Introduction

Aging is a posh phenomenon together with, over time, many structural modifications. Face growing old is characterised by a lack of pores and skin quantity, a lower and a redistribution of fats, primarily within the orbital and malar areas. In parallel, there’s a lower in collagen manufacturing, lowered fibroblastic exercise, dermal atrophy, and alteration of elastin. At the extent of the pores and skin a discount in cell renewal, dehydration, lack of radiance, elasticity, firmness, and the looks of effective strains and wrinkles are noticed.

In order to decelerate facial growing old, nonsurgical options allow sufferers to have easy and environment friendly therapies, corresponding to injectable anti-aging merchandise: biorevitalization merchandise, dermal fillers and hyaluronic acid (HA)-based formulation for pores and skin rejuvenation. The mostly biorevitalization options are vitamin blends, hint parts, natural silicon, and HA. HA might be mixed with a moisturizing agent, most frequently glycerol, but in addition mannitol or sorbitol.¹ The best instantly scientific results noticed after facial biorevitalization are discount of wrinkles, the advance of deep hydration, firmness, uniformity, and radiance of the complexion.^2,3 In latest years, dermal fillers that grew to become the fabric of selection are HA-based fillers to be used in mushy tissue and dermal correction and principally changing collagen fillers.^4,5

Hyaluronic acid is broadly utilized in anti-aging merchandise, both in native kind in merchandise to be injected by pores and skin biorevitalization strategies or cross-linked in dermal fillers. Naturally plentiful within the human physique, this biopolymer is among the most essential organic constituents of the extracellular matrix of the dermis and it kinds the elastoviscous fluid matrix wherein collagen and elastin fibers are embedded in a correct configuration. In the aged pores and skin, the shortage of connections with HA might contribute to the disorganization of collagen and elastin fibers and result in the presence of effective strains, wrinkles, and nasolabial folds.^6–8 Due to its excessive hydrophilic properties and its important benefit of structural conservation which clarify the explanation of HA’s volumizing potential after injection and its nonallergenic area.⁷ Native non-cross-linked HA utilized in pores and skin biorevitalization is a linear polysaccharide chain much like HA within the dermis. This native HA injected into the dermis permits hydration of the pores and skin via the next water-binding capability and builds up the extracellular matrix and reactivates fibroblasts and induces the synthesis of recent collagen, elastin, and endogenous HA.^9,10

Because of the excessive solubility of native HA and its half-life of some days in pure kind, HA should be chemically stabilized by a cross-linking course of to scale back its pure degradation. Depending on molecular weight of HA, the method and diploma of cross-linking, the HA molecule thus modified comes within the type of a extremely viscous, insoluble gel, usable as a dermal filler. The scientific impact and period of presence within the pores and skin are straight related to the rheological traits of the HA gel, its cohesiveness and its elasticity, the injected quantity, and the world handled.

Many practitioners deal with their sufferers with dermal fillers and biorevitalizing merchandise in the identical session however not in the identical pores and skin layer. These personalised therapies confirmed that this method will increase the impact of every product alone however there isn’t a evidence-based info to show it. The purpose of this research was to show the anti-aging efficiency and security of a brand new protocol, which targets the pores and skin high quality and wrinkle correction on the similar time. This protocol relies on injection of a biorevitalizing resolution (NCTF 135HA, FILLMED Laboratories, France) which accommodates 5 mg/mL of native HA together with one or two cross-linked HA-based dermal fillers, in the identical session: ART FILLER Fine strains (AFFL, FILLMED Laboratories, Paris, France; HA 20 mg/mL) or/and ART FILLER Universal (AFUni, FILLMED Laboratories, Paris, France; HA 25 mg/mL). Both AFFL and AFUni are formulated with a novel mixture of three sizes of hyaluronic acid chains, Tri-Hyal know-how, to attain the specified rheological traits, and a sustained efficacy for at the very least 18 months.¹¹

Materials and Methods

Subject Selection

The inclusion standards have been male or feminine topics older than 19 years of age with a Fitzpatrick phototype of I to IV and a rating of two, 3, 4, or 5 on the Bazin cheek folds wrinkle scale. All topics agreed to not expose themselves to the solar or UV throughout your complete research. Female topics agreed to do a being pregnant check and hold a dependable contraception methodology throughout complete research. The noninclusion standards included the contributors with any allergy to the research product, historical past of dermal fillers throughout final one 12 months, historical past of keloid scars, any facial pathologies corresponding to facial herpes, any systemic ailments, medicine and situation which can intervene with the outcomes of the research together with auto-immune ailments, coagulation problems.

