Treatment of Striae Distensae with Filler Injection: A Systematic Review

Figures & data

Figure 1 Flowchart of literature identification, screening, eligibility, and inclusion process.

Table 1 Study Characteristics

Study Characteristics									Treatment							Outcome
First Author’s Name	Title	Year	Country	Study Design	Sample Size	Mean Age	Female/Male	Striae Type	Study Group 1	Dose Group 1	Study Group 2	Dose Group 2	Study Group 3	Dose Group 3	Duration	Method of Measuring Improvement	Results	Side Effects
Casabona G^Citation6	Calcium Hydroxylapatite Combined with Microneedling and Ascorbic Acid is Effective for Treating Stretch Marks	2017	Brazil	Retrospective study	35	21–35	-	Red striae (n=25) and white striae (n=10)	CaHA filler was diluted 1:1 with lidocaine 2% without epinephrin, followed by microneedling and topical application of 20% ascorbic acid. Microneedling with ascorbic acid was repeated after 1 and 2 months	3.0mL	NA	NA	NA	NA	3 sessions over 8 weeks. all subjects were evaluated 1 month after the final treatment with microneedling and ascorbic acid.	Patients satisfaction, photography, Manchester scar scale.	The mean (±SD) pretreatment Manchester Scar Scale scores were 12.0 (±0.8), decreasing to 7.1 (±1.4) 1 month after the final treatment, indicating improvement in stretch mark appearance. Subjects were very satisfied (n = 22; 62.9%), satisfied (n = 8; 22.9%), neither satisfied nor dissatisfied (n = 4; 11.4%), or unsatisfied (n = 1; 2.8%) with their treatment results. Analysis revealed a significant correlation between Scar Scale scores and Patient Satisfaction scores. Skin biopsies showed increased quantity and quality of collagen and elastin fibers in areas treated with combination therapy. Procedures were well tolerated.	Two subjects with Fitzpatrick skin type III developed postinflammatory hyperpigmentation. Both were treated for 30 days with a whitening cream (Kligman`s formula) with complete resolution. Bruising (n = 32) and erythema (n = 35) resolved within 7 days, and mild pain resolved within 2 days. There were no serious adverse events.
Lim JT^Citation8	Treating Striae Distensae Albae in Asians: Efficacy and Safety of Combined MFU-V and CaHA	2021	Singapore	Prospective study	10	36	All female	SDA = Striae Distensae Albae	MFU-V at 3 focal depths (4.5, 3.0, and 1.5mm), followed by 3–6mL of diluted CaHA+ (1:1 ratio) with normal saline were injected subdermally along the SDA and adjacent areas, using a fanning technique and a 25G, 48-mm-long cannula.	3–6mL depending on surface area of SDA	NA	NA	NA	NA	Single session. Outcomes were assessed at 1 month, 3 months, and 5 months postprocedure	5-point quartile grading scale, an SDA scoring scale, a 10-point visual analog score, and a global aesthetic improvement scale	All patients exhibited improvement in SDA at 3 months, with further improvement at 6 months. Physicians’ assessment with the quartile grading scale showed that 8 patients improved moderately, whereas 2 had good improvement at 6 months. The mean overall SDA score was 11.6 at baseline, 11.1 at 1 month, 7.9 at 3 months, and 6.2 at 6 months. All patients had improved global aesthetic improvement scale at 3 and 6 months, with 4 patients being much improved, and 3 patients being very much improved at 6 months. At the end of the study, all patients were less bothered with their SDA compared with baseline with a mean reduction of 2.7 in visual analog score, and all patients were satisfied or very satisfied with the treatment.	No side effects were observed during the follow-up sessions. Some bruises were seen immediately after the filler injection in 4 patients, all of which resolved without treatment.
Casabona G^Citation7	Microfocused Ultrasound with Visualization for the Treatment of Stretch Marks	2019	–	Retrospective, nonrandomized study	20 Healthy female subjects aged 18 to 55 years who were previously treated with CaHA, topical 20% ascorbic acid solution, and microneedling, as described above, were provided an opportunity to receive additional treatment with MFU-V in an effort to achieve additional improvement in striae appearance.	18–55	All female	SR & SA previously treated with CaHA, topical 20% ascorbic acid solution, and microneedling, And with remaining skin atrophy.	MFU-V was delivered using transducers with a frequency of 7MHz at a focal depth of 3.0mm and a frequency of 10MHz at a focal depth of 1.5mm.	–	NA	NA	NA	NA	90 days	Manchester scar scale, Patient satisfaction.	At Day 90 post-treatment, the mean (± standard deviation) baseline Manchester Scar Scale score decreased from 9.35 (±1.18) to 6.30 (±1.26) and the mean Patient Satisfaction Scale score increased from 3.75 (±0.44) to 4.70 (±0.47). Most subjects (70%) were very satisfied with their results.	None
