Biostimulators vs. Energy-Based Devices: Clinical Guide to Long-Term Skin Rejuvenation

Dr. Nieves Romero – Dermatologist

Dr. Nieves is a medical doctor with a strong interest in aesthetic and regenerative medicine, focused on evidence-based and holistic approaches to skin health. Her work emphasizes understanding the skin as a reflection of internal balance, combining medical treatments with nutrition, lifestyle strategies, and preventive care to achieve natural and long-lasting results. She is passionate about continuous learning, scientific communication, and sharing knowledge that bridges clinical practice with modern aesthetic medicine.

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Comparing the effects of biostimulators vs. energy-based devices on long-term skin quality

The concept of skin quality has evolved significantly over recent years and is now understood as a combination of key attributes that define healthy and youthful skin. These include firmness, elasticity, evenness of tone and surface texture.

As the focus of aesthetic medicine increasingly shifts toward supporting informed long-term treatment planning, a wide range of treatments has emerged targeting each of these parameters. In some cases, combined approaches have been developed to address multiple aspects of skin quality simultaneously. Among the most widely used modalities are biostimulatory injectables, extracellular matrix bioremodellers and energy-based devices.

However, while these treatments are often discussed within the same therapeutic space, their mechanisms of action, clinical behavior over time and optimal patient selection differ considerably. Understanding these differences is essential when designing long-term skin quality strategies.

Mechanisms of action

Energy-based devices (EBDs) encompass a group of non-invasive medical technologies that deliver controlled energy to the skin in order to achieve specific clinical outcomes, such as improvements in skin elasticity, scarring and pigmentation. These modalities include ablative and non-ablative lasers, radiofrequency, high-intensity focused ultrasound and radiofrequency microneedling, among others.

The mechanism of action varies from one device to another depending on factors such as wavelength, depth of penetration and treatment parameters, which ultimately influence clinical results. Target tissues may involve epidermal ablation, dermal microthermal injury or deep volumetric heating, while preserving the surrounding tissue.

At a biological level, these controlled injuries trigger a wound-healing response characterised by fibroblast proliferation, increased collagen synthesis, upregulation of key growth factors and progressive extracellular matrix remodelling. Additional effects include angiogenesis and improved dermal vascularity, contributing to enhanced skin texture and firmness over time.

Emerging research suggests that some of these biological effects may extend beyond structural remodelling, influencing deeper pathways involved in skin ageing, a concept that warrants further exploration.

While energy-based devices rely on controlled physical energy to induce tissue remodelling, injectable biostimulators act through a fundamentally different biological pathway.

Biostimulatory injectables were developed as an approach to improve skin quality by enhancing dermal structure, rather than solely restoring volume. Their introduction marked a shift from traditional filling techniques toward biologically driven tissue regeneration.

They act by inducing a biologically mediated response within the dermis, aimed at enhancing extracellular matrix structure and function over time. Although their composition may vary, these agents share a common mechanism centred on the activation of dermal fibroblasts through a controlled inflammatory process.

This stimulation promotes the synthesis of collagen types I and III, key structural components responsible for skin firmness and elasticity, and supports progressive extracellular matrix remodelling. At a molecular level, biostimulators modulate signalling pathways involved in fibroblast proliferation and collagen deposition, including transforming growth factor-β–mediated processes.

As a result, clinical improvements develop gradually and are closely linked to individual biological response, skin quality and treatment technique, rather than immediate volumetric change.

Outcomes

Clinical outcomes vary significantly according to the underlying mechanism of action of each treatment modality.

Energy-based devices are often associated with earlier visible changes, largely driven by collagen contraction and controlled tissue injury. However, while dermal remodelling continues progressively over time, the maintenance of these results often depends on repeated or serial treatment protocols.

In contrast, biostimulatory injectables are characterized by a biologically progressive remodelling process, with more subtle changes observed in the short term and deferred clinical expectations. Nevertheless, their effects are generally more sustained over time and show less dependence on frequent maintenance sessions.

Patient selection

Patient selection for skin quality treatments is guided by a combination of clinical assessment, patient-reported concerns and the therapeutic options available within each practice. Following a comprehensive facial examination, treatment planning is influenced not only by objective findings (such as skin laxity, texture or volume loss) but also by the patient’s priorities, tolerance for injectable procedures and acceptance of potential side effects.

