INTRODUCTION
Minimally invasive soft-tissue augmentation of the face with volumizing fillers has become a popular alternative to traditional surgical procedures such as facelifts.1 One of the more widely used agents is poly-L-lactic acid (PLLA) (Sculptra™, Galderma), a nontoxic, immunologically inactive, synthetic biodegradable lactic acid polymer. Aside from providing instant volumizing effects, and in contrast to temporary, space-occupying replacement fillers such as collagen, PLLA has been shown to exert biologic activity by stimulating neocollagenesis.2-4 Specifically, the semi-permanent microspheres induce a local tissue response resulting in fibroblast stimulation and dermal remodeling that gradually promotes deposition of autologous collagen.5-8 Over a period of several months, the particles are degraded into lactate, and exhaled as carbon dioxide.9,10 Results persist for 18-24 months, with some reports stating that effects can last up to 3 years.1,11-13Several peer-reviewed clinical studies have demonstrated the efficacy of PLLA for facial rejuvenation.3,4 Incremental advances in the technical application, best-practices and mechanistic understanding of PLLA have led to a progressive off-label use of PLLA for non-facial sites, including but not limited to the hands, neck/décolleté, arms, abdomen, and gluteal area. The objective of this article is to review the clinical use and resulting outcomes of PLLA for body rejuvenation, and emphasize the various technical considerations specific to the different anatomic areas (Table 1).14-18
Dorsal Hands
Aged appearance of the hands, one of the most visible parts of the body, can create a stark contrast when compared to a younger-appearing, rejuvenated face. Together with chemical peels, laser/light technologies and dermabrasion, injectable fillers such as PLLA have increasingly been used for hand rejuvenation.19 It is noted that calcium hydroxyapatite (CaHa) is the preferred filler for hand volumization, but PLLA stands as a good alternative.Redaelli et al conducted a retrospective study of 27 patients (mean age of 65.9 years) to evaluate the cosmetic use of injectable PLLA for hand rejuvenation, and demonstrated that most of the patients were satisfied.20 During the treatments, intermetacarpal spaces were injected primarily parallel to the metacarpal bones using 2 ml of diluted PLLA per hand (0.05-0.1 ml with each injection). The preparation was reconstituted 12 hours prior to the injection and consisted of a vial of PLLA (150 mg versus the 367. 5 mg vials used in the USA) diluted with 0.5 ml of 3% carbocain and 5-8 ml of water. Less concentrated suspensions were used at follow-up sessions. A linear technique was used during each session, initially at monthly intervals for 3 months, and then every 3 months for 1 year (average of 4 treatments). The results were evaluated by a Definitive Graduated Score (DGS) based on the patient’s and doctor’s satisfaction scores (from 1 to 10) and by the photograph score. Over 80% of patients expressed satisfaction post-treatment, with average DGS score of 6.55. The DGS was higher than 8 in seven cases. Except of one case of fine nodule formation, there were no remarkable side effects.20Since the study was initially reported, numerous articles in the USA have demonstrated positive results using PLLA for hand rejuvenation.17,18,21-24 For each hand session treatment, each vial (367.5 mg) is typically reconstituted with approximately 10 ml of
