Poly-L-Lactic Acid (PLLA-SCA) as a Safe and Effective Method to Soften Transition Between Lower Eyelid and Midface

July 2025 | Volume 24 | Issue 7 | 692 | Copyright © July 2025


Published online June 26, 2025

Jose R. Montes MDa, Rod J. Rohrich MDb, Matthew H. Meckfessel PhDc, Jennifer H.T.D. Le PharmD RPhc

aJRM Eyes and Facial Rejuvenation, San Juan, PR; University of Puerto Rico, Ophthalmology, San Juan, PR
bDallas Plastic Surgery Institute, Dallas, TX
cGalderma Laboratories, L.P., Dallas, TX

Abstract
Worsening depression around the lower eyelid and midface are seen over time with age. Skin thinning, fat atrophy, along with pigmentation, skin texture, and shadow changes contribute to the "tired" look of the area. Current minimally invasive treatments approved by the US Food and Drug Administration (FDA) include hyaluronic acid injections, but these come with limitations, such as patient selection and potential risks of Tyndall effect and swelling, which are dependent on injection technique and product selection. However, poly-L-lactic acid (PLLA-SCA) may be an alternative treatment option as it regenerates the patient’s own collagen and elastin and improves skin quality. The aim of this case series is to discuss the technique to improve maxilla/malar projection, pigmentation, texture, and volume after PLLA-SCA treatment.

This is a case series where healthy adults with lower eyelid- midface deficiency due to congenital or age-related soft or hard tissue atrophy were injected with 2 to 2.5 mL of PLLA-SCA collagen activator (PLLA-SCA, Sculptra) per injection site diluted to 8 to 9 mL of sterile water for injection (SWFI) and 1 cc lidocaine 2%. Patients returned typically for 3 sessions every 6 weeks.

Patients had improvement in maxilla/malar projection, pigmentation, texture, and volume. Clinical outcomes are seen as early as 6 weeks after last session (3 sessions average) with minimal to no touchup required 4 to 5 years post-initial treatment. No unanticipated adverse events were noted.

PLLA-SCA is a safe and possibly long-term effective treatment option for patients who require softening of the lower eyelid and midface transition.

INTRODUCTION

Lower eyelid and midface aging is characterized by worsening depression, skin thinning, fat atrophy, hyperpigmentation, and skin texture changes.1 Extrinsic factors, like ultraviolet light exposure, cause photoaging through metabolic overreactivity. Rhytids form around the lateral canthus and lower eyelids as intrinsic, microscopic changes occur with degraded elastin and collagen.2

Other visible changes are seen with orbicularis rolls appearing in the pretarsal eyelids. The nasojugal groove, also known as the tear trough, forms below the lower eyelid. A contributing factor to tear trough deformity is fat loss at the inferior arcus marginalis. Whereas orbital septum attenuation can result in bulging of the lower eyelid fat pads. Changes in the centromedial cheek result in hollowing, also known as V deformity. The projection loss of the cheek occurs with festoons appearing in the mid-cheek.

Lower eyelid skin is thin, with minimal subcutaneous tissue.3 The orbicularis oculi muscle extends from the medial canthus to the lateral canthus and orbits.4 The orbicularis oculi muscle separates the deep fat compartments: medial suborbicularis oculi fat (SOOF), lateral SOOF, and deep medial cheek. The transverse facial artery is a small vessel that lies along the lateral face, connecting with infraorbital arterials and ends at the buccal area. Above the pre-septal orbicularis oculi muscle, lies the superficial lymphatic system.4 In the pre-septal orbicularis oculi muscle, the deep lymphatic system and superficial lymphatic system connect.

Commonly used treatments to improve the area include hyaluronic acid filler injections (HA filler).4 However, patients with transparent skin, prominent skin laxity, history of fluid retention, or eye area edema are not ideal candidates. Potential risks with HA filler treatment in the periorbital region, which are due to product selection and injection technique, may include Tyndall effect, swelling, and filler migration.

Poly-L-lactic acid collagen activator (PLLA-SCA, Sculptra) is an injectable that regenerates the patient's own collagen and

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