Minimally Invasive Aesthetic Treatment of the Face and Neck Using Combinations of a PCL-Based Collagen Stimulator, PLLA/PLGA Suspension Sutures, and Cross-Linked Hyaluronic Acid

Figures & data

Table 1 Published Multimodal Approaches Proposed for Face or Neck Rejuvenation

Face	Neck (±Decolletage)
RCTs (n Patients)
HA filler + RF vs HA filler (n = 10)^Citation57
BoNTx + HA filler vs BoNTx (n = 20)^Citation58
BoNTx + HA filler vs BoNTx + HA filler + cosmetic treatment (n = 20)^Citation59
BoNTx + HA filler vs BoNTx vs HA filler (n = 90)^Citation60
Non-Randomized Studies and Case Reports (n Participants)
HA filler + RF + (n = 1)^Citation61	BoNTx + HA filler + MFU-V (or CaHA) (n = 10)^Citation56
BoNTx + HA filler + laser resurfacing (n = 1)^Citation62	BoNTx + HA filler + IFU (n = 12)^Citation63
BoNTx + CaHA + HA filler + injectable PLLA (n = 2)^Citation20	CaHA + MFU-V (n = 47)^Citation64
BoNTx + CaHA + HA filler + MFU-V (n = 101)^Citation65	BoNTx + CaHA + HA filler + MFU-V (n = 101)^Citation65
BoNTx + HA filler (n = 60)^Citation66
Bimatoprost^a + BoNTx + HA filler (n = 116)^Citation55
Reviews
BoNTx + HA filler + various EBDs (laser, IPL, MFUS, FMR)^Citation22	Various techniques^b ^Citation52
BoNTx or HA fillers + IPL + lasers (ablative and non-ablative) + RF^Citation67

Notes: ^aBimatoprost 0.3% ophthalmic solution; ^bATX-101, ablative and non-ablative fractional lasers, BoNTx, cryolipolysis, HA fillers, IPL, laser lipolysis, liposuction, MFU-V, monopolar RF.

Abbreviations: BoNTx, botulinum neurotoxin; CaHA, calcium hydroxyapatite; FMR, fractional microneedle radiofrequency; HA, hyaluronic acid; IFU, intensity focused ultrasound; IPL, intense pulsed light; MFUS, micro-focused ultrasound; MFU-V, micro-focused ultrasound with visualization; PLLA, poly-L-lactic acid; RCT, randomized controlled trial; RF, radiofrequency; US, ultrasound.

Table 2 Sinclair Pharmaceuticals Products for Minimally Invasive Rejuvenation

	PCL Collagen Stimulator^a	PLLA/PLGA Suspension Suture^b	Cross-Linked HA^c
Concept	Dermal filler stimulating collagen production	3D cone-based suspension suture	Cross-linked resorbable high molecular weight HA gel
Indications	Volume restoration Facial reshaping Skin quality improvement	Facial and neck contour reshaping Tissue repositioning Collagen stimulation	Wrinkle correction Volume restoration Facial contouring
Product range	3 Products ≥18 Months 24 Months 36 Months Duration of effect^d	3 Products 8 Cones 12 Cones 16 Cones	5 Products BDDE cross-linked HA gels (20 mg/mL) Variable particle sizes

Notes: ^aEllansé^®; ^bSilhouette Soft^®; ^cPerfectha^®; ^dExpected longevity in vivo based on extrapolation of clinical data from S and M versions and accepted PCL degradation behavior.

Abbreviations: BDDE, butanediol diglycidyl ether; HA, hyaluronic acid; PCL, polycaprolactone; PLLA/PLGA, poly-L-lactic acid/poly-glycolic acid.

Table 3 Focus on Important Treatment Spacing Principles

Combined Use of EBDs and PLLA/PLGA Suspension Sutures

EBD tightening techniques should be used 6–8 weeks before (preferably) or 8–12 weeks after the PLLA/PLGA sutures insertion.

Resurfacing techniques should be performed 2–4 weeks before or after (preferably) the PLLA/PLGA suspension sutures insertion.

Combined Use of BoNTx and PLLA/PLGA Suspension Sutures

BoNTx injection should be performed 2 weeks before PLLA/PLGA sutures insertion.

Optional Touch Up Treatment

Should be injected 4–6 weeks after initial volume replacement/augmentation when using the PCL collagen stimulator, or 2 weeks after initial filler treatment when using the cross-linked HA.