Study Design

The research adhered to the Declaration Helsinki with the authorization of the ethics committee (Southeast V, Medical University of Grenoble) on November 13, 2019 below registration quantity 2019-A00144-53. All contributors signed a written consent kind, accepting not modifying their life-style and avoiding the solar publicity throughout the entire research. This research is a nonrandomized, noncomparative, potential multicentric research at 4 facilities in France for 120 days. The purpose of this research was to show the anti-aging efficiency and security of a brand new mixed protocol with injection of NCTF 135HA together with one or two different medical gadgets, both ART FILLER Fine strains and/or ART FILLER Universal (primarily based on the rating at baseline) via a 25G × 55 mm cannula (BIONUTRILIFT cannula, Softfil France) in the identical session. The protocol consisted of 1 injection session at day 0 and three follow-up visits at days 30, 60, and 120.

Study Products

NCTF 135HA, ART FILLER Fine strains and ART FILLER Universal are CE marked Class III medical gadgets in keeping with Directive 93/42EEC and have been freely marketed within the European Union, since 2007 and 2016, respectively.

ART FILLER Fine strains and ART FILLER Universal are the HA-based dermal fillers ready in prefilled sterile graduated disposable syringe of 1.0 mL and 1.2 mL, respectively. They comprise the cross-linked hyaluronic acid viscoelastic gel in addition to 0.3% by weight of lidocaine hydrochloride for its anesthetic properties. AF Fine Lines is a superficial HA filler which accommodates 20 mg of HA with a superb cohesivity and G′ roughly 70–80 with a level of modification of three% (MoD%). AF Universal is a medium to deep dermal filler which accommodates 25 mg of HA with a superb cohesivity and G′ roughly 120–130 with a MoD of 4% in keeping with the laboratory knowledge. NCTF 135HA is a HA-based microfiller which accommodates 5 mg/mL of non-cross-linked sodium hyaluronate and a polyrevitalising resolution described in Table 1. It is ready in 3 mL sterile disposable vials and must be ready in a sterile manner in a 3 mL sterile syringe earlier than injection.

Table 1 Composition of NCTF 135HA (Approved CE Marking Medical Device)

Injection Method

The doctor disinfected the handled space with chlorhexidine and determined to inject 1, 2, or 3 vectors for either side of the face with a mix of NCTF135HA with ART FILLER Fine strains and/or ART FILLER Universal. The variety of vectors varies in keeping with the pores and skin growing old grade of the face (Table 2). The injection process relies on the superficial subcutaneous injection by cannula in keeping with the fan approach (Figure 1).

Table 2 Amount of Product Injected According to the Skin Aging Grade (Bazin Cheek Folds Score)

Figure 1 Face injection process in keeping with the fan approach. Vector A: Entry level by zygomatic arch; Vector B: Entry level above the mandibular angle; Vector C: Entry level beside the oral commissure. The black arrows signifies the injection strains of the filler and the crimson arrows signifies the injection strains of the NCTF®134HA.

The injectors ought to inject the dermal fillers (ART FILLER Fine Lines or ART FILLER Universal in 5 strains with a single-entry level (fan approach, vector). Then, the NCTF 135HA which has been beforehand ready in a 3 mL sterile syringe, injected via with canula the identical entry level in 4 strains between the strains beforehand injected by dermal fillers.

Evaluation Methods

The scientific evaluation was carried out by a visible scoring system concerning the pores and skin wrinkles and pores and skin radiance in numerous zones on the face (Table 3).

Table 3 Clinical Assessments Used by the Investigators to Obtain Objective Evaluations of the Treatment Evolution

The Global Aesthetic Improvement Scale (GAIS) was assessed by the investigators and the themes, on a 7 grades of satisfaction degree together with: very a lot improved, a lot improved, improved, no change, worse, a lot worse, and really a lot worse.

