MIAMI BEACH Although most U.S. dermatologists have limited experience with poly-L-lactic acid, this filler can be used successfully to correct lipoatrophy, Susan H. Weinkle, M.D., said at a seminar sponsored by the Skin Disease and Education Foundation.
Proper reconstitution, technique, and patient education were among the practical tips Dr. Weinkle presented for preparation of both the product and the patient.
Poly-L-lactic acid (Sculptra, Dermik Laboratories), which is indicated for restoration and/or correction of lipoatrophy in people with human immunodeficiency virus, was fast-tracked and approved by the Food and Drug Administration in August. Some physicians have been using the filler off label to restore volume to the aging face.
"Both the HIV and aging patients develop lipodystrophy, a loss of fat and a loss of volume. Our colleagues in plastic surgery think the way to deal with this is to pull and stretch. We want to volumize and fill," said Dr. Weinkle, a dermatologist in private practice in Bradenton, Fla., who is on the advisory boards for Galderma, Procter & Gamble, and Dermik.
Poly-L-lactic acid (PLLA) is not a site-specific wrinkle filler; it's a "global volume sculptor," Dr. Weinkle said. It returns desired contours by smoothing wrinkles and folds from the inside out. The product stimulates a patient's own fibroblasts to produce collagen. "We're not just filling a wrinkle, we're revolumizing from within," she said during a live patient demonstration.
The filler material is freeze dried. Reconstitution with 5 mL sterile water or 4 mL sterile water and 1 mL lidocaine with epinephrine is recommended. Reconstitution with only 3 mL is possible, but this formulation should be reserved for experienced injectors who are treating the most severe cases, Dr. Weinkle said.
Do not shake the vial during or immediately after reconstitution. Set it aside for at least 2 hours. "I like to hydrate it the night before," she added. Shake firmly just prior to injection.
Unlike some fillers, PLLA does not require an allergic skin test, and refrigeration is not needed. But because it has only a limited shelf life once reconstituted, PLLA can be a costly option if patients cancel or miss an appointment. Some physicians are requiring patients to prepay the estimated $800-$1,000 for each vial.
"The cost across the U.S. varies a lot. If the patient does not show up, you have 72 hours to use it. If you have some left, give it to your office staff, if suitable. Your office staff is your best marketer," she said.
Prepare the area with a topical anesthetic such as Betacaine Plus. Injections should be deeper than the dermis and placed 0.5 to 1 cm apart. Inject 0.1 mL to 0.2 mL at each site. Dr. Weinkle suggested using an 18G BD Luer Lock 1-cc syringe. She injects bevel up and massages the area after every three to four injections.
It is important to undercorrect rather than overcorrect, she noted. "I usually inject a half cc on either side of the face to start and have them return in a month."
Patients must be told to expect little immediate gratification, Dr. Weinkle said. "Think of this as a staged procedure, like Mohs surgery. It typically takes three to five monthly treatment sessions to yield desired results. Uninformed patients are likely to call a few days after the initial sessiononce the swelling has gone downand say, 'I paid you so much and I have nothing,'" she said.
Dr. Weinkle likes to see patients every 4 weeks, which allows adequate time to gauge the results. "Then you can fine-tune it," she said. "As a physician you need an aesthetic eye. Next time I may think I need some more volumizing in a different area to get a little more lift."
The effect lasts 18-24 months, and PLLA is not permanent. Other fillers last 4-6 months.
Unlike collagen, injection of PLLA should stop as the needle is withdrawn, before the needle tip returns to the skin's surface. "I was injected myself 5 days ago, and I have some bruising from not using enough pressure," Dr. Weinkle said.
Another caveat is to inject PLLA rapidly to avoid clogging of the needle. If a clog does occur, it is necessary to change the needle. "There is a learning curve, but this is so easy," Dr. Weinkle said.
"Some patients will experience some minor discomfort and should be forewarned," Dr. Weinkle said. Most adverse events are technique dependent, such as the bruising. Also, if PLLA is injected too superficially, nodules can result.
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