CLINICAL: BIOSTIMULATORS

THE LONG GAME

With more patients seeking subtle rejuvenation, biostimulatory fillers are taking centre stage. Ellen Cummings asks the experts how these products differ from traditional fillers, which patients they suit best and why regenerative results are driving demand

The aesthetic medicine landscape is shifting, with patients increasingly seeking treatments that deliver subtle, natural results rather than the immediate “plumped” look often associated with traditional hyaluronic acid (HA) fillers. Biostimulatory fillers – injectables that stimulate collagen production and improve skin quality over time – are emerging as a key option for both patients and practitioners who want longevity, regeneration and natural-looking enhancements.

GROWING DEMAND

Demand for biostimulatory fillers has been steadily increasing over the past few years, a trend noted by multiple experts.

Dr Lisa Dinley, clinical trainer for Fillmed and founder of the Dr Lisa Dinley Clinic in Nottingham, explains, “According to the International Society of Aesthetic Plastic Surgery 2024, global data shows a steady growth in injectables overall, with HA fillers still dominant and rising by 5.2% compared to the previous year.

“Biostimulatory filler usage also increased as patients and clinicians seek longer-lasting, more ‘regenerative’ results. This has certainly been true amongst my patient demographic who want to look refreshed and rejuvenated without looking ‘done’.”

Dr Sophie Shotter, president of the British College of Aesthetic Medicine (BCAM), concurs, “Over the past three to five years, I’ve seen a steady shift toward biostimulatory fillers, driven by patients wanting structural and skin quality improvements that persist beyond the lifespan of HA fillers and feel more regenerative. Demand certainly accelerated post-pandemic as patient preference has shifted increasingly towards treatments that look ‘done by nature’, not ‘done by a syringe’.”

Dr Ash Soni, plastic and reconstructive surgeon and founder of The Soni Clinic in London and Berkshire, adds, “The undetectable era is real, and I have certainly seen an increase in the demand of regenerative collagen biostimulators. Patients no longer want a ‘quick fix’ but instead want something that will help with their skin quality and skin health.”

WHY PATIENTS ARE CHOOSING BIOSTIMULATORS

Patients are drawn to biostimulatory fillers for their gradual, natural results. Dr Dinley explains, “Patients are requesting a gradual, natural-looking change in their skin quality via collagen remodelling rather than an instant plumped-up look. They are also interested in a longer-lasting result, even if this takes longer to achieve over several visits. The skin quality gains that we are achieving, as well as re-volumisation, make these products really appealing to patients.”

Dr Shotter adds, “Patients like that results develop gradually, there’s less risk of looking ‘filled’, and the results can last longer thanks to the formation of new collagen. They also appreciate better tissue quality – thickness and elasticity – rather than just increases in volume.”

Dr Sarah Tonks, founder of The Lovely Clinic in Knightsbridge, agrees, noting patients “want to look natural like they haven’t had anything done, but at the same time they want to look visibly ‘better’ – clearer and smoother skin, more lifted”. Dr Soni highlights another driver: “There has been a lot of stigma out there in the last couple of years regarding traditional fillers because the media tends to show the worst and most drastic results. The best filler results are undetectable. Therefore, the trend has shifted towards collagen biostimulators.”

UNDERSTANDING BIOSTIMULATORY FILLERS

Biostimulatory fillers differ from traditional HA fillers in their mechanism of action. HA fillers volumise the skin immediately by adding gel to replace lost volume. Biostimulators, however, work at a deeper, regenerative level.

Dr Dinley explains, “Biostimulators such as PLLA, PDLLA and CaHA contain tiny particles in a carrier gel that, when injected into the dermis and subcutaneous layers, trigger a controlled foreign-body response. This inflammatory response starts a regenerative cascade of events, where fibroblasts are stimulated to make new collagen and extracellular matrix over weeks to months. The carrier gel helps to provide an immediate improvement whilst waiting for the biostimulatory action.”

“These particles or microspheres act as a temporary scaffold,” adds Dr Shotter. “The carrier gel in which the microspheres/ particles are carried is resorbed, and the patient’s own collagen remains.”

ONSET AND DURATION OF RESULTS

Results with biostimulatory fillers take time. Dr Dinley outlines typical timelines:

• PLLA: Subtle early changes with collagen induction over four to 12 weeks. Multiple sessions are usually needed, with results lasting up to 24 months after a series.

• PDLLA: Strong, visible results at 24 weeks, with earlier visible changes than PLLA. Longevity is approximately 12-24 months.

• CaHA: Immediate scaffolding effect, with collagen production over one to three months, lasting 12-18 months depending on dilution and treatment area.

Dr Shotter notes, “Meaningful improvement from biostimulators typically appears from six to eight weeks, with improvements continuing potentially up to six months as neocollagenesis consolidates. That collagen underpins the durability of the results.”

Dr Soni adds, “The results of Sculptra in my practice take a few weeks to start to show... patients have to allow for a bit of time while the results kick in, but when they do, it’s spectacular.”

