Aging, genetics and environmental factors contribute to multiple changes on the surface of the skin. These present with pigmentation, volume loss, loss of elasticity and loss of collagen. Altogether, areas of the face becomes "crepey", with resulting rhytids and an obvious appearance of thin and fragile skin. These are typically dermal manifestations of elastin and collagen loss resulting in a collective term of loss of "skin quality".

Current treatments to improve these changes involve the use of skincare, chemical peels, as well as more invasive repeated treatments such as microneedling and laser resurfacing. These commonly require repeated treatments and several days of downtime. More recently, treatment with a hybrid preparation of high and low-molecular weight complexes that are thermally cross-linked (Profhilo) has been suggested to stimulate collagen and elastin formation, thereby resulting in improvement in skin quality.

Aging, genetics and environmental factors contribute to multiple changes on the surface of the skin. These present with pigmentation, volume loss, loss of elasticity and loss of collagen. Altogether, areas of the face becomes "crepey", with resulting rhytids and an obvious appearance of thin and fragile skin. These are typically dermal manifestations of elastin and collagen loss resulting in a collective term of loss of "skin quality".

Current treatments to improve these changes involve the use of skincare, chemical peels, as well as more invasive repeated treatments such as microneedling and laser resurfacing. These commonly require repeated treatments and several days of downtime. More recently, treatment with a hybrid preparation of high and low-molecular weight complexes that are thermally cross-linked (Profhilo) has been suggested to stimulate collagen and elastin formation, thereby resulting in improvement in skin quality However, the evidence for this remains limited. Microfocused Ultrasound with Visualization (MFU-V) and Calcium hydroxylapatite (CaHA) have each been unequivocally proven to stimulate neocollagenesis and elastogenesis, leading to improvement in skin laxity. A recent study of a single-treatment single-depth of superficial MFU-V was found to result in aesthetic improvement of the accordion lines. In addition, there is recent evidence that CaHA in a hyperdiluted form can stimulate collagen and elastin formation. Indeed, this group of investigators has recently published the effectiveness of a single treatment of a combination MFU-V and diluted CaHA for improving brachial skin laxity. Arguably, there is a need to publish additional studies on these interventions for improving firmness and skin quality. In addition, there may be a theoretical cumulative benefit in using both treatments for improving skin quality, although the effectiveness of this combination has not been demonstrated.

With this background, the main rationale of performing this study is to demonstrate the safety and efficacy of a multimodality approach with a single treatment of superficial MFU-V and diluted CaHA for improvement of skin quality in Asian and Caucasian patients. The investigators selected Lower Face as the target area for the following reasons: 1) The Lower Face manifests the greatest with thinning, fine wrinkling and general fragility of the skin, 2) Volumization is not always aesthetically pleasing in this area but firmness of the skin is, 3) This area is an established treatment area for MFU-V, CaHA but not with other treatment options such as Profhilo.

Inclusion Criteria:

• Female patients with lower face wrinkles
• Otherwise generally healthy.
• Physically and mentally capable to provide informed consent to the study.
• Agreement to attend all follow-up visits as scheduled

Exclusion Criteria:

• Pregnancy or lactation;
• History of allergic reaction to calcium hydroxylapatite injection;
• Active local infections or skin diseases that might alter wound healing
• Acne or keloidal scarring
• Use of immunosuppressive drugs
• Any other diseases which can affect the wound-healing process
• Any procedures affecting facial wrinkles or skin quality in the lower face for the duration of the study
• Microdermabrasion and Peels
• Acne treatments
• Filler and Botulinum Toxin treatments
• Radiofrequency, Laser, IPL, Ultrasound
• Patients that had cosmetic treatments within 3 months of the baseline visit in the treatment area
• Subjects with dermatologic conditions in the treatment area including:
• Acne
• Rosacea
• Eczema
• Psoriasis
• Actinic keratosis,
• Severe sun damage
• Scars or a history of keloids

No individual participant data will be shared.

• Blinded assessment of aesthetic improvement at each visit as follows: Blinded reviewer to make qualitative comparisons of images of treated arms vs. baseline at each follow-up visit. If the reviewer perceived an improvement, he/she ask will be asked to select the correct post-treatment photograph