Hong, J. Y^Citation10	Remarkable improvement of striae distensae with polycaprolactone filler injection	2019	South Korea	Case report	1	-	-	SD	DLMR01 that is composed of fully solubilized form of poly-caprolactone (PCL) in water.	0.1 cc of filler was injected intradermally into each point at 5-mm intervals in the upper part of the stretch marks; the lower part remained as control. The injection was performed using a 33G nanoneedle.	NA	NA	NA	NA	4m	Three-dimensional camera analysis	After the injection, the PCL fillers show an immediate direct volumizing effect. The secondary “delayed” volumizing effect occurs as PCL fillers are gradually resorbed over several weeks while they stimulate neocollagenesis. The new collagen then replaces the volume ofthe resorbed portion of the filler, resulting in an elastic modulus almost equal to that of the dermis. These direct and secondary “delayed” volumizing effect of the PCL fillers make them anexcellent candidate for treating intractable SD	Injection pain was minimal. Immediate erythema and nodularity at the injection points disapeared the day after treatment.
Cassuto, D^Citation9	Case Report: Effective Treatment of Striae Distensae using Pneumatic Injection of Hyaluronic Acid	-	Milan, Italy	Case report	1	22	Female	SD	JVR technology was used to deliver cross-linked Hyaluronic Acid	35 shots to the dorsum at a setting of 40% pressure and filling level 4	NA	NA	NA	NA	Follow-up evaluations were conducted 3 months, 8 months, and 3 years after the treatment.	Photography	Positive effects were seen starting 3 months after the first treatment. In addition, the treatment diminished the appearance of the striae and improved its texture and color. The outcome was judged excellent by the patient, the investigator, as well as a blinded, board- certified plastic surgeon. Three years after the treatment, there were marked improvements in the striaes’ appearance and texture.	Transient bumps and spot bleeding entry points, mild pain
MacGillis D^Citation12	High-velocity pneumatic injection of non-crosslinked hyaluronic acid for skin regeneration and scar remodeling: A retrospective analysis of 115 patients	2021	Canada.	Retrospective study	115	48.6	All female	SA	Needle-free pneumatically accelerated jet injections using non-crosslinked HA.	The pharmacy-prepared non-animal derived non- crosslinked HA (10 mg/mL, York Downs Chemists). HA gels were diluted with normal saline to a final concentration of 2.5 mg/ mL.	Needle-free pneumatically accelerated jet injections using crosslinked HA.	Crosslinked HA (22.5 mg/mL, Esthélis Basic, Anteis, Lonay, Switzerland). HA gels were diluted with normal saline to a final concentration of 2.5 mg/mL.	NA	NA	Retrospective over 10 years.	GAIS score, pt satisfaction, photography	An average of 2.8 treatments was completed per patient. Patients were highly-satisfied with the treatment results in all categories with the average satisfaction scores of 3.68 (NCL-HA) and 3.76 (CL-HA). An average GAIS score of 1.7 (“much improved”) was calculated for neck, décolleté and perioral areas. An overall GAIS score averaged as 1.78 (NCL-HA) and 1.6 (CL-HA). Longevity of the effect averaged 13.1 months for NCL-HA and 13.2 months for CL-HA groups.	The average injection pain was scored 2 on the NPRS scale. There was a low incidence of side effects which include self-resolved bruises and temporary local edema occurred at low incidence (7% and 1% of the treatments, respectively).
Gupta^Citation11	A novel treatment of Striae distensae with pneumatic injection of hyaluronic acid	2021	USA	Case report	2	29, 60	Females	SD	Pneumatic injection of hyaluronic acid (HA) using a novel technology called jet volumetric remodeling (JVR). Treatment was performed with a mixed solu-tion of saline and non-cross- linked HA (H-100, World Dermic) at a 9:1 ratio.	200 shots to the breast striae, 50% intensity and 30% filling and 450 shots for abdominal striae, 50% intensity and 30 filling.	NA	NA	NA	NA	2 sessions 8 weeks apart, Assessment was repeated at 6 and 15 months after the second session	Manchester scar scale, Photography	Substantial improvement in color and texture as well as thinning and fading of the stretch marks were noted as early as 2 months after the first session (time of sec-ond session). Improvement was also noted at 6 months and 15 months after final session. The pre-procedure average Manchester scar scale score for the 3 sites (left breast, right breast and abdomen) was 11.66. The respective post-procedure scores were 6.33 at 6 months (−5.33 from baseline; 45.71% improvement) and 6.66 at 15 months (−5 from baseline; 42.88% improvement). Patients were satisfied with results and did not request additional treatments.	Treatment was tolerated well, and patients experienced only mild discomfort during procedure. Slight edema at the treatment sites was noted up to 72 hours post-treatment. No adverse effects were noted at the follow up visits.

