NAPLES, FLA. Proper technique is paramount to optimize outcome and avoid complications with either calcium hydroxyapatite or poly-L-lactic acid fillers, according to a presentation at a Dermatology Foundation-sponsored symposium.
Infiltration of local anesthesia, needle size, injection technique, multiple treatment sessions, and tips to avoid complications are among clinical pearls for optimal use of calcium hydroxyapatite (Radiesse, BioForm Medical) and poly-L-lactic acid (Sculptra, Sanofi-Aventis).
"Radiesse is for structure and support and Sculptra is for diffuse volume," said Dr. Ken K. Lee, director of dermatologic surgery at Oregon Health and Science University in Portland. The two fillers are not mutually exclusive, he added. "I use these two together all the time."
Focal treatment is the goal with these fillers, Dr. Lee said. "There is a paradigm shift from filling to contouring. Contouring really was only available before with fat transfer." The gauge of needles typically used to inject calcium hydroxyapatite (27G) or poly-L-lactic acid (25G or 26G) can hurt, Dr. Lee said. He recommended local infiltration with lidocaine with epinephrine prior to injection to reduce pain and bruising. Dr. Lee does not have a disclosure regarding either filler product.
The goal with calcium hydroxyapatite is not to fill in fine lines, but to give more structure, Dr. Lee explained. The synthetic particles form scaffolding for tissue in-growth. "It is off label for cosmetic useI do tell patients that."
Radiesse is packaged in 1.3-cc and 0.3-cc syringes. Inject into "deep dermis and a little bit into subcutaneous fat," Dr. Lee said. He recommended a threading and fanning technique, injecting only a small amount at each pass, such as 0.05 cc. Stop injection before exiting the skin and knead or mold any firm nodules after injection, he suggested.
"I don't just thread the material along the nasolabial line, I also crisscross to enhance the volume effect," Dr. Lee said. "This stuff is really thick and hard to get out of the needle, which is good. You don't want a lot of material in any one area."
Dr. Lee informs patients in advance that if they have prominent nasolabial lines or marionette lines they will likely need three syringes over two treatment sessions. "Then it doesn't look like you've failed them."
Volume from a single injection typically lasts about 9 months, Dr. Lee said. The double session strategy extends duration of effect to 1 year or longer. "Somehow getting it to last up to a year is much more appealing to patients. The downside is that complications last a long time, too."
Avoid filling thin eyelids and lips with calcium hydroxyapatite, Dr. Lee advised. Deposits can be seen in these areas. Dr. Lee said, "I really recommend collagen or hyaluronic acid for lips."
Poly-L-lactic acid, similar to calcium hydroxyapatite, is injected into the deep dermis or subcutaneous layer. Do not inject this filler superficially, Dr. Lee cautioned. "I aim for the subcutaneous layer. It is more difficult to consistently place in deep dermis and there are more complications." Inject a small amount on withdrawal.
Poly-L-lactic acid is a synthetic, biodegradable, biocompatible polymer that stimulates a patient's own collagen. Dr. Lee reconstitutes the filler with sterile water and 2% lidocaine. It is stable up to 72 hours after reconstitution. The vial is stored at room temperature but should be warmed prior to use, Dr. Lee suggested. "I have the patient hold the vial prior to injection. It helps to avoid clogging of the needle."
Massaging right after injections is very important, Dr. Lee said. "I tell patients to massage five times a day for 5 minutes for 5 days for distribution of the Sculptra."
Up to six treatment sessions may be necessary for full effect. Schedule treatment sessions about 46 weeks apart, Dr. Lee suggested. Volume enhancement with poly-L-lactic acid can last 2 years or more.
Hematoma is the most commonly reported complication in studies, Dr. Lee said. Subcutaneous papules are another potential problem. "You really have to be careful," he said. "Sculptra in cosmetic patients has really shown me how much volume affects the drooping of the skin."