Sculptra — Let's Get Into It
The answer to filler fatigue? Eh.
The midlife volume loss is real. And it seems I’m not the only one feeling deflated. After receiving multiple unsolicited DMs about Sculptra, I posted an AMA — an official call for inquiries about the collagen-stimulating injectable — and was flooded with questions.
I 100% get the curiosity: Sculptra is as appealing as it is perplexing. Injectors either adore it or abhor it. Some patients can’t get enough; others regret getting it at all. And then there’s the incessant chatter about it mucking up future facelifts. Naturally, we have questions, which my doctor pals have graciously agreed to answer.
But first, a few basic drug facts.
Sculptra, or poly-L-lactic acid, is essentially a ground-up suture material — the stuff comprising dissolvable stitches — that gets mixed with saline prior to injection. It works by irritating our tissues to trigger a wound-healing response, which spurs collagen-rich fibrous tissue to form under the skin. This process adds bulk to the face, filling out hollows over the course of several weeks.
The FDA originally approved the product in 2004 for the treatment of facial wasting (fat loss) associated with HIV. In 2009, Sculptra earned a cosmetic indication for use in immune-competent people with nasolabial folds and facial wrinkles. In 2023, the FDA sanctioned Sculptra for cheek lines, specifically. Galderma, the company that makes Sculptra, claims it can improve skin quality and radiance when used in the cheeks.
While everyone associates Sculptra with collagen, the injectable has recently been linked to elastin, as well. “Studies supported by gene analysis data demonstrate that Sculptra does more for the extracellular matrix of the skin than form collagen,” says Dr. Shino Bay Aguilera, a Fort Lauderdale dermatologist and Sculptra trainer. “It’s also able to produce elastin, which is crucial for proper skin health and function.”
Doctors aim to inject Sculptra subcutaneously (below the dermis) or deeper down, into the sticky tissue that overlies bone. (Both layers are rich in collagen-making fibroblasts.) Dr. Aguilera prefers to do the latter when possible, finding that Sculptra placed deep can “imitate and maintain the architecture of the bone,” which erodes over time, causing the skin to wrinkle, fold, and sag.
As with every treatment, Sculptra has its pros and cons — and it isn’t for everyone. Let’s get into your questions.
Several of you asked about best uses for Sculptra: Where does it work? Areas to avoid? Is it a good option for filling temples? Can it be used on wrinkly, deflated elbows?
Most experts agree that Sculptra shines in the temples. Though this is an off-label indication, says Dr. Aguilera, it’s “very effective for alleviating hollow temples and lifting the tails of the brows.”
Another common spot for Sculptra is the submalar region of the cheeks (think: buccal hollows or where you suck in to make a fish face). When injected under the dermis and fanned out just right, Sculptra can lend natural-looking volume to this area, which is otherwise hard to treat.
On a related note, Dr. Shereene Idriss, New York City dermatologist and founder of Dr. Idriss skincare, says she reserves Sculptra “for patients with severe hollowing along the lateral sides of their face, because the last thing I want to do is overstuff a face with hyaluronic acid (HA) injectables in order to give back volume.” Dr. Idriss also likes Sculptra for deep chest lines: “It has a better spreadability” than gel fillers, she says, and can help thicken the delicate chest skin.
Dr. Papri Sarkar, a dermatologist in Newton, Massachusetts, agrees that Sculptra can be a great option for certain off-the-face areas, including the chest, arms, legs, belly, and butt. For the reader who asked specifically about elbows: Yes, it can make a difference here, too, but remember, “your elbows are supposed to be kind of like that to allow flexion and extension of the forearms,” notes Dr. Aguilera. Some amount of skin bunching is normal and necessary, so don’t expect a miracle transformation.
