INTRODUCTION
The collagen stimulating agent Sculptra® (Dermik, Bridgewater, NJ, a subsidiary of Valeant Pharmaceuticals International, Inc.,) has been a part of the aesthetic toolbox for over a decade. Originally approved in 1999 as NewFill® for volume correction in HIV lipoatrophy, the product was quickly adopted for use in an off-label manner in the non-HIV population. FDA-approval of Sculptra Aesthetic for cosmetic use in 2009 has increased physician and patient interest in the product.
Despite the increasing popularity of poly-L-lactic acid (PLLA) use in the non-HIV population, there is limited information in the literature regarding the cosmetic application of PLLA for the practicing physician. The purpose of this article is to provide a personal experience on PLLA injection technique as well as an overall approach to patient management including patient selection, evaluation, treatment, and satisfaction.
Patient Selection and Approach
The Cosmetic Consultation
Patient education and counseling is of paramount importance during any cosmetic consultation, but in particular when considering a biostimulatory filler such as PLLA. It is important to understand the patient's concerns and goals in terms of facial rejuvenation. Questions to be discussed during initial consultation may include the following: What areas of his or her face or body concern the patient the most? Does he or she desire immediate results or improvement gradually over time? Are there social constraints in terms of employment or family/friends in which the patient desires little downtime or no visible stigmata of cosmetic interventions? Has he or she had procedures in the past and what is his or her comfort level with cosmetic procedures?
The Cosmetic Consultation
Patient education and counseling is of paramount importance during any cosmetic consultation, but in particular when considering a biostimulatory filler such as PLLA. It is important to understand the patient's concerns and goals in terms of facial rejuvenation. Questions to be discussed during initial consultation may include the following: What areas of his or her face or body concern the patient the most? Does he or she desire immediate results or improvement gradually over time? Are there social constraints in terms of employment or family/friends in which the patient desires little downtime or no visible stigmata of cosmetic interventions? Has he or she had procedures in the past and what is his or her comfort level with cosmetic procedures?
In the first author's experience, cosmetic consultations are an important time to set expectations, define goals clearly, and to educate patients on the options for treatment. Approximately half of my time during a cosmetic consultation, on average, is spent re-educating the patient as to the process of facial aging. A pared-down, relatable discussion between the physician and the patient of how skin, muscles, soft tissues, and even bones change over time is critical to developing a meaningful treatment plan. From this discussion, patients learn to appreciate that facial aging is not an isolated problem localized to a nasolabial fold or a jowl, but instead a culmination of global changes in the skeletal, soft tissue, and cutaneous compartments.1 This is often an "A-ha" moment for patients. I typically demonstrate on the patient, with he/she observing, the role of strategic volume replacement about the face. Global rejuvenation not only addresses a nasolabial fold, but also creates a more youthful visage overall.
Finally, a subsection of new consults are concerned about the placement of a foreign substance in their bodies. Some of these patients find it reassuring that PLLA is broken down into carbon dioxide and water over time.2 Furthermore, many find it appealing that PLLA causes a collagen response, so that his or her own cellular machinery is creating the desired volumization.
Management of Patient Expectations With PLLA
An impatient patient is not a good PLLA candidate. Patients are instructed that PLLA volume restoration is a treatment regimen requiring "delayed gratification." Patients are counseled that visible results are unlikely to occur before their 3rd monthly visit (2 months from initial treatment),3 consistent with the biological timeline of neocollagenesis secondary to PLLA implantation.2,4,5 Gradual volume restoration can be an advantage to many potential filler candidates wishing to remain discrete while improving their appearance. Setting realistic expectations is key to delivering high patient satisfaction, regardless of the recommended aesthetic treatment.
An impatient patient is not a good PLLA candidate. Patients are instructed that PLLA volume restoration is a treatment regimen requiring "delayed gratification." Patients are counseled that visible results are unlikely to occur before their 3rd monthly visit (2 months from initial treatment),3 consistent with the biological timeline of neocollagenesis secondary to PLLA implantation.2,4,5 Gradual volume restoration can be an advantage to many potential filler candidates wishing to remain discrete while improving their appearance. Setting realistic expectations is key to delivering high patient satisfaction, regardless of the recommended aesthetic treatment.
A formulaic approach to the number of vials of PLLA required for global volume restoration is discouraged. Patient age, comorbidities such as tobacco use,6 facial structure, and deficiencies,
