Seeing an aesthetic procedure all over social media can breed a strange sort of FOMO. (Hey, we’re not immune.) Yet it may be difficult to distinguish for-the-’Gram fads from truly “Worth It” tweaks. Which is why we’re launching a new series on RealSelf: Everybody’s Doing It. Each month, we’ll explore all sides of an of-the-moment cosmetic procedure, to bring you the uncensored truth about its efficacy and safety so you can decide if it’s right for you. Here, in our latest installment, we’re talking Sculptra.
Filler: it’s the vague catchall we use to describe the myriad injectable gels doctors rely on to shape and swell our lips, restore time-sapped fullness, and fake better bone structure. The majority of FDA-approved dermal fillers used in the United States are composed of a short-lived sugary substance called hyaluronic acid (HA)—but a few standouts are made from different, more durable biocompatible materials: Bellafill buoys acrylic beads in a collagen base; Radiesse is a synthetic calcium paste; and Sculptra (a.k.a Sculptra Aesthetic from Galderma), the star of this column, is a liquid-y suspension of the man-made polymer poly-L-lactic acid (PLLA).
These three are known as biostimulatory fillers, because they, quite literally, stimulate the biological process of collagen production to create a longer-lasting plump than do temporary HAs, which can be life-changing for those with waning facial volume and other signs of facial aging, from sagging to smile lines. However, patients seeking rejuvenation tend to be more wary of these collagen stimulators, says board-certified Boston dermatologist Dr. Papri Sarkar, for two main reasons: they’re not reversible, like HA fillers (which can be melted with a shot of enzyme), and they’ve historically gotten less airtime. “People simply haven’t heard that much about them,” she says.
If recent social media posts are any indication, however, Sculptra’s days of being upstaged by HA seem to be over. What Insta captions rarely reveal though are the shot’s eccentricities, which make it a tad more high-maintenance than, say, your average HA. So please, read on for the proverbial fine print.
How does Sculptra work?
Sculptra arrives at your doctor’s office as a powdered amalgam of PLLA microparticles plus mannitol (a preservative) and sodium carboxymethylcellulose (an emulsifier), in a glass vial. An appropriate dose of saline (or sterile water) transforms the dry mix into a syrupy suspension. Once injected, “the PLLA acts like scaffolding, providing a structure on which collagen can grow and making it easier for your body to build more of the protein,” says Dr. Sarkar.
Since collagen synthesis typically takes 6 to 12 weeks, the immediate swell you see post-shot is essentially water weight. Within two days, your body absorbs the saline, treated areas deflate back to baseline, and you’re left waiting for your collagen cells to slowly refill the voids. “I liken PLLA to collagen seeds,” says Dr. Jason Bloom, a board-certified facial plastic surgeon in Bryn Mawr, Pennsylvania. “We mix it with water, spread it evenly wherever we want new collagen growth, and then we wait for it to take root.” A second or even a third treatment, separated by roughly six weeks, is sometimes needed—with individual results lasting up to two years or more.
Doctors have found that “once you create this lattice-like structural support, not only can your collagen grow into it and bloom, but if you inject Sculptra again down the road, you’ll get greater longevity and a better overall result because there’s that preexisting scaffold,” says Dr. Lara Devgan, a board-certified plastic surgeon in New York City.
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Where Sculptra shines
Sculptra’s broad FDA indication—“shallow to deep nasolabial fold contour deficiencies and other facial wrinkles in which deep dermal grid pattern [cross-hatch] injection technique is appropriate”—allows for diverse applications, notes New York City board-certified dermatologic surgeon Dr. Jessica Weiser. On the face, injectors like it for seemingly bottomless-pit type areas, such as the temples and the tops of the nasolabial folds on either side of the nose, which can remain sunken-looking even after multiple syringes of HA. “Sculptra is my treatment of choice for temple hollowing,” says Dr. Weiser. “Your body produces this really nice, gentle swell of the temples, for a youthful appearance that’s not puffy or overdone.” Gaunt cheeks, in-front-of-the-ear hollows, and weak chins (and accompanying chin wrinkles) can also benefit from the natural collagen padding a Sculptra treatment provides.
On the body, hyper-dilute Sculptra injections are used off label, to thicken and smooth crepey skin on the upper inner arms, on the neck and décolletage, on the post-baby belly, on the inner thighs, and atop the knees. It can gradually level out cellulite dimples, contour irregularities, and hip dips. And according to every other video in our Insta feed, it can nonsurgically boost the butt—to modest effect. “You will see an improvement—approximately a 10% increase in volume, if we use lots of vials—but expectations have to be managed,” notes Dr. Sapna Palep, a board-certified dermatologist in New York City.
As Sculptra’s popularity soars, doctors are exploring new ways to leverage its powers. In New York City, board-certified dermatologist Dr. Bradley Bloom and his colleagues are investigating Sculptra’s synergy with ablative fractional lasers in treating deep wrinkles, raised scars, and stretch marks. Independently, each can spark collagen synthesis. When paired, he explains, “the laser creates channels in the skin [that] allow Sculptra to penetrate and be delivered more evenly throughout the dermis,” theoretically bolstering its effect. Since rehydrated PLLA particles are relatively large, “we need a channel of significant width”—which is something only skin surface-vaporizing ablative lasers can provide. While these tools are traditionally known to beget a gory recovery, less aggressive settings can be used when incorporating Sculptra, which may translate into less redness and a shorter downtime after each treatment session. “We’ve seen very promising results thus far,” Dr. Bradley Bloom says—including, in one study, as much as a 50% wrinkle reduction on the upper lip after three treatments.
The reported caveats and drawbacks of Sculptra
At this point, you’re probably thinking: Sign me up! (And also: Are hollow temples the new flat cheeks? Yesss.) As we mentioned earlier, however, not everyone is Team Sculptra. “I don’t think the results are as consistent as with an HA filler, because it’s based on your own collagen generation and not everyone responds the same,” says Dr. Nazanin Saedi, a board-certified dermatologic surgeon in Philadelphia. Not every injection site responds the same either: “It can happen that one area reacts more robustly than another,” says Dr. Weiser—a consequence of poor product dilution and disbursal.
Robust is not a word Dr. Jules Walters, a board-certified plastic surgeon in Metairie, Louisiana, would use to describe the product’s effect on curves. “Social media is flooded with videos of providers performing butt injections with Sculptra—but we rarely see photos of long-term results,” he says. Sculptra can’t give the projection that a fat transfer provides during a surgical Brazilian butt lift (BBL), he insists. And the injectable’s butt-augmenting abilities are further limited by the fact that it’s a purely additive procedure. “A big part of a successful BBL is liposuction of the waist, which improves the appearance of the butt before any fat is even added.” With Sculptra, he says, patients can wind up paying thousands for minimal payoff.
Our collective desire for instant gratification can also put Sculptra at a disadvantage. “Most people want to do something and see desired results right away,” says Dr. Saedi. With Sculptra, patients need a series of treatments, plus “there’s just a lot more wait and see.”
There’s also a lot more responsibility on the part of the patient, notes Dr. Weiser: “After injection, we require—not encourage, require—patients to massage treatment areas somewhat intensely for five minutes, five times a day, for five days, to keep the product from forming small lumps and nodules.” This is standard, nonnegotiable homework—“and compliance can always be an issue,” says Dr. Saedi.
Which brings us to Sculptra’s most dogging drawback: the lack of an antidote or reversal agent. If you don’t love your results, for whatever reason or if, God forbid, there’s a complication—the product enters and blocks a blood vessel at the time of injection or clumps into a nodule days later (both very rare but real risks)—you could be sort of…stuck.
For all these reasons, many physicians hesitate to treat first-time filler patients with Sculptra. Even if a newbie is an ideal candidate for the shot, “I’ll probably do an HA filler first, and then, once they’re less nervous and we’ve developed more of a rapport, I can introduce Sculptra and have them trust that in six weeks or so, they will look different,” says Dr. Sarkar. “The gradual change can be harder to see though, especially for new filler patients.”
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Countering the cons and sidestepping complications
Let’s tackle this hit list from the top, starting with Sculptra’s reputed unpredictability.
