Background: Facial aging involves progressive deterioration of the extracellular matrix (ECM), volume loss, and structural sagging. Minimally invasive strategies like absorbable threads provide mechanical support and biostimulation, but their efficacy may be compromised in patients with poor dermal quality. Calcium Hydroxyapatite (CaHA) is a well‐documented biostimulator that enhances collagen and elastin synthesis. This study explored whether combining CaHA with P (LA/CL)‐based absorbable threads could synergistically improve ECM remodeling and clinical outcomes. Aims: To evaluate the biological and clinical effects of the BIO3 protocol—sequential biostimulation with CaHA and P (LA/CL) threads—by integrating in vitro gene expression analysis and retrospectively collected clinical outcomes. Patients/Methods: An in vitro model of full‐thickness human skin was used to assess COL1A1 , COL3A1 , and ELN expression after treatment with CaHA, P (LA/CL) threads, or both. A retrospective clinical study was also conducted with 11 female patients aged 35–65 undergoing facial rejuvenation with threads alone ( n = 6) or preceded by CaHA ( n = 5). Clinical outcomes were assessed using GAIS, WSRS, facial laxity scores, ultrasound imaging, and satisfaction questionnaires at multiple timepoints. Results: Combined in vitro treatment resulted in significantly higher upregulation of ECM‐related genes compared to monotherapies. Clinically, all patients showed aesthetic improvement. The CaHA/P (LA/CL) group demonstrated greater dermal and subcutaneous thickening and higher GAIS ratings at D120. Patient satisfaction reached 100% in both groups by D30 and remained stable. No adverse events were reported. Conclusions: The BIO3 protocol—combining CaHA and P (LA/CL) threads—showed promising synergistic effects on ECM remodeling and aesthetic outcomes. These findings support the rationale for layered and sequential biostimulation strategies in clinical practice.

Background: Floating barbed threads are commonly used for minimally invasive midface lifting and rely on mobile subcutaneous tissue for support, which may limit stability. Fixation is primarily achieved by barb engagement within the subcutaneous fat and fibrous septa of the retinacula cutis. Objectives: To describe an anatomically guided modification of the APTOS Excellence Visage Soft (PLLA/PCL) thread technique, positioning the terminal segment posterior to the zygomatic retaining ligament line with the aim to enhancing mechanical stability. This technical report presents the anatomical rationale, procedural steps, and illustrative clinical cases demonstrating feasibility. Methods: The modified technique uses a single-entry point at the superior zygomatic margin, with five threads per hemiface. After linear insertion, the cannula is rotated laterally and inferiorly to position the terminal barbs posterior to the zygomatic retaining ligament line, thereby transferring tensile load toward a more fixed anatomical structure. Representative cases were documented and are presented. Results: Illustrative cases showed immediate midface elevation with improved malar projection and softening of the nasolabial and mentolabial folds. Standardized 3D imaging and vector analysis demonstrated a superolateral pattern of soft tissue displacement along the intended vectors, consistent with the proposed fixed-anchorage concept. The procedure was well tolerated, with only mild and transient local effects observed. One illustrative case included photographic follow-up at 12 months, in which preservation of midface contour and malar projection was visually appreciable. Conclusions: Redirecting the terminal thread segment posterior to the zygomatic retaining ligament line is a feasible modification that may contribute to improved vector stability by engaging a fixed fascial structure. Observations—including one case with 12-month follow-up—support the anatomical plausibility of the approach, although controlled studies with objective endpoints are necessary to confirm long-term efficacy and reproducibility.

Background/Objectives: Calcium hydroxylapatite (CaHA) is widely used in aesthetic medicine as a biostimulatory dermal filler. While its ability to induce neocollagenesis is well established, its broader transcript-level effects on fibroblast biology under aging-like conditions remain incompletely characterized. This study aimed to compare the gene-expression responses induced by three commercially available CaHA formulations in an EX-527-induced aging-like human dermal fibroblast model. Methods: An aging-like fibroblast phenotype was induced in primary human dermal fibroblasts using the SIRT1 inhibitor EX-527, which was maintained in culture throughout the CaHA treatment period. Cells were exposed to three commercially available CaHA formulations (D, R, S) for 72 h. Gene expression was assessed by RT-qPCR, evaluating markers related to extracellular matrix remodeling, Ki67 expression, inflammatory and regulatory cytokine signaling, mitochondrial stress response and energy metabolism, and longevity-associated genes. Results: All CaHA formulations induced upregulation of COL1A1 and Ki67, with greater responses observed in samples S and R. ELN expression was more selectively increased, particularly in sample S. Distinct cytokine gene-expression profiles were observed, with sample D associated with increased TNF-α expression, while samples R and S demonstrated reduced TNF-α and increased IL-10 expression. Genes associated with mitochondrial stress response and energy metabolism, including PGC-1α, SOD2, and PINK1, were upregulated across groups, with the highest induction generally observed in sample S. FOXO3, SIRT1, and SIRT3 expression also increased following treatment, with sample S showing the most pronounced response for FOXO3 and SIRT3. Conclusions: These transcript-level findings suggest that CaHA exposure is associated with differential gene-expression responses involving markers related to extracellular matrix remodeling, inflammatory and regulatory signaling, mitochondrial stress response, and longevity-associated pathways. Functional and protein-level validation will be required to determine whether these transcriptional changes translate into meaningful biological effects in more complex models of aging skin.