Facial skin revitalization with CPM®-HA20G: an effective and safe early intervention treatment

The Anatomical Layering Assessment: The Construction of Beauty

Restructuring an aging face from bone structure to the surface of the skin can be metaphorically compared to building and renovating a house. While each anatomical layer of the face undergoes an aging process of its own, there is also an interdependency of superficial structures on deeper layers, so that a change in one layer may lead to changes to the adjacent layers. This interaction among the structures deep into the skin, along with the skin's ability to envelope them is what determine the aspect of the aging face. Thus, a careful assessment of all the layers is imperative and we describe herein a step-by-step facial layering assessment and facial restructuring approach from bone structure to the surface of the skin to implement a treatment plan able to deliver a harmonious rejuvenating outcome.

Skin boosters: Definitions and varied classifications

BACKGROUND

The concept of "skin boosters" has evolved, marking a shift from traditional uses of hyaluronic acid (HA) fillers primarily for augmenting skin volume to a more diverse application aimed at improving dermal conditions. Restylane Vital and other HA fillers have been repurposed to combat skin aging and wrinkles by delivering HA directly to the dermis.

OBJECTIVES

This review aims to define the term "skin booster" and to discuss the various components that constitute skin boosters. It seeks to provide a comprehensive overview of the different ingredients used in skin boosters, their roles, and their impact on enhancing dermal conditions.

METHODS

A comprehensive review was conducted, focusing on representative skin booster ingredients. The approach involved analyzing the different elements used in skin boosters and their specific roles in enhancing dermal improvement.

RESULTS

The findings indicate that skin boosters, encompassing a range of ingredients, are effective in improving the condition of the skin's dermis. The review identifies key ingredients in skin boosters and their specific benefits, including hydration, elasticity improvement, and wrinkle reduction.

CONCLUSIONS

Skin boosters represent a significant development in dermatological treatments, offering diverse benefits beyond traditional HA fillers. This review provides valuable insights into the constituents of skin boosters and their effectiveness, aiding readers in making informed decisions about these treatments. The potential of skin boosters in dermatological practice is considerable, warranting further research and application.

An absence of imperfections: A proposed framework for defining, assessing, and achieving skin glow

BACKGROUND

Skin glow is a subcomponent of skin quality. It has become entrenched in the cosmeceuticals and aesthetics lexicons as a synonym for health and youth, but is not well-defined as a scientific metric.

AIMS

To examine the concept of skin glow and determine if it is an objective concept that can be defined and quantified.

METHODS

Literature review was used to develop a survey on current concepts relating to skin quality. The survey results were analyzed descriptively and presented to a focus group comprising five dermatologists and four aesthetic physicians. This group then discussed the concept of skin glow, how to define it and what metrics could be used to assess it.

RESULTS

Surveyed practitioners (n = 38) ranked skin quality as the fourth most important factor related to a person's overall aesthetic first impression. Almost all (95%) respondents reported routinely assessing skin quality, citing serial photography (83%), and visual inspection (67%) as the main means of achieving this. The focus group defined skin glow as even reflectance from an unaffected papillary and reticular dermal collagen layer, which is created only when skin does not exhibit any characteristics that detract from this even reflectance. Due to its complexity, the focus group proposed a hierarchal framework for assessment, encompassing patient self-rating, practitioner severity rating, and supplemental use of validated measurement devices.

CONCLUSIONS

Skin glow can be defined and quantified. More work is warranted to develop a practical skin glow assessment tool suitable for use in the clinic setting.

The Effectiveness of Injectable Hyaluronic Acid in the Improvement of the Facial Skin Quality: A Systematic Review

Background

Several studies have evaluated the role of various injectable formulations of hyaluronic acid (HA) in the improvement of the quality of facial skin. It is important to systematically summarize the available evidence in this regard.

Methods

Relevant databases were searched for clinical studies that evaluated the therapeutic role of any injectable formulation of HA in improving the quality of facial skin in adult humans until 31 December 2022. The available studies were critically analyzed and the data were extracted.

Results

A total of 2996 articles were screened and 13 studies were finally included. Eight studies evaluated the effect of various formulations of HA alone, while five evaluated the effect of various formulations of HA along with other active ingredients (cocktails) on the quality of facial skin. All types of HA formulations cause a significant improvement in facial skin quality, in terms of hydration, firmness, skin-tiring effect/fatigue, brightness, texture, radiance, and elasticity. The effect of HA monotherapy was more pronounced than that of the cocktail ingredients. HA treatment was quite safe and the patient satisfaction level was high.

