Multimodal skin rejuvenation with Restylane^® skin boosters non-animal stabilized hyaluronic acid: A retrospective case series of five patients

INTRODUCTION

Aging is a multifactorial process characterized by loss of subcutaneous volume, reduced elasticity and hydration, and the formation of wrinkles and folds. With increasing understanding of facial aging and a growing demand for minimally invasive procedures, injectable fillers have become central to facial rejuvenation and contour enhancement.^[1] Hyaluronic acid (HA), a key glycosaminoglycan in the extracellular matrix, maintains dermal hydration, elasticity, and structural integrity. However, endogenous HA levels decline with age, leading to decreased hydration and visible signs such as skin laxity and folds. Importantly, HA’s molecular consistency across species underpins its non-immunogenicity when utilized in dermal fillers.^[2]

Modern esthetic practice reflects a shift toward minimally invasive treatments that offer natural, long-lasting results with minimal downtime and risk. Patients increasingly value skin quality parameters, radiance, texture, and hydration over dramatic structural change.^[1]

Skin boosters Non Animal Stabilized HA (SB-NASHA) and Optimal Balance Technology, a range of non-animal-derived HA fillers, received US Food and Drug Administration approval in 2003 for correcting facial folds and contour defects. Its non-animal origin reduces immunogenicity and eliminates the need for pre-treatment allergy testing.^[2] SB-NASHA has since evolved, focusing on intrinsic dermal rejuvenation rather than volumization.^[1] SB-NASHA are engineered to provide deep dermal hydration and improve skin quality over time with an excellent safety profile.

Optimal outcomes depend on accurate delivery. Injections can be administered through blunt cannulas or sharp needles, based on practitioner expertise and treatment goals. Cannulas minimize bruising, reduce entry points, and enable smooth product distribution, whereas needles allow targeted bolus placement. The SmartClick^™ system, compatible with both, enhances precision by producing an audible click every 10 µL delivered, ensuring controlled dosing.^[1]

Treatment selection is guided by individual skin characteristics, including thickness, photo-damage, and tissue coverage. SB-NASHA Vital (20 mg/mL) is recommended for mature, thicker, or photo-damaged skin due to its higher HA concentration and lifting capacity.^[1] HA-based fillers, including skin boosters, are often combined with botulinum toxin type A (BoNT-A) or energy-based modalities (e.g., lasers, radiofrequency (RF) microneedling) to enhance rejuvenation outcomes.^[3,4] Evidence suggests that HA injections are best performed after device-based treatments for synergistic effects.^[4]

This retrospective case series describes five real-world patients who received customized regimens combining SB-NASHA with adjunctive therapies, underscoring the value of multimodal approaches for comprehensive skin rejuvenation. Although HA-based skin boosters are widely used, limited real-world data exist on their combined use with other minimally invasive techniques. This study aims to address this gap and support the development of optimal, evidence-based treatment protocols.

CASE REPORT

This case series includes a total of five patients, comprising three males and two females. Based on the Fitzpatrick Skin Type Classification, three patients had Skin Type IV – commonly seen in Mediterranean, Asian, or Hispanic individuals with medium skin tone, characterized as moderately sensitive to UV, who rarely burn and always tan well with sun exposure. The remaining two patients had Skin Type V – typically observed in Middle Eastern, Latin, light-skinned Black, or Indian individuals with olive or dark skin tone, who are minimally sensitive to UV and very rarely burn but tan very easily [Table 1].

In all the cases, the injection was administered using needles, and even distribution was ensured via the SmartClick^™ system.

Primary outcomes were assessed using the Global Aesthetic Improvement Scale (GAIS), evaluating five domains including light reflectance/radiance, skin tone, elasticity/firmness, smoothness/texture, and scar appearance [Figure 1], in addition to the Skin Quality Assessment Scale (SQS) [Figure 2]. Secondary outcomes comprised the Physician Global Evaluation Scale and the Patient Global Evaluation Scale.

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Figure 1:

Global aesthetic improvement scale scores before and after treatment across all 5 cases.

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Figure 2:

Comparison of before and after treatment skin quality assessment scale.

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At the end of treatment, 4 of 5 patients (Cases 1, 2, 4, and 5) achieved a “Very Satisfactory” rating (score 4) on both the physician and patient global evaluations scale, while one case (Case 3) was rated “Minimally Satisfactory” (score 2) on the physician and patient evaluation scales. Informed consent was obtained from all participating patients.

