‘Healthy skin is a reflection of overall wellness’
It is reasonable to suggest that the days of treating a patient wrinkle by wrinkle and line by line are almost behind us. Long gone are the days of only having two tools in the box: toxins and dermal fillers. Industry research, knowledge, training standards and expert support are now available in abundance to modern-day medical practitioners. Perhaps this means that now, more than ever, medical aesthetic practitioners are able to adequately support their patients with the concept described in the quote above. By treating skin concerns both directly and indirectly, and by taking into account a patient's skin concerns from a holistic level, advanced patient and skin assessment is possible. As well as physically assessing the skin, it is also vital to fully understand the patient's motivation for seeking treatment to further understand which products and treatments are safest and most appropriate for the patient.
The purpose of this article is to begin to highlight the key considerations associated with incorporating injectable skinboosters into clinical treatment plans, both as a standalone treatment and as part of a larger plan. Understandably, this assessment is made based on individual suitability following an assessment. The author will aim to highlight key factors that must be discussed when considering a patient for treatment and, notably, if the inclusion of a skinbooster would increase patient satisfaction, as well as overall skin health.
What is a skinbooster?
A quick internet search yields an abundance of websites with details on skinboosters. Basic explanations are largely the same, detailing the way small droplets of products are injected into the skin to increase hydration and skin rejuvenation.
Boxley (2018) noted the increasing number of hyaluronic acid (HA) products that are available commercially. These products are designed for intradermal injection through a mesotherapy technique and intended for skin rejuvenation. In line with this, the author also notes the increasing number of products that are available citing usage in bio-remodelling, collagen stimulation, skin rejuvenation, bio-revitalisation, bio-restructuration, skin hydration and skin quality improvement. With this is mind, the author feels it is reasonable to state that there is no singular definition of a skinbooster. Rather, this is a term that has been coined in relation to the method of injection (microdroplet/mesotherapy technique with either a manual or handheld device) and the product that is being injected (it appears that companies are offering different training methods and injection techniques, dependant on the molecular make-up of the product being used). Therefore, it is crucial that the practitioner takes this variability into account when discussing the use and inclusion of skinboosters in treatment plans and ensures that the patient is clear on how the practitioner intends to deliver the product into the skin. In the author's own practice, the term skinbooster is used when referring to the injection of lowly cross-linked/small-particle HA product into the superficial dermis with the intention of promoting skin hydration, reducing fine lines and improving the overall appearance of the skin.
A global approach
Narurkar (2016) highlighted the benefits and enhanced patient satisfaction associated with a comprehensive, multi-modal approach to treating the full face, although this study focused largely on the use of HA in its traditional form (as a product designed to address volume deficit). However, Narurkar (2016) noted that the treatment of the midface was perhaps what produced the high satisfaction rate associated with this method of treatment. The author feels that this could perhaps be due to the midface being one of the first areas that people notice when addressing someone face-on—or the first part of the face a person notices when looking in the mirror.
When thinking about a global approach to treatment, it is crucial to understand the patient's initial motivation for treatment and what concern has brought them to the practitioner in that instance, as well as addressing the skin in sufficient detail so as to provide a treatment plan that is safe, effective and appropriate.
Allergan (2014) created a ‘facial interest questionnaire’ designed for use during the consultation process. The questionnaire encourages the patient to consider and share the key reasons they have attended their consultation, as well as providing the practitioner with information on which areas are of greatest concern to them. The use of such tools should not be solely relied upon; instead, it is crucial to understand what enhancement the patient is truly seeking. This must be coupled with expansive knowledge of facial rejuvenation strategies and a repertoire of treatments available, so the practitioner can select those which are most appropriate.
In terms of a global approach, the author often finds that, while patients might often initially make an appointment seeking direct treatment for the nasolabial fold, for example, the author may find at the consultation that, while there is evidence of a prominent nasolabial line, there is generally significant global volume loss to the face and the patient's skin is actually showing anatomical signs of ageing across all structural components of the face.
Skin assessment
From a measured perspective, there are limited tests that can be practically completed by a practitioner to assess overall skin quality. The most accessible might be a skin imaging test. Commonly, surface imaging is used to analyse a patient's skin when looking for further issues regarding their skin quality, beyond those that can be seen on the superficial layer. Such concerns might include sun damage, tissue dehydration, oily skin or clogged pores. Having a clear understanding of facial skin health as part of the information that can be shared through taking a medical history and assessing diet and lifestyle factors can perhaps have a notable impact on the patient's end goal (Sturnham, 2016). However, skin imaging equipment may not be available in all clinics. This could be as a result of space, cost or the needs of the clinic's patient demographic. In this instance, it might be more appropriate to use qualitative assessment methods to inform treatment plans. This leads back to the importance of a thorough consultation and gaining an understanding of what troubles the patient, as well as what emotion they associate with various skin concerns. For example, dull skin might make a patient feel as though they look tired, while sagging skin might make a patient feel as though they look old, and so on. This can be coupled with the practitioner's clinical expertise, as they can also take into account the harmony of the patient's facial features so that a treatment plan that addresses all patient concerns while still taking into account patient suitability, ability (e.g. based on financial and time requirements) and desires, can be recommended. It is beneficial to adopt a holistic, qualitative approach for consultations and treatments, so as to gain an understanding of what triggers an emotional response from the patient, as well as their overall health, diet and lifestyle factors that might affect the outward appearance of the skin. Where there is evidence of full-face skin concerns, it is worth considering recommending the inclusion of an injectable skinbooster.