Conclusion

The clinical evidence on the use of injectable HA alone in the improvement of the quality of facial skin, in terms of hydration, firmness, skin-tiring effect/fatigue, brightness, texture, radiance, and elasticity, is quite promising. Large randomized controlled trials are required in this regard.

A Multicenter Noninferiority Study Comparing Safety and Effectiveness of Hyaluronic Acid Fillers for Correction of Nasolabial Folds in Chinese Subjects

Hyaluronic acid fillers are the preferred choice for minimally invasive facial volume restoration. In this study, a split-face design was used to compare the effectiveness and safety results of Belotero Balance Lidocaine (BEL) and Restylane (RES, control) to investigate whether BEL is noninferior compared with RES in nasolabial fold (NLF) correction.

Methods

This was a prospective, controlled clinical study in Chinese subjects. Subjects with symmetrical moderate NLFs according to the Wrinkle Severity Rating Scale were randomized to receive BEL in one NLF and RES in the other. The primary objective was to investigate whether BEL is noninferior compared with RES after being injected mid-dermally in moderate NLFs after 6 months. Secondary objectives included responses at other visits and pain sensation. Treatment-emergent adverse events (TEAEs) were assessed.

Results

A total of 220 subjects were enrolled. The Wrinkle Severity Rating Scale response rates at month 6 were 62.9% for BEL versus 64.9% for RES, demonstrating noninferiority. The secondary endpoints supported this. Significantly reduced pain scores were observed for BEL versus RES. For both products, injection site nodule and bruising were the most frequent treatment-emergent adverse events at the injection site. All treatment-related treatment-emergent adverse events were mild.

Conclusions

The study showed that BEL is effective and well tolerated for correction of moderate NLFs in Chinese subjects. Noninferiority of BEL was demonstrated compared with RES, and regardless of applied pain treatment, a further reduction in injection pain was observed in BEL.

Employing hyaluronic acid-based mesotherapy for facial rejuvenation

BACKGROUND

Mesotherapy is a method of treatment in which biocompatible substances are injected in small aliquots into different levels of skin. This technique can be used for facial rejuvenation.

AIM

To comprehensively evaluate efficacy of different hyaluronic acid (HA) materials for skin rejuvenation, and discuss longevity of these products, potential adverse effects, and different injection techniques.

MATERIAL AND METHODS

We searched Pubmed, Scopus, Web of science, Google Scholar, Embase, Cochrane Library, and Science direct until April of 2022. Thirty-four articles were selected including 23 articles about non-cross-linked HA and 11 articles about cross-linked HA.

RESULTS

Eleven and five different non-cross-linked HA and cross-linked HA materials were utilized, respectively. Treatment sessions for non-cross-linked HA were between 1 and 6 at weekly-to-bimonthly interval, and for cross-linked HA were 1-3 at 4-36 weeks apart. In most of the studies, serial micropuncture technique with 23-32 gauge needles was used for injection. Other injection techniques were Nappage (picotage), depot and micro-linear.

CONCLUSION

Mesotherapy with HA-based fillers is a favorable method for restoring youthful appearance, rejuvenation, and revitalization of skin. Proper selection and precise placement of HA in desired level of dermis is an essential key to optimize improvement and minimize side effects including skin irregularities and Tyndall effect. Adjuvant therapy with additional rejuvenation procedures to enhance esthetic results is required especially in elderly individuals with severe photodamaged skin. Moreover, preservation of esthetic results requires maintenance therapy every few months.

A split-face comparative performance evaluation of injectable hyaluronic acid-based preparations HCC and CPM-HA20G in healthy females

INTRODUCTION

Skin revitalizers are used for skin quality improvement purposes. Hyaluronan hybrid cooperative complexes (HCC, Profhilo®, IBSA Pharmaceuticals) are an anti-aging treatment with a large amount of pure hyaluronic acid (HA) based on stable, cooperative, and hybrid complexes. Cohesive polydensified matrix Hyaluronic Acid (CPM-HA20, Belotero Revive®, Merz Pharmaceuticals GmbH) is a slightly cross-linked HA (20 mg/ml) with glycerol (17.5 mg/ml).

AIMS

To evaluate the performance of HCC and CPM-HA20G for skin quality improvement in healthy female subjects.

