Biorevitalization: features of the procedure

Kristina Beznikina , dermatocosmetologist, certified trainer of the Vallex M company (Moscow).

Conceptual apparatus

In the broadest sense of the word, revitalization refers to the restoration of functions and abilities of the body, partially lost as a result of involutive processes. In a narrower sense – within the framework of aesthetic medicine – the concept of “revitalization” involves rejuvenation of the skin of the face, neck, décolleté and other parts of the body. To correct age-related changes in the arsenal of aesthetic medicine, there are a variety of injection and hardware techniques that help slow down the aging of the body. However, in cosmetology, the term revitalization most often refers to the use of hyaluronic acid (HA).

Today it is customary to distinguish two main directions:

• revitalization, which involves the use of stabilized HA;
• biorevitalization - the use of unstabilized HA.

There is no generally accepted classification of revitalizant drugs; however, they can be divided into several groups.

The mechanism of action of each drug consists of the totality of the mechanisms of all its active components. First, let’s look at the effect on tissue of the main, basic component of all revitalizants – hyaluronic acid.

Action of HA

When administered intradermally, HA naturally integrates with the surrounding tissue and provides optimal physiological conditions for the functioning of fibroblasts. In addition, HA has a powerful moisturizing effect due to its ability to attract water molecules, neutralizes free radicals, strengthens the walls of blood vessels, and improves skin immunity.

HA introduced into the dermis is distributed homogeneously and evenly, and after a certain time (from several hours to several months, depending on the presence or absence of stabilization of its molecules) it slowly “dissolves,” undergoing natural biodegradation and reaching the level of physiological concentration. To optimize aesthetic correction, various components can be included in the composition of these drugs, which give them additional properties.

The mechanism of action of stabilized HA is somewhat different from its unstabilized forms. The biological mechanisms of collagen synthesis during intradermal injections of stabilized hyaluronic acid are caused by mechanical irritation of receptors on the surface of fibroblasts, expression of type I and III procollagen genes and activation of the synthesis of new collagen fiber. Microtrauma caused by a sharp needle during intradermal drug administration induces the expression of connective tissue growth factors and transforming growth factor β (TGFβ). In parallel with these processes, there is a short-term increase in the activity of matrix metalloproteinases (MMPs), and then a suppression of their activity due to the action of tissue inhibitors. Thus, collagen degradation is suppressed and its synthesis is activated, complete collagen fibers accumulate in the injection area and the internal volume of tissues is maintained.

Based on the above mechanisms, we can conclude that intradermal injections of stabilized HA help increase skin elasticity and smooth out its microrelief (lifting effect). Therefore, indications for biorevitalization are:

• photo- and chronoaging;
• dry skin;
• preparation and rehabilitation after aggressive procedures (laser, IPL, radio wave lifting, plastic surgery, etc.);
• preparation and rehabilitation after sun exposure;
• correction of post-acne scars and stretch marks.

Choice of drug depending on the morphotype of aging

To date, there are no uniform algorithms for selecting drugs. However, to solve this issue, we can start from the morphotype of facial aging as a symptom complex of age-related manifestations, convenient for working with a cosmetic patient. The morphotype of facial aging is understood as a set of clinical signs that reflect the external manifestations of aging of the face and neck, including additional characteristics of photodamage to the skin, the presence of vascular and edematous components. At the Vallex M preventive medicine clinic, a pilot clinical and instrumental study was conducted in January-February 2009 in order to clarify and expand the existing understanding of the types of facial skin aging in women and to substantiate the approach to cosmetological correction. Based on the results of the study, the main morphotypes were confirmed and additional subtypes were identified.

Tired type of aging

It is observed in women with normal or thin skin, the subcutaneous fat layer is moderately expressed. The elasticity and firmness of the skin are relatively high. Wrinkles of medium depth. Characterized by moderate ptosis of the lower third of the face, nasolabial folds and marionette lines of medium depth. Signs of mild to moderate photoaging: slight hyperpigmentation and uneven skin tone. The lower third and neck area are quite intact. For deep hydration of the dermis, preparations of stabilized HA and unstabilized HA in combination with amino acids, vitamins, macro- and microelements are recommended.

Deformation type of aging

Most often characterizes women with normal or thick skin, the subcutaneous fat layer is well defined. The depth of wrinkles is average. Characterized by pronounced nasolabial folds and marionette lines. Ptosis of the lower third of the face is from moderate to severe, the degree of photoaging is from mild to moderate.

Based on examination and analysis of the absence/presence of sagging soft tissues, a slight degree of static wrinkles with sufficient depth of skin folds, as well as the presence in women of a deformative morphotype of aging shiny skin and multiple telangiectasias of the skin of the cheeks, two subtypes were identified:

• deformational with an edematous component: the skin has the greatest shine among all studied types;
• deformational with a vascular component: women have highly sensitive skin.

In most cases, women with an edematous and vascular component have high blood pressure (BP) and excess body weight. Perhaps the pathogenesis involves disturbances in blood flow in the capillary network of the skin and lymph flow. With age, these disorders worsen and manifest themselves as signs of lymphostasis (edematous component) and/or persistent angioneurosis of small vessels (vascular component). The long-term existence of pathological congestion in small vessels leads to the progression of the vascular component, strengthening the pattern of the superficial network of small vessels of the facial skin (erythrosis).

