Aesthetic Dermatology

MIAMI BEACH — Poly-L-lactic acid "is a little tricky to use, but with proper care it can be very effective," Dr. C. William Hanke III said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

He and other experts shared their tips for dilution, reconstitution, administration, and follow-up to optimize aesthetic outcomes with the deep tissue filler poly-L-lactic acid (Sculptra).

"You can have dramatic, dramatic improvements in these patients with facial asymmetry. When people look at themselves in the mirror and start crying, you know it was worthwhile," said Dr. Marta I. Rendon of the University of Miami. "A lot of patients say, 'I don't want to look 20. I just want to look less tired,'" said Dr. Susan Weinkle of the University of South Florida, Tampa.

Dr. Rendon agreed: "You really want a natural and youthful appearance. You want harmony—someone who looks well, younger, well rested. You are complementing their natural attributes."

Assess patient goals before the procedure. Sometimes what patients want is not what's best for them. "You have to use common sense. We don't want to distort peoples' faces so they end up walking around looking like chipmunks," she said.

Restoration of facial volume loss in people with HIV is the approved indication for Sculptra. "These HIV lipoatrophy patients are the most appreciative I've ever met. They look sick to the world and this [treatment] makes a big difference," said Dr. Hanke of Indiana University, Indianapolis.

These three dermatologists offered clinical pearls on the following issues involved in the use of poly-L-lactic acid:

▸ Patient preparation. Both Dr. Hanke and Dr. Rendon mark injection spots on the cheek and outline the area to be filled with poly-L-lactic acid. "Always map the injection sites and take pictures," Dr. Rendon said. "I like to know for next time where I put the product and how the patient responded."

During an initial assessment, establish realistic expectations, agree on a treatment plan, and explain subjective and objective assessments of results, she said.

▸ Dilution. Dr. Hanke uses a 5-cc dilution per vial—3 cc of sterile water the night before, followed by 2 cc of Xylocaine (lidocaine) right before injection. Dr. Weinkle adds all 5 cc of water the night before and 2 cc of Xylocaine just before injection.

"When you add the Xylocaine with epinephrine, turn the bottle upside down and add it slowly. It won't get as foamy," Dr. Weinkle said. This tip should expedite the procedure.

▸ Reconstitution. A minimum of 2 hours for reconstitution is recommended. "We have patients pay a deposit so their bottle is ready the day before," Dr. Rendon said.

Keep the vial warm to maintain the product in solution, Dr. Weinkle said. You can place it in warm water or keep it near your body, she added.

Dr. Hanke and Dr. Rendon use a mixer to keep the product reconstituted during use. "It works better than hand mixing for me. You do not want to see white powder. You want to see it in full suspension," Dr. Hanke said.

If there is a white clump in the syringe or if the needle clogs during use, "pull it back, mix it a little, and keep going," Dr. Rendon said.

▸ Technique. Both doctors use a 3-cc syringe, but Dr. Hanke injects with a 25-G needle and Dr. Rendon prefers to use a 26-G needle.

Larger needles are easier to use, Dr. Weinkle said, and can spread the material with fewer injections, but be careful if you fan. "As you go back into a triangle area over and over, you may end up with a glob of material at the entry point."

Dr. Rendon said, "I just got used to using the shorter [half-inch] needle, and I don't do as much fanning with Sculptra as with the other products."

Seat the patient upright at a 30-degree angle. "Do a deep dermal injection with about 0.1–0.2 cc per injection site," Dr Rendon advised.

Although tunneling and depot are the two main injection techniques, "you will develop your own systems with experience and change your techniques accordingly," she added.

Poly-L-lactic acid is thicker than many other filler materials. Pressure must be maintained on the syringe plunger to maintain the flow. "This [product] flows easily with experience," Dr. Rendon commented.

Dr. Weinkle's assistant keeps track of the syringe count during the procedure "so I don't end up injecting all the product on one-half of the face," she said. If you do use more product on one side and know the patient is coming back, tell them: "I focused on the left side this time. Next time I will focus more on the right side," she said. Then make a note in the chart to do so.

Another pearl is to put cotton swabs in an open bottle of Drysol (aluminum chloride) to use during the procedure. Dr. Rendon uses this technique to promote coagulation and minimize point bleeding at injection sites.

▸ Postprocedure care. Have an assistant stay with the patient and massage the injected areas for 5–10 minutes. "Always massage, but don't overdo it," Dr. Rendon said. "If they are on Coumadin [warfarin] or aspirin, you will create bruising."

"Some advocate further massaging at home, but I think that is less important," Dr. Hanke said.