METHODS

This was a split-face, single-blinded study that enrolled 24 healthy female subjects. Injections were given on three separate occasions. HCC was injected on the right cheek, while CPM-HA20G was injected on the left cheek. A battery of skin property measurements was used to evaluate the skin. Skin properties and overall satisfaction were analyzed using mixed models with the values at baseline, at week 1, week 8, and week 14 as an outcome and a random effect of subject and fixed effects of treatment, visit, and the treatment by visit interaction.

RESULTS

Both products showed evidence of effect relative to baseline on surface hydration (AU), elasticity (N/m) TEWL (g/m² h), and melanin (AU). CPM-HA20G also showed significant evidence of effect relative to baseline on water content (%), and HCC on pore count (n) and hemoglobin (AU). Satisfaction reported by the subjects themselves showed positive trends of satisfaction over time for multiple skin properties. There were no significant differences between the tested products in the observed skin characteristics over time.

CONCLUSION

These devices are effective and safe treatments for skin quality improvement, especially moisturization, with high patient satisfaction and generally mild and transient side effects.

Insights on Skin Quality and Clinical Practice Trends in Asia Pacific and a Practical Guide to Good Skin Quality from the Inside Out

OBJECTIVE

We sought to examine the current skin quality trends and gaps in clinical practice in the Asia Pacific region and develop a practical guide to improve skin quality.

METHODS

Medical practitioners from 11 countries in the Asia Pacific region completed an online survey on current trends in skin quality treatment. A panel of 12 leading experts convened for a virtual meeting to develop a practical guide for skin quality improvement.

RESULTS

A total of 153 practitioners completed the survey. The four most common skin quality issues were uneven skin tone, skin surface unevenness, skin laxity, and sebaceous gland hyperactivity and enlarged pores. Most practitioners reported using a combination of treatment modalities for each skin quality issue. It was also observed that each treatment modality could be used to treat several skin quality issues. A multimodal approach targeting different interrelated issues across the tissue planes was recommended for balanced results. The panel developed a practical guide for the appropriate combinations and sequence of treatments, and created treatment protocols for specific skin quality outcome goals. The guide employed an "inside-out" approach, treating the deeper tissue planes prior to the superficial layers to achieve harmonious results.

LIMITATIONS

Future studies are needed to support the recommended treatment protocols for skin quality improvement.

CONCLUSION

These findings provide valuable insights on current skin quality trends and gaps in clinical practice. The practical guide provides a framework for practitioners to customize their treatment plan according to each patient's needs.

Microinjections with hyaluronic acid in combination with glycerol: How do they influence biophysical viscoelastic skin properties?

BACKGROUND

Skin quality improvement with hyaluronic acid microinjections is increasing as a clinical treatment indication and as a scientific issue. This present study assessed changes in biomechanical viscoelastic skin properties after microinjections with the skin quality booster CPM-HA20G (Belotero Revive).

MATERIALS AND METHODS

Fifteen subjects have been randomized in a 2:1 ratio to receive either three treatments (total 3 ml per side) or a single-dose treatment (total 1.5 ml per side) with CPM-HA20G at dermal level into the lower cheeks via microinjections. Treatments were provided 4 weeks apart. Biophysical measurements were performed describing the viscoelastic skin properties and the underlying skin structure. The measurements were performed before injection (week 0) and on follow-up visits 4, 8, 16, 24, and 36 weeks after the last injection treatment.

RESULTS

One (p = 0.028) as well as three (p = 0.003) consecutive treatments with CPM-HA20G improved statistically significant skin firmness (R0). For the multiple-treatment group improved significant differences were observed for skin fatigue (R3; p = 0.007) and skin density (p = 0.017) with stable skin thickness levels (p > 0.05), too. There were zero-to-weak correlations between skin thickness and biomechanical skin properties (R0, r_s  = 0.084; R3, r_s  = 0.093).

CONCLUSION

Overall, microinjections with CPM-HA20G improved biomechanical viscoelastic skin properties with a stronger and more pronounced effect in the multiple-treatment group. The observed changes may explain some of the skin quality improvements observed after treatment with CPM-HA20G.

Facial Skin Revitalization with Cohesive Polydensified Matrix-HA20G: Results from a Randomized Multicenter Clinical Study

Background:

There is a growing interest in the application of hyaluronic acid (HA) derivatives in skin quality improvement. The aim of this study was to confirm safety and effectiveness of cohesive polydensified matrix-hyaluronic acid + glycerol (CPM-HA20G; Belotero Revive) in revitalization of early-onset photodamaged facial skin.

