NEW YORK — The use of dermal fillers to improve the appearance of aging skin remain a backbone of office-based procedures, but the objectives of filler and other cosmetic procedures are in the midst of a fundamental evolution, according to a panel of experts.

“There has been a major paradigm shift that is changing the way we consult with and educate patients,” said Michelle F. Henry, MD, whose aesthetic dermatology practice is based in New York City.

Moving from the “see a line, fill a line” approach in the early days of filler application, Henry explained that the ongoing advances in cosmetic dermatology are more focused on aging dynamics with attention to modifying skin in relationship to underlying ligaments, muscle, and bone.

Facial Structure Is Key Variable for Treating Skin

“We no longer treat the skin. We are treating the structure,” said Henry, attributing the recent and rapidly expanding transformation to both scientific advances and patient demand. A growing proportion of her patients prefer to look good for their age rather than pursuing obliteration of age-related lines in a quest to look decades younger.

For more consumers, “the best outcome is one that no one notices,” said Henry, who spoke during a symposium on aesthetic dermatology at the Annual Atlantic Derm Conference (ADC).

This reorientation is not entirely new, but the objectives have the potential to be met more consistently with ultrasound-guided injection of fillers and with more strategic use of the two currently available biostimulators, poly-L-lactic acid (PLLA) and calcium hydroxylapatite (CaHA), along with a growing list of neuromodulators.

Over the last several years, several groups have worked to provide a more detailed representation of facial taxonomy, which Henry called an “anatomical GPS” and a “safety roadmap” for guiding injections to maximize cosmetic benefit and reduce risk.

“Ultrasound is our next step. I think we will see this rapidly adopted,” said Henry, who reported that she is now in the process of incorporating this tool into her own practice. Not only can fillers, biostimulators, and neuromodulators be injected more strategically, but also “we will no longer be injecting blindly,” a major factor implicated in the worst complications associated with cosmetic injections, she noted.

In the context of biostimulators, the ability to inject strategically might further increase their utility relative to non-biostimulatory fillers, such as hyaluronic acid, which provide instant volume but are not helpful for “collagen biobanking,” a concept that addresses aging dynamics.

“Collagen biobanking is a proactive strategy to stimulate neocollagenesis and build dermal collagen reserves before significant age-related loss,” Henry said.

In addition to the biostimulant injectables, she said, collagen biobanking can be accomplished with several energy-based devices, such as microfocused ultrasound or radiofrequency microneedling. These options, unlike non-biostimulatory fillers, offer a sustained response that not only fill defects but also improve skin quality, she added.

“I have increased my use of biostimulators very substantially over the past several years,” said Henry, which she indicated is a direct consequence of the paradigm shift that involves attention to underlying facial structure.

Tools to stimulate collagen are also mainstays for Melissa K. Levin, MD, who practices medical and cosmetic dermatology in New York City.

She uses both PLLA and CaHA but does not consider them interchangeable. Citing published studies, she reported that they are both associated with fibroblast stimulation, but the expected maximum duration of the effect is longer with PLLA (25 vs 18 months), whereas CaHA is more closely associated with improved skin elasticity and wrinkle improvement.

The efforts to develop a more advanced vocabulary around skin quality might be playing a role in the ongoing evolution in cosmetic dermatology to the degree that it allows clinicians and patients to communicate about shared goals, according to Levin, who was also a participant in the ADC symposium. She cited a recent publication outlining a consensus on skin attribute definitions that is an example of efforts to help physicians and patients communicate.

Ultimately, both Henry and Levin reported that they typically rely on a combination of therapies to optimize results. These might include deep collagen stimulation with a biostimulator, collagen remodeling with an energy or mechanical device, improvements in surface texture achieved with chemical peels or fractional lasers, and botulinum toxins to achieve immediate modification of wrinkles.

Another speaker in the same symposium, Anthony Rossi, MD, who is affiliated with Memorial Sloan Kettering Cancer Center in New York City, and also practices cosmetic dermatology, spoke specifically about the evolving role of botulinum toxin, and made the same point about considering tools, including botulinum toxin injections, in the context of facial structure and skin layers. He said injection techniques, doses, and targets differ for the dermis, subcutaneous skin, the superficial musculoaponeurotic system, the deep fat layer, and the periosteum.

As with fillers and biostimulators, there is a growing literature regarding strategies to improve the safety and efficacy of botulinum toxin injections while avoiding a diminishing response due to resistance. “We have a rapidly growing number of FDA-approved options but so far they all contain the same 150 Da botulinum protein as the active component,” Rossi said.

He does not view them as interchangeable. The effects vary due to differences “in their complexing proteins, excipients, and manufacturing that involves bacterial strain, purification, and other variables,” Rossi said.

Henry reported having financial relationships with Allergan, Merz Pharma, and Revance Therapeutics. Levin reported having financial relationships with Allergan, L’Oreal, Lutronic, Merz Pharma, RoC Skincare, Sciton, and Skincare Science. Rossi reported no potential conflicts of interest.