Safety

Safety evaluation contains all the themes who obtained at the very least one injection of one of many gadgets below research. Immediate tolerance was assessed by measuring the ache primarily based on an analog 10-grade scale from absence to 10 for very intense ache and recording all native hostile occasions related to the injection. They have been scored primarily based on a 0–3 scale by the investigator at every go to from the primary injection till the top of the research for erythema, ecchymosis, hematoma, edema, dyschromia, nodule/papule, and pruritus. In parallel, the sufferers recorded any native or systemic reactions or problems on a day by day log.

Statistical Methodology

The most important criterion for this research relies on Bazin 8-point scale scientific scoring of the cheek folds (Figure 2).¹² For this scale, a lower of 1 level of the rating thought of as profitable esthetic evolution. Assuming a normal deviation of the before-after variations=2; then 35 sufferers are required to have a 90% likelihood of detecting a distinction between technique of 1.0 with a significance degree (alpha) of 5% (calculated with the pattern dimension for paired t-test (one-tailed)).

Figure 2 Bazin cheek wrinkles scale.

However sensible expertise with such process reveals {that a} notified physique expects security knowledge on at the very least 100 follow-up topics. For this motive, it was lastly proposed to incorporate 100 topics. Statistical evaluation was carried out with R 4.0.2, MATLAB R2020b, GraphPad InStat and Excel 2016.

Descriptive statistics are offered for every parameter (ie variety of observations, imply, commonplace deviation, minimal, most, median) with 95% confidence interval. The repartition of the pattern dimension is offered for the evolution of the scientific scores within the completely different courses of scores below the type of n/share. Analyses have been carried out per space and per remedy.

The imply and median modifications of the values between D0 and different time factors (D60 and D120) have been calculated, and the statistical significance of the modifications have been calculated by a Student’s t-test for paired sequence or its nonparametric equal, the Wilcoxon check. A lower of 1 grade is taken into account a passable esthetic enchancment. The share of success was calculated by the ratio of passable responses.

Results

Study Population

Ninety-nine wholesome topics between 45 and 79 years outdated (imply age: 63.9 years) have been enrolled within the research in Paris, France together with 1 male and 98 feminine volunteers. The Fitzpatrick phototyping distribution was 54% phototype II, 37% phototype III, 5% phototype IV, and three% phototype I. Some sufferers weren’t in a position to come again for the D60 follow-up session go to as a result of COVID-19 lockdown interval in France and because of this the outcomes have been analyzed solely on D30 and D120.

Performance Analyses for Each Clinical Assessment

Cheek Folds

A big enchancment of pores and skin wrinkles rating was obtained for cheek folds at D30 and D120 versus baseline, after the mixed injection protocol (p<0.0001). Thirty days after the injection (D30), the cheek folds rating decreased by 45% (imply rating 1.8±1.4 vs 3.3±1.1 at baseline; p<0.0001) and this rating continued to lower till D120 by 55% (imply rating 1.5±1.4 vs 3.3±1.1 at D0; p<0.0001), with a hit fee of 77% (at the very least one grade diminution) (Figure 3).

Figure 3 Mean wrinkles rating assessed on cheek folds by Bazin scale and imply pores and skin radiance rating from very boring pores and skin (Grade 4) to very radiant pores and skin (Grade 0) AT D0, D30, and D120 after BIONUTRILIFT injection remedy. Statistical significances of the modifications skilled at every time level in comparison with the baseline (D0) are proven as *p≤0.0001.

Radiance

A big enchancment of pores and skin radiance rating was noticed forever factors by 52% at D30 and by 61% at D120 vs baseline (1.5±0.79 and 1.2±1.0 at D30 and D120 respectively in comparison with 3.1±0.76 for baseline, p<0.0001 for all). At D120, a 96% success fee was noticed (at the very least one grade enchancment) (Figure 3).

Perioral Scores

Thirty-five topics amongst 99 have been injected for vector C, which straight handled the perioral zone. The outcomes revealed that though there was not the direct injection within the perioral zone on 64 topics, there’s a distance impact on nasolabial folds, marionette strains and higher lips rating. For this motive, the outcomes on the perioral scores have been calculated individually for the inhabitants injected or not for vector C (Figure 1 and Figure 5).