Methods:

A total of 159 subjects with early signs of facial photodamaged skin were randomized in a 2:1 ratio to multiple- or single-dose treatment with CPMHA20G. Effectiveness assessments included biophysical measurements of skin hydration; elasticity, firmness, and roughness; investigator- and subject-assessed Global Aesthetic Improvement Scales; and FACE-Q Skin Changes and Treatment Satisfaction questionnaires.

Results:

In both treatment groups, skin hydration improved from baseline to all follow-up visits in subjects with dry or very dry skin. This improvement was significant at week 16 after initial treatment in the multiple-dose group (P = 0.0013). Investigator- and subject-reported outcomes showed that the majority of subjects across all skin hydration types benefited from treatment, with higher satisfaction rates observed in the multiple-dose group. According to investigator-assessed Global Aesthetic Improvement Scale, 90.7% of subjects at week 12 in the multiple-dose and 74.6% of subjects at week 4 in the single-dose group were rated as at least “improved.” All related treatment-emergent adverse events were transient, expected injection-site reactions of mild to moderate intensity.

Conclusions:

Effectiveness of CPM-HA20G for skin hydration in subjects with dry or very dry skin was demonstrated up to 9 months after last injection. Overall, CPM-HA20G demonstrated effective and safe use in facial skin revitalization among subjects with early-onset photodamaged skin.

Approach to differentiate between hyaluronic acid skin quality boosters and fillers based on their physicochemical properties

BACKGROUND

The clinical indications, applications, and effect of the injectable hyaluronic acid range skin quality boosters (SQBs) are different than those of filler products. Material properties are increasingly being discussed for differentiation and in connection with clinical effects and esthetic indications.

AIMS

The aim of this study is to evaluate whether SQB products can be differentiated from filler products by their physicochemical material properties.

MATERIAL AND METHODS

Physicochemical properties (extrusion force, swelling degree, rheology, and cohesivity) of two SQBs (BEL_R , JUV_VE ) were compared with those of fillers (BEL_B , JUV_VT ) using the same manufacturing technology.

RESULTS

Cohesivity was almost equal for SQBs and fillers. Few statistically significant differences in physicochemical properties were found. Properties of SQBs differed from fillers mainly in their delta of rheological properties and extrusion force.

CONCLUSION

In this study, physicochemical differences between SQB and filler were determined and described, supporting the presence of two categories and their different clinical indications and applications.

A prospective open-label, multicentre study evaluating a non-cross-linked hyaluronic acid based soft-tissue filler in the correction of lateral canthal and perioral lines

OBJECTIVE

The aim of this investigation was to assess the effectiveness of a non-cross-linked hyaluronic acid based soft-tissue filler in the correction of lateral canthal lines and periorbital lines.

MATERIAL AND METHODS

A total of 59 female Caucasian patients with a mean age of 52.6 ± 9.0 years were enrolled in this prospective open-label, multicentre study and received intradermal injections of a soft-tissue filler at baseline, after 3 and 6 weeks. Aesthetic improvement and patient satisfaction, skin hydration, skin firmness and skin elasticity, as well as adverse events were assessed at 3, 6, 8, 12 and 16 weeks.

RESULTS

At baseline, the lateral canthal skin firmness was 0.206 ± 0.07 mm and increased after 8 weeks to 0.087 ± 0.08 mm with p < 0.001, while the perioral skin firmness was 0.205 ± 0.09 mm and increased after 8 weeks to 0.116 ± 0.08 mm with p < 0.001. Increases in skin hydration were observed after 8 weeks in both areas, however, did not reach statistical significance at any point. At week 8, 12 and 16 a majority (93.1%, 91.1% and 73.7% respectively) of the patients stated that they were 'satisfied' or 'very satisfied' with the treatment.

CONCLUSION

Overall, the skin firmness and skin visco-elasticity showed significant increases in the lateral canthal and perioral region. Moreover, albeit not statistically significant, skin hydration increased in both areas after 8 weeks. The procedure has been shown to be safe and satisfactory for the treated patients; however, emergence of oral herpes should be added to the safety profile of intradermally applied hyaluronic acid treatments.