Figure 2 Assessment of quality of the included case reports.

Table 2 Assessment of the Quality of Included Cohort Studies

	Selection			Outcome			Score
	Representativeness of the Exposed Cohort	Ascertainment of Exposure	Demonstration That Outcome of Interest Was Not Present at Start of Study	Assessment	Follow-Up Long Enough	Adequacy of Follow Up of Coherts
Gabriela 2017^Citation6	0	1	1	1	1	1	5
Joyce 2021^Citation8	0	1	1	1	1	1	5
Gabriela 2019^Citation7	0	1	1	1	1	1	5
Diane 2021^Citation9	0	1	1	1	1	1	5

Casabona G, Marchese P. Calcium hydroxylapatite combined with microneedling and ascorbic acid is effective for treating stretch marks. Plast Reconstr Surg Glob Open. 2017;5(9):e1474. doi:10.1097/GOX.0000000000001474

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Lim JT. Treating striae distensae alba in Asians: efficacy and safety of combined MFU-V and CaHA. Plast Reconstr Surg Glob Open. 2021;9(2):e3429. doi:10.1097/GOX.0000000000003429

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Gasa Casabona G. Microfocused ultrasound with visualization for the treatment of stretch marks. J Clin Aesthet Dermatol. 2019;12(2):20–24.

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Hong JY, Han HS, Kwon TR, et al. Remarkable improvement of striae distensae with polycaprolactone filler injection. J Eur Acad Dermatol Venereol. 2019;33(11):e399–e400. doi:10.1111/jdv.15702

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Cassuto D. Case report: effective treatment of striae distensae using pneumatic injection of hyaluronic acid. Available from: elogioasia.com. Accessed November 14, 2023 2022.

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MacGillis D, Vinshtok Y. High-velocity pneumatic injection of non-crosslinked hyaluronic acid for skin regeneration and scar remodeling: a retrospective analysis of 115 patients. J Cosmet Dermatol. 2021;20(4):1098–1103. doi:10.1111/jocd.14002

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Gupta A, Kroumpouzos G. A novel treatment of striae distensae with pneumatic injection of hyaluronic acid. J Appl Cosmetol. 2021;39(1):17–24.

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