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"Hyaluronic acid supplementation with Hyal® ACP for ageing skin and solar elastosis on the décolleté"
Plastic Surgery, July 2014

With increasing age, the skin gradually loses important physiological functions, as a result of which elasticity, resilience and moisture decrease and wrinkles appear - a visible indicator of skin ageing. Intrinsic factors such as genetic disposition and extrinsic factors such as alcohol, nicotine, lifestyle, sleeping habits and, in particular, sunlight exposure are involved in the ageing process. The extrinsic factors act synergistically with the intrinsic factors and thus accelerate the formation of wrinkles.

Hyaluronic acid stimulates the regenerative capacity and maintains the skin's vitality

Hyaluronic acid (HA) is a glycosaminoglycan and natural component of the dermal matrix that plays a central role in maintaining the skin's moisture and elasticity. In addition to a high water-binding capacity, hyaluronic acid has an activating effect on fibroblast and keratinocyte functions - mediated by specific receptor interactions. Among other things, this stimulates collagen and elastin biosynthesis, improves the skin's ability to regenerate and boosts its vitality.

Skin ageing is accompanied by a loss of hyaluronic acid function

Studies by several research groups confirm that decreasing hyaluronic acid activity is of essential importance in skin ageing. It was shown that the content of dermal hyaluronic acid decreases in the course of intrinsic ageing processes [2, 3]. Another group described an age-dependent change in the histolocalisation of hyaluronic acid in the skin as well as chemical alterations due to the binding of hyaluronic acid to HA binding proteins [4], resulting in a loss of water binding capacity and the ability to interact with specific receptors.

UV radiation is the most important extrinsic ageing factor and is able to inhibit the hyaluronic acid synthesis capacity of fibroblasts [6]. Chronic UV exposure also led to a redistribution of hyaluronic acid in the skin, whereby hyaluronic acid accumulated in elastotic material of the dermis surface, while it was lost from the deeper dermal matrix [1]. Altered hyaluronic acid homeostasis associated with downregulation of HA receptors in photo-ageing has been described elsewhere [7]. In summary, it can be deduced from the above findings that the vital functions of hyaluronic acid, which are essential for the skin, are lost during ageing processes. It is therefore plausible to assume that supplementation with hyaluronic acid can at least partially counteract intrinsic and extrinsic skin ageing (especially photo-ageing).

The décolleté places high demands on a rejuvenation treatment with fillers

The décolleté is particularly susceptible to signs of ageing due to its special localisation and structural characteristics. The comparatively thin skin in this sensitive area is only sparsely lined with supporting fatty tissue. Tensile forces on the female breast during movement or when sleeping on the side are stresses that contribute to the formation of "creases" and can affect the aesthetic appearance even at a younger age. In addition, many people underestimate the exposure of the décolleté to sunlight and often neglect effective UV protection. Solar collagenosis is therefore very common in this region.

In recent years, patients have frequently asked us for aesthetic correction of the décolleté. In view of the anatomical features and the large surface area of the décolleté, biodegradable hyaluronic acid-based filling materials are our first choice for smoothing the skin relief in this region. They are very fluid and are well suited for injecting fine lines and, after appropriate processing, for volume augmentation of wrinkles with greater depth and for levelling out large areas of volume loss. In contrast, we do not consider permanent fillers to be indicated - we do not consider them because of the higher risk of late complications [5]. In the following, we present a patient with solar elastosis of the décolleté who was treated with Hyal® ACP, an autocrosslinked biodegradable hyaluronic acid. As Hyal ACP is manufactured without additional chemical cross-linking agents - i.e. without harmful foreign substances - this product offers maximum safety and was selected by us for extensive use on the décolleté.

Treatment of elastotic ageing skin on the décolleté significantly reduced deep wrinkles and signs of photodermatosis

A 64-year-old female patient, a smoker, presented to us with clearly visible photodermatosis and partially deep wrinkles on the décolleté. The treatments with Hyal ACP were carried out intradermally on the décolleté including the lower neck region after local anaesthesia with tetracaine cream using injection needles (Becton Dickinson 4 mm, 30 G) - depending on the requirements in a linear or punctual injection technique at a puncture angle of approximately 40 to 45 degrees. Approximately two millilitres of Hyal ACP (two-percent hyaluronic acid sodium salt solution) were used per session, corresponding to two pre-filled syringes per session. The injections took place on weeks 0, 2 and 6. After two and eight weeks, the skin findings were compared with the initial findings at week 0 - in each case before the Hyal ACP injections.

At the beginning, the patient's skin showed the following findings on a four-point scale (0 = not present, 1 = mild, 2 = moderate, 3 = severe): Actinic elastosis (2 points), loss of elasticity (2 points) and age-related skin dryness (2 points). In addition, the skin appeared clearly reddened due to frequent exposure to sunlight (Fig. 1). After just two weeks, the findings of actinic elastosis, loss of elasticity and age-related skin dryness had each improved by one point from moderate to mild (Fig. 2). The improved skin appearance remained unchanged over the entire treatment period until the last appointment after eight weeks. The photo documentation shows a significantly younger appearance of the skin and a much smoother surface structure due to the reduced wrinkle depth and improved elasticity (Fig. 1b). Although the patient continued to be exposed to sunlight during the treatment period, the reddening of the décolleté had visibly diminished eight weeks after the start of treatment. Apart from slight injection-related swelling, which subsided after a few days, there were no side effects. The patient rated the pain intensity on an 11-point scale (from 0 = no pain to 10 = very severe pain) as almost painless with two points.

Hyal ACP has a high priority in the rejuvenation treatment of the décolleté

We have had good experience with the use of Hyal ACP on the décolleté for various reasons: firstly, the good injectability and tolerability of the injected material offers a high degree of safety when used on this very sensitive area of skin. On the other hand, Hyal ACP makes it possible to counteract elastotic skin changes, which occur particularly early in the décolleté area as a result of sun exposure. The excellent spreadability and high fluidity of Hyal ACP supports the regeneration process in the area. The treatment cycles described by us can be repeated at intervals of around six months for long-term skin rejuvenation.

In the patient described here, Hyal ACP produced an impressive visual rejuvenation of the skin on the décolleté. With reference to the positive stimulation of keratinocytes found by Wohlrab et al [8] in in vitro studies, positive effects can also be expected in vivo and thus provide indications of a possible strengthening of the barrier function by Hyal ACP. Whether intradermal treatment with hyaluronic acid also has positive effects on other age-related losses of physiological skin functions, such as reduced blood circulation, declining immune function, increased susceptibility to infection and impaired wound healing, should be investigated in larger-scale long-term studies.

Source: Plastic Surgery, July 2014