Consensus on the Use of Hyaluronic Acid Fillers from the Cohesive Polydensified Matrix Range: Best Practice in Specific Facial Indications

Background

As the treatment indications for the Cohesive Polydensified Matrix^® hyaluronic acid (CPM-HA) portfolio continue to expand and diversify, injectors new to the range or those who are expanding the treatments they offer may be unsure of the optimal product and injection technique for specific facial areas. Each product in the CPM-HA portfolio has been intentionally designed to provide the best physical properties for a specific indication and target tissue. This document has been developed to provide a comprehensive, one-stop reference for clinicians using the portfolio.

Methods

An international panel of experts in the field of aesthetic medicine convened to develop guidelines on effective and safe injection technique when performing treatments with the CPM-HA range of soft-tissue fillers.

Results

Consensus members considered treatment indications in the upper, middle and lower face. Landmark deficiencies and anatomical considerations are described for each indication and consensus recommendations provided on the optimal product, injection depth and treatment technique. This is supplemented by the experts advice on avoidance of complications. Throughout, an evidence-based approach to selection of products and injection techniques is provided. The result is a fully tailored approach to a range of indications covering the full portfolio of CPM-HA products, including the newest addition for skin revitalization.

Conclusion

The recommendations in this consensus document are provided to assist clinicians in the selection of CPM-HA products, administration techniques and depths of injection with the aim of providing seamless and natural treatment results, enhanced safety and patient satisfaction.

Skin Quality - A Holistic 360° View: Consensus Results

Introduction

Skin quality is an important component of human attractiveness. To date, there are no standardized criteria for good skin quality. To establish a consensus for good skin quality parameters and measurement and treatment options, a virtual skin quality advisory board consisting of a global panel of highly experienced aesthetic dermatologists/aesthetic physicians was convened.

Methods

A total of 10 dermatologists/aesthetic physicians served on the advisory board. A modified version of the Delphi method was used to arrive at consensus. Members accessed an online platform to review statements on skin quality criteria from their peers, including treatment and measurement options, and voted to indicate whether they agreed or disagreed. Statements that did not have agreement were modified and the members voted again. Consensus was defined as: strong consensus = greater than 95% agreement; consensus = 75% to 95% agreement; majority consent = 50% to 75% agreement; no consensus = less than 50% agreement.

Results

There was strong consensus that good skin quality is defined as healthy, youthful in appearance (appearing younger than a person's chronological age), undamaged skin and that skin quality can be described across all ethnicities by four emergent perceptual categories (EPCs): skin tone evenness, skin surface evenness, skin firmness, and skin glow. The EPCs can be affected by multiple tissue layers (ie, skin surface quality can stem from and be impacted by deep structures or tissues). This means that topical approaches may not be sufficient. Instead, improving skin quality EPCs can require a multilayer treatment strategy.

Conclusion

This global advisory board established strong consensus that skin quality can be described by four EPCs, which can help clinicians determine the appropriate treatment option(s) and the tissue or skin layer(s) to address. Skin quality is important to human health and wellbeing and patients' perception for the need for aesthetic treatment.

[Skin quality and ways to improve skin quality]

BACKGROUND

Skin quality has a significant impact on the perception of attractiveness. Procedures to improve skin quality, whose quality is assured, should have sufficiently documented scientific evidence of in vivo and in vitro efficacy and significant effects proven in studies.

OBJECTIVES

This paper will present findings from recent studies and experience of experts on skin quality and treatments to improve skin quality.

MATERIALS AND METHODS

A PubMed database search was conducted in February 2021 on the terms skin quality and minimally invasive skin quality improvement procedures. Two reviewers independently screened the titles, resulting in the selection of 30 papers.

RESULTS

Hyaluronic acid (HA) is the most commonly studied agent for skin rejuvenation treatments. The efficacy and safety of the superficially injected HA products are excellently proven on the basis of current data. According to these findings, they ensure an improvement of skin quality without significant volume changes. The skin is hydrated, its elasticity increased, the skin surface smoothened, the complexion (skin redness, glow) improved and fine lines and wrinkles are reduced. They are injected intradermally and have a clinically proven effect duration of up to 12 months.

CONCLUSIONS

Hyaluronic acid is outstandingly suitable for deep hydration of the skin, and its effect is long-term and safe. Natural treatment results fulfil the needs of the patients and increase the patient-practitioner relation. Superficially injected HA products are currently the criterion standard to increase skin quality.