHA in the treatment of skin laxity and cellulite above the knees.