Both Dr. Rendon and Dr. Weinkle recommend follow-up massaging of the treated areas. Dr. Weinkle tells patients to follow the "rule of fives"—5 minutes five times a day "This compliance with postop care is associated with better outcomes," she said. Dr. Rendon advises 5 minutes of massage three times per day.

▸ Adverse events. Avoid injection of certain areas to minimize the risk of adverse events such as papules, nodules, or inflammatory granulomas. "You can use the product anywhere there is fat loss in the face, except the glabellar area and vermillion border," Dr. Rendon said.

"If you get close to the eye with injecting Sculptra, sometimes [patients] will not be able to close their eyes afterward," Dr. Weinkle said. "I had some Sculptra injected near my eye, and I was unable to close my eye for 3 hours. It freaked me out. Warn patients about this."

In addition, "do not inject this product into the lips. The skin is too thin—you'll get nodules," she said.

Caution is also advised regarding perioral injections in a heavy smoker.

"I got burned once with a woman who had an adverse effect," Dr. Weinkle recalled. "As they smoke and contract the muscles so strongly by pursing their lips, they move the product and get nodule formation."

▸ Long-term expectations. Most patients require three to four treatment sessions for maximal results with poly-L-lactic acid. "The timing of repeat injections is every 4–6 weeks until you get the desired effect," Dr. Rendon said. "It's not a product with immediate results. It's a slow, progressive improvement over 4–6 months."

Dr. Weinkle said, "Patients also need to be educated that time marches on and they may need to return for a Sculptra booster."

Dr. Weinkle is on the speakers' bureau for Dermik Laboratories, the manufacturer of Sculptra. Dr. Hanke and Dr. Rendon do not have disclosure statements regarding Sculptra or Dermik.

MIAMI BEACH — Poly-L-lactic acid "is a little tricky to use, but with proper care it can be very effective," Dr. C. William Hanke III said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

He and other experts shared their tips for dilution, reconstitution, administration, and follow-up to optimize aesthetic outcomes with the deep tissue filler poly-L-lactic acid (Sculptra).

"You can have dramatic, dramatic improvements in these patients with facial asymmetry. When people look at themselves in the mirror and start crying, you know it was worthwhile," said Dr. Marta I. Rendon of the University of Miami. "A lot of patients say, 'I don't want to look 20. I just want to look less tired,'" said Dr. Susan Weinkle of the University of South Florida, Tampa.

Dr. Rendon agreed: "You really want a natural and youthful appearance. You want harmony—someone who looks well, younger, well rested. You are complementing their natural attributes."

Assess patient goals before the procedure. Sometimes what patients want is not what's best for them. "You have to use common sense. We don't want to distort peoples' faces so they end up walking around looking like chipmunks," she said.

Restoration of facial volume loss in people with HIV is the approved indication for Sculptra. "These HIV lipoatrophy patients are the most appreciative I've ever met. They look sick to the world and this [treatment] makes a big difference," said Dr. Hanke of Indiana University, Indianapolis.

These three dermatologists offered clinical pearls on the following issues involved in the use of poly-L-lactic acid:

▸ Patient preparation. Both Dr. Hanke and Dr. Rendon mark injection spots on the cheek and outline the area to be filled with poly-L-lactic acid. "Always map the injection sites and take pictures," Dr. Rendon said. "I like to know for next time where I put the product and how the patient responded."

During an initial assessment, establish realistic expectations, agree on a treatment plan, and explain subjective and objective assessments of results, she said.

▸ Dilution. Dr. Hanke uses a 5-cc dilution per vial—3 cc of sterile water the night before, followed by 2 cc of Xylocaine (lidocaine) right before injection. Dr. Weinkle adds all 5 cc of water the night before and 2 cc of Xylocaine just before injection.

"When you add the Xylocaine with epinephrine, turn the bottle upside down and add it slowly. It won't get as foamy," Dr. Weinkle said. This tip should expedite the procedure.

▸ Reconstitution. A minimum of 2 hours for reconstitution is recommended. "We have patients pay a deposit so their bottle is ready the day before," Dr. Rendon said.

Keep the vial warm to maintain the product in solution, Dr. Weinkle said. You can place it in warm water or keep it near your body, she added.

Dr. Hanke and Dr. Rendon use a mixer to keep the product reconstituted during use. "It works better than hand mixing for me. You do not want to see white powder. You want to see it in full suspension," Dr. Hanke said.

If there is a white clump in the syringe or if the needle clogs during use, "pull it back, mix it a little, and keep going," Dr. Rendon said.

▸ Technique. Both doctors use a 3-cc syringe, but Dr. Hanke injects with a 25-G needle and Dr. Rendon prefers to use a 26-G needle.

Larger needles are easier to use, Dr. Weinkle said, and can spread the material with fewer injections, but be careful if you fan. "As you go back into a triangle area over and over, you may end up with a glob of material at the entry point."

