Battle against Aging and Folds: Benefit and Risks of the Semi-Permanent Fillers Polylactic Acid and Calcium Hydroxylapatite


Background: Semi-permanent fillers are among the most favorable fillers on the market. Through their unique mode of action and its associated lasting aesthetic effect, they take an exceptional position. Objective: To compare the two semi-permanent fillers Poly-L-Lactic Acid (PLLA) and calcium hydroxylapatite (CaHA) in reference to the aesthetic result, patient satisfaction and side effects. Methods: Studies on side effects, patient satisfaction and aesthetic results after augmentation with semi-permanent fillers were analyzed. Results: Semi-permanent fillers seem excellently suited for the augmentation of very deep wrinkles particularly in the lower half of the face. In general, high patient satisfaction can be determined with both fillers. Here, the effect from the polylactic acid can be verified for up to two years while no effect could be verified already after one year in a majority of the patients augmented with CaHA. Short-term side effects such as bleedings or erythema in the region of the augmented area have been observed in both fillers during augmentation. The incidence of nodules and granulomas seems significantly higher in augmentations with PLLA compared to CaHA. Rare side effects such as an embolization of a blood vessel caused by the implant have been described for both fillers in case reports. Conclusion: Semi-permanent fillers are superbly suited for wrinkle augmentation. Which filler is the preferred one in what case depends strongly on the individual needs of the patient and the therapist’s experience.

Share and Cite:

Hanf, E. and Gresser, U. (2014) Battle against Aging and Folds: Benefit and Risks of the Semi-Permanent Fillers Polylactic Acid and Calcium Hydroxylapatite. Advances in Aging Research, 3, 130-141. doi: 10.4236/aar.2014.32021.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Goldman, M.P. (2011) Cosmetic Use of Poly-l-Lactic Acid. My Technique for Success and Minimizing Complications. Dermatologic Surgery, 37, 688-693.
[2] Lam, S.M., Azizzadeh, B. and Graivier, M. (2006) Injectable Poly-L-Lactic Acid (Sculptra): Technical Considerations in Soft-Tissue Contouring. Plastic and Reconstructive Surgery, 118, 55-63.
[3] Schneider, L.A., Wlaschek, M. and Scharffetter-Kochaneck, K. (2003) Hautalterung-Klinik und Pathogenese. Journal der Deutschen Dermatologischen Gesellschaft, 3, 223-232.
[4] Beljaards, R.C., Roos, K.P. and Bruins, F.G. (2005) New Fill for Skin Augmentation: A New Filler or Failure? Dermatologic Surgery, 31, 772-776.
[5] Bauer, U. and Graivier, M.H. (2011) Optimizing Injectable Poly-L-Lactic Acid Administration for Soft Tissue Augmentation: The Rationale for Three Treatment Sessions. Canadian Journal of Plastic Surgery, 19, 22-27.
[6] American Society of Plastic Surgeons (2013) Plastic Surgery Statistics Report.
[7] Fakhre, G.P., Perdikis, G., Shaddix, K.K., Terkonda, S.P. and Waldorf, J.C. (2009) An Evaluation of Calcium Hydroxylapatite (Radiesse) for Cosmetic Nasolabial Fold Correction: A Meta-Analysis and Patient Centric Outcomes Study. Annals of Plastic Surgery, 63, 486-489.
[8] Alam, M., Gladstone, H., Kramer, E.M., Murphy, J.P., Nouri, K., Neuhaus, I.M., Spencer, J.M., Spenceri, E., Van Dyke, S., Ceilley, R.I., Lee, K.K., Menaker, G., Monheit, G.D., Orentreich, D.S., Raab, B. and Smith, K.C. (2008) ASDS Guidelines of Care: Injectable Fillers. Dermatologic Surgery, 34, 115-148.
[9] Jansen, D.A. and Graivier, M.H. (2006) Evaluation of a Calcium Hydroxylapatite-Based Implant (Radiesse) for Facial Soft-Tissue Augmentation. Plastic and Reconstructive Surgery, 118, 22-30.
