Patient age affects technique when sculpting with Sculptra

Las Vegas - Sculptra (Dermik) can offer a highly effective restoration of volume, but age plays an important role in how dermatologists should approach their technique of sculpting with the filler, Danny Vleggaar, M.D., says.

Dr. Vleggaar is head of dermal rejuvenation and substitution therapy, esthetic and reconstructive surgery at Clinic Vert-Pre in Geneva and spoke at the 5^th Annual Meeting and Exhibition of the American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS), here.

In assessing the aging face, Dr. Vleggaar says he keeps three key elements in mind: quality, accumulation and volume. As the skin loses collagen, elastin, fat and its ability to absorb water, the result is a loss of volume. In the aging tissues and in aging skin, there is not enough quality - or elasticity - left to adapt to this volume loss.

Effects of age

The appearance of a younger face underscores how the three components work together in aging skin: Younger patients typically will present with only one or two of the characteristics.

For instance, a younger person with significant volume loss due to HIV may not have accumulation of tissue since there is no significant loss of tissue quality.

"There can be significant volume loss, but not an accumulation of tissue or folds, and the overall quality of most tissues is still good; the bone structure and muscles are still intact," Dr. Vleggaar tells Dermatology Times.

In an older face, however, due to this quality loss from aging and consequent poorer adaptability to volume loss, the dermis is more capable of shifting and tissue can accumulate in areas such as the cheek and jawline.

Sculptra, a semi-permanent poly-L-lactic acid filler, can be suitable for both situations, offering correction of facial lipoatrophy in aging and youthful skin types by providing roundness and fullness to sagging or hallowed areas.

In an older face, Dr. Vleggaar says he searches for the area of accumulation by squeezing the tissue together and applying pressure, then releasing and observing whether the skin quickly goes back to its original shape.

Since older faces tend to droop downward, volume loss particularly affects the perioral region, which becomes the more projected accumulation zone.

In treating such patients with Sculptra, Dr. Vleggaar says he concentrates on that perioral area, beginning with the chin area to ovalize the face and pushing tissue upward to set back marionette lines.

"In my personal sculpting technique, I strongly practice shifting tissue back to its place to blend the accumulation of tissue in the face, and I look at accumulation zones as areas where tissue with higher flexibility can be moved or lifted to more rigid areas," Dr. Vleggaar says.

He also uses different techniques in the upper and lower face, with a 25-gauge, 1.5-inch needle in the preauricular area using a subcision technique with the needle; a 26-gauge, 5/8-inch needle using a serial threading technique in the mid-face; and serial depots in the upper face.

On younger faces, there is typically a more forward projection of the perioral region, even when there is volume loss elsewhere. The process is therefore simpler, involving treatment focused instead on the mid-cheek area, as there is typically no need to volumize the perioral area.

Asymmetry

One situation doctors may encounter in either young or older faces is asymmetry, and Dr. Vleggaar cites an example of a patient with more volume loss on one side of the face, but less sagging than the other side. He was able to restore symmetry by adding the filler to just one side.

Dr. Vleggaar notes that since Sculptra is indicated by the Food and Drug Administration (FDA) for HIV-related facial lipoatrophy, most manuals in the United States focus on such cases of young male patients with HIV.

However, these techniques should not necessarily be used on middle-aged patients who exhibit all three of the aging face components he mentioned.

"If those techniques were applied to an older face, the results could be inappropriate or disappointing," he explains.