Dr. Rendon said, "I just got used to using the shorter [half-inch] needle, and I don't do as much fanning with Sculptra as with the other products."

Seat the patient upright at a 30-degree angle. "Do a deep dermal injection with about 0.1–0.2 cc per injection site," Dr Rendon advised.

Although tunneling and depot are the two main injection techniques, "you will develop your own systems with experience and change your techniques accordingly," she added.

Poly-L-lactic acid is thicker than many other filler materials. Pressure must be maintained on the syringe plunger to maintain the flow. "This [product] flows easily with experience," Dr. Rendon commented.

Dr. Weinkle's assistant keeps track of the syringe count during the procedure "so I don't end up injecting all the product on one-half of the face," she said. If you do use more product on one side and know the patient is coming back, tell them: "I focused on the left side this time. Next time I will focus more on the right side," she said. Then make a note in the chart to do so.

Another pearl is to put cotton swabs in an open bottle of Drysol (aluminum chloride) to use during the procedure. Dr. Rendon uses this technique to promote coagulation and minimize point bleeding at injection sites.

▸ Postprocedure care. Have an assistant stay with the patient and massage the injected areas for 5–10 minutes. "Always massage, but don't overdo it," Dr. Rendon said. "If they are on Coumadin [warfarin] or aspirin, you will create bruising."

"Some advocate further massaging at home, but I think that is less important," Dr. Hanke said.

Both Dr. Rendon and Dr. Weinkle recommend follow-up massaging of the treated areas. Dr. Weinkle tells patients to follow the "rule of fives"—5 minutes five times a day "This compliance with postop care is associated with better outcomes," she said. Dr. Rendon advises 5 minutes of massage three times per day.

▸ Adverse events. Avoid injection of certain areas to minimize the risk of adverse events such as papules, nodules, or inflammatory granulomas. "You can use the product anywhere there is fat loss in the face, except the glabellar area and vermillion border," Dr. Rendon said.

"If you get close to the eye with injecting Sculptra, sometimes [patients] will not be able to close their eyes afterward," Dr. Weinkle said. "I had some Sculptra injected near my eye, and I was unable to close my eye for 3 hours. It freaked me out. Warn patients about this."

In addition, "do not inject this product into the lips. The skin is too thin—you'll get nodules," she said.

Caution is also advised regarding perioral injections in a heavy smoker.

"I got burned once with a woman who had an adverse effect," Dr. Weinkle recalled. "As they smoke and contract the muscles so strongly by pursing their lips, they move the product and get nodule formation."

▸ Long-term expectations. Most patients require three to four treatment sessions for maximal results with poly-L-lactic acid. "The timing of repeat injections is every 4–6 weeks until you get the desired effect," Dr. Rendon said. "It's not a product with immediate results. It's a slow, progressive improvement over 4–6 months."

Dr. Weinkle said, "Patients also need to be educated that time marches on and they may need to return for a Sculptra booster."

Dr. Weinkle is on the speakers' bureau for Dermik Laboratories, the manufacturer of Sculptra. Dr. Hanke and Dr. Rendon do not have disclosure statements regarding Sculptra or Dermik.

MIAMI BEACH — Poly-L-lactic acid "is a little tricky to use, but with proper care it can be very effective," Dr. C. William Hanke III said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

He and other experts shared their tips for dilution, reconstitution, administration, and follow-up to optimize aesthetic outcomes with the deep tissue filler poly-L-lactic acid (Sculptra).

"You can have dramatic, dramatic improvements in these patients with facial asymmetry. When people look at themselves in the mirror and start crying, you know it was worthwhile," said Dr. Marta I. Rendon of the University of Miami. "A lot of patients say, 'I don't want to look 20. I just want to look less tired,'" said Dr. Susan Weinkle of the University of South Florida, Tampa.

Dr. Rendon agreed: "You really want a natural and youthful appearance. You want harmony—someone who looks well, younger, well rested. You are complementing their natural attributes."

Assess patient goals before the procedure. Sometimes what patients want is not what's best for them. "You have to use common sense. We don't want to distort peoples' faces so they end up walking around looking like chipmunks," she said.

Restoration of facial volume loss in people with HIV is the approved indication for Sculptra. "These HIV lipoatrophy patients are the most appreciative I've ever met. They look sick to the world and this [treatment] makes a big difference," said Dr. Hanke of Indiana University, Indianapolis.

These three dermatologists offered clinical pearls on the following issues involved in the use of poly-L-lactic acid:

▸ Patient preparation. Both Dr. Hanke and Dr. Rendon mark injection spots on the cheek and outline the area to be filled with poly-L-lactic acid. "Always map the injection sites and take pictures," Dr. Rendon said. "I like to know for next time where I put the product and how the patient responded."

