The skin provides the primary protection for the body and is essential in the maintenance of general homeostasis. Overall skin quality has a strong influence on the perceived age, health and attractiveness of an individual. In the literature, it has been acknowledged by Arora et al (2020) that skin changes associated with ageing, such as loss of elasticity and turgor, can have a negative psychosocial impact.
Humphrey et al (2021) stated that the demand for improvements in skin quality is growing rapidly, as flawless skin is one of the most universally desired features. The quality of the skin has been shown to have a substantial impact on emotional health, quality of life, self-perception and interactions with others.
Skin quality among individuals of different ethnicities remains understudied within aesthetics in regard to skin ageing, but the literature has highlighted variations. Langton et al (2019) stated that, despite the protective effect of increased melanocytes and melanin, both intrinsic and photoaging still occur and cause the skin to be less resilient and elastic in ageing.
Skin requires sufficient moisture for biomechanical functions, which can impact normal skin physiology. As such, adequate hydration is paramount in establishing skin health. Furthermore, dehydration can cause dry, flaky and tight skin that increases the appearance of age. Therefore, increasing moisture and hydration can rejuvenate the skin by improving its appearance and health (Nikolis and Enright, 2018).
The skin in ageing
During the ageing process, there is a degradation and disorganisation of dermal fibres; collagenesis and elastogenesis are diminished and reduced glycosaminoglycans is observed. These processes result in reduced skin quality due to a reduction in elasticity and resistance (Ypiranga and Fonseca, 2019).
During the ageing process, the extracellular matrix predominantly in the dermis is progressively damaged, which affects the normal organisation of skin cells, and its overall capacity for repair is reduced (Arora et al, 2020). With increasing age, there is less collagen and a more significant proportion of fragmented collagen in the skin. Kapoor et al (2021) commented that these changes lead to a reduction in mechanical tension of the extracellular matrix and less collagen synthesis.
Extrinsic factors, such as ultraviolet radiation, pollution, smoking and stress, can accelerate the ageing process, according to Bonté et al (2019). Intrinsic factors and certain health conditions also add to the effects of skin ageing. Intrinsic ageing is associated with structural and functional deterioration of the skin, with declining levels of collagen, elastin and hyaluronic acid, as well as other components. Together with other age-related damage, the skin changes lead to a reduced barrier function and hydration, as well as increases in sagging, pore size, wrinkles, dullness, rough texture, hyperpigmentation, dryness and erythema (Haydont et al, 2019). Optimal skin health is aided by skincare regimens that prevent radiation and pollution damage and, ultimately, reinforce the skin surface to minimise the effects of ageing on the skin (Bonté et al, 2019).
Educating patients about skin health
Non-surgical treatments are becoming increasingly popular, with hyaluronic acid (HA) injections being listed as the second most common non-surgical procedure by worldwide statistics from the International Society of Aesthetic and Plastic Surgery (2020). These statistics also showed that 85% of patients were female. Despite the popularity of these treatments, it is important that patients understand that skin treatments alone will not optimise their overall skin quality results. Getting the most out of in-clinic treatments also relies on a good homecare skin routine and other factors, for example, reducing extrinsic factors.
Practitioners should educate patients when discussing overall skin health. It is essential that patients use sun protection factor (SPF) daily, whether the sun is out or not, as part of their skincare regimen and take effective measures to protect their skin from further damage and developing skin cancer (Haswell, 2018). This will also optimise their treatment results.
Education about other skin products to improve skin quality, such as acids, peptides and retinol, as well as daily SPF use, should form part of the holistic skincare consultation.
Skin boosters
Skin booster treatments are a relatively new concept within the aesthetics sector, and they have gained increasing popularity in recent years, especially among younger patients. According to Arora et al (2020), skin boosters can be defined as biological materials or bio-actives that help or encourage the skin to increase or improve its function. Skin boosters can be used to treat the loss in skin nourishment and vital components, which is the concept involved in the biorevitalisation of the skin.
Skin boosters' primary component is HA, which is one of the skin prominent glycosaminoglycans produced by fibroblasts and keratinocytes. HA can hold water molecules up to 1000 times the molecular weight and is found in the epidermis, dermis and extracellular matrix. Skin HA accounts for almost 50% of the total body's HA. Skin HA cross-links with other extracellular matrix proteins, including collagen, improving the tissues' robustness and has a shock-absorbing role in the skin (Kapoor et al, 2021).
» Although there are many different HA-based products ranges available to improve skin quality, Kleine-Börger et al (2022) recently studied five skin booster product ranges from different companies and manufacturing technologies and investigated the physicochemical properties of specific HAs for improving skin quality «
Through critical analysis, Bukhari et al (2018) showed that HA has biomedical and tissue regeneration potential. Therefore, it has been recognised as a key component in multiple cosmetic products in various forms and exhibits remarkable face rejuvenating properties. HA showed promising efficacy in skin tightness and elasticity, and it has been used to achieve skin hydration, stimulation of collagen and elastin and facial volume restoration.