Indications for use
Without a clear understanding of what a skinbooster is, it is reasonable to look at other key factors when selecting the appropriate product and the appropriate time to select this procedure. Firstly, this would depend on the indications for treatment discussed above. This raises the question of whether the patient would benefit from hydration, for restored elasticity or smoothness. With the molecular make-up of each commercially available product being different, this may be difficult to distinguish. Therefore, key products should be looked at and considered.
» It is the role of the practitioner to safely manage all patient expectations and provide the rationale for why a treatment has been included in the plan «
It is becoming increasingly clear than an understanding of product ingredients is vital to determine who these products are best indicated for.
Should a patient present with skin that they feel is outwardly dull or perhaps crepey, thus seeking skin that appears brighter and smoother, it is important to understand whether there any changes that can be made to diet and lifestyle, which may negate the need for multiple invasive treatments. For example, assessment must be made based on multiple considerations ranging from the patient's water intake through to assessment of medications that may be affecting hydration levels or skin quality. It is the practitioner's duty as a medical professional to consider all aspects of the patient holistically. Similarly, consideration must be lent to the patient's skincare routine. While a positive assessment of the latter is beneficial, this does not necessarily negate the need for an injectable treatment, but it certainly must be noted as part of the larger treatment plan and long-term maintenance of the effects of any in-clinic procedures. The author finds the use of injectable skinboosters favourable when addressing full-face concerns and believes that the improvement to the dermis that the skinbooster offers provides a complementary foundation for further aesthetic treatments. Anecdotally, the author has found this has boosted overall patient satisfaction and allows patient to maintain their results for longer.
Safety considerations
Despite the low cross-linking, the complications that may occur with a skinbooster remain the same as those that could occur with any HA injection. Allergan (2018) warned against:
Due to the mode of administration, it is possible for products to produce localised swelling and bruising. It is important to explain to the patient that extended downtime is likely when it comes to such side effects, due to the potential multi-puncture nature of the injection technique. As with other HA products, no allergy test is explicitly required.
Duration of effect
The expected duration of effect is lower than that of traditional HA, since skinboosters are injected into the superficial dermis. Certain products are to be maintained every 6 months, following two to three treatments on a monthly basis while the condition of the skin is improved (Restylane, 2018). This could pose a significant problem from the patient perspective, notably, in the first instance, where there may an extensive cost outlay, as well as having the time (and any associated downtime) to return for treatments. This is where it is vital that the practitioner discusses and understands the patient's lifestyle, so they are able to advise and recommend accordingly. This is also reflected in product information regarding other products. Studies are currently being undertaken to determine whether the duration of effect can last up to 9 months (Consulting Room, 2019). It must be noted that the number of treatments required can vary and, ultimately, this is down to clinical judgement and patient satisfaction. Similarly, the duration that the effects are maintained can vary significantly from patient to patient, depending on lifestyle factors, so patients must always be made aware of this.
Studies and patient satisfaction
The role and effect of small-particle HA (SP-HA) has been clinically studied on several occasions. Nikolis and Enright (2018) noted that administration technique varies depending on individual preference, so caution must be exercised. The product selected must be injected appropriately for the indication it has been selected for, and the method used should be safe and in-line with variables, such as extrusion force, rather than simply being a preferred injection technique. The study notes that use of SP-HA (or skinboosters) significantly improved the hydration levels in the injected area. This was measured by comparing trans-epidermal water loss scores and pH values at baseline and after three treatments (Nikolis and Enright, 2018). This is significant, as the desired result must be considered from the point of consultation, raising the question as to whether three treatments are sufficient or unnecessary for the patient in question. It is the role of the practitioner to safely manage all patient expectations and provide the rationale for why a treatment has been included in the plan. Where indicated, the author personally favours the use of a skinbooster both early in the treatment plan to ensure the skin is in optimal condition to receive corrective treatments, as well as in follow-on treatments. Then, patients should be treated again once the treatment plan has been completed to ensure the skin remains hydrated and supported. This process is supported by the findings of Bertucci and Lynde (2015), which highlighted that injection of skinboosters using an intradermal, microdroplet technique is an effective and safe treatment for skin rejuvenation, with mild, transient side effects.
Conclusion
Everything practitioners do should seek a rational outcome. Therefore, it is important to distinguish what each procedure is indicated for and when it is appropriate to use it alone or to complement a larger treatment plan. It is also crucial to include one's own clinical judgement in any recommendation once individual factors have been considered in full. It is the ethical duty of the medical practitioner to ensure they understand the product they are using and are administering it appropriately, following accredited training. There is a justified demand for skinboosters, but their use must be considered appropriately, depending on the needs of the patient. There is no one straightforward protocol for this treatment. Therefore, it is down to the practitioner to consider the benefits a skinbooster would bring and at what point it should be used.