Biorevitalization in photo- and chronoaging correction programs

Currently, due to their biologically active properties, high safety of use and clinical effectiveness, preparations based on hyaluronic acid (HA) are widely used in aesthetic medicine. Literature data convincingly prove that intradermal administration of unmodified HA preparations causes proliferation of fibroblasts, an increase in their synthesis of their own HA, collagen, and elastin, which helps restore the morphological structure of the dermis, increase skin turgor and elasticity. At the same time, there are a large number of discrepancies, conflicting data and conclusions, and in addition, the physiological and morphological aspects of the effects of different HA preparations on the skin have not yet been sufficiently studied.

BIOLOGICAL ROLE OF HYALURONIC ACID IN THE DERMIS

For a long time, hyaluronic acid was assigned only a passive role in the formation of a three-dimensional hydrated matrix of the dermis. But research over the past three decades has radically changed the understanding of the role of HA in the skin and in the body as a whole. According to modern concepts, HA carries out mechanical and biologically active functions with the help of specialized receptors located on cell membranes. HA affects the migration, differentiation and proliferation of fibroblasts, stimulates the growth and proliferation of microcirculatory vessels, triggers regeneration processes, and provides antioxidant protection. The main biologically active functions of HA in the dermis include: formation of a three-dimensional gel intercellular matrix, binding and retention of water, trophic functions (carrying nutrients, removing waste and toxins from the cell), binding to cellular receptors, embryogenesis, angiogenesis, antioxidant protection, regeneration damage.

The fact that hyaluronic acid is part of many tissues (skin, cartilage, vitreous body) determines its use in various branches of medicine: ophthalmology, arthrology, plastic surgery and aesthetic medicine.

THE PLACE OF HYALURONIC ACID IN SKIN AGING

Involutional changes in the skin are part of the aging process of the body as a whole. At the morphological level, the aging process manifests itself in the form of increasing skin hypotrophy. First, the activity of fibroblasts and the level of blood flow in the microvasculature decreases, which leads to a decrease in the synthesis of HA, collagen, elastin and a deterioration of the microenvironment of fibroblasts in the dermis. This, in turn, reduces the level of proliferation of fibroblasts and blood vessels and leads to a decrease in their total number. Such morphological changes contribute to an even greater decrease in the synthesis of HA and collagen. The structure of the dermis is disrupted with the formation of wrinkles, hyperpigmentation and telangiectasia are formed, the fiber frame of the dermis and subcutaneous fat is weakened, accompanied by gravitational ptosis of the soft tissues of the face.

BIOREVITALIZATION – BASIC AGING THERAPY

The term “biorevitalization” literally means “biological revitalization of the skin at the morphological level.” The biorevitalization technique was developed by the Italian scientist A. di Pietro. Numerous studies have shown that an absolutely necessary element for the healing of skin damage is an intensive increase in the concentration of HA in the damaged area (40–70 times). To clarify the role of HA in repair, scientists conducted an experiment in which a large amount of native HA was injected into intact skin using a needle. As histological studies have shown, the introduced HA triggered regeneration processes in the skin. Since there was no damage, those skin defects that accumulated with age were restored. That is, on histological sections it was noted that the skin began to renew itself, self-heal. Subsequently, they demonstrated that even after complete removal of the drug, the dermis still functions in a “younger” mode for a long time. This process was called biorevitalization.

Biorevitalization is one of the few techniques that can effectively restore morphological defects of the skin and can be used as a basic technique for the treatment of all types of aging, affecting all its key links.

The morphological and clinical effects of biorevitalization include:

• an increase in the number of fibroblasts in the dermis;
• proliferation of the microvasculature;
• increasing the synthesis of endogenous HA, collagen and elastin.

As a result, skin turgor and elasticity increase, fine wrinkles are smoothed out, the skin is moisturized, and its normal color is restored. The biorevitalization technique is widely used to restore damage, treat scars and heal postoperative wounds.

