Consensus Recommendations on the Use of Injectable Poly-L-Lactic Acid for Facial and Nonfacial Volumization

April 2014 | Volume 13 | Issue 4 | Supplement Individual Articles | 44 | Copyright © April 2014


Danny Vleggaar MD,a Rebecca Fitzgerald MD,b Z. Paul Lorenc MD FACS,c J. Todd Andrews MD,d Kimberly Butterwick MD,e Jody Comstock MD,f C. William Hanke MD,g T. Gerald O’Daniel MD FACS,h Melanie D. Palm MD MBA,i Wendy E. Roberts MD,j Neil Sadick MD,k and Craig F. Teller MDl

aHead of Cosmetic Dermatology in Private Practice, Geneva, Switzerland
bDepartment of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
cLorenc Aesthetic Plastic Surgery Center, New York, NY, USA
dRiver Oaks, 3355 West Alabama, Houston, TX, USA
eDermatology/Cosmetic Laser Associates of La Jolla Inc., La Jolla, CA, USA
fSkin Spectrum, Tucson, AZ, USA
gDepartment of Dermatology, Saint Vincent Carmel Medical Center, Laser & Skin Surgery Center of Indiana, Carmel, IN, USA
h222 S. First Street, Louisville, KY, USA
iArt of Skin MD, Solana Beach, CA, USA
j35-280 Bob Hope Drive, Rancho Mirage, CA, USA
kSadick Dermatology, New York, NY, USA
lBellaire Dermatology Associates, 6565 W. Loop S, Bellaire, TX, USA

  • The authors have achieved optimal results in the following areas:
    • Temporal fossa
    • Malar/submalar areas
    • Chin and mandible
    • Décolletage
  • Potentially problematic areas include:
    • Areas of hyperdynamic muscle movement (eg, perioral and periocular regions)
      • This may lead to microparticle clumping, localized overcorrection, and nodules/ papules.
    • Neck and hands
      • The thin skin in these areas requires superficial injections, increasing the possibility of nodule and papule formation.
    • Injection Techniques
     Favorable injection techniques allow slow, safe, uniform dispersion of PLLA at the proper depth for optimal cosmetic benefit.
    General considerations include:
  • Injection should be into the subcutaneous or supraperiosteal plane.
    • Superficial injection (ie, into the dermis) should be avoided, as this may lead to visible neocollagenesis.
  • A reflux maneuver should be performed routinely to eliminate any risk of inadvertent intravascular injection.
  • Injection should be performed slowly.
  • If the needle clogs, it should be removed and the foam pushed out of the syringe hub. A new needle should then be affixed and primed prior to injection.
  • Injection technique can generally be selected based on the experience and comfort level of the clinician, with consideration given to the anatomic area being treated (see below).
    • A cross-hatch pattern should be considered, especially while becoming familiar with PLLA.
    • With more experience, fanning, cross-fanning, and depot approaches are also commonly utilized.
      • Fanning has the advantage of fewer needle sticks; however, vigilance is required to avoid multiple deposits at the apex of the fan.
    • Site-specific recommendations on the injection of PLLA for facial soft tissue augmentation include (Figure 1)34:
  • Medial cheek/Mid-face
    • Inject supraperiosteally over the zygoma, maxilla, and canine fossa/pyriform aperture.
    • Inject into the deep subcutaneous plane in the submalar/ mid-cheek, where bony background is absent.
  • Lateral face
    • Inject in the superficial subcutaneous fat above the parotid gland and masseter muscle.
    • table 2
  • Mandible/Chin
    • Inject supraperiosteally over the menton, pre-jowl sulcus, and antegonial notch
  • Temporal fossa/Lateral brow
    • Inject supraperiosteally at the origin of the temporal muscle.
    • Inject supraperiosteally at the tail of the brow.
  • Periorbital supraperiosteal injections approached through the orbicularis oculi muscle should be avoided.
    • This approach may lead to papule formation, perhaps resulting from extrusion of PLLA along the needle tract during muscular contraction.
    • Injection Quantity and Frequency
  • The amount of surface area to be treated is the sole determinant of the amount of PLLA used during a session.
    • The vast majority (~98%) of patients should receive 1-2 vials per session if treating the whole face (0.5–1 vial per side).
      • Up to 3 vials may be required for a patient requiring treatment over a very large surface area.
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