Abbreviations: BoNTx, botulinum neurotoxin; EBD, energy-based device; HA, hyaluronic acid; PLLA/PLGA, poly-L-lactic acid/poly-glycolic acid.

Figure 1 (A) Algorithm for upper-face rejuvenation when using cross-linked HA or PCL collagen stimulator injections for eyebrow elevation. (B) Algorithm for upper-face rejuvenation when using PLLA/PLGA sutures for eyebrow elevation.

Note: ^aSpacing between steps 2 and 3: 4–6 weeks if step 1 treatment was PCL Collagen stimulator or 2 weeks if step 1 treatment was cross-linked HA.
Abbreviations: BoNT, botulinum neurotoxin; HA, hyaluronic acid; PCL, polycaprolactone; PLLA/PLGA, poly-L-lactic acid/poly-glycolic acid.

Figure 2 Algorithm for mid-face rejuvenation.

Note: ^aSpacing between steps 2 and 3: 4–6 weeks if step 1 treatment was PCL Collagen stimulator or 2 weeks if step 1 treatment was cross-linked HA.
Abbreviations: BoNT, botulinum neurotoxin; HA, hyaluronic acid; PCL, polycaprolactone; PLLA/PLGA, poly-L-lactic acid/poly-glycolic acid.

Figure 3 Algorithm for lower-face rejuvenation.

Note: ^aSpacing between steps 3 and 4: 2 weeks if step 1.1 is cross-linked HA, or 4 to 6 weeks if step 1.1 is PCL collagen stimulator.
Abbreviations: BoNT, botulinum neurotoxin; DAO, depressor anguli oris; HA, hyaluronic acid; PCL, polycaprolactone; PLLA/PLGA, poly-L-lactic acid/poly-glycolic acid.

Figure 4 Algorithm for neck rejuvenation.

Note: ^aPossible touch up with a HA filler indicated for neck rejuvenation 2 weeks after PLLA/PLGA sutures.
Abbreviations: BoNT, botulinum neurotoxin; EBD, energy-based device; HA, hyaluronic acid; PLLA/PLGA, poly-L-lactic acid/poly-glycolic acid.

Table 4 Recently Published Consensus Guidelines on Combination Rejuvenation Treatments of the Face and Neck

First Author, Year	Target Areas	Combination Treatment Components	Target Population, Consensus Method, Specific Comments
Chao 2017^Citation53	Upper, mid-, and lower face	BoNTx, CaHA, HA, MFU-V	Asian patients Formal consensus-based guidelines Demand for beautification more common than in Caucasian
Kapoor 2017^Citation54	Upper, mid-, and lower face Neck	BoNTx, HA	Indian patients Formal consensus-based guidelines Facial anthropometry, morphology, and age-related changes in Indians are specific
Carruthers 2016^Citation6	Upper, mid-, and lower face	BoNTx, CaHA, HA, MFU-V	All Fitzpatrick skin types Formal consensus-based guidelines Recommended spacing consecutive treatments on same area 1–2 weeks apart, if possible MFU-V recommended before injectable agents
Fabi 2016^Citation51	Neck, decolletage, hands, upper arms, abdomen, buttocks, knees
Sundaram 2016^Citation18	Upper, mid-, and lower face Neck	BoNTx, HA MFUS, RF	Diverse populations, worldwide perspective Formal consensus-based guidelines Recommended re-evaluation of patients 2–4 weeks after either treatment Summary statements for specific groups (age, gender, ethnicity)
Werschler 2015^Citation16	Face	MFUS, RF ± HA	Caucasians Informal consensus Discussion on decision approach (initial assessment; patient expectations; treatment selection) and various fillers (CaHA, HA, PLLA)
Carruthers 2008^Citation68	Upper, mid-, and lower face	BoNTx, HA	Diverse populations Informal consensus Discussion on the influence of patient sex, ethnicity, cultural ideals, and skin colour; general techniques; patient education and counselling
Wu 2016^Citation69	Upper, mid-, and lower face, neck	BoNTx, HA ±IPL	Asian patients Informal consensus Treatment selection according to age

Abbreviations: BoNTx, botulinum neurotoxin; CaHA, calcium hydroxyapatite; HA, hyaluronic acid; IPL, intense pulsed light; MFUS, micro-focused ultrasound; MFU-V, micro-focused ultrasound with visualization; PLLA, poly-L-lactic acid; RF, radiofrequency; wks, weeks.

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