Announcer:
Welcome to CME on ReachMD. This activity, entitled “PLLA: The Right Patient at the Right Time” is provided by Prova Education and is supported by an independent educational grant from Galderma.
Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the Learning Objectives.
Dr. Bloom:
Determining which patients will benefit from biostimulant injections and which will benefit from surgery is an important consideration for aesthetic clinicians, but what specific factors can help guide optimal patient selection, administration techniques, and sequencing of therapy for our patients? That will be the critical question we address today.
This is CME on ReachMD, and I’m Dr. Jason Bloom. Here to review those key factors is Dr. Melanie Palm from San Diego, California and Dr. Susan Weinkle from Bradenton, Florida. Let’s begin our discussion today by focusing on what happens to our skin as we age.
Dr. Weinkle:
Sure.
Dr. Bloom:
So, Dr. Palm, would you be able to offer us some insights here?
Dr. Palm:
Absolutely, um, you know, unfortunately, our skin ages, and so, um, I talk to patients a lot in consultation about not only how the skin changes from intrinsic and extrinsic factors but also the layers underneath. I talk to them about how muscle atrophies over time, how our fat compartments change. Most of them start to shrink, but some areas like the submentum or the intraorbital fat pad can actually increase in volume over time. There’s incredible bony absorption that happens, um, you know, in terms of changes in our jawline, changes in our maxilla, changes in our…
Dr. Weinkle:
Our orbits.
Dr. Bloom:
Right.
Dr. Weinkle:
Our orbits absorb and widen.
Dr. Bloom:
Widen, yep.
Dr. Palm:
Yeah.
Dr. Weinkle:
And that’s why we look so sunken.
Dr. Bloom:
Right.
Dr. Weinkle:
And that’s why we get that A-frame deformity, right?
Dr. Palm:
Exactly, and that all plays a role in how the visage of our face appears to others, and so in terms of the skin specifically, you know, UV radiation, um, environmental factors play a huge role but intrinsic genetic as well, and so we can rehab some of that with some of the injectables we have. So, with some of our collagen stimulators, we know from PLLA research that was done back in the HIV lipoatrophy ways, or era, that it actually increases the thickness of the dermis through the subclinical inflammation that causes neocollagenesis, and with HAs, we know from research that was actually done with NASHA product, the original Restylane, um, that it, it puts pressure on these fibroblasts, and when we stretch those fibroblasts, they’re going to build some collagen.
Dr. Weinkle:
Mmm, they get…
Dr. Palm:
So, you know, not its primary mechanism of action, but even with the HAs, we can build some collagen, and if we start to build the collagen, thicken the dermis, support some of the tissues, we see, um, correcting of those changes between cosmetic units that happens as we lose volume but also luminosity of the skin, smoothness, pore size. If we’re actually supporting the skin and we’re thickening the dermis, we start to see some of those changes as well.
Dr. Bloom:
So, let’s say, Dr. Weinkle, that you’re talking to a patient and you’re going through your thought processes, and you’re trying to determine if the patient needs a product that you can give injectably in the office.
Dr. Weinkle:
Mm-hmm.
Dr. Bloom:
Such as PLLA or poly-L-lactic acid, or if you think they need surgery to a specific area, for example – walk us through that process. What are you looking at? What are some of the things that you’re deciding?
Dr. Weinkle:
Okay, well, again, with setting expectations. If that patient thinks that two vials of PLLA is going to totally lift this 20-year sagging face, it’s not going to happen.
Dr. Bloom:
Right.
Dr. Weinkle:
Or if they’ve got so much laxity of their obicularis oculi and so much festooning, there’s just not a filler in my cupboard, and sometimes I really think, all right, is this going to be economically feasible and realistic in this patient’s budget and expectations for what my needle can do,
Dr. Bloom:
Yeah, to rejuvenate in an injectable manner, but also you’ve got to talk to the patients and say, “What is your downtime tolerance?”
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
Right, right.
Dr. Palm:
Yeah, and I think your relationship doesn’t end there because even with surgery, and we know patients, if they have a full facial rhytidectomy, they start to lose support in their lateral face.
Dr. Weinkle:
Right.
Dr. Palm:
In that area that’s been lifted.
Dr. Weinkle:
And they get atrophy.
Dr. Bloom:
Right.
Dr. Palm:
Yeah.
