What is beauty and what facial features creates a beautiful face? A youthful and attractive face has proportions which follow a ratio of 1.61 in various dimensions. At Orion Aesthetics, which is the best cosmetic dermatology clinic in greater Sacramento, Rocklin, Roseville area, we use the golden ratio to create beautiful faces. An aged face, by contrast, moves away from desirable proportions and demonstrates more topographical irregularities and harsher transitions between facial boundaries. Facial aging is a complex and dynamic alteration of balance and proportion characterized by a myriad of features involving the bone, ligaments, fat, and skin that ultimately lead to volume loss and redistribution. The lower face widens as the jowls form and shortens as bone is remodeled in the maxilla and mandible. The orbital diameter increases and the maxillary height decreases. As bone resorbs, it leads to a smaller platform for the overlying soft tissues and causes the whole soft tissue structure overlying the bone scaffold, to fall down with gravity and fold on itself causing wrinkles. “folding in” of these tissues known as the concertina effect. Elongation of the nasal tip and loss of a definitive jawline reflect the forward movement and resorption of the maxilla and mandible. In the midface, redistribution, accumulation, and atrophy of fat lead to volume loss. Areas such as the forehead and cheeks lose fat while the mouth and jaw accumulate fat.

Fillers are of 2 main types, space-occupying fillers and collagen inducing fillers (bio stimulatory agents). Space occupying fillers or direct filling agents are made of Hyaluronic Acid and these are used to correct the volume. HA fillers act as inert volumizing agents. The biostimulatory agents induce collagen production. Though HA fillers have been shown to stimulate a comparatively small degree of collagen deposition, their efficacy is based upon their ability to directly fill soft tissue, not collagen stimulation. More volume can be obtained by using more HA fillers at any one session with this direct filling agent. In contrast, Calcium Hydroxyappatite (CaHA), Poly lactic acid (PLLA), and polymethylmethcrylate (PMMA) are known to act through the stimulation of collagen. As PLLA depends exclusively on the host response to the product, rather than a direct fill, the amount of product used at any one session is determined by the surface area to be treated at that session, while the final volumetric correction is determined by the number of treatment sessions. These treatment sessions are spaced 4 to 6 weeks apart to allow time for the host response to develop between sessions.

CaHa and PLLA are durable, but ultimately biodegradable, products. The microparticles in CaHA injections are more readily degraded than those in PLLA, lasting for up to 12 to 18 months. PLLA is the most durable of all currently FDA-approved biodegradable products, with results from studies used to garner initial FDA approval showing full correction still present in 80% of subjects at 24 months. Unlike CaHa and PLLA microparticles, PMMA is not biodegradable, making it theoretically permanent.

Injectable poly‐l‐lactic acid (PLLA) is a semipermanent filler that was initially approved in 2004 for use in patients with facial lipoatrophy associated with human immunodeficiency virus. In 2009 it was approved for cosmetic use for contour deformities in the skin such as lines,wrinkles, and acne scars. Sculptra is a lyophilized powder of synthetic l‐polymers of polylactic acid, sodium carboxymethylcellulose, and mannitol that is reconstituted with sterile water to create a 4.5% suspension of PLLA microspheres in 2.7% methylcellulose.

PLLA is a synthetic polymer of lactic acid derived from the alpha-hydroxy-acid family, biocompatible and biodegradable that has been used in medicine for more than three decades. The diameter of the microparticles is tightly controlled, measuring 40 μm to 63 μm on average. The product is considered a deep tissue regenerator.

PLLA comes to a powder in a vial and it’s reconstituted with sterile saline to produce 8-10mls of the final product for the face and 20mls for the body. Its injected in a crosshatch method in deep subcutaneous tissues.

Recommendations on the preparation and storage of PLLA focus on ensuring complete and homogenous dispersion and hydration of PLLA in sterile water for injection (SWFI) or bacteriostatic water, in a volume that facilitates injection Reconstitution/Dilution Prior to reconstitution, tap the vial to ensure there is no powder sticking to the top of the vial or rubber stopper. Use an antiseptic to clean the rubber stopper. Add 8ml to 10 mL SWFI or bacteriostatic water slowly to the powder.

Dilution in this volume range leads to:

  • Even PLLA distribution.
  • Easier injection, with reduced risk of needle blockage.
  • Decreased incidence of papules and nodules

Hydration

Hydrate at room temperature for ≥24 hours. Adequate powder hydration allows the avoidance of injecting dry PLLA microclumps, which will hydrate in vivo and potentially lead to formation of nodules.

