Improvement of Facial Skin Laxity by a Combined Technique With Hyaluronic Acid and Calcium Hydroxylapatite Fillers: A Clinical and Ultrasonography Analysis

January 2022 | Volume 21 | Issue 1 | Features | 102 | Copyright © January 2022


Published online December 28, 2021

Bruna Souza Felix Bravo MD MSc,a Laís Bezerra de Menezes Penedo MD,a Raquel de Melo Carvalho MD,a Hélio Amante Miot MD PhD,b Mariana Calomeni Elias MDa

aBravo Clinic, Rio de Janeiro, Brazil
bBotucatu Medical School, São Paulo State University, São Paulo, Brazil

Abstract
Background: Facial aging involves skeletal changes, loss of volume in the fat compartment, and skin component changes. The current objective of cosmetic facial filling is to reestablish the overall aspect that was lost during the aging process. Hyaluronic acid (HA) and calcium hydroxyapatite (CaHA) fillers are indicated for facial rejuvenation, and these agents promote dissimilar effects regarding volume restoration and dermal biostimulation.
Objective: This study aimed to assess clinical and ultrasonographic improvements in facial skin laxity using a technique that combines the injection of HA and CaHA.
Methods: A 120-day follow-up, quasi-experimental study was conducted based on the enrollment of fifteen women (36–47 years old) with mild face flaccidity scores who underwent subcutaneous injection of up to 3 mL of HA (zygomatic-malar region, pyriform aperture, temporal region, and jaw) followed by 3 mL of 1:1 diluted CaHA using a fan technique (temporal, zygomatic-malar, and jaw regions). Objective: Adverse effects were registered, and the monthly assessed outcomes included clinical improvement, satisfaction, and high-frequency ultrasonography (dermal thickness) parameters.
Results: At 120 days of follow-up, clinical assessment by blinded physicians yielded six (40%) very improved patients and nine (60%) exceptionally improved patients. All the participants were highly satisfied with the results and reported exceptional improvement. Dermal thickness increased 11.1% (8.8–13.4%), and augmented dermal homogeneity was evidenced by ultrasonography. Local adverse effects were mild and transient.
Conclusion: In conclusion, the combined technique with HA and CaHA fillers was well-tolerated and yielded high satisfaction and safe improve in facial skin laxity and dermal thickness in women with mild midface aging.

J Drugs Dermatol. 2022;21(1): 102-106. doi:10.36849/JDD.633

INTRODUCTION

Facial appearance has a fundamental social function, as, at a glance, it accounts for meaningful perceptions of health, wellness, wealth, successful fertility and attractiveness.1 These aspects have become more relevant in the digital era, in which high-resolution pictures and videos are constantly being shared. Moreover, several apps with filters to improve any look at a touch are freely available. Consequently, the concern for good appearance inflicts a major impact on self-esteem, which leads to an intense search for a plethora of invasive and noninvasive rejuvenation procedures based on the development of new techniques and technologies.2,3

The natural process of facial aging mainly involves skeletal changes, loss of volume in the fat compartment, and changes in skin components (eg, loss of dermal collagen and elastic fibers). As facial fat is highly compartmentalized, its morphologic changes contribute to facial aging as these compartments lose volume.4,5 Therefore, the essential objective of cosmetic facial filling is currently to reestablish that lost during the aging process.

Facial bone resorption, which occurs precociously in the maxilla, as well as the loss of collagen due to aging lead to an undesirable and stigmatized appearance of tissue laxity and skin wrinkling. Dermal fillers are minimally invasive nonsurgical procedures capable of restoring facial volume and stimulating elastogenesis and collagenesis, which can revert the facial aging appearance.

Hyaluronic acid (HA) is a glycosaminoglycan that has become the most popular dermal filler to provide volume augmentation in areas of volume loss. As HA is a natural dermal extracellular
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