European expert recommendations on the use of injectable poly-L-lactic acid for facial rejuvenation.

Over the last few years, there have been a number of important changes in how we appreciate and understand the aging face. Volume loss is now recognized as a major component of facial aging. Treatment options that replace lost volume are increasingly used for recontouring and rejuvenation of the aging face.

Consensus recommendations on the use of injectable poly-L-lactic acid for facial and nonfacial volumization.

Poly-L-lactic acid (PLLA) was approved for use in Europe in 1999. In the United States, it was approved by the Food and Drug Administration in 2004 for the treatment of facial lipoatrophy associated with human immunodeficiency virus, and in 2009 for cosmetic indications in immune-competent patients. The need for consistent, effective PLLA usage recommendations is heightened by an increased consumer demand for soft tissue augmentation and a shift toward a younger demographic.

Satisfying patient expectations with poly-L-lactic acid soft tissue augmentation.

Patient interest and physician use of soft tissue augmentation have increased significantly in recent years, especially among younger patients. A recent consumer survey conducted on behalf of the American Society of Plastic Surgeons found that the majority of respondents would rather have a facial injectable treatment than a surgical treatment. In another recent survey, consumers gave the highest overall satisfaction ratings to injectable filler treatments (92%), including poly-L-lactic acid (PLLA), and injectable wrinkle relaxers (92%), with injectable fillers receiving the highest "extremely satisfied" rating (45%).

Understanding, avoiding, and treating potential adverse events following the use of injectable poly-L-lactic acid for facial and nonfacial volumization.

Injection-related adverse events (AEs) may occur with the use of any injectable substance, including all commercially available fillers. The most common of these AEs include discomfort, bruising, edema, and erythema, which are generally transient and resolve spontaneously. The majority of AEs widely felt to be associated with poly-L-lactic acid (PLLA) are papules, nodules, and granulomas.

The history behind the use of injectable poly-L-lactic acid for facial and nonfacial volumization: the positive impact of evolving methodology.

Poly-L-lactic acid (PLLA) was first approved for soft tissue augmentation in Europe in 1999 for the cosmetic correction of scars and wrinkles. Due, in part, to inadequate usage recommendations that included those related to product reconstitution and hydration, injection sites, techniques, and timing, and patient selection, PLLA use was initially associated with suboptimal cosmetic benefit and a high rate of specific adverse events, such as the formation of nodules. As clinical experience with PLLA has increased, the implementation of specific methodological changes has allowed greater, more consistent cosmetic effects to be achieved, with a low rate of adverse events.

Composition and mechanism of action of poly-L-lactic acid in soft tissue augmentation.

Poly-L-lactic acid (PLLA) is a synthetic, biocompatible, biodegradable polymer. For its use in soft tissue augmentation, it is supplied as a lyophilized powder containing PLLA microparticles, the size and chemical attributes of which are tightly controlled. As a biocompatible material, PLLA generates a desired subclinical inflammatory tissue response that leads to encapsulation of the microparticles, stimulation of host collagen production, and fibroplasia.

Facial volume restoration of the aging face with poly-l-lactic acid.

The purpose of this article is to discuss current techniques used with poly-l-lactic acid to safely and effectively address changes observed in the aging face. Several important points deserve mention. First, this unique agent is not a filler but a stimulator of the host's own collagen, which then acts to volumize tissue in a gradual, progressive, and predictable manner.

Appropriate selection and application of nonsurgical facial rejuvenation agents and procedures: panel consensus recommendations.

As injectable products have been introduced and as clinicians have gained experience with them, applications and techniques for injection have evolved, with better cosmetic results, enhanced patient safety, and greatly improved patient satisfaction. Within the past four years, several consensus recommendation panels have been convened to summarize the accumulated clinical experience and knowledge about the application of these products. The guidelines that already exist in the literature are referred to, and suggested guidelines for the administration of poly-L-lactic acid-for which no consensus guidelines have previously been published-are included in this article.

Nonsurgical modalities to treat the aging face.

