Thursday, July 28, 2016
Sculptra: Beyond the face
Sculptra Aesthetic (injectable poly-L-lactic acid [PLLA], Galderma) is gaining traction in off-the-face treatments, some say. But is the practice to use PLLA for the body in patients’ best interests? Surgeons on both sides weigh in.
Some surgeons tell Cosmetic Surgery Times that this PLLA-based treatment, which has been shown to last more than two years when used to reduce facial wrinkles and folds, can also be used, off label, to diminish cellulite, emphasize muscle definition and even treat plantar foot atrophy.
New York City-based cosmetic surgeon Joseph Eviatar, M.D., uses Sculptra in men to create fuller and shapelier calves, pecks, butts and biceps. Final results from body sculpting with Sculptra take about three months, but outcomes are stellar and patients don’t need implants, he says.
“… the option of an implant can be scary, as they can harden over time, cause discomfort and often look drastic and unnatural. Sculptra appears to be a safe option providing natural results with minimal downtime,” Dr. Eviatar says.
Another off-label use of Sculptra that works, according to Dr. Eviatar, is to treat cellulite in the butt and thighs.
“We use the same concentration (8 cc sterile water, plus 1 cc lidocaine added to product) as we would in the face, but we need about six vials of product, whereas, with the face we use about two to three vials,” Dr. Eviatar says. “We inject the Sculptra at the deep dermis level to fill in the divots. We do not inject into the fat or near the bone, as you would with the face. The needle fanning technique creates damage to the top dermis layer and allows for a healing response, which also stimulates collagen production, making cellulite appear less obvious.”
Patients being treated for cellulite on the buttocks or thighs generally need about three treatments, spaced three weeks apart. The Sculptra continues to work three to four months after the last treatment and results are permanent with cellulite, according to Dr. Eviatar.
Sculptra for Biceps & Breasts
“In regard to biceps and upper chest (in men), Sculptra seems to be a homerun,” he says.
Ideal patients for that indication are those who have little definition and want to accentuate the areas a little more, according to the cosmetic surgeon.
“We inject Sculptra just under the surface of the skin to make the area ‘pop.’ We use about one vial of product and perform two to three treatments,” Dr. Eviatar says.
Dr. Eviatar has used Sculptra and is conducting studies on Sculptra’s use for treating the décolletage, upper breast area and buttocks.
“In general, injecting Sculptra in the body doesn’t require a large amount of time. Though the surface area is larger, it takes less or the same amount of time as injecting Sculptra in the face. We generally charge the same amount of money that the face would cost, yet we are using double the product,” Dr. Eviatar says.
Ideal candidates for body Sculptra treatments are people 40 to 60 years of age, who are in pretty good shape and just have problem areas, according to the cosmetic surgeon.
Dr. Eviatar says he has not seen any complications using Sculptra for these indications. Surgeons using the approach should let patients know to expect some bruising at the site, as with any injectable.
“It is important that the dilution of the product is correct,” Dr. Eviatar says. “We find that less dilution can cause some lumps, so the 8 cc to 9 cc of sterile water appears to be optimal. Also, physicians must inject the correct layer of skin for different body parts. An example with cellulite: If Sculptra is injected into the fat layer, the outcome will not be very good.”
Charleston, SC-based facial plastic surgeon David W. Rodwell, III, M.D., says he prefers to focus on his area of anatomic expertise, so the only area outside of the face that he treats with Sculptra is the upper chest, or décolletage.
“I do not perform injections elsewhere, such as the hands or thighs/buttocks. However, there is some promising buzz in our community about transitioning Sculptra into use for areas of cellulite,” Dr. Rodwell says. “The upper chest is a perfect area for Sculptra and responds quite well with great patient satisfaction.”
Dr. Rodwell emphasizes dilution, as well.
“A few pearls for using Sculptra in this area are to use a more dilute solution, consider cannulas and combine with other treatment modalities,” Dr. Rodwell says. “My typical Sculptra dilution is 8 cc to 9 cc when used in the face, but for the décolleté area I prefer a 12 cc dilution for a more even distribution to a broad area. Although the skin is delicate in this area, it is still relatively thick and can be slow to show improvement, so a series of two to three Sculptra treatments spaced six weeks apart seems to be ideal for most patients.”
Dr. Rodwell says he achieves best results when he combines Sculptra with a series of moderately intense fractionated CO2 laser treatments. The combination approach results in even more collagen production to reverse the skin aging and sun damage in the upper chest.
Sculptra for Hands & Feet
New York City-based cosmetic dermatologist and dermatologic surgeon Ariel Ostad, M.D., tells Cosmetic Surgery Times that many people don’t know that Sculptra can be used to effectively treat plantar foot atrophy.
“It fills the flattened area and provides internal cushioning in the feet, creating padding between the skin and bones of the foot. This cushioning can prevent calluses from repetitive pressure,” Dr. Ostad says. “We have successfully used it on the bottoms of the feet to alleviate pain and pressure from standing, wearing high heels and running. We use it frequently on patients who run, in order to prevent Achilles tendinitis, runners’ knee and shin splints.”
Dr. Ostad says Sculptra can also be used on the hands. In appropriate candidates, he dilutes Sculptra in 7 cc of saline with 2 cc of lidocaine 1%. After injecting those patients, he says, it’s good to massage the area to avoid granuloma formation.
Sculptra for the Face Only
But not everyone is a fan of using Sculptra off the face. In fact, Miami, Fla.-based plastic surgeon Jacob Freiman, M.D., says he feels strongly that Sculptra should not be used anywhere but the face.
“I believe the reason Sculptra has not been approved for other parts of the body is because it doesn't make sense,” Dr. Freiman says.
Dr. Freiman says that since Sculptra must be injected deep, surgeons would need massive amounts to see even the slightest difference. The massive injection would result in poor blood supply and may ultimately cause a seroma. If surgeons inject Sculptra on body area too close to the skin, small nodules will result. And the cost is prohibitive, he says.
“Consider that it could take over 1000 ccs of fat to perform the proverbial Brazilian Butt Lift,” Dr. Freiman says. “A similar amount of Sculptra would cost over a million dollars for only a temporary effect. Currently, I do not know of any board-certified plastic surgeons performing body Sculptra.”
Disclosures: Drs. Freiman, Ostad, Rodwell and Eviatar report no relevant disclosures. Dr. Eviatar's research is self-funded.