During an initial assessment, establish realistic expectations, agree on a treatment plan, and explain subjective and objective assessments of results, she said.

▸ Dilution. Dr. Hanke uses a 5-cc dilution per vial—3 cc of sterile water the night before, followed by 2 cc of Xylocaine (lidocaine) right before injection. Dr. Weinkle adds all 5 cc of water the night before and 2 cc of Xylocaine just before injection.

"When you add the Xylocaine with epinephrine, turn the bottle upside down and add it slowly. It won't get as foamy," Dr. Weinkle said. This tip should expedite the procedure.

▸ Reconstitution. A minimum of 2 hours for reconstitution is recommended. "We have patients pay a deposit so their bottle is ready the day before," Dr. Rendon said.

Keep the vial warm to maintain the product in solution, Dr. Weinkle said. You can place it in warm water or keep it near your body, she added.

Dr. Hanke and Dr. Rendon use a mixer to keep the product reconstituted during use. "It works better than hand mixing for me. You do not want to see white powder. You want to see it in full suspension," Dr. Hanke said.

If there is a white clump in the syringe or if the needle clogs during use, "pull it back, mix it a little, and keep going," Dr. Rendon said.

▸ Technique. Both doctors use a 3-cc syringe, but Dr. Hanke injects with a 25-G needle and Dr. Rendon prefers to use a 26-G needle.

Larger needles are easier to use, Dr. Weinkle said, and can spread the material with fewer injections, but be careful if you fan. "As you go back into a triangle area over and over, you may end up with a glob of material at the entry point."

Dr. Rendon said, "I just got used to using the shorter [half-inch] needle, and I don't do as much fanning with Sculptra as with the other products."

Seat the patient upright at a 30-degree angle. "Do a deep dermal injection with about 0.1–0.2 cc per injection site," Dr Rendon advised.

Although tunneling and depot are the two main injection techniques, "you will develop your own systems with experience and change your techniques accordingly," she added.

Poly-L-lactic acid is thicker than many other filler materials. Pressure must be maintained on the syringe plunger to maintain the flow. "This [product] flows easily with experience," Dr. Rendon commented.

Dr. Weinkle's assistant keeps track of the syringe count during the procedure "so I don't end up injecting all the product on one-half of the face," she said. If you do use more product on one side and know the patient is coming back, tell them: "I focused on the left side this time. Next time I will focus more on the right side," she said. Then make a note in the chart to do so.

Another pearl is to put cotton swabs in an open bottle of Drysol (aluminum chloride) to use during the procedure. Dr. Rendon uses this technique to promote coagulation and minimize point bleeding at injection sites.

▸ Postprocedure care. Have an assistant stay with the patient and massage the injected areas for 5–10 minutes. "Always massage, but don't overdo it," Dr. Rendon said. "If they are on Coumadin [warfarin] or aspirin, you will create bruising."

"Some advocate further massaging at home, but I think that is less important," Dr. Hanke said.

Both Dr. Rendon and Dr. Weinkle recommend follow-up massaging of the treated areas. Dr. Weinkle tells patients to follow the "rule of fives"—5 minutes five times a day "This compliance with postop care is associated with better outcomes," she said. Dr. Rendon advises 5 minutes of massage three times per day.

▸ Adverse events. Avoid injection of certain areas to minimize the risk of adverse events such as papules, nodules, or inflammatory granulomas. "You can use the product anywhere there is fat loss in the face, except the glabellar area and vermillion border," Dr. Rendon said.

"If you get close to the eye with injecting Sculptra, sometimes [patients] will not be able to close their eyes afterward," Dr. Weinkle said. "I had some Sculptra injected near my eye, and I was unable to close my eye for 3 hours. It freaked me out. Warn patients about this."

In addition, "do not inject this product into the lips. The skin is too thin—you'll get nodules," she said.

Caution is also advised regarding perioral injections in a heavy smoker.

"I got burned once with a woman who had an adverse effect," Dr. Weinkle recalled. "As they smoke and contract the muscles so strongly by pursing their lips, they move the product and get nodule formation."

▸ Long-term expectations. Most patients require three to four treatment sessions for maximal results with poly-L-lactic acid. "The timing of repeat injections is every 4–6 weeks until you get the desired effect," Dr. Rendon said. "It's not a product with immediate results. It's a slow, progressive improvement over 4–6 months."

Dr. Weinkle said, "Patients also need to be educated that time marches on and they may need to return for a Sculptra booster."

Dr. Weinkle is on the speakers' bureau for Dermik Laboratories, the manufacturer of Sculptra. Dr. Hanke and Dr. Rendon do not have disclosure statements regarding Sculptra or Dermik.