A combined treatment for skin laxity using fillers and technologies associated: The sandwich protocol

Non-invasive facial and body contouring procedures are gaining prominence among patients and physicians due to their demonstrated effectiveness, reduced downtime, and lower risk of complications when compared to invasive techniques, such as plastic surgery. Microfocused ultrasound (MFU), injectable biostimulators, such as poly-L-lactic acid (PLLA) and calcium hydroxyapatite (CaHa), and fractional radiofrequency microneedling (FRM) have been used to effectively treat skin laxity, a common complaint in dermatology clinics.¹ While combining different treatments at a same-day session is considered to be safe, effective, and a growing practice among dermatologists, there remains a significant lack of literature evaluating the combination of technologies and injectable treatments for facial and body skin laxity and body contouring.^1,2

We describe a novel protocol, here referred to as “Sandwich Protocol,” which involves a same-day session combining MFU, injectable biostimulators (PLLA or CaHA), and FRM for the skin laxity treatment. This protocol is performed over 1–4 sessions, with a minimum interval of 30 days between treatments. The number of sessions is determined based on the severity of skin laxity and according to the patient’s budget, as the costs of these treatments are considered high. This comprehensive approach is performed in the following sequence:

1. MFU (UltracelQ+^®, Jeysis, South Korea) is performed with a thin layer of ultrasound gel at a depth of 2.0, 3.0, and 4.5 mm, at energy levels 0.4, 1.0, and 1.0 j, respectively, 20 shots per 5 cm², 2 passes for each tip, on the sagging skin area.

2. Each vial of PLLA (Sculptra^®, Galderma) was reconstituted into a 16 mL solution, comprising 2 mL of 2% lidocaine and 14 mL of sterile water. Similarly, each 1.5 mL syringe of CaHA (Radiesse^®, Merz) was diluted with 1.5 mL of 2% lidocaine and 3 mL of saline in a 10 mL syringe, yielding a final volume of 6 mL. The mixture was thoroughly homogenized before injection using a syringe connector and two 10 mL syringes. The quantities of bio-stimulators applied adhered to the recommendations by Mazzuco et al., with one vial of Sculptra or two syringes of Radiesse allocated to each treatment area, equivalent to the size of an A4 sheet of paper (600 cm²).³ The biostimulators fillers were injected sub-dermally in the treated area using a 22G 70 mm cannula with a retrograde fanning technique. The choice of product for each patient was determined based on the patient’s preference and the characteristics of the area to be treated.

3. FRM (Eletroderme^®, LMG, Brazil) was applied at three different depths, using the following parameters: First pass at a depth of 2.8 mm (130 ms pulse duration and 25j energy), second pass at a depth of 2.5 mm (120 ms pulse duration and 20j energy) and a final pass at a depth of 1.5 mm (110 ms pulse duration and 15j energy).

After the procedure, patients report experiencing minor erythema and ecchymosis for 2–5 days [Figure 1]. Results can be seen around 45 days after the session, with progressive clinical improvement in skin laxity in the next 6 months [Figure 2].

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Figure 1:

(a) A 47-year-old female patient, showing the appearance of the décolletage before the sandwich protocol. (b) The same patient 18 months following a single session of the sandwich protocol, with skin laxity improvement in the décolletage and a reduction in sleep wrinkles.

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Figure 2:

(a) A 55-year-old female patient, before and (b) 1 month after the second session of the sandwich protocol applied to treat laxity in the medial thigh area. The interval between the two sessions was 10 months.

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The simultaneous application of MFU, injectable biostimulators, and FRM in a single session enables a synergistic treatment of the dermis, subdermal connective tissue while minimizing recovery time.

MFU is a device that promotes neocollagenesis and collagen remodeling by delivering heat energy to the dermis and subdermal connective tissue, sparing the epidermal surface, and creating focused thermal injury zones in the targeted area. As a result, skin tightening is obtained.⁴ FRM is also a precise thermal injury device that targets different MFU depths of coagulation by stimulating collagen synthesis at a more superficial skin layer, achieving a synergistic effect.⁵ Modifying our previously described technique¹, in the sandwich protocol, the application depths of microneedling radiofrequency differ from those of MFU, allowing comprehensive action across the entire dermis and superficial subcutaneous tissue layers responsible for skin restructuring. We believe that this modification not only improves treatment efficacy but also enhances the safety of combining these technologies, minimizing the risk of overheating, which can lead to burns and subsequent scarring.

Injectable biostimulators may further stimulate fibroblast and collagen production and have been shown to enhance the effects of MFU and FRM. Once lidocaine is typically added to the suspension, the injection of biostimulators before FRM helps reduce the pain associated with its application, enhancing treatment tolerability.^1-3

This protocol aims to demonstrate that combining technological devices with injectable fillers in a same-day session can enhance treatment outcomes for skin laxity without significantly increasing adverse events and, possibly, enhancing the effect through the synergistic action of the three treatments performed on the same day. The authors have been performing this protocol for approximately 24 months, observing an improved response compared to treatments performed individually and an increased patient comfort and treatment tolerability. While results may vary among individuals, especially in photographic documentation, the inclusion of biostimulators in combination with MFU and FRM may enhance collagen induction, improve tolerability, and contribute to more sustained outcomes compared to dual-modality approaches. Moreover, combining the treatments on the same day reduces the time required to complete all sessions, as well as the costs associated with the number of office visits. Further studies are required to assess its long-term efficacy and safety.