When it comes to aesthetic medicine, some fads have come and gone, but certain treatments continue to stand the test of time as aesthetic practice bedrocks. For San Diego dermatologist Melanie Palm, MD, Sculptra Aesthetic (poly-l-lactic acid (PLLA), Galderma) is one of those foundational treatments. “It is not difficult to do with proper training,” she says. “It becomes a real favorite and still differentiates aesthetic practices from others in the area.”
Douglas Mest, MD, who specializes in aesthetic medicine in Hermosa Beach, CA, says he is pleased to see that Sculptra Aesthetic has “now come into its own.” He participated in pioneering studies for injectable PLLA and has been using it in practice since it first came to market. “We’re much more knowledgeable about how Sculptra Aesthetic works, the correct dilution, how to stay out of trouble by avoiding injection into concentric muscles,” Dr. Mest asserts. “It’s almost like it’s a new product that we’re discovering, and it’s been great to see. Those of us that use a lot of Sculptra Aesthetic in practice just love the results.”
Getting Familiar with a Unique Biostimulator
Sculptra Aesthetic is a unique injectable biostimulator, different from the injectable fillers and neuromodulators that are so well known. As such, when the product first came to market, physicians and patients required education about the product, its application, and its clinical benefits. Lack of familiarity with the product may have delayed uptake among physicians, suggests Ft. Lauderdale-based dermatologist Shino Bay Aguilera, DO. He admits he was hesitant to adopt Sculptra Aesthetic. “I was one of those people who didn’t want to use it. It is a great technology, but the problem was that there was not much consensus around technique and optimal application,” he says. “Now, everybody wants to know about it, because people finally see that the product has its place in the aesthetic market. It provides something that’s completely different when you compare all the aesthetic injectables.”
“Those of us that have fallen in love and have really enjoyed the benefits of Sculptra Aesthetic in our patients have seen that it benefits a wide breadth of patients,” observes Dr. Palm. She says that Sculptra Aesthetic is often her top choice for filler-naive patients in their thirties—the ones who say, “I just don’t look like my old face. I look a little tired.”
Jason Bloom, MD, a facial plastic surgeon in suburban Philadelphia, also finds that Sculptra Aesthetic can be used for a wide variety of patients. In younger patients, Sculptra Aesthetic can enhance a patient’s existing volume. “They don’t want some gel in the face that’s going to be too obvious,” he says. “They just want to stimulate their own collagen and look better.”
For middle-aged patients who have begun to experience more notable volume loss, Sculptra Aesthetic can be beneficial and may offer advantages over HA fillers, including a longer duration of effect. “Another kind of patient I’ll use Sculptra Aesthetic for is someone who’s very volume depleted who might be a candidate for fat grafting but for whom grafting isn’t feasible,” Dr. Bloom offers. “Sculptra Aesthetic will help stimulate collagen and produce volumization over time.”1,2
Sculptra Aesthetic contains consistently sized (40-63microns) microparticles of poly-l-lactic acid that are shown to induce a controlled inflammatory response.3 The consistent size of the PLLA particles is important, Dr. Palm notes. “The particular particle size avoids phagocytosis. So it’s a very controlled, minimally inflammatory response that predictably produces collagen stimulation over a period of months,” she explains.3 Biopsy data show that by three months post-injection, fibrous capsules form, indicating collagen stimulation.4 At six months, PLLA degradation is underway and new Type 1 collagen is seen.
“Sculptra Aesthetic is natural in its production of collagen and natural in its own breakdown,” Dr. Mest notes, adding that lactic acid monomers, byproducts of PLLA breakdown, occur naturally in the body.
Optimal results with Sculptra Aesthetic depend on the injector understanding proper product placement and degree of correction. Sculptra Aesthetic is provided as a powder that is reconstituted with sterile water by the injector prior to placement. The water provides a temporary volume enhancement at the time of placement that subsides over a few days. Sculptra Aesthetic should be placed in indicated areas only.1
“For practitioners looking to do it, there’s definitely a learning curve with Sculptra Aesthetic because of the delayed mechanism of action. There’s usually an ‘A-ha’ moment where the light bulb goes off and people ‘get it,’” Dr. Mest suggests. “Experience is essential to become comfortable with it. And then that’s when it becomes really fun.”
Experts continue to explore new ways of administering Sculptra Aesthetic, Dr. Palm notes.