A uniform distribution of product should be ensured for each treated region (ie, coat the region); injection should not vary by particular focal areas or based on specific cosmetic deficits. The final volumetric correction is determined by the number of treatment sessions. Treatment can continue until the patient is satisfied with the results. For clients with significant volume loss, Dr Uppal likes to use 1 vial each side for the first session, wait for 6 weeks and do another 1 vial each side and then wait for 5 months before doing another round of 1 vial each side.

Most experts find 3–5 sessions to be optimal. Younger or fuller faces need less product and fewer sessions. An interval of at least 4 weeks between sessions is recommended. We at Orion Aesthetics have found that most of our clients consider Dr Uppal to provide the best Sculptra filler treatment in Sacramento. Subsequent courses of treatment typically occur 2 years after the initial course. During these courses, less PLLA per session, and a fewer number of sessions, are generally required. In Dr Uppal’s experience, you will need a touch up of 1 vial each side every 2-3 years. No other filler is needed unless you need filler in lips. Some patients prefer once-a-year, single-session maintenance treatments to keep pace with the aging process.

Sculptra is Dr Uppal’s favorite volumizing filler for cheeks, zygoma, temples, and any part of body including hands, feet, legs, arms, abdomen, chest, where there is loose skin. According to Dr Uppal, Sculptra is the most economical filler because it produces more volume and lasts longer than any other filler in the market. Dr Uppal, the best cosmetic dermatologist in Sacrameto, Rocklin, Roseville and Lincoln areas. He has produced the best results in cheek lifts and faces which need a facelift but the client refuses surgical facelift.

Though an increase in volume may be visible in the patient’s face immediately following injection, this is due to mechanical distention from the suspension of the microparticles and resolves within several hours to a few days. The degree of distention may be used as an approximation of how the patient will appear following ~3 treatments, allowing for a prediction of the number of treatments that will be required to achieve the desired results. Within 3 weeks, the microparticles are encapsulated, and at 1 month the PLLA microparticles are surrounded by mast cells, mononuclear macrophages, foreign body cells, and lymphocytes. At this time, an increase in the number of collagen fibers is also apparent. The inflammatory response lasts 6 months. Significant increases in type I collagen are observed around the periphery of the PLLA encapsulation up to between 8 and 24 months post-injection, as collagen production continues, and more recent work has demonstrated the presence of type III collagen adjacent to the PLLA particle. The PLLA microparticles last in the tissues for 9-12 months. At 1, 1, 3, and 6 months there is 6%, 32%, and 58% reduction in PLLA microparticles respectively, and are metabolized by the same metabolic pathway as lactic acid.

PLLA is injected into the reticular dermis or subcutaneous fat by a fanning, cross-hatching grid, or depot technique. Following injection, the areas are massaged for several days to evenly disperse the product, as particles will remain in this area and degrade over years. Although the implant creates immediate temporary space-occupying effects, the long-term restoration of tissue volume occurs through a controlled inflammatory process that stimulates fibroblasts and other cells to lay down a matrix of collagen and elastic fibers, as PLLA is gradually degraded over 8–30 months. This process provides progressive volume correction after the carrier solution is absorbed, for effects that last 24 months or longer.

After injection, implants are palpable for the first 3 months. Moderate inflammation can be seen, and the microspheres are surrounded by a fine capsule, macro- phages, and some lymphocytes. By 4 months, the implants should no longer be clinically detectable. After 6 months, most microspheres are porous, fissured, or deformed and a secondary stronger inflammatory phase occurs, evidenced by the presence of macrophages and many foreign body giant cells. This inflammatory reaction is stimulated by the remaining crystals of PLLA, which is an eosinophilic material that is polarizable and has a fusiform or spiky shape, present in both the extra- cellular matrix and within giant cells. It elicits resorption and formation of fibrous connective tissue around the foreign body, causing dermal fibroplasia, leading to the clinical volumizing effect. The volume restoration process occurs gradually over 3–6 months, and dermal thickness increases over time. Between 8 and 30 months, PLLA is slowly degraded into lactic acid microspheres by hydration, loss of cohesion and molecular weight, and solubilization and phagocytosis of PLLA by the host’s macrophages. After 9 months, the PLLA microspheres are completely degraded, and there is no remnant fibrosis. The newly formed collagen remains and results in cosmetic augmentation that lasts at least 24 months.

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