Dr. Weinkle:
A lot of that preauricular atrophy here, and that’s a telltale sign that needs to be addressed.
Dr. Palm:
Yeah, so knowing that there’s going to be a continuance of care, and there’s going to be some upkeep even if you choose a surgical resolution.
Dr. Bloom:
Right. So, how can biostimulant products such as poly-L-lactic acid or PLLA or different hyaluronic acid products like HAs, how does that guide your decision on which product you select for patients?
Dr. Palm:
Sure. I think for me it’s about the physical properties of the product.
Dr. Bloom:
OK.
Dr. Palm:
The timeline that I have to treat the patient.
Dr. Weinkle:
Mm-hmm, mm-hmm, it’s important.
Dr. Palm:
And also the anatomy or the area I’m trying to correct because certain fillers, certain biostimulants are better served in certain areas, and oftentimes I’ll combine the two. So, for example, with hyaluronic acid fillers, I tend to think in terms of crosslinking, the concentration, and then what’s the physical characteristics of the products as well, and, and, um, and that really guides in my using this as a deeper filler.
Dr. Weinkle:
Mm-hmm.
Dr. Palm:
With a, with a stiffer property, a high elastic modulus that I’m using to lift tissues.
Dr. Weinkle:
To lift.
Dr. Palm:
Is this something that’s maybe somewhere in between and I’m using that for, you know, some folds, a little bit of lines, you know, superficial, subcutaneous, or is this truly something that it’s a dermal issue and I’m trying to just line chase?
Dr. Bloom:
Right.
Dr. Palm:
Um, you know, poly-L-lactic acid is a much different sort of beast, and it’s not just poly-L-lactic acid that we’re talking about with biostimulators.
Dr. Bloom:
Right.
Dr. Palm:
There’s others in that class, so we do know, I mean, HA to a certain extent builds a little bit of collagen when you place it.
Dr. Bloom:
Sure.
Dr. Palm:
But there’s also, um, products such as calcium hydroxyapatite that are on the market that give a little immediate fill and build a little collagen.
Dr. Weinkle:
Mm-hmm.
Dr. Palm:
And then PMMA, which is collagen character with the polymethyl methacrylate, which I don’t personally use but can be used as collagen stimulation, and so with PLLA, we know there’s a very predictable, subclinical, inflammatory reaction. That’s not how I explain it to patients.
Dr. Bloom:
Right.
Dr. Palm:
And I, I think how I explain it to patients is, is that we’re going to use a product that comes as a powder. We’re going to mix it in a little bit of sterile water, and it’s similar to lactic acid. It gets broken down into carbon dioxide and water by our own body over a period of months, which we now know is months and months and months, and in response, our body is going to start to build collagen, and I think for many patients, it’s very appealing that their own body is producing their own filler.
Dr. Weinkle:
Because it’s natural.
Dr. Bloom:
Right.
Dr. Palm:
It’s natural, and, and I think if you’re looking for slow, gradual, but meaningful results, then considering a collagen stimulating agent might be something to add to the patient’s sort of, um, overall treatment plan. So, often I’ll use that as scaffolding, and it’s sort of my baseline, my foundation, and then I use accentuation points where, um, other fillers and injectable products are sort of better served.
Dr. Bloom:
That’s it. We’re putting it in the places where we want to increase volume or some collagen stimulation. So, now, um, what, what do you feel about that, Dr. Weinkle? Like, anything to add here?
Dr. Weinkle:
Well, first of all, I think it’s very important as we talk about expectations, I reconstitute my PLLA with 9 cc, okay?
Dr. Bloom:
I do the same.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
Now, when you put 9 cc of water in that face…
Dr. Bloom:
Sure.
Dr. Weinkle:
And they look in the mirror, and they go, “Well, I really like this,” and I say, “In three days from now, you’re not going to be loving me,” because that water, that is the carrier for this.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
It’s going to get reabsorbed.
Dr. Palm:
Mm-hmm.
Dr. Bloom:
Sure.
Dr. Weinkle:
And then you’re going to look in the mirror and say, “What did I pay for?”
Dr. Palm:
Yeah.
Dr. Bloom:
Right.
Dr. Weinkle:
But gradually over the…
Dr. Bloom:
We planted the seed.