[10] De Lorenzi, C. (2013) Complications of Injectable Fillers, Part I. Aesthetic Surgery Journal, 33, 561-575.
[11] Cohen, J.L. (2008) Understanding, Avoiding and Managing Dermal Filler Complications. Dermatologic Surgery, 34, 92-99.
[12] Funt, D. and Pavicic, T. (2013) Dermal Fillers in Aesthetics: An Overview of Adverse Events and Treatment Approaches. Clinical, Cosmetic and Investigational Dermatology, 6, 295-316.
[13] Lemperle, G., Morhenn, V. and Charrier, U. (2003) Human Histology and Persistence of Various Injectable Filler Substances for Soft Tissue Augmentation. Aesthetic Plastic Surgery, 27, 354-366.
[14] Vleggaar, D. (2006) Soft-Tissue Augmentation and the Role of Poly-L-Lactic Acid. Plastic and Reconstructive Surgery, 118, 46-54.
[15] Bolton, J., Fabi, S., Peterson, J. and Goldmann, M. (2011) Poly-L-Lactic Acid for Chest Rejuvenation: A Retrospective Study of 28 Cases Using a 5-Point Chest Wrinkle Scale. Cosmetic Dermatology, 24, 278-284.
[16] Woerle, B., Hanke, W. and Sattler, G. (2004) Poly-L-Lactic Acid: A Temporary Filler for Soft Tissue Augmentation. Journal of Drugs in Dermatology, 3, 385-389.
[17] Broder, K.W. and Cohen, S.R. (2006) An Overview of Permanent and Semipermanent Fillers. Plastic and Reconstructive Surgery, 118, 7S-14S.
[18] Koolmann, J. and Röhm, K.H. (1994) Gewebe und Organe, Kalzium P. 386 ff. Taschenatlas der Biochemie. Stuttgart Thieme.
[19] Sanofi Aventis, SCULPTRA® Aesthetic (2012) Injectable Poly-L-Lactic Acid. Package Insert, Bridgewater.
[20] Fabi, S.G. and Goldman, M.P. (2012) The Safety and Efficacy of Combining Poly-L-Lactic Acid with Intense Pulsed Light in Facial Rejuvenation: A Retrospective Study of 90 Patients. Dermatologic Surgery, 38, 1208-1216.
[21] Narins, R.S., Baumann, L., Brandt, F.S., Fagien, S., Glazer, S., Lowe, N.J., Monheit, G.D., Rendon, M.I. Rohrich, R.J. and Werschler, P. (2010) A Randomized Study of the Efficacy and Safety of Injectable Poly-L-Lactic Acid versus Human-Based Collagen Implant in the Treatment of Nasolabial Fold Wrinkles. Journal of the American Academy of Dermatology, 62, 448-462.
[22] Palm, M.D., Woodhall, K.E., Butterwick, K.J. and Goldman, M.P. (2010) Cosmetic Use of Poly-L-Lactic Acid: A Retrospective Study of 130 Patients. Dermatologic Surgery, 36, 161-170.
[23] Lowe, N.J., Maxwell, C.A., Lowe, P., Shah, A. and Patnaik, R. (2009) Injectable Poly-L-Lactic Acid: 3 Years of Aesthetic Experience. Dermatologic Surgery, 35, 344-349.
[24] Schierle, C.F. and Casas, L.A. (2011) Nonsurgical Rejuvenation of the Aging Face with Injectable Poly-L-Lactic Acid for Restoration of Soft Tissue Volume. Aesthetic Surgery Journal, 31, 95-109.
[25] Daines, S.M. and Williams, E.F. (2013) Complications Associated with Injectable Soft-Tissue Fillers. A 5-Year Retrospective Review. JAMA Facial Plastic Surgery, 15, 226-231.
[26] Salles, A.G., Lotierzo, P.H., Gimenez, R., Camargo, C.P. and Ferreira, M.C. (2008) Evaluation of the Poly-L-Lactic Acid Implant for Treatment of the Nasolabial Fold: 3-Year Follow-Up Evaluation. Aesthetic Plastic Surgery, 32, 753-756.
