Use of poly-L-lactic acid shows promise as treatment for lipodystrophic facial aging

He reports having used the new filler for correction of mid-cheek and adjacent perioral intrinsic involutional loss of subcutaneous volume over six months in 15 patients (27 treatments). Cosmetic results as of February were excellent, based on assessment of pre- and post-treatment photographs, and there was no evidence of skin irregularities, nodules or papules. The efficacy of the augmentation combined with the safety of the treatments also translated into high patient satisfaction rates.

"Long term follow-up is planned and will be important for evaluating longevity and safety, but I truly believe this material holds exciting promise as a modality to achieve long-lasting correction of the volume loss that is an important, under-recognized component of soft tissue facial aging," says Dr. Key, associate clinical professor of dermatology, Oregon Health & Science University, Portland, Ore.

"Interest in poly-L-lactic acid is based on its positive track record for safety and efficacy. It is the same material that has been used for decades for absorbable sutures, and in its approved indication for treatment of facial lipoatrophy associated with HIV infection, it has been shown to provide a long-lasting fibroblastic response, Dr. Key says.

Patients chosen by Dr. Key for poly-L-lactic treatment for aging-associated lipodystrophy either are not good candidates for lipografting due to inadequate donor material or had failed to maintain sustained correction with previous fat transplantation. They all received a comprehensive, informed consent that includes discussion of off-label use as a cosmetic treatment, potential adverse events, early subsidence of correction associated with water resorption and delayed gain of correction, which may peak as late as six to eight months post-treatment.

Injection specifics Dr. Key performs the poly-L-lactic acid injection for midfacial volumetric correction using submucosal, perioral, infraorbital and zygomaticotemporal nerve blocks with 1 percent plain lidocaine. The lyophilized filler material is reconstituted at least 24 hours and up to 72 hours prior to the procedure using 4 ml sterile water and 1 ml of 2 percent lidocaine. The total volume of reconstituted solution is aliquoted into separate, 1 ml tuberculin syringes with attached 25 gauge needles that reduce the clogging seen with the smaller 26 gauge needles.

The syringes are agitated prior to injection, which is performed with the patient in a semi-upright position to allow visualization of gravitational displacement of tissue loss. The injection technique itself is similar to what is described by Roger Amar, M.D., and Bill Coleman, M.D., for fat micrografting and involves a threadlike injection with the needle slightly beveled and placed into the resistance-free, subcutaneous plane. The poly-L-lactic acid is delivered as the needle is withdrawn to avoid intra-arterial injection.

"It is important to inject threshold quantities of the material and note that this is not a shallow plane of injection into the dermis. The goal is to achieve compartment filling, and I believe there is an inter-related trabecular structural matrix below the dermis where this material can induce a fibroblastic response. In the end, however, a difference of 1 mm or 2 mm in injection depth is probably not critical for achieving the volume effect, although I do think it is important in avoiding nodules and papules," Dr. Key says.

To further minimize the risk of those complications, the skin is coated lightly with petrolatum after the injection and gently massaged while feeling for any irregularities that should be smoothed away. Post-treatment, patients may develop local bruising and/or swelling, but those effects are transient and the procedure is associated with minimal down time.

Disclosure: Dr. Key reports no financial interest in Dermik Laboratories or Sculptra.