CHOOSING THE RIGHT PRODUCT

Different biostimulatory fillers have varying compositions, mechanisms and indications. Dr Dinley explains the nuances:

• PLLA (e.g. Sculptra, Julaine): Slow degradation, up to ~24 months of results, suitable for volume restoration and skin quality improvement.

• PDLLA (e.g. Juvelook, Lenisna): Faster degradation, 12-24 months longevity, effective for skin refinement, tightening, and subcutaneous volumisation. Reversible with heat.

• CaHA (e.g. Radiesse/Radiesse+): Immediate scaffolding, collagen production over one to three months, excellent for contouring and hyper-dilute applications for skin quality. Dr Shotter highlights practical distinctions: “PLLA/PDLLA need a series of treatments, usually two to three sessions around six weeks apart. CaHA is often a single session. Volume per session often involves lower per-session volumes for PLLA/PDLLA, whereas with CaHA, volumes are tailored to indication. For technique I would usually advocate using a cannula, as for most biostimulators we want to achieve regeneration across a larger area.”

Patient concerns, age and facial area also influence product choice. Dr Dinley advises, “For skin laxity and crepey skin such as face/neck/decolletage, hyper-dilute CaHA is effective. Juvelook can refine and tighten intradermally, including peri-orbital and peri-oral areas. Lenisna is indicated for deeper subcutaneous placement, improving global laxity and volumisation.”

Dr Shotter adds, “Midface deflation, temple hollowing and lower-face laxity are all best suited with PLLA/PDLLA. Jawline, chin or lateral cheek for definition respond well to CaHA.”

Dr Soni emphasises versatility, particularly for patients experiencing skin changes after weight loss: “In my practice, PLLA is proving amazing at dealing with rapid weight loss in patients who have been on GLP-1 medications. These patients lose elasticity and quality of the skin and need a surge of type 1 collagen to give them that natural lift.”

SAFETY, ADVERSE EVENTS AND PATIENT EDUCATION

Safety is paramount. Early adverse events can include bruising, swelling and tenderness. Nodules may develop weeks to months later, often mitigated through proper dilution, placement and post-injection massage (for PLLA).

Dr Dinley outlines, “If nodules are encountered, Juvelook and Lenisna can be managed with injections of saline to lower the glass transition temperature, then application of heat with an energy-based device.”

More serious complications like vascular compromise are extremely rare but require vigilance.

Dr Shotter advises, “Meticulous patient selection, consent about gradual timelines, strict asepsis, correct reconstitution/ dilution, slow injection of small threads of product in safe planes, preference for cannulas, and staged treatment planning. Keep detailed batch/lot documentation and provide detailed post-care guidance for patients.”

Dr Tonks adds, “This is really key. Patients have to understand the effect is gradual and that a course of treatment is necessary.” Dr Soni echoes the importance of setting expectations: “You have to have this conversation with a patient in a consultation and be realistic. It will take time, but it’s worth the wait.”

BIOSTIMULATORS AND COMPLEMENTARY TREATMENTS

Biostimulators can work alongside other regenerative treatments, including PRP/ PRF. Dr Dinley notes, “PRP/PRF can be used in combination with biostimulators and can either be used to prime the tissues first, to enhance cell stimulation effects, or in between biostimulator sessions to help accelerate results.”

Dr Shotter agrees that PRP/PRF is synergistic but not a replacement: “They pair well with biostimulators for patients prioritising skin quality, but they don’t provide a scaffold or the same durability of volumetric change.”

TECHNOLOGICAL ADVANCES

Recent innovations have expanded the capabilities and safety of biostimulators.

Dr Dinley points to newer products, saying, “The widespread adoption of hyper-dilute CaHA protocols has signalled a shift in treatments focusing on improving skin quality. Sculptra gained a 2023 FDA approval to improve skin quality in the cheeks as well as re-volumising. There has also been a move to less crystalline biostimulatory products that are more suited to flexible and delicate areas of the face, such as the PLLA microspheres of Julaine and PDLLA with hyaluronic acid, as in Juvelook and Lenisna.”

Dr Shotter adds, “Novel products like Julaine avoid some of the pitfalls of other PLLA products, leading to no need to massage at home due to less particle clumping, and non-inflammatory neocollagenesis. HArmonyCa combines cross-linked HA with CaHA to give an immediate lift as well as lasting biostimulation.”

Dr Tonks emphasises the patient-driven shift: “They want less downtime, if not no downtime, and they want something undetectable.”

Dr Soni summarises the trend succinctly: “Patients no longer want a ‘quick fix’; they want results that improve skin quality and look natural over time.”

CONCLUSION

Biostimulatory fillers represent a fundamental shift in aesthetic medicine, moving away from instant volumisation toward gradual, regenerative improvements in skin quality, contour and elasticity. By carefully selecting the right product, planning a staged treatment approach and setting realistic patient expectations, practitioners can deliver subtle, natural and long-lasting results. Whether used for the face, neck, décolletage or body, these treatments are increasingly central to achieving what today’s patients desire most: results that are undetectable but transformative.