What's the actual procedure like?
What we do is, patients avoid aspirin and nonsteroidal anti-inflammatories, like ibuprofen, for a week or so before the procedure, because it is a series of injections into the deep parts of the face. So anything like that can cause more bruising than they need to have. So they avoid those types of things. Other than that, they basically just come in as an office procedure.
Typically, when I'm treating a full face, as I would with lipoatrophy, we would do some nerve blocks to anesthetize most of the face. The Sculptra is mixed the night before. Sculptra has to be mixed the night before use because it has to hydrate for a number of hours. So it comes as a freeze-dried powder, and we hydrate it the night before.
Hydrating means just adding a lot of water?
Adding water, not a lot of water. We basically add 3 cc of water, which is less than a teaspoon of water, the night before. Then we come up to a teaspoon, which is a total volume of 5 cc, with some lidocaine, which is like a local injection that will add to the numbing effect of the injections so that the patient is more comfortable during the injections themselves.
What is the active ingredient?
It's L-lactic acid, which may not be the full name. It is essentially an irritant that is injected that the body forms a collagen reaction to. So each little particle of Sculptra is like sand in an oyster. The body forms a pearl around it. Now, if you have too much sand altogether, then you get a lump. So the trick with Sculptra is to dilute it to the proper dilution, so the individual particles are spread apart enough so that you don't get lumping, but you get a total volume improvement once all that collagen is formed around each little particle that is in excess of the initial volume of material that's placed. Is that clear?
Yes, very clear.
OK. So the patient comes in, we give them some nerve blocks to anesthetize the face -- which is essentially what you get at a dentist before you get dental work done. Not a pleasant experience, but nonetheless, not a difficult one to take. No anesthesia is needed; no intravenous or sedation or anything like that is needed. Then we proceed with the injections. The injections are a series of needle sticks throughout the face, in the areas that we want to fill with Sculptra.
The needle gauge is a fairly small needle gauge. It's relatively painless, although not completely painless -- the process. But most patients grade the whole experience, on a zero to 10 scale, if 10 were the most severe pain that they had, they would grade it at around a three or a four, in terms of how painful or how uncomfortable the experience is.
How long does it take?
The whole process of injecting takes about 15 to 20 minutes.
How do you go about determining where the injections go exactly?
Well, I get the patient involved to tell me where they want to have filling. That's the best way. Then, just based on experience with how the material should be placed in different parts of the face -- because there is a little bit of a difference, depending where we're trying to fill -- how deep or how superficial the material should be placed to give the best possible result.
It's very helpful to see pictures of what the patient looked like before they had the lipoatrophy, because that way we can also try to figure out with the patient if they [are] going to actually be able to be like that [again]. Or will they have to settle for some filling, but less volume in their face than they had before they had the disease.
How long before you see an effect? Do you see one immediately?
Well, immediately, you have some swelling. So patients love the way they look immediately. They look great, all swollen up, and just like they ought to have looked before. Then, within the first few days, all the swelling goes away, and so all the effect goes away completely.
So here they are. They have either spent a fair amount of money on this, or they have certainly gone through an uncomfortable procedure and they don't see anything a week later. Then the body starts to form collagen. It takes about three weeks, when most patients tend to start to see some filling and feel some feeling. If they have never had Sculptra before, they will feel it before they see it, in the sense that the tissues will feel fuller and firmer to them, as they touch their face.
So it's a gradual process of growing collagen.
Right. So the process is sort of 80 percent, 85 percent there at about six to eight weeks. Typically, I'll see a patient back at about six weeks and decide whether they need another cycle of treatment.
Very typically, even with mild lipoatrophy patients, the patients need at least two cycles of treatment, and each cycle involves injecting one vial of Sculptra -- which is 5 cc of fluid with the Sculptra mixed into it -- per side of the face. A minimal sort of a treatment would be two cycles, so four vials altogether. But more typically, with more severe lipoatrophy, we'll inject eight to 10 vials, fairly typically. And that's spread apart. Each injection session is two months apart from the one before. So it's a long process of gradual filling, but it is reliable.
