European Expert Recommendations on the Use of Injectable Poly-L-Lactic Acid for Facial Rejuvenation

September 2014 | Volume 13 | Issue 9 | Original Article | 1057 | Copyright © September 2014

Redaelli Alessio MD,a Berthold Rzany MD ScM,b Linda Eve MD,c Yann Grangier MD,d
Pedro Herranz MD,e Frédérique Olivier-Masveyraud MD,f and Danny Vleggaar MDg

aCosmetic Department, Visconti di Modrone Medical Center, Milan, Italy
bDivision of Evidence-Based Medicine in Dermatology, Charité-Universitätsmedizin, Berlin, Germany
cEvenLines Clinic, Bournemouth, UK
dClinique de l’Ocean, Quimper, France
eDepartment of Dermatology, La Paz University Hospital, Universidad Autónoma, Madrid, Spain
fPrivate Practice, Paris, France
gHead of Cosmetic Dermatology in Private Practice, Geneva, Switzerland

Over the last few years, there have been a number of important changes in how we appreciate and understand the aging face. Volume loss is now recognized as a major component of facial aging. Treatment options that replace lost volume are increasingly used for recontouring and rejuvenation of the aging face. In this review we present and discuss the European Expert Group recommendations on the ideal use of the unique collagen stimulator, poly-L-lactic acid (PLLA, Sculptra®, Sinclair Pharmaceuticals) for facial rejuvenation lasting up to 25 months. Optimal results are achieved based on a detailed knowledge of facial anatomy, correct treatment procedure, specifically the right dilution, the correct injection technique, as well as appropriate patient aftercare. PLLA is an effective and safe collagen stimulator that treats the whole face. PLLA is simple to use, provides the foundation for facial rejuvenation, is easy to combine with other treatments, and gives long-lasting effects with a high level of patient satisfaction.

J Drugs Dermatol. 2014;13(9):1057-1066.


Facial aging is no longer considered purely gravitational decent. Volume loss, a dynamic process with skin thinning and collagen loss, fat redistribution, muscle atrophy and bone remodeling, is a major component.1-3 While surgery can address lax or sagging skin, or the need to tighten or resuspend facial muscle, it does not address volume loss without fat grafting, or treat the face as a whole.
Treatment options such as poly-L-lactic acid (PLLA, Sculptra®, Sinclair Pharmaceuticals) that replace volume by considering the entire face and its structural foundation provide a more holistic approach, may forestall further deterioration, and avoid/ postpone need for surgery.1,2,4

The Dynamic Process of Facial Aging

Multiple changes in skin, subcutaneous fat, muscle and bone contribute to facial aging.5-7 As facial aging primarily comprises soft-tissue changes, bone atrophy and remodeling,2,8-10 evaluating the whole face and structural tissue integrity is pivotal to provide natural-looking results.


Craniofacial skeletal remodeling, with expansion and loss of bone, is an important contributor to facial aging.4,11-25 By the age of sixty, 25% of bone mass is lost,26 with increases in orbital aperture; decreases in glabellar, pyriform, and maxillary angles.11 Mandibular angle changes may cause blunting or loss of lower facial border definition;4 pyriform aperture increases the appearance of nose elongation and drooping nasal tip.16 Midfacial bone loss may exacerbate the nasolabial fold by reorienting the malar fat pad medially and inferiorly.22


Changes in fat contribute to facial aging.27,28 Fat pad compartments are located in two layers: a superficial layer between the dermis and fascia superficialis contributing to a healthy looking face, and a deep layer around or under the muscles, contributing to a youthful appearance.29 Age-related changes in volume and positioning lead to changes in facial appearance.30,31 Fat redistribution causes atrophy in certain areas (ie, periorbital, forehead, buccal, temporal, and perioral areas) and hypertrophy in others.5 Fat pads become more discernible as separate entities, as do many underlying facial structures, such as submaxillary glands and bony protuberances. 32 The malar fat pad gradually slides forward and down to bulge against the nasolabial crease, giving nasal fold prominence. Fat redistribution and demarcation may disturb a smooth transition from one anatomical region to another, giving an unbalanced appearance. Sagging (jowl, submental area, and nasolabial fold) becomes pronounced due to relative excess of skin and/or lack of elastic recoil and fat accumulation.32


It is unclear whether muscles age histologically, or change physiologically in response to the aging process of underlying