Blending Hyaluronic Acid and Calcium Hydroxylapatite for Injectable Facial Dermal Fillers: A Clinical and Ultrasonography Assessment

Round 1

Reviewer 1 Report

The authors presented a manuscript containing very interesting and and important, since this new approach that combines the combination of CaHA and HA in the same syringe, in an attempt to demonstrate the results of biostimulation.

However, there are some information missing regarding the study design:

-Was the study approved by the ethics committee?

-This is a prospective or retrospective study?

Trade mark is missing after Belotero Intense, Radiesse+, GE and Canfield

Methodology:

Did the author use only one entry point? How did the author manage to achieve all length of the pre-auricular region? What was the length of the cannula used?

Author Response

The authors presented a manuscript containing very interesting and important, since this new approach that combines the combination of CaHA and HA in the same syringe, in an attempt to demonstrate the results of biostimulation.

1. Thank you for your interest and kind review!

However, there are some information missing regarding the study design:

-Was the study approved by the ethics committee?

1. All patients provided informed consent for the case details and images to be published in this report. Institutional Review Board appraisal was not required or sought as this report was not part of a prospective or systematic investigation of filler treatments. Moreover, it followed general principles for routine CaHA, HA, and injection. Institutional approval was not required to publish these unidentified cases.

-This is a prospective or retrospective study?

1. Correct. That´s a retrospective report of 15 regular patients who had suitable clinical pictures in the follow-up. This was updated in the methods.

The trademark is missing after Belotero Intense, Radiesse+, GE, and Canfield

1. Correct. These TM were added to the manuscript.

Methodology:

Did the author use only one entry point? How did the author manage to achieve all length of the pre-auricular region? What was the length of the cannula used?

1. Yes, one entry point at the jowl area, using a 5 cm 22G cannula.
   This important point was added to the revised manuscript.

Reviewer 2 Report

Very well prepared work, well documented and explained. However, there is a seemingly necessary lack of qualification and disqualification for the procedure (exclusion criteria). Please complete. Otherwise, no comments.

Author Response

Very well-prepared work, well documented and explained. However, there is a seemingly necessary lack of qualification and disqualification for the procedure (exclusion criteria). Please complete. Otherwise, no comments.

1. Thank you for your interest and kind review!

Best indications and contraindications for the procedure were essential, indeed! They were included in the revised manuscript.

Reviewer 3 Report

The use of mixed fillers is increasing interest in aesthetic medicine consultations. The combination of calcium hydroxyapatite and hyaluronic acid allows correction in a more effective way and for a longer time than both separately. 15 cases are presented for correction of facial volume loss. The technique is the usual one and the methodology to determine the injected material is correct with ultrasound. The photos are of quality, although there could have been more cases presented.

HArmonyCa has currently been marketed; it would be convenient for subsequent work to compare the results with the mixture made in consultation as in this manuscript.

Given the interest in knowing the longer-term effect, a follow-up with iconographic recording at 365 days would also be advisable, which I invite the authors to present in the future.

Author Response

The use of mixed fillers is increasing interest in aesthetic medicine consultations. The combination of calcium hydroxyapatite and hyaluronic acid allows correction in a more effective way and for a longer time than both separately. 15 cases are presented for correction of facial volume loss. The technique is the usual one and the methodology to determine the injected material is correct with ultrasound. The photos are of quality, although there could have been more cases presented.

1. Thank you for your interest and kind review!

HArmonyCa has currently been marketed; it would be convenient for subsequent work to compare the results with the mixture made in consultation as in this manuscript.

1. Correct. This important point was added to the revised manuscript.

Given the interest in knowing the longer-term effect, a follow-up with iconographic recording at 365 days would also be advisable, which I invite the authors to present in the future.

1. Correct. This is relevant and easy to accomplish. We will follow these patients for this purpose. Thank you so much!