Optimizing Facial Rejuvenation Outcomes by Combining Poly-L-Lactic Acid, Hyaluronic Acid, Calcium Hydroxylapatite, and Neurotoxins: Two Case Studies

February 2014 | Volume 13 | Issue 2 | Original Article | 191 | Copyright © February 2014

Z. Paul Lorenc MD FACSa and Elizabeth Daro-Kaftan PhDb

aLorenc Aesthetic Plastic Surgery Center, New York, NY
bPeloton Advantage, LLC, Parsippany, NJ

Reversal of the visible signs of facial aging with the use of injectable products as an alternative to surgery has become more popular, with nearly 5 million procedures performed in the United States in 2012. Volume augmentation products, such as hyaluronic acid (HA), calcium hydroxylapatite (CaHA), and poly-L-lactic acid (PLLA), are often used in combination with one another and with neurotoxins for facial rejuvenation because of the complementary modes of action. This article presents 2 case reports involving patientspecific combinations of 2 different HA products, injectable PLLA, and CaHA with incobotulinumtoxinA or abobotulinumtoxinA. The combination of HA, CaHA, PLLA, and neurotoxins has resulted in outstanding outcomes for many patients, with no clinical evidence of increased adverse events secondary to combination therapy.

J Drugs Dermatol. 2014;13(2):191-195.


Visible signs of facial aging are the result of several dynamic physiologic processes including dermal atrophy, loss of facial fat, collagen breakdown, and loss of bone.1-3 Dermal injectable products have become important alternatives to traditional surgical procedures for the correction of facial rhytides and the restoration of facial volume. The popularity of these products has grown accordingly, with nearly 5 million cosmetic procedures involving injectable products performed in the United States in 2012.4 Many of the aesthetic goals traditionally associated with costly cosmetic procedures can now be achieved for a fraction of the cost. A facelift can cost more than $6,000, eyelid surgery close to $2,700, and cheek implants nearly $3,000, according to The American Society for Aesthetic Plastic Surgery (ASAPS), whereas cost of cosmetic procedures involving injectable products ranges from $550- $941 (National Average).4 We can provide patients with a more global approach to facial rejuvenation focusing on re-volumizing the face. Results can last for several years depending on treatment, and most patients can return to their daily routines immediately after treatment. Ultimately, the patient will determine cost-effectiveness through discussions with their physician before undergoing appropriate treatment.
Currently there are a variety of injectable treatments available to restore the youthful appearance of the face by replacing lost tissue volume, as well as filling and effacing rhytides and deep folds. Due to complementary modes of action, biodegradable volume augmentation products such as hyaluronic acid (HA), calcium hydroxylapatite (CaHA), and poly-L-lactic acid (PLLA) are often used in combination with one another and with neurotoxins. 3,5 This allows for targeting specific effects of aging in different anatomical regions of the face. Injectable PLLA is a volume restoration product that contains biocompatible, biodegradable microparticles of PLLA, which stimulate the production of type 1 collagen, providing gradual volume.6,7 HA–based fillers function primarily by attracting and binding water molecules to create immediate volume.8 A biocompatible mixture of an aqueous gel containing synthetic CaHA microparticles provides immediate volume and serves as a matrix for the development of new tissue via neocollagenesis.9,10 The neurotoxin botulinum toxin type A temporarily denervates and relaxes muscles, resulting in a reduction of furrows and lines.11-13
Considerations regarding the use of volume augmentation products include rheologic properties, lifting capacity, and migratory ability of the product.14 Injectable volume restoration products are offered with a range of rheologic properties and those with a high degree of firmness (G’), elasticity, and viscosity may be best utilized in treating the nasolabial folds and midface/lower face by creating lift and volume and resisting post-injection spreading; whereas the use of less-firm and lessviscous products may be better for treating more shallow folds and lines.15,16 HA products are available in small gel particle (SGP-HA) and large gel particle (LGP-HA) sizes; SGP-HA is indicated for submucosal implantation for lip augmentation.17-20 The primary author routinely dilutes SGP-HA 1:1 with 1% lidocaine to decrease the viscosity, allow for better spread/flow, and possibly decrease the potential for the Tyndall effect.