In cases primarily characterised by dermal laxity, loss of firmness and reduced skin luminosity (particularly when accompanied by mild volume depletion) biostimulatory injectables are among the options clinicians may consider, given their potential to support structural integrity while stimulating progressive collagen remodelling. Conversely, when epidermal alterations predominate, including surface irregularities, scarring, dyschromia or fine rhytides, energy-based devices such as fractional lasers represent another modality clinicians may weigh when evaluating targeted tissue-based approaches.

Increasing evidence supports the use of combined approaches, demonstrating that sequential or integrated treatment with biostimulatory injectables and energy-based devices can enhance clinical outcomes by addressing multiple layers of skin ageing simultaneously. This multimodal strategy reflects a

more comprehensive approach to long-term skin quality improvement, rather than reliance on a single modality.

Safety considerations differ between biostimulatory injectables and energy-based devices, reflecting their distinct mechanisms of action. With energy-based treatments, adverse effects are most commonly related to thermal injury and may include transient erythema, oedema, crusting or, in some cases, post-inflammatory hyperpigmentation, particularly in higher phototypes. These risks are closely linked to device selection, parameter settings and operator experience.

Biostimulatory injectables are generally associated with injection-related effects such as swelling, bruising or tenderness, while delayed complications (Including nodule formation or prolonged inflammatory responses) are more closely related to product placement, dilution and technique.

Across both modalities, appropriate patient selection, thorough counselling and practitioner expertise remain critical determinants of safety, reinforcing the importance of individualised treatment planning rather than protocol-driven approaches.

Improving long-term skin quality requires more than selecting a single technology or treatment modality. While both biostimulatory injectables and energy-based devices play a valuable role in contemporary aesthetic practice, their clinical behaviour, durability of results and optimal indications differ according to their underlying mechanisms of action.

Energy-based devices may offer earlier visible changes through controlled tissue injury and remodelling, whereas biostimulatory injectables promote gradual, biologically driven improvements in dermal structure and function. Understanding these distinctions allows clinicians to better align treatment choice with individual skin characteristics, patient expectations and long-term aesthetic goals.

Rather than viewing these approaches as competing options, a tailored and, when appropriate, combined strategy may provide more comprehensive and sustainable improvements in skin quality. Ultimately, informed clinical judgement, patient-centred decision-making and a thorough understanding of each modality remain central to achieving predictable and long-lasting outcomes.

References

1. Draelos ZD, Lewallen RP, Mamelak AJ, et al. Skin quality: a holistic 360° view — consensus results. Clin Cosmet Investig Dermatol. 2021;14:123–130. Available from: https://www.dovepress.com/skin-quality–a-holistic-360-view-consensus-results-peer-reviewed-fulltext-article-CCID
2. Alexiades-Armenakas M, Harris T, Meves A, et al. Energy-based devices for the treatment of facial skin conditions: mechanisms and clinical applications. J Clin Aesthet Dermatol. (available from) https://pmc.ncbi.nlm.nih.gov/articles/PMC11189641/
3. Kwon HH, Choi SY, Youn SW, et al. Current clinical application of energy-based devices in dermatology: mechanisms and safety. Cosmetics (Basel). 2023;12(5):201. Available from: https://www.mdpi.com/2079-9284/12/5/201#:~:text=Conclusions:%20Energy%2Dbased%20devices%2C,improvement%20but%20also%20biological%20rejuvenation
4. Recent advances in collagen biostimulators for facial rejuvenation: a systematic review in aesthetic dermatology. Aesthetic Dermatology & Cosmetic Science. (Year not specified). Available from: https://directivepublications.org/aods/articles/Recent-Advances-in-Collagen-Biostimulators-for-Facial-Rejuvenation-A-Systematic-Review-in-Aesthetic-Dermatology.pdf
5. (Author(s) not available). Title related to collagen biostimulators (PMID: 41184662). PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/41184662/
6. Expert consensus on collagen biostimulator choice in Latin America: patient selection, ethnic skin phenotypes, and accessibility. ResearchGate. (Year not specified). Available from: https://www.researchgate.net/publication/398106689_Optimizing_Collagen_Biostimulator_Choice_in_LATAM_Expert_Consensus_on_Patient_Selection_Ethnic_Skin_Phenotypes_and_Accessibility
7. Systematic review: combining biostimulators with other modalities in aesthetic medicine. PubMed. (PMID: 39719485). Available from: https://pubmed.ncbi.nlm.nih.gov/39719485/

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