Although HA has known hydrophilic properties, published studies have reported varied results on the efficacy of small particle HA in improving skin hydration. Nikolis and Enright (2018) stated that, due to the multifactorial environmental and intrinsic influences, it is difficult to accurately measure skin hydration, and this may account for the mixed findings found in the literature.
Some studies on ‘skin quality boosters’ have reported a clinical improvement in skin hydration, skin elasticity and fine lines, as well as smoother skin structure (Kleine-Börger et al, 2022). A clinical observation by Nikolis and Enright (2018) suggests that small particle HA may rejuvenate the skin by increasing hydration to the treatment area. By injecting HA into the dermis, the objective is to reduce the appearance of ageing indicators associated with loss of mechanical properties of the skin. This treatment aims to promote a global improvement of the skin, maintain skin hydration and delay or reverse the ageing process using small quantities of HA.
Ypiranga and Fonseca (2019) agree that, after injecting HA into the dermis, it improves hydration and stimulates collagen production by mechanical tension, consequent to stretched fibres.
Kapoor et al (2021) commented that HA injected in the skin layer leads to the synthesis of new collagen, elastin and HA, as well as improved hydration, better texture, less appearance of fine lines and enhanced skin elasticity. As the restoration of the structural extracellular matrix is the primary mechanism for rejuvenating the dermal component and its function, HA's degradation is not the primary determinant of the treatment's longevity.
Practitioner considerations
Prior to treatment, essential planning is paramount and should support a holistic, full-face approach. Haddad et al (2019) stated that designing an adequate treatment plan includes selecting the most suitable procedures and the safest way to deliver the treatment for the patient. To do this, it is important to take into consideration the rheological characteristics of the products and consider what is needed to achieve a fresher, natural look.
Patient selection and managing patient expectations are extremely important, and a full consultation and discussion of past medical history must be carried out. Practitioners must consider whether the patient is suitable for treatment and be honest about what a skin booster aims to achieve. Consider what is trying to be achieved from the treatment. If skin quality improvement is the aim of the treatment or if the patient also has volume loss, then perhaps this is what needs to be addressed. The patient may benefit from more than one product or treatment modality for their skin or deeper layers and, therefore, may require a multi-treatment approach to gain their desired result. Some deeper soft tissue fillers may also be indicated to address volume loss. Additionally, patients who are hesitant about dermal filler treatment often find this to be a good entry treatment, as long as they fully understand that this will not create volume.
Ensure that the patient does not have any contraindications to treatment, for example, active skin infections, acne or a bleeding disorder.
Know the products
With the different choices of skin booster treatments on the market, it can be difficult to know what to choose, so the practitioner's knowledge of products is essential. Although there are many different HA-based products ranges available to improve skin quality, Kleine-Börger et al (2022) recently studied five skin booster product ranges from different companies and manufacturing technologies and investigated the physicochemical properties of specific HAs for improving skin quality. The products were Belotero Revive, Juvederm Volite, Restylane Skinbooster Vital, Viscoderm Hydrobooster and Profilho. The aim of their study was to investigate the physicochemical properties of specific HAs for improving skin quality, as published data is limited on this. The findings demonstrate that HA concentration (mg mL−1) exhibits statistically significant positive correlations with extrusion force, swelling degree, rheological performance and cohesivity, and there were significant differences between the assessed products.
La Gatta et al (2021) also characterised three commercial skin boosters. Their performances were compared, and biophysical and biochemical parameters for skin boosters were discussed to support clinicians in the tuning of their use. Data revealed large variability in the behaviour of the gels and it may be useful to improve customisation of gel design toward specific uses. Therefore, it is important to consider the product choice and factors that may affect this, as well as the risks versus benefits for the patient.
The treatment
Some patients may require one skin booster treatment that lasts for 6–9 months, while others will require two or more treatments at 4–6-week intervals or a course of treatment for the best results. It is essential that the patient knows what to expect and how frequently they will need to have the treatment to gain optimum results and then maintain these. Patients and practitioners need to consider the number of treatments, time for appointments and budget constraints.
Skin boosters are an injectable gel that targets the skin globally or very fine lines directly and are made of stabilised HA, which may or may not be cross-linked. It is essential that the practitioner selects the correct product and understands the implications of stabilisation and/or cross-linking. The practitioner's knowledge about the product, depth and technique of injection is essential to provide the optimum outcome for the patient and reduce the risk of treatment-related complications.
Intradermal, superficial injections may be indicated for non-cross-linked products, but mid to deep dermis injections are indicated for cross-linked products due to the risk of lump formation. The formation of a lump in the skin surface could require dissolving with hyaluronidase, posing an unwanted risk to the patient due to an avoidable complication.
Prior to skin booster treatments, the patient's face or neck should be suitably prepared by removing all makeup, using a topical anaesthetic and cleansing the skin.