Despite its multipurpose appeal, there are some definite no-fly zones for Sculptra — primarily the eyelids, the lips, and around the mouth. Sculptra is more likely to form nodules in these mobile areas, doctors say, so it’s safer to treat them with hyaluronic acid fillers if they bother you. (I’ll talk more about Sculptra nodules in a future post.) HA is also a better choice for the forehead and the nose, adds Dr. Sarkar, both of which are considered high-risk areas for fillers of all types.
Our next set of questions probes the differences between hyaluronic acid and poly-L-lactic acid injectables: Does Sculptra work a lot better than HA for certain areas? Is it better to use Sculptra with HA or no need? Can Sculptra remain long-term the way other fillers can?
Whew, okay! We just covered hot spots for Sculptra — but, really, a talented injector could use hyaluronic acid filler in all the same facial areas with similar success. In most cases, filler choice is a matter of personal preference. Sculptra may be slightly less detectable here or there, but that doesn’t mean you have to use it.
You can also mix and match fillers, using Sculptra in one part of the face and HA in another. Or, if you don’t get the oomph you’d hoped for from Sculptra, you could chase it with HA — if/when your doctor deems it appropriate — to augment your result. (For various reasons, you shouldn’t layer the two products in the same area during the same appointment, my sources say. I can expand on this later, if you like.)
No injectable is universally beloved, of course. Hyaluronic acid, for example, has endured its share of backlash lately — but it does boast at least one distinct advantage over Sculptra: its relative predictability. I can sense your skepticism through the screen, so let me clarify. Yes, if injected improperly, HA can migrate and get lumpy and swell up and give the under-eyes a bluish hue. And, yes, it has been shown to stick around longer than advertised. It can pile up over time. It can block the lymphatics, preventing drainage, and contribute to malar edema. And certain kinds of HA can be a bitch to dissolve. (Reversing filler is an incredibly fraught subject; you can read more about it here.)
But when you use HA, you pretty much know what to expect in terms of aesthetic payoff. When your provider pushes a certain number of cc’s, that same amount of volume is transferred to your face. In this context, hyaluronic acid filler is predictable.
We can’t say the same for Sculptra. Since its effects are dependent on the biological process of collagen production, everyone responds differently. Some people experience significant plumping from a single session while others see only modest gains after several rounds of Sculptra.
This makes some doctors uneasy. “Sculptra is a great product for the right patient — namely, someone who has very little fat,” says New York City dermatologist Dr. Joshua Zeichner. “But it doesn’t offer me the control I have with hyaluronic acid fillers. When I inject hyaluronic acid, I know exactly what type of result I’m going to see — and I see that result almost instantaneously.”
With Sculptra, potential improvements are iffy and slow to show. “It takes time to see results — about four to six weeks [at least],” notes Dr. Sarkar.
And, ultimately, if you don’t love the way you look, you’re sort of stuck, because Sculptra is not reversible. While a shot of the enzyme hyaluronidase can break down hyaluronic acid filler (at least to some extent), there isn’t a designated eraser for Sculptra. You have to wait it out. Exactly how long does it last (in you versus me versus the latest celeb to deny having injectables)? Unclear.
Based on the duration of the FDA trial, the company can claim results lasting up to 25 months. In reality, though, the collagen and resulting volume that Sculptra produces don’t vanish at the two-year mark. The fade is gradual and largely ruled by our unique physiology as well as “an individual's age, weight fluctuations, skin condition, lifestyle, and areas treated,” says Dr. Idriss.
As Beverly Hills plastic surgeon Dr. Catherine Chang explains: “The company [says] around two years in terms of seeing max effects, but we know that the body loses collagen naturally, at a rate of about 1% per year.” In her opinion, “Sculptra isn’t really permanent, because while it is stimulating the body to make more collagen, you're naturally losing collagen at the same time.”
Dr. Lara Devgan is a plastic surgeon in New York City who uses only hyaluronic acid fillers in the face. “There are a few reasons why I don’t prefer Sculptra for the face,” she writes via text. “First, facial beauty hinges on topography and the balance between light and shadows. Sculptra does not lend itself to this specificity, because it creates diffuse, non-specific fullness that can be reminiscent of an ovoid, egg-shaped face. Second, Sculptra is not completely predictable and will grow variable amounts in different people, and I value predictability and precision highly when it comes to the face. Third, in a world where we have reversibility, I don’t love the notion of a permanent filler in the face.”