[27] Lemperle, G., Holmes, S., Cohen, S.R. and Lemperle, S. (2001) A Classification of Facial Wrinkles. Plastic and Reconstructive Surgery, 108, 1735-1750.
[28] Zielke, H., Wölber, L., Wiest, L. and Rzany, B. (2008) Risk Profiles of Different Injectable Fillers: Results from the Injectable Filler Safety Study (IFS Study). Dermatologic Surgery, 34, 326-335.
[29] Beer, K.A. (2009) Clinicopathologic Correlation of Delayed-Onset Periorbital Poly-L-Lactic Acid Nodules Dermatologic Surgery, 35, 399-402.
[30] Hamilton, D., Gauthier, N., Robertson, B.F. and Late-Onset, (2008) Late-Onset, Recurrent Facial Nodules Associated with Injection of Poly-l-lactic Acid. Dermatologic Surgery, 34, 123-126.
[31] Oppel, T., Schaller, M., Flaig, M. and Korting, H.C. (2003) Fremdkörpergranulome nach dermaler Injektion eines auf Polymilchsäure basierenden Implantates zur Behandlung von Falten. Journal der Deutschen Dermatologischen Gesellschaft, 3, 220-222.
[32] Cassuto, D., Marangoni, O., De Santis, G. and Christensen, L. (2009) Advanced Laser Techniques for Filler-Induced Complications. Dermatologic Surgery, 35, 1689-1695.
[33] Nichols, B.J., Carpenter, J., Hribar, K.P., Go, J. and Rice, D.H. (2011) Acute Parotitis after Injection of Poly-L-Lactic Acid for Malar Augmentation: A Case Report and Review of Relevant Anatomy. Dermatologic Surgery, 37, 381-386.
[34] Robert, S.A.I. and Arthurs, B.P. (2012) Severe Visual Loss and Orbital Infarction Following Periorbital Aesthetic Poly-(L)-Lactic Acid (PLLA) Injection. Ophthalmic Plastic & Reconstructive Surgery, 28, e68-e70.
[35] Daley, T., Damm, D., Haden, J.A. and Kolodychak, M.T. (2012) Oral Lesions Associated with Injected Hydroxyapatite Cosmetic Filler. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, 114, 107-111.
[36] Merz North America (2013) RADIESSE. Injectable Implant Instructions for Use.
[37] Tzikas, L.T. (2008) A 52-Month Summary of Results Using Calcium Hydroxylapatite for Facial Soft Tissue Augmentation. Dermatologic Surgery, 34, S9-S15.
[38] Smith, S., Busso, M., McClaren, M.K. and Bass, L.S. (2007) A Randomized, Bilateral, Prospective Comparison of Calcium Hydroxylapatite Microspheres versus Human-Based Collagen for the Correction of Nasolabial Folds. Dermatologic Surgery, 33, S112-S121.
[39] Moers-Carpi, M., Vogt, S., Santos, B.M., Planas, J., Vallve, S.R. and Howell, D.J. (2007) A Multicenter, Randomized Trial Comparing Calcium Hydroxylapatite to Two Hyaluronic Acids for Treatment of Nasolabial Folds. Dermatologic Surgery, 33, S144-S151.
[40] Bitar, G.J., Osunsade, O. and Devabhaktuni, A. (2012) Injection/Filler Rhinoplasty. Aesthetic Medicine. In: Erian, A. and Shiffman, M.A., Eds., Advanced Surgical Facial Rejuvenation, Springer Berlin Heidelberg, Berlin, 625-639.
[41] Jacovella, P., Peiretti, C.B., Cunille, D., Salzamendi, M. and Schechtel, S.A. (2006) Long-Lasting Results with Hydroxylapatite (Radiesse) Facial Filler. Plastic and Reconstructive Surgery, 118, 15S-21S.