Marionette Lines

Regardless the variety of vectors, the info confirmed a major enchancment of wrinkles rating for marionette strains at D30 and D120 vs baseline (2.5±1.4 at D30 and a pair of.4±1.5 at D120 vs 3.5±1.2 at baseline, p<0.0001 for all) (Figure 4). However, the advance was additionally important for the inhabitants not be injected with vector C as follows: 2.2±1.3 and D30 and D120 vs 3.2±1.1 at baseline (p<0.0001 for all). This outcome reveals the gap impact of vector A (cheek injection) and vector B (mandibular injection) on perioral zone. In parallel, injection of vector C (perioral injection) has additionally an area impact on the identical space as follows: 3.1±1.4 at D30 and a pair of.7±1.6 at D120 vs 4.1±0.98 baseline (p<0.0001 for all) (Figure 5).

Figure 4 Evolution of world imply wrinkles rating assessed on marionette strains, NSL folds and higher lips at D0, D30 and D120 by Bazin scale mixed remedy (three vectors). Statistical significances of the modifications skilled at every time level in comparison with the baseline (D0) are proven as *p≤0.0001.

Figure 5 Evolution of imply wrinkles rating assessed on marionette strains, NSL folds and higher lips at D0, D30 and D120 by Bazin scale mixed remedy (vectors A+B (A) and solely vector C (B)). Statistical significances of the modifications skilled at every time level in comparison with the baseline (D0) are proven as *p≤0.0001; **p<0.0006.

NSL Folds

A big enchancment of wrinkles rating was noticed for nasolabial folds at D30 and D120 vs baseline (2.5±1.1 at D30 and a pair of.4±1.2 at D120 vs 3.4±0.88 at baseline, p<0.0001 for all) (Figure 4).

Moreover, the amelioration was additionally important for the inhabitants with out vector C injection as follows: 2.3±1.0 at D30 and a pair of.2±1.2 at D120 vs 3.2±0.82 at baseline (p<0.0001 for all). This outcome helps the gap lifting impact of vector A and vector B on perioral zone. Furthermore, injection of vector C has additionally an area impact on the identical space as follows: 2.9±1.2 at D30 and a pair of.6±1.2 at D120 vs 3.7±0.88 baseline (p<0.0001 for all) (Figure 5).

Upper Lips

A big enchancment of wrinkles rating was achieved for higher lips wrinkles at D30 and D120 vs baseline (2.2±1.5 at D30 and a pair of.1±1.6 at D120 vs 3.5±1.4 at baseline, p<0.0001 for all) (Figure 4). In addition, the advance was important for the inhabitants with out vector C remedy as follows: 2.1±1.5 at D30 and a pair of.1±1.7 at D120 vs 3.1±1.4 at baseline (p=0.0005 and p<0.0001, respectively). This outcome confirms the gap lifting impact of vector A and vector B on perioral zone. Finally, injection of vector C has additionally an area impact on the identical space: 2.4±1.4 at D30 and a pair of.3±1.3 at D120 vs 4.2±1.2 baseline (p=0.0005 and p<0.0001, respectively) (Figure 5).

Global Aesthetic Improvement Assessment

The satisfaction fee was evaluated by investigator GAIS (IGAIS) and in addition by topic GAIS (SGAIS).

IGAIS: The satisfaction fee evaluated by the doctor almost reached 100% of enchancment for D30 and D120: 99% and 98%, respectively.

GAIS: The sufferers noticed a superb international esthetic enchancment and near the satisfaction fee obtained by the investigator: 86% each for D30 and D120.

The satisfaction fee by GAIS was confirmed between the themes and investigators (Figure 6). The before-after scientific images revealed the seen esthetic modifications demonstrated in Figure 7.

Figure 6 Investigator and topic satisfaction fee (%) of the brand new protocol BIONUTRILIFT evaluated by GAIS.

Figure 7 Before-after images. Exemplary pictures illustrating earlier than the remedy. (A) A feminine topic with a baseline rating of 5 on the Bazin cheek folds wrinkle scale (left photograph, D0) and after the remedy with three vectors with a rating of two at D30 (center photograph), and a rating of 1 at D120 (proper photograph). (B) The before-after images on nasolabial fold of a feminine topic with the rating of 5 on the Bazin nasolabial fold rating at baseline (left photograph) which decreased to attain 3 at D30 (center photograph). This rating remained secure at 3 at D120 (proper photograph) (C) The before-after images of a feminine topic on cheek folds with a rating of seven on the Bazin cheek fold scale at baseline (left photograph) which decreased to five at D30 (center photograph) and to 4 at D120 (proper photograph).