While topical local anaesthetic creams (for example, Emla or LMX4 cream) can be used and is accepted practice, some practitioners prefer to use ice. Nikolis and Enright (2020) stated that icing the areas for 5–10 minutes before the procedure, in addition to the anaesthetic effects, has the secondary benefit of reducing bleeding and bruising by constricting superficial vessels. The patient must be informed prior to the treatment that there is a risk of bruising from multiple punctures, and this should form part of the consent process.
As the treatment often covers a large surface area, it is important to plan and, depending on the treatment, it is useful to mark out the area for injection. For example, if the skin booster is a 2ml treatment, it is important to plan to use 0.5ml in each quadrant to achieve an even distribution of the product and optimum results. Kleine-Börger et al (2022) commented that the most common injection technique is multiple microinjections over a large area into the dermal or immediate subdermal layer with relatively small volumes of 0.01–0.05 ml per injection point. When injecting, depending on the product being used, the spacing of each injection can be between a few millimetres and up to 1cm. However, Nikolis and Enright (2020) found that, in patients with more visible skin damage, closer spacing is necessary to achieve the desired result.
Successful management of skin quality requires specific quantities of HA to be precisely placed at the appropriate depth using a reproducible volume (Nikolis and Enright, 2020). Some skin boosters will allow the practitioner to create more of a bespoke treatment and focus on specific areas of concern, such as the perioral area or radial cheek lines. In these cases, the volume of product to be used in this area of concern also needs to be accounted for.
If the product is placed at the desired depth, according to the manufacturer's guidance, the chances of unfavourable results are significantly minimised.
During a skin booster treatment, needles should be changed frequently, as they become blunt with multiple punctures. A minimum of one new needle per side is recommended, but whenever the practitioner feels that the needle is not optimal, it should be changed.
After treatment, the patient should be given adequate aftercare instructions that include information to reduce the risk of infection, such as a clean pillowcase the night following treatment. The patient must be suitably educated about what complications are possible and what to do in the event of a complication or if they have any concerns.
Incorporating skin boosters into an aesthetic practice
Using skin boosters within your practice will give you a treatment to offer to improve the skin quality of patients of various ages and skin types. If patients are aiming to address volume loss at deeper layers of the face, then skin boosters alone may not be the treatment they are looking for. The skin booster may form part of a holistic treatment plan to treat volume loss and skin quality. In older patients, soft tissue fillers can be used to address volume loss and, once the volume is replaced, the skin booster can enhance the results by making the overlying skin smoother and more hydrated. Ayatollahi et al (2020) reported that skin booster therapy with HA is a safe and well-tolerated procedure that results in an improvement in skin elasticity and a relative increase in skin hydration.
Skin boosters can also be extremely beneficial in ‘hard to treat’ areas, such as the perioral areas, where volume loss is less of the problem, but skin quality is the primary concern. In younger patients who do not have volume loss, they can be used independently for overall skin rejuvenation and hydration.
The products must be sourced from a reputable Care Quality Commission (CQC)-registered pharmacy and administered at the correct depth with the correct technique by a trained and registered medical practitioner. The practitioner must also be suitably qualified and prepared for adverse events or complications, during and post-procedure. It is also advisable to have access to support as needed from groups such as the Aesthetic Complications Expert group (ACE) or Complications in Medical Aesthetic Collaborative (CMAC).
Conclusion
Skin boosters are a valuable addition to an aesthetics business if used appropriately. A holistic full-face approach is needed when assessing patients for treatment and, sometimes, skin boosters alone cannot achieve the desired result, especially in older patients. Practitioners must have knowledge of the safe and effective use of the product chosen and be aware of its limitations as a treatment. The literature supports the benefit of skin boosters in improving overall skin quality but to varying degrees, depending on the product. Some future research comparing different brands of skin boosters would be useful, but the variables for individuals are very difficult to control. Additionally, intrinsic and extrinsic factors relating to skin quality and the ageing process make this a difficult area to study.
Key points
- Hyaluronic acid is a key component of skin boosters, aiming to increase skin hydration, along with other benefits
- Skin boosters can be used for a variety of patients and as a single modality treatment or form part of a treatment plan using a holistic full-face approach
- Skin boosters are an effective treatment modality employed within facial rejuvenation to improve skin quality
- The correct product choice and injection technique and depth of injection are paramount in achieving optimum results
- It is the practitioner's responsibility to provide excellent patient consultations and education about overall skin health within an aesthetic practice.
CPD reflective questions
- What changes occur within the skin during the ageing process? Consider intrinsic and extrinsic ageing.
- According to the literature, what does a skin booster treatment actually do to help improve skin quality?
- As a practitioner, what are the important factors to consider and steps to be taken prior to treatment with a skin booster?
- What is the correct depth and injection technique for skin boosters and how often are they needed to maintain patient results?
- Consider your skin consultations in practice. How can you ensure that you are providing a holistic full-face approach to treatment and providing education to protect the skin within these?