The Patient Perspective
Generally, patients in the US are more familiar with neuromodulators and hyaluronic acid fillers; neuromodulators lead among injectable aesthetics. “Very few people want to look ‘overdone.’ That is a major fear in a lot of patients. And I think that’s one reason why, in the States, more people do neuromodulators than they do fillers,” Dr. Mest says. Sculptra provides natural looking results with minimal risk for being “overdone,” he adds. “For men specifically, I think this is a tremendous product, because I don’t think men really ever want to look ‘done’ or ‘overdone.’”
Prior to injection with Sculptra Aesthetic, patients must understand that the cosmetic enhancement will be gradual.1 This will avoid any disappointment or dissatisfaction. The experts agree that patients will see long-term volumization by around three months and that improvement will continue for up to a year. Results may be maintained up to two years after the last injection session. The clinical trials of Sculptra Aesthetic followed patients out to 25 months.5
“We set appropriate expectations that even though patients are getting this temporary structural improvement because of the water fill effect, that’s going to go away in a couple of days,” Dr. Palm says. “But it’s a bit of a preview of the direction that we’re headed over a period of months with a series of treatments with Sculptra Aesthetic.”
Sculptra Aesthetic’s specific mechanism of action and indications mean that there are opportunities for patients to also receive other injectable treatments. For example, says Dr. Bloom, “People who want lip augmentation or neuromodulators come back for those treatments, as well. But Sculptra Aesthetic is providing that overall volume that they need.”
Dr. Mest concurs. “It’s not like Sculptra Aesthetic is the only thing to do. There are people that, because they have an event coming up or some other need, request an immediate-acting product. Sometimes you do an immediate product in one area and a gradual product in another area,” he suggests. “It’s all about the anatomy and the balance.”
Dr. Aguilera points out that a product that has been on the market for many years may also have a lot of coverage on the Internet. He urges peers to educate patients about assessing reliable Internet sources and to proactively address myths and facts about treatment. Emphasize that the use of Sculptra Aesthetic has evolved, and the product is used safely and effectively for patients around the globe.
Dr. Aguilera also emphasizes the need to educate patients about the aging process. Few patients understand the anatomical and structural changes that occur with age. Without this knowledge, they can’t appreciate how Sculptra Aesthetic works. To aid this education in his practice, he has developed educational videos he uses in his clinic to educate patients.
Training
With Sculptra Aesthetic's unique mechanism of action, history of safe use, and long-lasting aesthetic effects, what would prevent a physician from offering it in practice? A lack of training, say the experts. And they have advice to overcome this obstacle.
Galderma offers training for physicians interested in bringing Sculptra Aesthetic into their practice. Opportunities include on-demand programs, as well as training and evaluation tools for qualified providers. But for best outcomes, physicians should expand beyond these offerings.
“My best recommendation is to seek out CME companies that provide training with biostimulators,” Dr. Aguilera asserts. In CME trainings, doctors can demonstrate injection techniques and share valuable real-world tips, he says. Dr. Aguilera offers live Master Classes in his practice.
Dr. Bloom recommends relying on feedback from trusted and experienced peers. “When I buy a new device who do I call? I get some guidance from the rep. But I get most of my advice for anything that I have in my office from colleagues, by asking, ‘What are you doing? What are your settings? How are you doing this? How has this worked in your office?’” he says. “I seek out the advice of colleagues who have offices and practices like mine whenever I bring a new anything into my office.”
1. Sculptra Aesthetic injectable poly-L-lactic acid. Instructions for Use. Galderma Laboratories. July 2016.
2. Goldberg D, Guana A, Volk A, Daro-Kaftan E. Single-arm study for the characterization of human tissue response to injectable poly-L-lactic acid. Dermatol Surg. 2013 Jun;39(6):915-22.
3. Vleggaar D, Fitzgerald R. Dermatological implications of skeletal aging: a focus on supraperiosteal voluminization for perioral rejuvenation. J Drugs Dermatol. 2008;7(3):209-220.
4. Stein P, Vitavska O, Kind P, Hoppe W, Wieczorek H, Schürer NY. The biological basis for poly-L-lactic acid-induced augmentation. J Dermatol Sci. 2015 Apr;78(1):26-33.
5. Brown SA, Rohrich RJ, Baumann L, et al. Subject global evaluation and subject satisfaction using injectable poly-L-lactic acid versus human collagen for the correction of nasolabial fold wrinkles. Plast Reconstr Surg. 2011;127(4):1684–1692.
