LAS VEGAS Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.
"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.
"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.
Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.
"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.
"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.
The speakers offered a number of tips:
▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.
Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.
▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.
"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 46 months."
He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.
▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.
"You really have to keep snapping the syringe," he said.
Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.
▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.
▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 46 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.
Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.
▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.
He noted that he has used it successfully to reduce the appearance of acne scars.
The corrections associated with poly-L-lactic acid treatment are thought to last 1824 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.
Dr. Ditre and Dr. Monheit have no relevant disclosures to report.
Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT