Poly-L-lactic acid injection for HIV-associated facial lipoatrophy: treatment principles, case studies, and literature review

Safety and Efficacy of Poly-L-Lactic Acid Filler (Gana V vs. Sculptra) Injection for Correction of the Nasolabial Fold: A Double-Blind, Non-Inferiority, Randomized, Split-Face Controlled Trial

BACKGROUND

Poly-L-lactic acid (PLLA) fillers have shown excellent results as soft tissue fillers for progressive midface volume enhancement, with long-lasting results and high patient satisfaction.

OBJECTIVE

Herein, we investigated the safety and effectiveness of a new PLLA filler (Gana V) in comparison with those of the widely used Sculptra.

METHODS

This double-blind, non-inferiority, randomized, split-face controlled trial was performed in France to evaluate the safety and effectiveness of injectable Gana V compared with those of Sculptra for correction of nasolabial fold (NLF) depression. The primary outcome was improvement in NLFs, as determined using the Wrinkle Severity Rating Scale (WSRS). This trial is an interim report of the results at 6 months. The trial was registered at ClinicalTrials. gov, number NCT05215054.

RESULTS

Fifty-five participants with moderate-to-severe NLFs (mean age 53.8 [standard deviation 8.7] years; 48 [87.3%]) female) were enrolled. After 6 months, Gana V showed improved WSRS score (mean difference - 0.25; 95% confidence interval [CI] - 0.49 to - 0.01) in intention-to-treat analysis, while Sculptra did not (mean difference - 0.20; 95% CI - 0.42 to 0.03). Furthermore, Gana V showed an acceptable 6-month effectiveness compared with Sculptra, within our defined non-inferiority margin (pnon-inferiority = 0.1787). The immediate results by the investigator after the initial injection showed higher satisfaction in the Gana V than in the Sculptra group. Gana V and Sculptra showed no difference in adverse reactions. Similar patterns were observed in per-protocol analyses.

CONCLUSIONS

Gana V is non-inferior to Sculptra with respect to the correction of NLFs and has higher investigator satisfaction. Further research is required to ensure long-term safety.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Strategies and techniques for improving heat resistance and mechanical performances of poly(lactic acid) (PLA) biodegradable materials

Poly(lactic acid) (PLA) has attracted much attention as a substitute for petroleum-based plastics, but its low heat resistance limits its application range in packaging fields and disposable products. This paper summarizes the structural factors affecting the heat resistance of PLA and systematically summarizes methods to improve its heat resistance. PLA is a semi-crystalline polymer, and crystallinity, crystal size, and other factors are important factors affecting heat resistance. This paper systematically analyzes the means to control the crystallization behavior of PLA, and summarizes the effects of nucleating agents, cross-linking, grafting, and annealing processes on the crystallization behavior and heat resistance of PLA. The effects of PLA molecular chain cross-linking and grafting on the motility of PLA molecular chains and the heat resistance of PLA materials are further discussed from the perspective of PLA molecular chain segment movement. The research work on combining PLA with reinforcements such as high heat-resistant polymer materials, fiber, and nanoparticles to improve the mechanical properties and heat resistance of PLA by introducing rigid groups or structures is described in detail. Improving the heat resistance of PLA material is an important strategy to promote the application of biodegradable materials, and has broad research value and application prospects.

Injectable formulations of poly(lactic acid) and its copolymers in clinical use

Poly(lactic acid) and its copolymers have revolutionized the field of drug delivery due to their excellent biocompatibility and tunable physico-chemical properties. These copolymers have served the healthcare sector by contributing many products to combat various diseases and for biomedical applications. This article provides a comprehensive overview of clinically used products of poly(lactic acid) and its copolymers. Multi-dimension information covering product approval, formulation aspects and clinical status is described to provide a panoramic overview of each product. Moreover, leading patented technologies and various clinical trials on these products for different applications are included. This review focuses on marketed injectable formulations of PLA and its copolymers.

5-year study of a polyacrylamide hydrogel-based filler for rehabilitation of HIV-related facial lipoatrophy

BACKGROUND

Lipoatrophy of the face negatively impacts the quality of life and body image of individuals on antiretroviral therapy. Facial fillers can minimize the stigma associated with the human immonodeficiency virus (HIV).

OBJECTIVES

In this 5-year follow-up study, the author assessed the safety and efficacy of a permanent, non-biodegradable, polyacrylamide hydrogel for facial volume restoration, and compared the results with those of a previous 18-month follow-up study.

METHODS

Thirty-one HIV-positive individuals, initially enrolled in the study between January 2008 and January 2009, received treatment of facial wasting by injection of the polyacrylamide gel until complete volume restoration was achieved. Asepsis rules were strictly observed before and during each injection session. Patients evaluated their aesthetic outcomes on a visual analog scale.

RESULTS

Patient satisfaction was high. There was no occurrence of local infection, foreign-body reaction, or product during the 5 years of follow-up. Small, palpable, nonvisible nodules were recorded in nine cases. It appears that these same nodules were present in the 18-month study. It is believed that the nodules were caused by overfilling in the same site.

CONCLUSIONS

As supported by the initial 18-month study, polyacrylamide hydrogel filler appears safe and effective for the treatment of HIV-related lipoatrophy. With strict observation of asepsis rules and patient adherence to posttreatment instructions, this filler can be ideal for treating facial wasting in patients with HIV.

LEVEL OF EVIDENCE

3 Therapeutic.

A systematic review of filler agents for aesthetic treatment of HIV facial lipoatrophy (FLA)

HIV facial lipoatrophy (FLA) is characterized by facial volume loss. HIV FLA affects the facial contours of the cheeks, temples, and orbits, and is associated with social stigma. Although new highly active antiretroviral therapy medications are associated with less severe FLA, the prevalence of HIV FLA among treated individuals exceeds 50%. The goal of our systematic review is to examine published clinical studies involving the use of filler agents for aesthetic treatment of HIV FLA and to provide evidence-based recommendations based on published efficacy and safety data. A systematic review of the published literature was performed on July 1, 2015, on filler agents for aesthetic treatment of HIV FLA. Based on published studies, poly-L-lactic acid is the only filler agent with grade of recommendation: B. Other reviewed filler agents received grade of recommendation: C or D. Poly-L-lactic acid may be best for treatment over temples and cheeks, whereas calcium hydroxylapatite, with a Food and Drug Administration indication of subdermal implantation, may be best used deeply over bone for focal enhancement. Additional long-term randomized controlled trials are necessary to elucidate the advantages and disadvantages of fillers that have different biophysical properties, in conjunction with cost-effectiveness analysis, for treatment of HIV FLA.

The life cycles and biological end pathways of dermal fillers

BACKGROUND

There is an increased demand for soft tissue augmentation procedures. A wide range of products can provide correction through different mechanisms and it is important for clinicians to understand the biological pathways of each material. This study presents a systematic review of the pathways of commonly used fillers, with consideration of the complications associated with each.

METHODS

The PubMed (National Library of Medicine) database was searched for MeSH headings for different types of fillers, including trade names, between January 1, 2000, and January 1, 2013. Article titles were screened, and only studies designed to determine the mechanism of action and histopathology of complications were included.

RESULTS

When restricted to studies on biological mechanisms, 109 manuscripts were identified and the mechanisms of action of short-term and long-term degradable as well as permanent fillers were reviewed. Hyaluronic acid fillers, which are the most commonly used, form a fibrous capsule and induce limited de novo collagen. Poly-l-lactic acid and calcium hydroxylapatite are semipermanent fillers that provide long-term restoration of tissue volume by stimulating fibroblasts to lay down a matrix of collagen and elastic fibers. Polymethyl methacrylate is the only FDA-approved permanent implant that is held in place by encapsulation, providing a scaffold upon which the dermis can recover to its original thickness.

DISCUSSION

Soft tissue augmentation products are variable, and no single product can be considered the most effective or ideal. An understanding of biological mechanisms may help guide physicians choose the best suited product among the various options available while minimizing the occurrence of complications.

Current treatment methods for combination antiretroviral therapy-induced lipoatrophy of the face

Summary

Combination antiretroviral therapy (CART) reduces the mortality and morbidity in HIV-infected patients. However, facial lipoatrophy (FLA) is one of the well-known side-effects of this treatment and subsequently imposes major problems for HIV-infected patients. In the last decade, ample experience has been obtained with both local therapeutic options as well as possible systemic treatment options. Soft tissue fillers are a relatively simple and efficient treatment option for FLA. Especially, the biodegradable semi-permanent fillers combine a good effect with durability and an acceptable safety profile. The best way to prevent or restrict the development of FLA remains the exclusion of thymidine analogue nucleoside reverse-transcriptase inhibitors from the CART schedule.

Techniques for the optimization of facial and nonfacial volumization with injectable poly-l-lactic acid

With the recognition of the key role of volume loss in the facial aging process, injectable dermal fillers and volumizers have become increasingly important treatment options for recontouring and rejuvenating the aging face. While replacement fillers effectively correct individual lines and wrinkles, volumizing agents that replace collagen provide a longer-lasting, volume-based alternative. Poly-L-lactic acid (PLLA) has been shown to increase dermal thickness and volume for up to 2 years and beyond. Although early clinical use of this agent in patients with HIV-associated facial lipoatrophy was associated with a significant rate of nodule or papule formation, subsequent experience has helped define the proper reconstitution volumes and injection techniques for optimizing results and minimizing nodule/papule formation. While injectable PLLA has been used successfully for rejuvenation of most facial areas, increasing experience suggests that it is a versatile agent capable of providing aesthetic enhancement in multiple areas of the body, including the dorsum of the hands, the décolleté, the neck, the buttocks, the medial ankles, and acne scars. Although the current published experience in these areas is limited, further studies and clinical use of injectable PLLA will clarify the potential of this agent as a minimally invasive alternative and/or adjunct to surgery for restoring volume loss in multiple anatomic areas.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article.

Polyacrylamide gel for facial wasting rehabilitation: how many milliliters per session?

BACKGROUND

Facial lipoatrophy is most distressing for HIV patients in pharmacologic treatment. Nonabsorbable fillers are widely used to restore facial features in these patients. We evaluated the safety and aesthetic outcomes of two samples of HIV+ patients affected by facial wasting who received different filling protocols of the nonabsorbable filler Aquamid® to restore facial wasting.

METHODS

Thirty-one HIV+ patients affected by facial wasting received injections of the nonabsorbable filler Aquamid for facial wasting rehabilitation. Patients were randomly divided into two groups: A and B. In group A, the facial defect was corrected by injecting up to 8 ml of product in the first session; patients were retreated after every 8th week with touch-up procedures until full correction was observed. In group B, facial defects were corrected by injecting 2 ml of product per session; patients were retreated after every 8th week until full correction was observed.

RESULTS

Patients of group A noted a great improvement after the first filling procedure. Patients in group B noted improvement of their face after four filling procedures on average. Local infection, foreign-body reaction, and migration of the product were not observed in either group during follow-up.

CONCLUSION

The rehabilitation obtained with a megafilling session and further touch-up procedures and that with a gradual build-up of the localized soft-tissue loss seem not to have differences in terms of safety for the patients. However, with a megafilling session satisfaction is achieved earlier and it is possible to reduce hospital costs in terms of gauze, gloves, and other items.