Fillers & Energy-Based Therapies: The Current Landscape Around Combination Use

By News & Research | 20 June 2023

Fillers & Energy-Based Therapies:

The Current Landscape Around Combination Use

By Dr Carol Wang, Aesthetic Educator at AACDS

Facial ageing is a complex process, and using different treatment modalities to address multiple issues is common practice. Dermal fillers and energy-based therapies (e.g., IPL, laser, and RF) address various skin issues related to facial ageing and may be combined for synergistic results.

Research in this area has been limited, and the potential interactions between dermal fillers and energy-based therapies need to be better understood. Currently, recommendations and protocols are clinician-dependent anecdotal rather than “best practice” guidelines.

This post will explore some of the existing literature and its recommendations in the said space based on the best available evidence.

Energy-Based Devices

There is a range of energy-based devices with various aesthetic applications, including skin resurfacing, skin tightening, and pigmentation treatment. Examples include Intense Pulsed Light (IPL), neodymium-doped yttrium aluminium garnet (Nd: YAG), Erbium, Radiofrequency (RF), and CO2. These devices can either be ablative (removing the top layer of skin) or non-ablative (heating a target chromophore whilst leaving the top layer of skin intact). Energy-based devices emit different wavelengths, which affects the depth of energy penetration, and the target chromophore (e.g., water, melanin, and haemoglobin). Each chromophore preferentially absorbs energy at specific wavelengths, affecting its targeted treatment in clinical application. For example, IPL is a non-ablative laser targeting the chromophore melanin and can be used for hair removal at a wavelength of 600-1100nm. CO2 is an ablative laser targeting the chromophore water in the skin and is often used for laser skin resurfacing.

Dermal Fillers

Losing subcutaneous fat and the facial muscles working closer to the skin surface are results of facial ageing. Dermal fillers help to diminish facial lines and restore volume and fullness in the face.

Dermal fillers can plump thin lips, enhance shallow contours, soften facial creases and wrinkles, improve the appearance of recessed scars, reconstruct contour deformities in the face, and decrease or remove the shadow of the lower lids (American Society of Plastic Surgeons, 2023). Dermal fillers are temporary treatments for facial ageing, and ongoing treatments will be needed for long-term results.

There are several different types of dermal fillers. The most common types are Calcium hydroxylapatite (e.g., Radiesse), which is found naturally in human bones and is a mineral-like compound; Hyaluronic acid (HA) (e.g., Restylane), a natural substance in the body. High concentrations are found in soft connective tissues and the fluid surrounding the eyes. It’s also in some cartilage, joint fluids, and skin tissue. It is extracted and reformulated and has become one of the most popular injectable fillers. Other types of dermal fillers include Polyalkylimide (e.g., Aquamid); Polylactic acid (e.g., Sculptra); and Polymethyl-methacrylate microspheres (PMMA) (e.g., Bellafill). Dermal fillers differ in chemical makeup, longevity and have varying degrees of softness. For example, softer fillers are used in the lips, while sturdier fillers might be desired to enhance cheekbones (American Society of Plastic Surgeons, 2023).

Because the predominant type of filler currently used is HA, we will focus primarily on HA-based fillers.

The Literature

A study by Farkas et al. (2008) sought to histologically look at the interaction between dermal filler and seven different types of commonly used laser devices, both ablative and non-ablative, including IPL, Nd: YAG, Erbium, and CO2, performed two weeks apart. Although the study was performed on pig skin, the researchers proposed it as a close surrogate for the characteristics and qualities of human skin. The study found that HA fillers were unaffected by non-ablative or superficial ablative lasers. Fillers were injected either subcutaneously or intradermally. However, more aggressive, deeper laser treatments demonstrated some filler-laser interaction, which suggested some potential clinical implications on the longevity of the filler and/or efficacy of laser treatments, especially if the targeted chromophore is water (e.g., Er: YAG or CO2 devices), which may compromise the integrity of water-based HA fillers. The filler placed in the deeper dermal or subcutaneous layers was deemed too far from the skin surface to be affected by any epidermal/superficial papillary dermal treatments, such as IPL. The study recommended that if aggressive deep resurfacing and superficial filler are to be done in combination, the laser should be performed first and staged in separate procedures to maximise the treatment effect of each modality. This also helps to minimise the risk of infection.

A randomised trial (Goldman et al., 2007) looked to see if energy-based therapies could be safely administered immediately after HA filler treatment without compromising the effect of the dermal filler. Thirty-six patients had their nasolabial folds treated, one side with HA filler alone and the contralateral side with filler and non-ablative laser/RF/IPL. It focussed primarily on the clinical outcomes (i.e., the effect on perceived patient outcomes rather than any histological changes or interaction between filler and laser. It found that energy-based therapies immediately after HA filler did not significantly affect the clinical results of the filler. It concluded that laser, RF, and IPL treatments could safely be administered directly after HA filler without reducing the overall clinical effect.