Injectable shaping agents include neurotoxins (botulinum toxin type A products), replacement fillers (hyaluronic acid [HA] agents), and biostimulatory fillers (calcium hydroxylapatite [CaHA], polymethylmethacrylate [PMMA], and poly-L-lactic acid [PLLA]). This article presents an overview of the agents currently available for use in facial rejuvenation in the United States.

Surgical versus nonsurgical rejuvenation.

The number of cosmetic procedures for facial rejuvenation has increased steadily over the past decade. The increase in the application of nonsurgical modalities, particularly injectable shaping agents, has been remarkable. As knowledge and experience about facial aging has increased, techniques and tools have improved, and it is increasingly apparent that surgical and nonsurgical/injectable modalities are complementary.

Facial aesthetic analysis.

Consideration of the individual patient's appearance based on systematic mapping and a three-dimensional evaluation of the four levels of facial structure (bone, muscle, fat, and skin) will help the clinician choose the most appropriate modalities for facial rejuvenation. This article addresses these concepts and also discusses universal perceptions of attractiveness.

Update on facial aging.

Facial aging was once thought to be the result of the relentless downward pull of gravity on skin and underlying fat. In turn, facial fat was believed to be a contiguous sheet of tissue. However, over the past four decades, a number of investigators have examined more closely the causes of facial aging, leading to a better understanding of age-related changes, and have confirmed and further explored the proposal by Gonzalez-Ulloa and Flores in 1965 that facial aging involves changes in muscle and bone, as well as skin and fat.

Using poly-L-lactic acid (PLLA) to mimic volume in multiple tissue layers.

Sculptra (Sanofi-Aventis, Bridgewater, NJ) was approved by the U.S. Food Drug Administration (FDA) for use in HIV-related lipoatrophy in 2004 and received FDA approval for cosmetic use as Sculptra Aesthetic in July 2009.

Dermatological implications of skeletal aging: a focus on supraperiosteal volumization for perioral rejuvenation.

It is becoming widely accepted that volume changes in the skin and soft tissue contribute greatly to age-related facial reshaping. A significant contribution to these volume changes is the loss of craniofacial skeletal support to the overlying soft tissue. Gravity, once considered the major culprit in facial aging, is now recognized to determine the direction, rather than the extent, of tissue deflation.

Soft-tissue augmentation and the role of poly-L-lactic acid.

Background: Facial rejuvenation has traditionally centered on the correction of ptosis, lines, and wrinkles, typically achieved by surgical tightening of the skin or by injecting soft-tissue fillers. In recent years, volumetric augmentation and recontouring have been recognized as fundamentally important aspects of facial rejuvenation.

Methods: An overview of volume restoration and recontouring is presented.

Full scope of effect of facial lipoatrophy: a framework of disease understanding.

Background: Facial lipoatrophy has been observed to occur in a variety of patient populations, with inherited or acquired disease, or even in aging patients as a natural progression of tissue change over time. There is currently no framework from which physicians of all medical specialties can communally discuss the manifestations, diagnoses, and management of facial lipoatrophy.

Objective: The aim of this assembly was to derive a definition of facial lipoatrophy capable of being applied to all patient populations and develop an accompanying grading system.

Facial volumetric correction with injectable poly-L-lactic acid.

Background: Polymers of lactic acid'have been widely used for many years in different types of medical devices, such as resorbable sutures, intrabone implants, and soft tissue implants. Injectable poly-L-lactic acid (PLLA; Sculptra), a synthetic, biodegradable polymer, has gained widespread popularity in Europe for the treatment of facial changes associated with aging.

Objective: To provide background information on injectable PLLA and to describe clinical experience with its use in Europe for facial volume enhancement.

Facial enhancement and the European experience with Sculptra (poly-l-lactic acid).

The primary reason patients seek aesthetic treatments is to combat the signs of aging. However, the majority of facial treatments and procedures fill specific wrinkles or pull-taught sagging skin, without returning the volume and contours of a youthful face. Injectable poly-L-lactic acid (Sculptra) is a synthetic, biodegradable polymer, popular in Europe for the correction of lipoatrophy.