Dr. Weinkle:
Yes. Over the next six weeks, it’s going to sprout the collagen.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
And you’re going to begin to see the improvement in texture.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
Tone, light reflection, the things we talked about. It’s very important, also, to say, “This is doable,” and I think that’s one of the exciting things. I often will treat that patient once a month or every four, four to six weeks for maybe three or four treatments.
Dr. Bloom:
So, Dr. Palm, now that we have a better understanding, really, kind of, of the differences between the poly-L-lactic acid and the different hyaluronic acid products, there are some variances in how we reconstitute and how we inject these products. Dr. Weinkle was saying she reconstitutes with 9 cc. I do the same. Tell me, what are you doing, and, also, what’s the differences in your injection technique? Are you using needles? Cannulas?
Dr. Palm:
Sure.
Dr. Weinkle:
Mm-hmm.
Dr. Palm:
You know, there was consensus guidelines which I was a part of where most of us use somewhere between 5 and 9 cc. I think many of us 8 to 10 is typically what we use for facial rejuvenation.
Dr. Weinkle:
Mm-hmm, right.
Dr. Bloom:
Yeah.
Dr. Palm:
And then we, I think we, most of us add a little bit of lidocaine into that.
Dr. Weinkle:
Plain?
Dr. Palm:
Plain or with epi. I use a little epi on certain areas, but on the face it’s usually plain.
Dr. Weinkle:
I use plain.
Dr. Palm:
Yeah.
Dr. Bloom:
I use plain as well.
Dr. Palm:
And so you want to make sure you have a homogenous cloudy solution that you’re actually using, and, um, and, and then, you know, I think issues with, we’re getting a little off topic, but with clogging. Just avoid when you’re actually drawing up, that white precipitate. We used to think that was carboxymethyl cellulose. It’s not. It’s just PLLA particles that are not in the suspension, but that really can be problematic for people as they’re beginning to inject.
Dr. Weinkle:
So, what needle are you using or cannula?
Dr. Palm:
So, I don’t use a cannula.
Dr. Weinkle:
I don’t, either.
Dr. Palm:
I use needles, um, for Sculptra. I do use cannulas in other applications.
Dr. Weinkle:
Oh, me too, of course.
Dr. Palm:
On facial rejuvenation, I think that’s important for the audience to know, but I’m a needle girl with that, and I do reflux. So, we know reflux maneuvers, there’s a high false negative rate with it.
Dr. Bloom:
Sure.
Dr. Palm:
We don’t know the true value of it. I still perform it, but I think with PLLA, it’s a watery enough substance, a couple times a year I see a flash.
Dr. Bloom:
Oh, absolutely.
Dr. Palm:
And I, and so I do use it with this product.
Dr. Weinkle:
I, I don’t, I don’t reflux it, but what I do is I keep a moving needle. I’m in that subcu plane.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
It’s less vascular.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
And so as I’m moving with that needle, I’m never stationary with it, giving, well, unless it’s in the temple sometimes or the deep plane.
Dr. Bloom:
Sure.
Dr. Weinkle:
But when I’m globally injecting it, as long as you, even if you go in a vessel, if you go through the vessel…
Dr. Palm:
Mm-hmm.
Dr. Bloom:
Yeah, you’re still safe.
Dr. Weinkle:
With a slow plunger pressure, you’re safe.
Dr. Palm:
Yeah.
Dr. Weinkle:
You’re safe, you’re not going to, I mean, knock wood, we hope it’s here. Um, I’ve been injecting PLLA 14 years since it came to market in August of 2004.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
And so it, I feel like it’s that moving, constant, not stationary injecting that makes a difference.
Dr. Palm:
Yeah.
Dr. Bloom:
Yeah, it’s really nice to see all these different techniques. I use cannulas for PLLA.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
Oh, do you really?
Dr. Bloom:
Except for the temples, and it, you know, I definitely had some patients early on when I was injecting with needles maybe come back because, not come back because of the bruising, but cannulas have really cut that down for me, but it’s good to just see, you know, what other people are doing.
Dr. Palm:
Yeah.
Dr. Weinkle:
Yeah, yeah, exactly. What size cannula do you use?
Dr. Bloom:
I use a 25 gauge, either inch-and-a-half or two inch.
Dr. Palm:
Yeah.
Dr. Weinkle:
Yeah.
Dr. Bloom:
Yeah. Reflecting on your experience, Dr. Weinkle, how do you prevent adverse events in your practice, and then what recommendations do you make to your patients and tell them when they’re receiving PLLA?