DISCUSSION

This retrospective case series provides valuable real-world insights into how SB-NASHA, when combined with adjunctive modalities, can significantly improve multiple dimensions of skin quality.

Our primary outcomes highlighted consistent improvements across GAIS domains – including radiance, skin tone, elasticity, texture, and acne scar appearance. Notably, all five cases demonstrated at least a +1 to +2 point gain in radiance and scar appearance. These results resonate with findings in the literature showing enhanced hydration, elasticity, and surface smoothness after HA injections.^[5] Furthermore, all five cases demonstrated improvement in scar appearance, consistent with published evidence that microinjection of non-animal stabilized HA gel is both effective and safe in patients with moderate-to-severe atrophic acne scars.^[6] SQS improvements across domains such as firmness, discoloration, texture, and oiliness [Figure 2] reinforce the observable clinical benefits of SB-NASHA, aligning with the consensus that HA booster treatments are effective in enhancing skin hydration and modulating textural parameters without causing volume distortion.^[1]

Use of microneedling RF with dermal fillers and neuromodulators may further enhance clinical outcomes and increase patient satisfaction.^[7] In this case series, microneedling RF was performed 2–3 weeks before SB-NASHA injections in cases 1 and 2 [Figure 3], resulting in marked improvements in skin texture and acne scar appearance. This approach aligns with findings from a clinic-histological study reporting that when RF was administered before HA filler injection, there were significant enhancements in hydration and collagen synthesis, attributed to RF-induced glycosaminoglycan production and neo-collagenesis.^[4] Regarding safety, a comprehensive review over 4.5 years of combined RF microneedling and injectables (including HA fillers and neuromodulators) reported no documented adverse events, supporting the safety of this multimodal approach when properly timed.^[8]

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Figure 3:

Pre and post photo documentation of cases 1 and 2. Case 1 and Case 2: Arrows and circles both indicate the primary area of lesion.

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Laser therapy, particularly Q-switched Nd:YAG in combination with SB-NASHA (Vital), proved effective in correcting pigmentation and enhancing radiance in Cases 1, 3, and 5 [Figures 3 and 4]. The laser delivers a photo-mechanical action that supports skin repair and scar reduction^[9] as observed in our cases. Using the laser first, followed by intradermal HA injections, allows pigmentary correction before deep skin hydration. This sequence-based approach aligns with evidence that recommends a 2-week interval between booster injections and energy-based device treatments – such as lasers or RF to minimize inflammation.^[9]

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Figure 4:

Pre and post photo documentation of cases 3, 4, and 5. Case 3, Case 4 and Case 5: Arrows and circles both indicate the primary area of lesion.

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By combining chemical peels with dermal fillers, a synergistic beneficial effect is achieved. These rejuvenating procedures significantly increase patient satisfaction and are relatively easy for practicing dermatologists to adopt.^[10] In Case 4, the Depigmentation RX peel was used before SB-NASHA, yielding profound improvements in pigmentation, texture, and overall skin quality [Figure 4].

Combination treatments using HA fillers and BoNT-A are common in esthetic medicine and can be used in combination for injection to correct static wrinkles, volume loss, and structural failure.^[3] In Case 5, laser therapy, SB-NASHA, and BoNT-A were used in combination to deliver non-volumetric, skin-level rejuvenation [Figure 4]. A pivotal multi-center, open-label clinical study demonstrated that combining BoNTA and HA fillers resulted in high patient satisfaction and enhanced esthetic outcomes.^[3]

While the improvements observed are promising, the small sample size and retrospective design limit generalizability. In addition, patient-reported outcomes regarding skin feel and quality of life could enrich future studies.

CONCLUSION

Considering the skin type characteristics of the Indian population, this case series highlights that SB-NASHA (Vital), when appropriately combined with modalities such as RF microneedling, Q-switched Nd:YAG laser, dermal fillers, and neuromodulators, can produce noticeable improvements in skin radiance, tone, texture, elasticity, and scar appearance, offering high patient satisfaction and an excellent safety profile. However, future studies involving larger and more diverse populations across different ethnic, geographic, and age groups are needed to confirm these findings.