Proponents of the drug acknowledge that outcomes absolutely do hinge on a person’s innate ability to build collagen—and this is hard to gauge ahead of time (save for the certainty that younger cells are generally more fruitful than older ones). That said, when doctors see patients at follow-up visits, they expect for their skin to have rebounded to where it was on injection day (though, as noted earlier, sometimes additional shots are needed).
For those who can’t do without the instant oomph of conventional filler, injectors can layer an HA, like Restylane, on top of Sculptra—a sort of stopgap maneuver to ease the collagen-germination layover. The reality is, experts say, HAs are often in play anyway—they’re being used to balance areas that Sculptra is ill-suited for, like the tear troughs and lips, and to achieve their own special effects, like “very precisely defining the angle or edge of a jawline, or creating a distinct highlight over a cheekbone,” says Dr. Weiser.
Nodules, according to Dr. Jason Bloom, are a rare side effect of Sculptra, and roughly 80% of them resolve on their own. Those that don’t can usually be flushed out with saline or broken up with steroid injections, he says. The most tenacious lumps, however, do have to be surgically removed—which is why doctors go to great lengths to prevent them.
“Sculptra needs a lot of love and attention—it’s just not as well-behaved [as other fillers],” notes Dr. Sarkar. “You really can’t tell how much PLLA you’re getting in each drop of Sculptra you inject—and that’s why proper preparation and technique are so important.” It all starts with dilution—sufficiently watering down the product to disperse and emulsify the particles. Doctors typically dilute Sculptra more than the manufacturer recommends in order to ensure it spreads well. After reconstituting the powder, they let it rest: “Putting in the sterile water and allowing the dilution to sit for at least a couple of days prior to injection makes the particles nice and soft and less likely to clump,” explains Dr. Weiser. “Doctors who mix it up two hours before injecting it are more likely to have problems [with nodules].”
In the moments before injection, doctors (or their medical assistants) will warm the vials—in their palms or by some other means—to further enhance the fluidity of the suspension.
In Dr. Sarkar’s experience, the sodium carboxymethylcellulose is often to blame for the clotting of particles. “It usually floats to the top of the vial, so I try not to draw any of that up into my needle,” she says.
To lay the seeds of Sculptra evenly, doctors commonly inject in a grid-like crosshatch pattern or by radially spinning their needle or cannula from a single entry point, to fan out the liquid. (Ice packs and a topical anesthetic are typically applied first to make this process more tolerable.) In some locations, they’re aiming for bone; in others, the shallower subcutaneous space. Most injectors make a point to undercorrect—just in case the body reacts more exuberantly than expected.
Post-shot, “we massage the heck out of patients,” says Dr. Sarkar—“five minutes per area as we’re injecting and then again before they leave the office,” all the while impressing upon patients the vital importance of self-massaging at home.
The number of vials one may need depends on the specific areas being treated and the extent of volume loss, but doctors typically use one or two vials total during a single session when addressing the face, sometimes adding a third to improve the décolleté. (“There’s nothing to show that using more than two vials in the face alone at one time is beneficial,” notes Dr. Jason Bloom.) For the body, dozens of vials may be injected, over several appointments, to give an appreciable volume gain.
Is Sculptra right for you?
Sculptra was originally approved to treat lipoatrophy, or facial fat loss, in HIV patients—a fact that truly speaks to its volumizing prowess—and doctors still rely on it for ultralean folks who lack the natural padding of youth. “I use it in my marathon runners and anyone who just rips through HA because their metabolism is so great,” says Dr. Jason Bloom. For these folks, Sculptra may even be a more affordable option: “If someone would ordinarily need 10 syringes of HA, I can use two vials of Sculptra and get close to the same level of volumization,” he adds. But for better or worse, the effects of Sculptra do come on gradually, reiterates Dr. Sarkar, giving “a less marked change—a subtle transformation that looks very, very natural.” Patience is key. The risks and complications of Sculptra are fairly comparable to other fillers—assuming you choose an injector who understands the drug’s nuances and play masseuse as prescribed.