The main indications for biorevitalization are:

• skin dehydration of various origins, caused by both hormonal changes, unfavorable meteorological conditions, and improper cosmetic care, etc.;

• decrease in turgor caused by a deficiency of endogenous glycosaminoglycans as a result of a decrease in the synthetic activity of fibroblasts;

• photoinduced aging, characterized by hyperkeratosis and hyperpigmentation, chronic inflammation, increased activity of metalloproteases, etc.

Currently, the indications for the administration of unmodified HA are expanding and are no longer limited only to clinical signs of dehydration, decreased tone, etc. In our practice, we widely use this technique to reduce the reparative period after chemical peeling procedures, fractional photothermolysis and other skin resurfacing, to increase efficiency physiotherapeutic anti-age methods (photo- and RF-therapy), in the complex treatment of atrophic (post-acne) skin scars.

The choice of drugs containing native hyaluronic acid is quite wide:

Features of biorevitalization

• Biological and photoinduced aging

The introduction of native hyaluronic acid is carried out primarily to prevent involutional changes. The biorevitalization method can also be recommended for patients in case of oxidative stress, for preparing the skin before sun exposure and recovery after it. This is because hyaluronate reduces inflammatory responses by inhibiting lipid peroxidation that occurs as a result of oxidative stress. Thus, biorevitalization acts as a kind of “airbag”. Additionally, active prolonged hydration is achieved.

The course of treatment ranges from 4-6 sessions with a frequency of 1 time in 2-3 weeks, administration technique: papular, linear-retrograde.

It must be remembered that in patients with skin phototypes IV-VI (according to Fitzpatrick), if the biorevitalization method is carried out in the spring-summer period, it is necessary to use sunscreen (SPF no less than 30, PPD no less than 10), avoid sun exposure immediately after the procedure and during the next 2-3 days. Otherwise, an inflammatory reaction in the skin at the injection sites can lead to the formation of hyperpigmentation.

At the same time, in our clinical practice we rarely use the biorevitalization method in the form of monotherapy. When correcting clinically diagnosed involutional skin changes (patients over 35 years old), we recommend the biorevitalization method to potentiate the clinical effect of physiotherapeutic techniques. Thus, in patients with thin skin and a finely wrinkled type of aging, the combination of RF technologies (radio wave lifting) and the introduction of native HA is optimal. Hydration of the epidermis and dermis increases the permeability of tissues to electrical current, thereby improving uniform heating of tissues and protein denaturation, which allows reducing both the number and frequency of RF therapy sessions. If telangiectasias and hyperpigmentation predominate in the clinical picture, in addition to biorevitalization, additional phototherapy (IPL technology) is recommended, aimed at stimulating the dermis with damage to superficially located dilated vessels and destruction of unevenly deposited pigment.

The synergy of these two techniques is especially important in the correction of photo-induced skin aging. Since the stimulating effect of phototherapy is based on the fact that photons of light emitted by the device’s LED activate a number of components of the mitochondrial respiratory chain.

Thus, the primary infrared photoreceptor is cytochrome oxidase, which activates the mitochondrial respiratory chain, thereby increasing ATP production. The mechanism by which hyaluronic acid creates an environment favorable for cell activity, as well as its antioxidant effect, potentiate the effect of phototherapy. Biorevitalization and photorejuvenation procedures are carried out at intervals of 2 weeks, the course is 3-4 sessions.

For patients with thick, porous skin and deep wrinkles, the combination of biorevitalization with fractional non-ablative laser skin damage (fractional photothermolysis) is optimal.

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 administered 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.

Literature:

Lyudmila Petrovich, Odessa National University named after I. I. Mechnikov

Natalya Goryanova, Odessa National University named after I. I. Mechnikov

Shandra A. A., Odessa National University named after I. I. Mechnikov

Denisenko O. V., Odessa National University named after I. I. Mechnikov

Les Nouvelles Esthetiques 2015/№1

Olga Zabnenkova – candidate of medical sciences, professor of IDPO RUDN University, head of the department of cosmetology and plastic surgery of MS DETAL LLC (Russia, Moscow);

Lyudmila Kamelina is a dermatocosmetologist at the Danishchuk Clinic, a trainer at Fitogen (Russia, Moscow).

KOSMETIK international journal, No. 3 (41), 2010

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

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

This article is part of the special project Injection anti-aging

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