With this morphotype, preference is given to drugs with stabilized HA due to its more pronounced lifting effect. In the presence of the edematous subtype, biorevitalization procedures are not carried out or are carried out with caution due to the increased hydrophilicity of the tissues.

Wrinkled type of aging

It is detected in patients with thin skin, the subcutaneous fat layer is poorly expressed. The severity of wrinkles is high. Ptosis of the lower third of the face is moderate. Dry skin and the highest tolerance to various external irritants are often observed. Women with wrinkled aging do not complain of increased sensitivity of the skin in general and to cosmetics in particular. They tolerate insolation well, tan quickly, and are prone to hyperpigmentation, solar lentigo, and hyperkeratosis.

Annual courses of biorevitalization with stabilized and unstabilized HA preparations in combination with amino acids, vitamins, and antioxidants that help improve synthetic processes in the dermis can significantly improve the quality of the skin and increase its visco-elastic properties.

Features of biorevitalizants of different groups

According to our observations, a regimen that meets the requirements of versatility and effectiveness (for the age category after 25–30 years) is the combined use of new generation biorevitalizants, which include a functional amino acid cluster and unstabilized hyaluronic acid (Jalupro), and preparations based on stabilized HA ( for example, Restylane Vital) while taking dietary supplements (Proglyme).

Multicomponent preparations based on unstabilized HA

A mixture of lyophilized amino acids (glycine, L-proline, L-lysine monohydrochloride, L-leucine), which are part of the new generation biorevitalizants, ensures active synthesis of collagen by fibroblasts. Hydroxyproline and hydroxylysine play an important role in the formation and stabilization of the three-dimensional structure of collagen and elastin, protect them from the effects of proteolytic enzymes, stimulate epidermal cells and increase the level of skin hydration. Moreover, proline and lysine take part in the synthesis of collagen and elastin, and their hydroxylation occurs after inclusion of a protein molecule in the polypeptide chain. These amino acids make up about 30% of the collagen molecule.

The amino acid glycine, the only amino acid that does not have optical isomers, is better known for its angioprotective properties, the ability to reduce psycho-emotional arousal and improve brain function. When administered intradermally, it maintains the flexibility of the collagen molecule, every third amino acid of which is represented by glycine.

The levorotatory isomer of the essential amino acid leucine takes part in the synthesis of almost all proteins, including collagen and elastin. Elastin gives flexibility and elasticity to fabrics. L-leucine helps restore skin after injury and surgery.

Another equally important component of multicomponent preparations is unstabilized HA, which is included in the composition of the preparations in the form of a low molecular weight polymer with a molecular weight of 120–200 kDa. It ensures the transport of amino acids, causes rapid and pronounced tissue hydration, stimulates the processes of proliferation, differentiation and migration of skin cells, including fibroblasts.

Techniques for administering multicomponent biorevitalizants:

• papular - the drug is injected into the upper and middle layers of the dermis, the bevel of the needle points upward, the volume of the drug injected in one injection is about 0.01 ml.
• linear-retrograde - the needle is inserted along its entire length, parallel to the skin, into the middle layer of the dermis, the drug is injected on the reverse stroke of the needle.
• fan-shaped - the injection technique is similar to the linear-retrograde one, however, the drug is administered in the form of a fan, and the needle is not removed from the skin.
• short-linear - the needle is inserted at ½ length, the drug is injected into the middle layer of the dermis on the reverse stroke of the needle.
• mesh (lattice) – the drug is administered using a linear-retrograde technique in two mutually perpendicular directions.

Monocomponent preparations based on stabilized HA

Preparations based on stabilized HA differ in their duration of action from drugs based on unstabilized HA. Due to the chemical stabilizer, HA is more slowly exposed to tissue enzymes, the action of which is aimed at resorption of exogenously administered HA and the effect of the procedures is maintained for a longer time. The clinical effect of procedures using drugs based on stabilized HA has a cumulative effect and actively manifests itself after a course of procedures.

Techniques for drug administration: short-linear, linear-retrograde, fan, mesh (see above). NB! The drugs are injected strictly into the middle layer of the dermis (without the formation of papules)!

Combined protocol

The combined protocol begins with injections of a preparation of unstabilized HA with an amino acid cluster. Then, after 2 weeks, a procedure using a stabilized HA drug follows. And then the procedures are repeated at two-week intervals (a total of 4 procedures with unstabilized HA and 3 procedures with stabilized HA). This scheme allows the skin to recover faster, launches synthetic rejuvenation processes, tightens and restores elasticity to the skin.

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Despite the huge variety of revitalization drugs presented on the aesthetic medicine market, there is no universal one that would suit all patients without exception. Considering the multicomponent nature of many drugs, it is necessary to carefully study the mechanisms of action of each of them, which, firstly, will help make the right choice of drug, and secondly, will allow you to work safely.

First published: Les Nouvelles Esthetiques Ukraine, No. 6 (70), 2011-2012