MAUI, HAWAII Snapping a set of before and after photos at an unconventional 22.5-degree angle in addition to the standard anteroposterior, lateral, and oblique shots often makes it easier for patients to recognize the improvement they have gained with poly-L-lactic acid injections, according to one expert.
"The mechanism of action with PLLA [Sculptra] is so delayed that patients forget what they looked like. A set of photos taken at a less acute 22.5-degree angle shows the convexity of the malar eminence better. You notice the baseline volume loss much more," Dr. Douglas R. Mest explained at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
Facial volume loss averages 1 teaspoon per year after age 40. It's due to a combination of facial fat loss and redistribution, bone resorption, facial muscle atrophy, and dermal thinning. This volume deficit is a three-dimensional cosmetic problem, and PLLAa pure biostimulantis the best treatment for it yet, according to Dr. Mest, an anesthesiologist specializing in cosmetic dermatology in Manhattan Beach, Calif., and the chief investigator in the phase III trial that won approval of PLLA for the treatment of HIV-related facial lipoatrophy.
In addition to recommending shooting those 22.5-degree before and after photos, Dr. Mest shared other tips in getting the most out of PLLA:
▸ Start with the standard treatment areas. PLLA is quite unlike other facial fillers, and there is a definite learning curve in its use. The cheeks are the easiest area in which to achieve volume replacement. Other standard areas are the nasolabial folds, submental area and jawline, and marionette lines.
"What we've learned about staying out of trouble is that there are areas that are very easy to treat with biostimulating products, including calcium hydroxyapatite [Radiesse] and PLLA, and if you're starting out, that's where to start," he said.
Advanced treatment areas are those where treatment-induced lumps or bumps are more apt to show, either due to thin skin or because active muscle groups sweep up the product and make it more visible. The upper lip, temples, hands, and neck fall into this category.
▸ Delay treatment. The product labeling says to wait at least 4 weeks between PLLA treatments. Dr. Mest said he now routinely waits at least 6 weeks. That's because collagen synthesis doesn't really get underway until 2-3 weeks after treatment.
"Sometimes when you treat at 4 weeks, patients will not necessarily have seen the improvement. I think if you wait another 2 weeks you'll see it," he explained.
Some experienced physicians now wait 3 months between PLLA treatments, but "I find 6 weeks is a nice compromise," Dr. Mest added.
▸ Treat the whole face, not individual lines. "Patients often come in asking for treatment of certain lines or wrinkles, when what they really need is treatment of the underlying region with a deep revolumizing agent. The example I use with patients is instead of treating each line on the raisin to make it a grape, we add volume back to the raisin to make it a grape," he said.
▸ Tackle the temple hollows. This reproportions the face, restoring the triangle of youth and making for a less severe look, but is best taken on after gaining skill with PLLA.
"Patients seldom come in asking for treatment of temple hollowing, but once you see it done you start noticing how many people need it," according to Dr. Mest.
He disclosed that he is a consultant to Dermik Laboratories Inc. and a physician trainer for BioForm Medical Inc.
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The pretreatment photo at left was taken at a 45-degee angle. In the photo at right, taken at a 22.5-degree angle, the area needing treatment is more obvious. Photos courtesy Dr. Douglas Mest