The collagen itself, once it's established, does it remain in place, and is it fairly permanent?
Collagen deposition is a dynamic process. So it's not like the collagen is deposited and it just sits there. It's constantly being deposited and reabsorbed by the body. The role of Sculptra is to maintain itself there, to stimulate ongoing collagen production. The studies that were done that the FDA reviewed before approving Sculptra actually showed that at two years, patients were better off than they were at one year after treatment. So you even have some increase, gradual increase in volume, even down the line.
So there's collagen turnover, but as long as the irritants from Sculptra remain in place, the body produces collagen there.
What happens if the irritants go away?
Well, they all do. They dissolve to water, eventually, and go away. So what happens then is that the collagen that was deposited there starts to go away. That's when patients will come in. And like I said: We haven't seen that yet because we are only about a year and a half into the experience of Sculptra here. But judging from what the European guys tell me, at that point, patients will come in and need another touch-up treatment with another couple of vials of Sculptra to maintain the result.
What are some of the responses? What do patients say to you when they come back for that second visit?
Typically, after one treatment session most patients say, "Well I see a little bit of an improvement. I don't see a whole lot. Is this worth it?" I tell them yes, because it is, and I know that it will be for them.
Then after the second treatment they come in and say, "Wow, this is looking really good. Can we do more?" But the response is always, at each session, "Gee, I wish we had a little bit more funded." So it's important to actually realize that the 5 cc of volume we're putting in to each side doesn't translate to 5 cc of actual volume of collagen response. It's more like 2 cc. So it's about half, or a little bit less than half, of what patients will see at the end of their injection session, is what they'll end up with after that first treatment.
But that builds a nice base. Then with the second treatment, patients really see usually a pretty impressive improvement. Then with ongoing treatments after that, again, satisfactory improvement with each session. So it's clear to them that it's worth doing as they proceed in this process. I have not had an unhappy Sculptra patient yet.
Yes. As long as patients know what to expect and don't expect to have overnight improvement, and [realize] that it's going to take many, many months to get them to where they want to be -- as long as they know what to expect -- the material does what it's supposed to do.
Do you ever use it for other parts of the body?
I'm a facial plastic surgeon, so I don't do anything outside the face. But I do use it off-label, for cosmetic use in patients. But of course, that's off-label, and it's not sanctioned by its FDA uses.
Are there any other particular products that look really promising to you?
The other big product that's being used, I think, fairly commonly -- in New York, anyway -- is Radiesse [calcium hydroxylapatite]. Radiesse is temporary filler that can give volume that is a one-to-one volume ratio. It's relatively inexpensive, compared to Sculptra, and the effects last for about a year. You don't have to wait as many weeks between treatment sessions. You just put in what you want to put in, and you're done.
Does it work in the same way by producing collagen?
No. It works just as a space filler. So it just sits there and takes up space. It's very popular, and I think the results are good, judging from colleagues of mine that use it and like it. I think patients like it because it's less expensive than Sculptra, but the longevity is not there. I'm more of a proponent of doing something that will last as long as possible, so that patients don't have to keep running back and getting more injections.
What's the cost of Sculptra treatment?
Typically, the cost of treatment is about $1,000 per vial, so it's quite costly. It's a very costly material for us to obtain, as doctors. So you can imagine if even a mild case of lipoatrophy requires two vials, that's a $2,000 investment -- which is not inexpensive, for sure; but it's $2,000 over two to three years, so that's, I don't think, too bad. Probably most patients spend more on their hair than they do on that. But having said that: [Dermik Laboratories], the company [that produces Sculptra], has a program where patients who earn less than a certain income per year can qualify for either reduced cost or free Sculptra. It's a fabulous program. It's, I think, a wonderful thing that the company's doing. Every doctor who has had Sculptra training knows about this program and can supply the appropriate forms to their patients. I have a number of patients on that program, as well.
Click here to contact Dr. Minas Constantinides via his Web site.
Get your questions answered at The Body's Ask the Experts forum on facial wasting!