Similarly, Park et al. (2011) found that combining a non-ablative infrared device with HA filler does not appear to be superior (or inferior) to HA filler alone in treating moderate-to-severe nasolabial fold wrinkles.

A study by Kim et al. (2020) examined the interaction of picosecond laser and HA filler. It ran two concurrent studies, one in rats and the other in human patients with acne scarring. It found that picosecond laser immediately after HA filler did not cause any histological changes in the filler or surrounding skin, and combined treatment was both safe and effective clinically.

Marquardt et al. (2020) studied the effect of combined HA or PLLA fillers (e.g., Sculptra) on the epidermis and subsequent fractionated CO2 treatment. Although it did not primarily study the interaction between filler and laser treatment, it concluded that there were synergistic effects between fractional ablative laser treatment and injection of HA dermal fillers – supporting the combination use of both.

A systematic review (Urdiales-Gálvez et al., 2019) assessed the concomitant (same-day) use of dermal HA fillers and laser technology for facial rejuvenation. It primarily focussed on the Juvaderm VYCROSS range and looked at seven studies involving combined light system treatments with fillers. It found that six studies documented no histological changes in fillers injected after applying radiofrequency, IPL, or laser treatments, and one study documented improvement in collagen after IPL treatment and filler injection.

Based on this, the summary and suggested recommendations are as follows:

Summary:

  • The currently available scientific evidence about the combined use of HA fillers and energy-based devices is limited and is constrained to mainly small and non-randomized studies.
  • However, most of these studies found that, on average, the same-day treatment of laser and HA fillers for facial rejuvenation was a safe and effective strategy which improves clinical results and patient satisfaction.
  • Future well-designed clinical studies are needed regarding the effectiveness and safety of combination filler/laser treatments.

    Recommendations: 

  • If combining HA and light treatments on the same day, always start with the light treatments, avoiding skin manipulations after having injected HA.
  • The difference in timing between laser treatment and HA filler injection is not decisive; what matters is the sequence of the treatments (laser first and subsequently HA injection) and the wavelength of the laser.
  • In the above, light systems should always be non-ablative, minimizing the risk of wounds in the skin that can cause infections.
  • In subsequent light sessions, avoid using lights or lasers with wavelengths higher than 1000 nm after HA treatments, with a pulse duration of milliseconds.
    • To the best knowledge, there have not been any problems or interactions with other non-ablative lasers of lower wavelengths.
  • In subsequent sessions, all light systems, which use pulse durations in microseconds, nanoseconds, or picoseconds, regardless of the wavelength used, may be used after any HA.
  • The depth of the injected filler is important to consider if the laser is performed after HA. This is the basis for recommending non-ablative lasers prior to HA filler injection.
    • A prospective study evaluating the elapsed time between laser and HA filler, and the impact of HA filler concentration and depth of injections, may give a better understanding of the outcomes.
  • A correct diagnosis of the photodamage and loss of volume suffered by the patients will help to choose and properly tailor therapeutic management, combining proper photodamage and loss of volume treatments in the same session.
  • Although both strategies are relatively safe, they are not exempt from the appearance of possible complications. Most of the complications are transient and can be successfully treated. Adequate patient selection, technique and filler will help ensure a desirable outcome.


References:

American Society of Plastic Surgeons. (2023). Dermal Fillers. Retrieved 25/5/2023 from

https://www.plasticsurgery.org/cosmetic-procedures/dermal-fillers

Farkas, J. P., Richardson, J. A., Brown, S., Hoopman, J. E., & Kenkel, J. M. (2008).

Effects of common laser treatments on hyaluronic acid fillers in a porcine model. Aesthetic surgery journal, 28(5), 503-511.

Goldman, M. P., Alster, T. S., & Weiss, R. (2007). A randomized trial to determine the

influence of laser therapy, monopolar radiofrequency treatment, and intense pulsed light therapy administered immediately after hyaluronic acid gel implantation. Dermatologic surgery, 33(5), 535-542.

Kim, J. E., Hong, J. Y., Lee, H. J., Lee, S. Y., & Kim, H. J. (2020). Picosecond‐domain

fractional laser treatment over hyaluronic acid fillers: in vivo and clinical studies. Lasers in Surgery and Medicine, 52(10), 928-934.

Marquardt, Y., Fietkau, K., & Baron, J. M. (2020). Biological effects of hyaluronic

acid-based dermal fillers and laser therapy on human skin models. Journal of Drugs in Dermatology, 19(9), 897-899.

Park, K. Y., Park, M. K., Li, K., Seo, S. J., & Hong, C. K. (2011). Combined treatment

with a nonablative infrared device and hyaluronic acid filler does not have enhanced efficacy in treating nasolabial fold wrinkles. Dermatologic surgery, 37(12), 1770-1775.

Urdiales-Gálvez, F., Martín-Sánchez, S., Maíz-Jiménez, M., Castellano-Miralla, A., & Lionetti-Leone, L. (2019). Concomitant use of hyaluronic acid and laser in facial rejuvenation. Aesthetic plastic surgery, 43, 1061-1070.
 

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