Indicated for the treatment of facial lipoatrophy in persons with HIV infection, the new filler material poly-L-lactic acid is also being used by some physicians off-label as a volume restorer for cosmetic enhancement in non-HIV patients. So far, poly-L-lactic acid is showing promise as a new modality for restoring volume to the aging face.
"This agent is used not for correcting lines and wrinkles, but for improving the appearance of deeper defects, such as for hollows in the cheeks, temples and under the eyes. As it is still relatively new, further experience is needed to determine optimum methods for reconstitution and injection and to characterize the longevity of its benefits. However, poly-L-lactic acid seems to have brought a new tool for achieving longer-lasting volume augmentation," says Dr. Rostan, who is a dermatologist and cosmetic surgeon in private practice in Charlotte, N.C.Poly-L-lactic acid is a biocompatible, biodegradable polymer used in resorbable sutures and facial implants. It is injected subdermally and provides an immediate benefit due to volume filling and some post-treatment edema. As those effects diminish over a period of weeks and the polymer slowly begins to degrade, collagen remodeling occurs to augment volume and maintain the treatment benefit.
Patients typically receive a series of two to four injections that are administered at intervals of two to four weeks. The material is supplied as a powder that is reconstituted with sterile water for injection. Many users are also adding 1 cc of lidocaine to the vial, which may contribute to the overall comfort of the injection procedure.
"The injections are very well-tolerated, but with the use of this larger (25 gauge) needle, there is a greater risk for bruising, and patients need to be prepared to expect that," Dr. Rostan tells Cosmetic Surgery Times.
Delivery subdermally and not more superficially is important to avoid granulomatous reactions that can lead to the appearance of papules. When attention is given to proper injection technique, poly-L-lactic acid has had a very favorable safety and efficacy profile.
"My patients have been very happy with the amount of volume restoration they are achieving with this material, but it will be important to gather data during continued follow-up in order to evaluate their satisfaction over the long-term," Dr. Rostan says.
Safe, significant resurfacing
Fractional resurfacing is a versatile technique that can be used to treat photo-damaged skin on the face, neck, chest and forearms, as well as for melasma and atrophic acne scars. It is rapidly gaining popularity because it can provide significant rejuvenation without significant downtime, Dr. Rostan says.
"This treatment can be used to achieve improvements in the textural and pigmentary changes of photoaging that exceed the results of nonablative laser or intense pulsed light procedures. While the benefits are not as significant as those achieved when ablative CO2 or erbium:YAG laser (FriendlyLight) resurfacing is performed, fractional resurfacing causes little to no morbidity and affords the opportunity to safely and very effectively treat extrafacial skin," Dr. Rostan explains.
In fractional resurfacing, the laser energy is delivered in microscopic spots using a computer-generated pattern to produce columns of photocoagulated tissue. The thermal injury penetrates deep into the dermis to induce connective tissue remodeling. However, only about 15 percent to 20 percent of the total skin area is affected.
"With up to 80 percent of the skin spared, there is little to no down time and enhanced post-treatment healing," Dr. Rostan says.
Varying treatment modalities
Patients with significant photodamage who might be considered candidates for ablative laser resurfacing typically receive four or five treatments performed at intervals of 10 to 14 days.