Science and Rationale for Skin Boosting: Rejuvenating Aging Skin
The normal process of aging eventually leads to decreased skin tone and firmness and the appearance of visible wrinkles, but one way to rejuvenate aging skin is a technique called skin boosting. Skin boosting is the placement of hyaluronic acid (HA) deep in the dermis to replenish what is lost with time. The objective of skin boosting is to improve skin health without volumizing the skin.
This educational article expands on a recent CME activity in which Dr. Andreas Nikolis demonstrated microinjection skin boosting techniques on the lower face and cheeks, hands, and décolletage of patients using non-animal origin, stabilized hyaluronic acid (NASHA®).
Rationale for Using Non-Animal Origin, Stabilized Hyaluronic Acid (NASHA®) for Skin Boosting
HA is a naturally occurring polysaccharide that is a critical component of normal, healthy skin 1. Decreased levels of HA in the dermis, which results from the normal aging process, lead to the most visible alterations of aging skin, including wrinkling, dryness, and decreased elasticity 1,2. NASHA® is a small-particle, non-animal origin stabilized HA developed in 2004 to help facilitate the rejuvenation of aging skin. Its low degree of natural cross-links coupled with a limited number of synthetic cross-links provides a minimally modified version of natural HA, whose stabilized structure has viscoelastic properties important for achieving optimal esthetic outcomes 3.
“The end result is an HA that is very resistant to degradation, that resembles natural HA, but has longer-lasting effects than does unstabilized HA. Its precise injection into the deep dermis allows for sufficient, but not excessive, water absorption/retention in a very controlled process.”--Andreas Nikolis, MD
Dr. Nikolis explained that as clinicians, every aspect associated with skin rejuvenation is based on clinical evidence. Clinical trials supporting skin boosting and skin rejuvenation are plentiful (see table below) and demonstrate that the placement of NASHA® deep in the dermis, in reproducible fashion, leads to improved skin appearance and elasticity, and a decrease in skin roughness, as well as improving hydration and reducing transepidermal water loss. These improvements can last up to six months according to data that has been published to date. Part of the technique is placing the product at the right depth: deep in the dermis, almost to the level of the subcutaneous junction. The reason for this is twofold:
“Number one, we do not want to have any superficial product that is palpable or visible, and number two, studies have found that this is the right depth in order to achieve the peak clinical result.”--Andreas Nikolis, MD
There are a number of acceptable injection techniques for skin boosting. These include the 1) short linear technique (See Image 1); 2) micropuncture technique (See Image 2); 3) linear technique; and 4) fanning technique. Dr. Nikolis indicated that two of the most commonly used microinjection techniques for skin boosting are the short linear technique and the micropuncture technique. Both techniques are demonstrated in the Skin Boosting Technique: A New Approach to Hyaluronic Acid Microinjection CME activity and use a syringe that deposits 10 microliter aliquots spaced approximately 1 cm apart in the deep dermis.
“You can use a serial puncture technique with a 29-gauge needle, or you can actually place your needle under the skin and do a series of injections. The goal of deciding which treatment strategy to use is based on the patient’s skin characteristics.”
“I personally like to choose a direct needle injection technique, especially when the skin is thin and I can see those underlying structures that I would like to avoid; this is often the case for hand injections, where you have veins or tendons showing.”--Andreas Nikolis, MD
A 2018 expert consensus on the use of NASHA® supported use of the skin boosting technique on the lower face and cheeks, hands, and décolleté (although a broader use was also agreed upon) (4). While skin boosting can be performed on women and men between the ages of 18 and 70, the ideal candidates are generally between 30 and 65 years of age (4). When optimal injection techniques are used, adverse events are mild but can include temporary erythema, swelling, and bruising, which are associated with the procedure and not with NASHA®. No severe adverse events have been reported in clinical studies (5).
As mentioned, skin booster microinjection techniques most commonly deposit 10 separate microliter aliquots about 1 cm apart in the deep dermis. Participants of the 2018 NASHA® expert consensus also confirmed that the use of the SmartClick™ system ensures high precision during the injection of NASHA® skin booster. The SmartClickTM system is also demonstrated in the Skin Boosting Technique: A New Approach to Hyaluronic Acid Microinjection CME activity; however, this system is not yet approved for use in the United States.
