The Influence of Different Treatment Combinations on Skin Laxity and Dimpling

November 2020 | Volume 19 | Issue 11 | Original Article | 1030 | Copyright © November 2020


Published online October 23, 2020

doi:10.36849/JDD.2020.5117

Rolf Bartsch MD,a,* Gabriela Casabona MD,b,* Christian Sitzwohl MD,a Oliver Kimberger MD,a
Jeremy B. Green MD,c Julia Stanger MD,a Konstantin Frank MD,d Emy C. Onishi MD,e Sebastian Cotofana MD PhDf

aPrivate Practice, Vienna, Austria
bOcean Clinic, Marbella, Spain
cSkin Associates of South Florida, Coral Gables, FL
dDepartment for Hand, Plastic and Aesthetic Surgery, Ludwig – Maximilian University Munich, Germany
ePrivate Practice, Manila, Philippines
fDepartment of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN
*Both authors contributed equally to this work

Abstract
Objective: The aim of the study was to identify the effectiveness of the combination of tissue stabilized guided subcision, microfocused ultrasound, and minimally invasive calcium hydroxylapatite injections in various sequences for treating skin surface irregularities of the buttocks and thighs.
Material and Methods: 61 females (body mass index: 22.6 ± 2.4 kg/m², age: 37.2 ± 6.8 years) were enrolled in this randomized interventional prospective study. Treatment arms included a variable combination and sequence of three treatment modalities: (1) Tissue-stabilized guided subcision, (2) microfocused ultrasound, and (3) calcium hydroxylapatite injections. Six months after the final intervention skin laxity and skin dimpling severity scores were assessed by the study participants, the treating physicians and by eleven blinded independent board-certified experts.
Results: No adverse events were observed during the study that required intervention outside the standard of care treatment protocol. The combination of three treatment modalities was shown to provide greater improvement in skin laxity 1.88 (95% CI, 0.66–5.37) and skin dimpling 1.31 (95% CI, 0.61–2.81) scores as compared to any combination of two modalities. The combination of concomitant microfocused ultrasound and calcium hydroxylapatite injections followed three months later by tissue stabilized guided subcision yielded the greatest improvement in skin laxity 2.23 (95% CI, 0.51–9.82) and skin dimpling 1.79 (95% CI, 0.67–4.78) at 9-month follow-up. Conclusion: This study provides evidence for the effectiveness of combination therapies for the improvement of skin surface irregularities on the buttocks and thighs.

J Drugs Dermatol. 2020;19(11): 1030-1038. doi:10.36849/JDD.2020.5117

INTRODUCTION

Skin surface irregularities of the gluteal and posterior thigh regions can be majorly (though not exclusively) attributed to the effects of skin laxity and skin dimpling. This aesthetically unpleasing appearance can lead to profound feelings of body dissatisfaction, psychosocial stress, and decreased quality of life.1–5

A recent anatomic investigation by Rudolph et al3 revealed that the subdermal junction is in a delicate balance between containment and extrusion forces. Containment forces are effected by skin thickness and the superficial fascial system whereas extrusion forces are generated by muscular contraction, high body mass index (BMI) and increased tissue pressure as observed in tissue edema.3 A decrease in containment forces occurs with increasing age as the skin thins by 0.3% per year3 and the superficial fascial system becomes less stable. The latter is a subdermally located biomechanical unit composed of the superficial fascia and the fibrous septae inserting superficially into the dermis, and extending deep to the deep fascia; thus, encompassing the superficial and the deep fatty subcutaneous layers.

Therapeutic options for the treatment of skin surface irregularities that have demonstrated efficacy include tissue-stabilized guided subcision (TSGS) which releases subdermal fibrous septae, and microfocused ultrasound (MFU) and calcium hydroxylapatite (CaHA) injections which induce neocollagenesis via fibroblast stimulation.6–8 Whereas evidence exists for the effectiveness of each as monotherapy, there is no published data on the combination of the three treatment
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