MAUI, HAWAII A key to minimizing the risk of bump and nodule formation when injecting poly-L-lactic acid is uniform product distribution by lengthening the dilution time, according to Dr. Douglas Mest.
"I will not inject PLLA if it hasn't been hydrated at least overnight. Longer is even better. The product insert allows for up to 72 hours hydration in sterile water; if you use bacteriostatic sterile water I think it's fine to keep it longer. Most experts keep it around for up to 3 weeks," Dr. Mest said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
The hydrated product can be kept in the refrigerator but should be brought to room temperature before injection. It should not be heated because that can damage the microscopic PLLA particles, according to Dr. Mest of the Blue Pacific Aesthetic Medical Group, El Segundo, Calif.
Other tips he offered to avoid papules and nodules with PLLA (Sculptra) include:
▸ Adjust dilution volume to fit the clinical situation. Small dilution volumes can lead to nonhomogeneous distributionand increased likelihood of nodules.
"The product insert says use 3-5 mL because that's how the original studies were done. But I've learned with this product that to have a more robust response, as in an on-label patient [with HIV-related facial lipoatrophy], I'll increase the total diluent to 6 mL per vial," he said.
▸ Use the appropriate gauge needle. Dr. Mest's analysis of the published literature suggests that adverse event rates are similar with 25- and 26-gauge needles. Using a smaller-gauge needle than 25 is not recommended, he said.
▸ Supraperiosteal placement is best. "This way you're only going to have volume go outward, so if you have any problems you're not going to feel them. Personally in the midface I'll do a supraperiosteal placement, then a more superficial placement, staying out of any active muscle areas," he explained.
▸ Don't overcorrect. PLLA is a pure biostimulant. The improvement may not be evident for 4-6 weeks or longer.
▸ Don't superficially place. "You should not see your needle when you're doing this. It's not a dermal product," he noted.
▸ Treat nodules conservatively. In a clinical trial led by Dr. Mest, 12 of 13 nodules that occurred resolved spontaneously during 36 months of follow-up. "I don't recommend aggressively treating the nodules and papules with high-dose steroids," said Dr. Mest, who serves as a consultant to Dermik Laboratories, which markets Sculptra.
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