[42] Lemperle, G., Gauthier-Hazan, N. and Wolters, M. (2006) Komplikationen nach Faltenunterspritzung und ihre Behandlung. Handchirurgie, Mikrochirurgie, Plastische Chirurgie, 38, 354-369.
[43] Alam, M., Havey, J., Pace, N.B.S., Pongprutthipan, M. and Yoo, S. (2011) Large-Particle Calcium Hydroxylapatite Injection for Correction of Facial Wrinkles and Depressions. Dermatologic Surgery, 65, 92-96.
[44] Comite, S., Greene, A., Cieszynski, S.A., Zaroovabeli, P. and Marks, K. (2007) Minimizing Discomfort during the Injection of Radiesse with the Use of Either Local Anesthetic or Ice. Dermatology Online Journal, 13, 5.
[45] Grunebaum, L.D., Elsaie, M.L. and Kaufmann, J. (2010) Six-Month, Double-Blind, Randomized, Split-Face Study to Compare the Efficacy and Safety of Calcium Hydroxylapatite (CaHA) Mixed with Lidocaine and CaHA Alone for Correction of Nasolabial Fold Wrinkles. Dermatologic Surgery, 36, 760-765.
[46] Roy, D., Sadick, N. and Managat, D. (2006) Clinical Trial of a Novel Filler Material for Soft Tissue Augmentation of the Face Containing Synthetic Calcium Hydroxylapatite Microspheres. Dermatologic Surgery, 32, 1134-1139.
[47] Sadick, N., Katz, B. and Deborshi, R. (2007) A Multicenter, 47-Month Study of Safety and Efficacy of Calcium Hydroxylapatite for Soft Tissue Augmentation of Nasolabial Folds and Other Areas of the Face. Dermatologic Surgery, 33, S122-S127.
[48] Marmur, E.S., Taylor, S.C., Grimes, P.E., Boyd, C.M., Porter, J.P. and Yoo, J.Y. (2009) Six-Month Safety Results of Calcium Hydroxylapatite for Treatment of Nasolabial Folds in Fitzpatrick Skin Types IV to VI. Dermatologic Surgery, 35, 1641-1645.
[49] Marmur, E.S., Green, L. and Busso, M. (2010) Controlled, Randomized Study of Pain Levels in SubjectsTreated with Calcium Hydroxylapatite Premixed with Lidocainefor Correction of Nasolabial Folds Dermatologic Surgery, 36, 309-315
[50] Tracy, L., Ridgway, J., Nelson, J.S., Lowe, N. and Wong, B. (2013) Calcium Hydroxylapatite Associated Softtissue Necrosis: A Case Report and Treatment Guideline. Journal of Plastic, Reconstructive & Aesthetic Surgery, 67, 564-568
[51] Merz Aesthetic der V Effect (2010) Der V-Effekt Volumenaufbau für jugendliche Formgebung Arztfolder. Hg. v. Merz Ästhetics. Frankfurt.
[52] Goldan, O., Garbov-Nardini, G., Regev, E., Orenstein, A. and Winkler, E. (2008) Late-Onset Infections and Granuloma Formation after Facial Polylactic Acid (New-Fill) Injections in Women Who Are Heavy Smokers. Plastic and Reconstructive Surgery, 121, 336e-338e.
[53] Sires, B., LauKaitis, S. and Whitehouse, P. (2008) Radiesse-Induced Herpes Zoster. Ophthalmic Plastic and Reconstructive Surgery, 24, 218-219.
[54] Aktories, K., Förrstermann, U., Hofmann, F., Starke, K. and Biel, M. (2008) Allgemeine und spezielle Pharmakologie und Toxikologie. Kapitel 8 Lokalanästhetika, 245-251. 10. Aufl., Urban & Fischer, München.
[55] Rossner, F. (2010) Unerwünschte Wirkungen auf ein injiziertes Polymilchsäurepräparat Ergebnisse der Injectable Filler Safety-Studie. Dissertation, Charité Universitätsmedizin Berlin, Berlin.

Copyright © 2022 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.