Effectiveness of Skin Boosting
Dr. Nikolis reiterated that skin boosting should be considered:
- To improve visible lines which appear when smiling and at rest
- When skin has lost elasticity and looks tired and worn
- To restore the plumpness and radiance to that of hydrated skin 1
- To improve skin health without adding volume
- To improve skin that has become rough or has an uneven texture
The effectiveness of skin boosting techniques has been documented in a number of clinical studies, as follows:
These clinical studies confirm that injection of HA using skin boosting techniques is associated with reduction of wrinkles, as well as improved skin texture, firmness, and hydration. Moreover, results are progressive and persistent with repeated treatment (2,4,11).
Dr. Nikolis commented:
“There are two components that really guide clinicians. The first is the efficacy and safety data that is published in the literature that allows us to really choose products that work and are safe to use. The second component is patient satisfaction, and that is one of the key components found in the skin boosting literature. Patient outcomes have demonstrated efficacy throughout the clinical trials when evaluated. Outcomes up to six months have been demonstrated, and patient satisfaction rates have been high throughout that period.”
“Skin boosting is usually undertaken monthly for either two or three sessions, and then a maintenance treatment is provided every 6 to 12 months. However, every patient is different, every patient is unique, and every patient needs to be evaluated for a tailored maintenance program.”
Skin boosting using NASHA® has been shown to be a safe and effective approach to improving skin health without volumizing. Not only that, but outcomes are progressive and persistent with repeat treatments, with high rates of patient satisfaction.
- Distante F, Pagani V, Bonfigli A. Stabilized hyaluronic acid of non-animal origin for rejuvenating the skin of the upper arm. Dermatol Surg. 2009;35:389-394.
- Landau M, Fagien S. Science of hyaluronic acid beyond filling: Fibroblasts and their response to the extracellular matrix. Plast Reconstr Surg. 2015 Nov;136(5 Suppl):188S-195S.
- Brandt F, Bassichis B, Bassichis M, O’Connell C, Lin X. Safety and effectiveness of small and large gel-particle hyaluronic acid in the correction of perioral wrinkles. J Drugs Dermatol. 2011;10(9):982–987.
- Belmontesi M, De Angelis F, Di Gregorio C, et al. Injectable non-animal stabilized hyaluronic acid as a skin quality booster: An expert panel consensus. J Drugs Dermatol. 2018 Jan 1;17(1):83-88.
- Nikolis A, Enright KM. Evaluating the role of small particle hyaluronic acid fillers using micro-droplet technique in the face, neck and hands: a retrospective chart review. Clin Cosmet Investig Dermatol. 2018;11: 467-475.
- Gubanova EI, Starovatova PA, Rodina MY. 12-month effects of stabilized hyaluronic acid gel compared with saline for rejuvenation of aging hands. Esteticheskaya Meditsina. 2010;1:94-98
- Ribé A, Ribé N. Neck skin rejuvenation: Histological and clinical changes after combined therapy with a fractional non-ablative laser and stabilized hyaluronic acid-based gel of non-animal origin. Journal of Cosmetic and Laser Therapy. 2011;13: 154-161
- Kerscher M, Bayrhammer J, Reuther T. Rejuvenating influence of a stabilized hyaluronic acid-based gel of nonanimal origin on facial skin aging. Dermatol Surg. 2008 May;34(5):720-726
- Williams S, Tamuric S, Stensvik H, Weber M. Changes in skin physiology and clinical appearance after microdroplet placement of hyaluronic acid in aging hands. J Cosmetic Derm. 2009;8:216-225.
- Streker M, Reuther T, Krüger N, Kerscher M. Stabilised hyaluronic acid-based gel of non-animal origin for skin rejuvenation: face, hands and décolletage. J Drugs Dermatol. 2013 Sep;12(9):990-994.
- Halachmi S, Ben Amitai D, Lapidoth M. Treatment of acne scars with hyaluronic acid: an improved approach. J Drugs Dermatol. 2013;12(7):121-123.