Facial Dermal Fillers

Abstract

TO THE EDITOR Mastery of volume replacement has become essential to the successful practice of aesthetic medicine. We appreciate the informative review written by Drs. Dayan and Bassichis of the most commonly used commercially available dermal filler agents (“Facial dermal fillers: selection of appropriate products and techniques” [ Aesthetic Surg J 2008;28:335–347]). We would, however, like to clarify some of the issues raised in the section devoted to poly-L-lactic acid (PLLA). In this section, the authors comment, “Concerns over delayed type hypersensitivity reactions occurring months following use may be hindering its [PLLA's] widespread acceptance as a cosmetic agent.” This statement is accompanied by an alarming photograph of a man with large disfiguring facial nodules (Figure) and reference to an article titled “NewFill for skin augmentation: new filler or failure?” Details of the injection technique used in this patient are not provided. The reference details 3 case reports and 2 photographs of 3 women with similarly alarming and dramatic presentations.1 Based on experience gained in the last decade of use, it is now widely accepted that these cases resulted from incorrect product reconstitution and incorrect injection technique and a less refined product.2 Figure Granulomatous reaction 12 months after 3 poly-L-lactic acid treatments. (Reproduced from Dayan SH, Bassichis A. Facial dermal fillers. Selection of appropriate products and techniques. Aesthetic Surg J 2008;28:335–347.) This is not to say that granulomatous reactions do not occur with PLLA. Granulomatous reactions, sometimes occurring months to years after administration, have been reported with all currently available commercial devices, including collagen; hyaluronic acid (HA); PLLA (Sculptra; Dermik Laboratories, Berwyn, PA); silicone calcium hydroxyl apatite (CaHA) (Radiesse; Bioform Medical, San Mateo, CA); polymethylmethacrylates (PMMA) (Artefill, …