The primary reason patients seek aesthetic treatment
from dermatologists or plastic surgeons is to combat
the signs of aging.1 Increased interest in this goal has
been driven by the development of newer treatment options
that help restore a more youthful visage, as well as the increasing
societal emphasis on the value of an appearance that conveys
youth, vitality, and fecundity.2,3
An enhanced understanding of the dynamic anatomical and
physiological changes associated with the aging face has, in turn,
allowed a more sophisticated appreciation of the interdependent
nature of such changes and how they work in concert to affect
overall facial aesthetics.4 As our knowledge and experience have
grown, it has become possible to more specifically tailor treatment
approaches to the individual needs of each patient.
Soft tissue augmentation is one important option in aesthetic
enhancement, and it continues to grow in popularity for a number
of reasons. These include practical considerations such as its
minimally invasive nature5 and its ability to directly nullify volume
loss, which is now appreciated as a key root cause of the declining
aesthetics associated with facial aging.4
Agents that replace collagen are effective tools for addressing
volume loss.2 Among these, poly-L-lactic acid (PLLA) carries
great potential as a cosmetic treatment. Poly-L-lactic acid is
a stimulator of host collagen synthesis; this neocollagenesis
acts to volumize soft tissue in a gradual, progressive, and predictable
manner.4 The patient photographs found in the “Facial
Volumization with PLLA: Representative Results” portion of
the "Consensus Recommendations on the Use of Injectable
Poly-L-Lactic Acid for Facial and Nonfacial Volumization" section
of this supplement6 demonstrate the ability of PLLA to
provide natural-looking restoration of lost facial volume.
Despite the considerable value conveyed by its mechanism of action,
the full clinical potential of PLLA was not initially realized, as
its use was associated with the frequent occurrence of adverse
events, such as nodules and papules.7-11 These results were due, in large part, to inadequate recommendations regarding the methodology
of PLLA use12 and patient selection, and a somewhat
common misunderstanding of the clinical implications of its underlying
mechanism. However, our understanding of the use of
injectables, including PLLA, for cosmetic enhancement is in a continual
state of evolution and refinement. Considerable time has
passed since the introduction of PLLA for soft tissue augmentation,
and the collective experience of innumerable clinicians and
investigators now forms a requisite knowledge base that can better
inform its appropriate clinical utilization.
An international group of experts, each with more than a decade
of experience in the use of PLLA, was convened in 2013
to discuss the evolving literature on PLLA, share their personal
experiences and perspectives, and synthesize consensus recommendations
on the appropriate use of PLLA for soft tissue
augmentation.6 The objective of these recommendations is to
enhance the use of this agent in order to decrease adverse
events and improve patient outcomes.
Danny Vleggaar MD,
aHead of Cosmetic Dermatology in Private Practice, Geneva,
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
- Klein AW. Skin filling. Collagen and other injectables of the skin. Dermatol
- Coleman KR, Carruthers J. Combination therapy with BOTOX and fillers:
the new rejuvnation paradigm. Dermatol Ther. 2006;19(3):177-188.
- Lowe NJ, Maxwell CA, Patnaik R. Adverse reactions to dermal fillers: review. Dermatol Surg. 2005;31(11 Pt 2):1616-1625.
- Fitzgerald R, Vleggaar D. Facial volume restoration of the aging face with
poly-l-lactic acid. Dermatol Ther. 2011;24(1):2-27.
- Palm MD, Goldman MP. Patient satisfaction and duration of effect with PLLA:
a review of the literature. J Drugs Dermatol. 2009;8(suppl 10):s15-s20.
- Vleggaar D, Fitzgerald R, Lorenc ZP, et al. Consensus recommendations on
the use of injectable poly-L-lactic acid for facial and nonfacial volumization. J Drugs Dermatol. 2014;13(suppl 4):s44-s51.
- Valantin MA, Aubron-Olivier C, Ghosn J, et al. Polylactic acid implants (New-
Fill) to correct facial lipoatrophy in HIV-infected patients: results of the openlabel
study VEGA. AIDS. 2003;17(17):2471-2477.
- Moyle GJ, Brown S, Lysakova L, Barton SE. Long-term safety and efficacy
of poly-L-lactic acid in the treatment of HIV-related facial lipoatrophy. HIV Med. 2006;7(3):181-185.
- Engelhard P, Humble G, Mest D. Safety of Sculptra: a review of clinical trial
data. J Cosmet Laser Ther. 2005;7(3-4):201-205.
- Mest DR, Humble G. Safety and efficacy of poly-L-lactic acid injections in
persons with HIV-associated lipoatrophy: the US experience. Dermatol
- Lafaurie M, Dolivo M, Porcher R, Rudant J, Madelaine I, Molina JM. Treatment
of facial lipoatrophy with intradermal injections of polylactic acid in
HIV-infected patients. J Acquir Immune Defic Syndr. 2005;38(4):393-398.
- Lowe NJ. Dispelling the myth: appropriate use of poly-L-lactic acid and clinical
considerations. J Eur Acad Dermatol Venereol. 2006;20(suppl 1):s2-s6.