The bottom line on filler longevity: We don’t know how long any of these substances (or their consequences) truly last in the body, so it pays to be conservative.
Our final questions for this post relate to filler fatigue. Readers are wondering, Can Sculptra make you look overfilled? What does an over-Sculptra’d face look like?
Sculptra is often marketed as more “natural” than traditional gel fillers, but that doesn’t mean it’s foolproof.
“Patients can definitely become overfilled from Sculptra, just as they can with hyaluronic acid or calcium hydroxyapatite [Radiesse],” says Dr. Zeichner. “It all comes down to how much you’re using, where you’re injecting the product, and what plane of the face it’s being placed in.”
Unlike an HA-stuffed face, with amorphous lips and exaggerated cheeks encroaching on the eyes, “overfilled Sculptra faces tend to look puffy and round,” says Dr. Zeichner, echoing Dr. Devgan’s earlier sentiment. (Again, Sculptra delivers diffuse volume to broad areas, not crisp contours or pinpoint definition.) If the lower face is over-injected with Sculptra, Dr. Zeichner adds, the result can resemble weight gain.
“I’ve seen a lot of unhappy Sculptra patients over the years, whether for persistent nodules or for an overfilled appearance or fullness/smoothness where there should be dimension and natural contours,” says Beverly Hills plastic surgeon Dr. Anita Patel. “This isn’t to say one can’t create these issues with HA fillers, but in those cases, we can more readily dissolve the filler.” (She’s careful to note that injectors bear responsibility for the outcomes they create. The products themselves aren’t usually to blame.)
While HA overload is fairly ubiquitous, especially in certain zip codes, Sculptra-induced filler fatigue may be somewhat less prevalent. “I have never seen an overfilled look from Sculptra,” New York City dermatologist Dr. Dan Belkin tells me. Perhaps some practitioners see less bad work with Sculptra because “the learning curve is higher,” he theorizes. “I think injectors administering it tend to be more skilled and well trained, on average, than those administering HA.”
Dr. Kami Parsa, an oculoplastic surgeon in Beverly Hills, who’s known for his expertise in correcting filler complications, believes that “Sculptra only causes an overfilled appearance if it’s injected over a previously placed hyaluronic acid filler,” he says. “The HA fillers block lymphatics and then the increased fluid from Sculptra will cause prolonged swelling.” (The fluid he’s referring to is the saline that’s added to Sculptra prior to injection.)
Since biostimulators aren’t humectants, like HA, they don’t sponge up water, giving skin that “doughy” look we hear about with gel fillers. With both types of injectables, however, overfilling can mess with muscle mechanics, making the face move unnaturally, especially when speaking and smiling.
With Sculptra getting more airtime on social media, patients are asking for it by name. And there are injectors using it indiscriminately — sometimes interchangeably with HA — across age groups. Some are even promoting it as a form of “prejuvenation” — a way to thwart early collagen loss and preserve plumpness.
All of which speaks to this observation from an astute reader: Why are doctors using Sculptra more frequently now for cheek filler? Seems aggressive.
Indeed.
Ultimately, if “the wrong candidates request this procedure and the wrong providers succumb and do whatever the patient asks, this is when problems arise and faces get out of hand,” says Dr. Idriss. “In my experience, using Sculptra on the right patient — someone whose face is sinking — can offer a lot of benefit in terms of how they’re aging by helping to support the skin structure. But the key here, as with any cosmetic procedure, is choosing the right candidate. And to take it a step further, matching the right candidate with the right provider.”
I hope you found this helpful. I’ll tackle your questions about Sculptra risks, pricing, and autoimmune considerations in future posts (below). xx