Dr. Weinkle:
I think that if you inject globally and understand where the product can be placed. I do not inject it in the teardrop.
Dr. Bloom:
Yeah.
Dr. Weinkle:
That’s an accident waiting to happen.
Dr. Bloom:
Absolutely.
Dr. Weinkle:
I do not put it in the lips, and, quite frankly, I do not put it in the hands. I don’t like those areas of very thin skin. I’ve even seen nodules from very hyper dilute Sculptra in the hands.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
I think choosing the location where you use the product, doing the proper dilution, hyperdiluting it for the décolletage, for the arms, for the knees.
Dr. Bloom:
Yeah.
Dr. Weinkle:
Oh my goodness, it’s been wonderful in those sorts of areas.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
And I think that’s a whole new thing as, as well as the buttocks. I mean, I’ve heard of people putting as many as 40 vials in the buttocks.
Dr. Bloom:
Wow.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
Of PLLA, so, but I think that cutting, knowing where to use it, where to place it, and then telling the patient, “For several days, 5, 5, and 5.” I still tell them five times a day, five minutes at a time for five days if they will massage, and I tell them it doesn’t have to be, “You’re not going to hurt the product. You’re just going to make sure it stays evenly dispersed just like I injected it.” I, I really have had, found it to be a very safe, um, product in my hands.
Dr. Bloom:
Yeah, I think icing, and if you tell the patients that the 5/5/5 massage stimulates collagen, they’re going to do that.
Dr. Weinkle:
They’ll probably do it.
Dr. Bloom:
Some great input. Well, this has certainly been a really fascinating discussion, and I’d like to just all bring it together, and if, if we could each share some key takeaways from this. So, let’s, let’s start with you, Dr. Palm.
Dr. Palm:
Well, um, you know, I’m, I feel like this is confessional. I’m a PLLA patient myself, so I, I do really like the product, um, and collagen stimulators in general. I think they can provide really important scaffolding for some of the volume loss, whether it be fat or belly loss that we have, and gives very natural-looking results. Many of my patients want something that their own body is in charge of, and I think that’s very appealing for them. So, I think doing that and knowing proper injection plane, proper techniques, dilution, and some of the new information about reconstitution is really important for those as they practice in their clinics.
Dr. Bloom:
Absolutely. Dr. Weinkle?
Dr. Weinkle:
I think it’s important with that patient expectation challenge. This is not an immediate result. This is not something one vial in most of my patients it’s going to treat.
Dr. Bloom:
Right.
Dr. Weinkle:
They have to look at what the budget is, what their expectations, what their timeline is. Um, if they’re son is getting married in six weeks, this is probably not the right direction for them. So, as long as we can set expectations, timelines, let the patient know, once we get to there, it’s a very durable result, it’s a very natural result. I like the fact that it doesn’t impede muscle movement, and we know sometimes those HAs actually put pressure on the muscles and you don’t get that natural look that I think you get with PLLA.
Dr. Bloom:
Yeah, I mean, I will just say that PLLA has been one of my favorite injectables in my practice, but it’s not for everyone in terms of the injector.
Dr. Weinkle:
Right.
Dr. Palm:
No.
Dr. Bloom:
It’s not something that you can just go and start injecting. So, like Dr. Palm was saying, there are consensus recommendations out there that I think are important to investigate, and if you’re interested in starting with this product, it’s important to understand that this is a moving, really fluid, um, product in terms of new evidence. New things are coming out that is going to help us get better results for our patients, and to investigate that, to understand, and to keep learning.
Dr. Palm:
Mm-hmm.
Dr. Weinkle:
Yeah, and it’s good to get training.
Dr. Palm:
Yeah.
Dr. Bloom:
Yes, absolutely.
Dr. Weinkle:
To go and get trained and hands-on so you get the feel of the plane of injection and how to inject it.
Dr. Bloom:
Absolutely. And with those takeaways in mind, I’d like to thank my panelists here, Dr. Palm and Dr. Weinkle – again, so great speaking with you guys again today.
Announcer:
You have been listening to CME on ReachMD. This activity is provided by Prova Education and is supported by an independent educational grant from Galderma.
To receive your free CME credit, or to download this activity, go to ReachMD.com/Prova. Thank you for listening.
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