Poly-L-lactic acid: consultation on the injection techniques.

OBJECTIVES When poly-L-lactic acid (PLLA) was first introduced (marketed as New-Fill), incorrect injection technique was largely responsible for the manifestation of device-related adverse events in the form of subcutaneous papules and areas of induration. Now marketed as Sculptra, widespread clinical experience with injectable PLLA has resulted in a wealth of information on product reconstitution and correct injection technique. The injection techniques for the optimal use of injectable PLLA are detailed here. RESULTS When injecting PLLA it is important to adhere to the product guidelines in terms of injection volume, depth and placement. As the material provides a gradual restoration of volume, PLLA should be injected conservatively, avoiding the possibility of overcorrection. Injections should be sufficiently deep to avoid areas of induration in the superficial layers of the dermis. Areas above hypermobile muscles should also be avoided to prevent localized coalescence of injected material. While utilization of a specific injection technique depends on the position and severity of the volume deficiency, all injections use a 26-gauge needle and are separated by 0.5-1.0 cm. In the lower face a 'criss-cross' and 'tunnelling' technique should be employed, depositing the material into the deep dermis at the junction with the hypodermis, followed by massage every 3-4 injections. Massage should be continued by the patient for at least a week following the treatment session. The 'criss-cross' and 'tunnelling' procedures involve the deposition of 0.1-0.2 mL of PLLA per injection. Material injected into the temple area should be deposited deep next to the bone with a 'depot' technique. Injections around the orbits or perioral region are possible, but should not be attempted without sufficient training. CONCLUSION Adhering to the correct injection technique enables the physician to provide durable, natural-looking volume restoration with a very low incidence of device-related adverse events.