Safety and Tolerance

No severe hostile occasions have been reported in the course of the research. Sixty-seven hostile occasions have been reported and amongst them, 57 AEs have been regarding anticipated hostile occasions that occurred incessantly after dermal injections: the pores and skin reactions have been principally involved as ecchymosis (n=27, 40%), swelling (n=11, 16%), erythema (n=5, 7%), ache (n=4, 6%), irregularities on palpation (n=4, 6%), ache at palpation (n=2, 3%), pruritus (n=2, 3%), stinging (n=2, 3%), which disappeared later (not one of the reported native reactions have been nonetheless current at D60 n=69 nor D120 n=93 among the many knowledge collected). There was just one topic with palpable nodule and one topic with average pigmentation which disappeared earlier than D30. The nonrelated hostile occasions have been restricted to at least one topic suffered from zona on one arm roughly two months after injections and one case had eyes dryness and stinging. The general security was excellent and acceptable hostile occasions have been summarized in Figure 8.

Figure 8 Local hostile occasions.

Discussion

Nonsurgical beauty drugs procedures for the face are growing significantly to enhance the standard and look of the pores and skin. Several practitioners use the affiliation of dermal fillers and biorevitalizing merchandise to deal with their sufferers to convey a world method of facial growing old.13 This personalised method will increase the impact of every product alone however there isn’t a evidence-based info to show it.

The purpose of this scientific research was to show the efficacy and security of a brand new mixed protocol with injection of a biorevitalizing resolution, NCTF 135HA, together with one or two HA-based dermal fillers, both ART FILLER Fine strains and/or ART FILLER Universal (primarily based on the growing old grade at baseline). The separate impact of biorevitalizing options and dermal fillers has been broadly demonstrated within the literature. Biorevitalization appears at enhancing the intrinsic high quality of the cutaneous envelope. However to our information, no printed scientific research have demonstrated the efficacy and security of the mix of dermal fillers and a biorevitalizing product.

Clinically, probably the most rapid results noticed after facial biorevitalization are the discount of wrinkles, the advance of pores and skin hydration degree, pores and skin firmness, uniformity and radiance of the complexion.^14,15 Likewise, a rise in density and thickness of the dermis is reported with biorevitalization options and hyaluronic acid fillers.^8,16

As dermal fillers are used to fill massive static defaults, facial growing old remedy with dermal fillers alone can not attain the advance of pores and skin high quality corresponding to biorevitalizing options merchandise as a result of they comprise quite a few nutritive compounds, in addition to nonreticulated hyaluronic acid to quickly “fill” the tissues with water. The curiosity of this research was to indicate the impact of this mixture remedy with HA fillers and a biorevitalization product.

This research confirmed a major enchancment of pores and skin wrinkles rating for cheek folds and pores and skin radiance rating on the similar time and this enchancment remained important even 120 days after injections. These confirmed enhancements verify the pertinence of a mixed protocol with the intention to provide international therapeutic in a short- and long-term interval.

Interestingly, the mixed protocol confirmed the gap lifting impact of vector A (cheek injection) and vector B (mandibular injection) on perioral zone. Proven in our scientific research, this distance impact remained important 120 days after injections. Regarding the protection, most reported reactions remained of sunshine depth and corresponded to ordinary and anticipated hostile results reported with such therapies (ecchymosis, swelling, erythema, hematoma, edema).^8,14

Conclusion

The advantage of this mixed protocol was the advance of pores and skin high quality of the face on the similar time with filling impact of the fillers on the facial wrinkles. The danger– profit ratio of such remedy can due to this fact be thought of as favorable. Moreover, this protocol suggests the curiosity to adapt injection protocol to the pores and skin wants of the affected person. This noninvasive therapeutic technique brings affected person satisfaction via an adaptative and a extra international method to facial growing old.

Abbreviations

NLF, nasolabial folds; AF, ART FILLER; FL, effective strains; Uni, common.

Acknowledgments

Special because of Dr Karim Nadra and Dr Hanane Issa for his or her priceless helps on launching and executing the research. The authors additionally respect Mme Audrey Binabout for the monitoring of this research.

Disclosure

FF and SC are the worker of FILLMED Laboratories in Paris. The authors report no conflicts of curiosity on this work. This research was financially supported by FILLMED Laboratories.

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