Bottoms up

How can we meet the demand for non-surgical bottom enhancements to help our patients achieve the results they want safely and effectively? Dr Sabika Karim explores the role of Lanluma (PLLA)

DR SABIKA KARIM

Dr Sabika Karim has more than 10 years’ experience at the forefront of her field. With a keen interest in teaching and research, her practical approach to applying her insight has resulted in her developing ground-breaking new aesthetic treatments for the face and body. She is an international laser expert and a Key Opinion Leader and trainer for Sinclair Pharma’s Lanluma and MaiLi. As a trainer for Sinclair, Dr Karim has been treating with Lanluma in the buttocks since before its launch in February 2021.

The growing trend for a shapelier bottom has led to an increased demand for surgical and non-surgical bottom enhancements. Whether it is due to the Kim Kardashian effect or the pressure of posting pictures on social media, enhancement of the buttocks is becoming ever more desired. Patients are weary of the surgical Brazillian Buttock Lift (BBL) as this carries significant pain, downtime and risks, with the risk of mortality being reported as high as up to 1:2351 by Mofid et al. in 2017.1

Patients are seeking safer alternatives. Energy-based devices can help treat fat pockets, increase muscle tone and improve skin quality. For volume enhancement, the only non-surgical option for enhancing volume and shape is injection with dermal fillers. To date, in the UK, the choices have been hyaluronic acid fillers, with only Hyacorp having been approved for the body, or off label fillers such as collagen stimulators such as Radiesse, Ellanse or Sculptra. Though hyaluronic acid fillers (on or off label) give an instant result, the amount of filler required can make the buttocks feel hard and be costprohibitive for the patient. The duration of results is only six to 12 months.

The launch of Lanluma, a Poly-L-lactic acid (PLLA) approved for use both in the face and body, has opened up this procedure for patients and physicians. The on-label use of the PLLA for buttock enhancement gives long-lasting results in excess of two years. Because of the mechanism of action as a collagen stimulator, the results of the enhancement look and feel natural. Not to mention there is little downtime as the patient can sit and sleep on their buttocks.

For an experienced practitioner, who understands the anatomy of the buttocks, patient selection and assessment, the non-surgical buttock enhancement is a safe procedure that can improve the shape, volume and skin texture of the buttocks.

However, patients must realise that just because this procedure is non-surgical, it doesn’t mean it is non-medical.

NON-SURGICAL BUTTOCK ENHANCEMENT

The non-surgical buttock enhancement treatment is for men and women aged 20-60, BMI 18.5-25, of stable weight and healthy lifestyle, who require one or more of the following:

• Change in the shape of the buttocks
• Lifting of buttocks
• Increased volume of buttocks
• Improvement in skin texture
• Improvement in the appearance of cellulite in the buttocks

Patients present with different types of buttock shapes.

Desirable shapes differ, for example, the Caucasian preference has traditionally been the heart shape, whereas round is the desired shape for South Americans and millennials.

The reason I choose to use PLLA for buttock augmentation is because it is a synthetic polymer derived from the alpha hydroxy acid family, which is biocompatible, biodegradable, non-immunogenic and has a long history of safe use. Lanluma is CE approved for body contouring and use in the buttock. The PLLA can be injected both subdermally or supraperiosteally, and the PLLA stimulates the fibroblast to produce collagen. Its slow degradation kinetics where the PLLA is absorbed over two years means long-lasting results for my patients, in excess of two years.

CONSULTATION

The consultation is key to any aesthetic procedure. In addition to the usual patient demographics and previous medical, surgical and aesthetic history, lifestyle and if they are a stable weight, it is important to establish a rapport with the patient to make them feel comfortable. One key question that I ask all patients is the precipitating factor for the consultation. It is usually a milestone birthday or a picture on social media. It can even be an important work or social event. I then ask the patient to complete a Body Dysmorphic Disorder questionnaire. 2

For volume/shape enhancements, the options are:

1. Filler – PLLA/HA
2. Surgical referral
3. No treatment

For Skin texture improvements and the appearance of cellulite:

1. Minimally invasive – PLLA
2. Invasive – such as Cellulaze or Cellfina
3. Energy-based devices – such as RF microneedling with Secret RF
4. No treatment

If the patient wishes further to discuss the PLLA option (with Lanluma), I would describe the procedure and discuss possible side effects, complications, contraindications, and aftercare.

EXAMINATION AND SETTING PATIENT EXPECTATIONS

I stand in the mirror with the patient and ask them what they are trying to achieve. If they advise me they want a significant volume or a drastic change to their buttocks, I would advise them they are not suitable for the procedure and refer them to surgical colleagues. Most of my patients just want reshaping, lifting and skin improvement, all of which can be delivered non-surgically with PLLA. We discuss the likely results, the number of sessions and cost, bearing in mind that each treatment will give equivalent to a maximum of approximately 100-120ml volume improvement.

I ask the patient to identify their buttock shape on a chart, and what shape they would like to achieve is recorded.

On examination, the patient is weighed, height measured, and BMI recorded. The shape of the buttocks is recorded, as is any buttock Ptosis. Grade III Ptosis is extremely difficult to treat, and results will only be modest.

The standard protocol is to send the patient home with written information on the procedure, the product, side effects, possible complications and treatment plan, including cost and number of sessions.

It is very important to explain to patients that PLLA does not give immediate results other than for a few days with initial volume due to the water used for reconstitution.

New collagen takes time to be produced; results will start to show after two months and progressively improve over nine months. New collagen growth will vary between patients and depends on age, smoking, sun exposure and lifestyle. The longevity of results may be affected by excessive sun exposure and smoking as these will cause premature breakdown of the new collagen, and smoking also slows the production of new collagen.

We then discuss possible side effects, which include injection-related side effects such as reaction around the treated area (bleeding, pain, induration and swelling), Infection and inflammation (cellulitis and staphylococcal infection, and abscess), skin and subcutaneous tissue disorder (bruising, bleeding, atrophy and skin hypertrophy, erythema, telangiectasia, papules and nodules), and those specifically related to Lanluma such as nodules or a foreign body reaction.

The contraindications for Lanluma are any person with active inflammation or infection; hypersensitivity to any of the components; use near the periorbital or lip area; patients with active autoimmune diseases, such as rheumatoid arthritis; or patients with diseases for which interferon therapy is indicated or required. The safety and effectiveness of the product has not been evaluated in patients under the age of 18 or in women who are pregnant, breastfeeding or lactating.

THE TREATMENT

On the day of treatment, each vial of Lanluma X containing 630mg of PLLA is mixed with 40ml of sterile water for injection. The vial is then agitated for 10 minutes and left to rest.

The patient is asked to sign the consent form, weighed, and photographs are taken at 0, 45 and 90 degrees.

With the patient standing, the area around the periphery of the deficit is marked out as well as the site of the desired maximum projection. The anatomical landmarks are also marked out to ensure that the entry point avoids the superficial branches of the upper gluteal artery. The periphery of the deficit is then marked into quadrants, with the central point identified. Next, I mark out how much product by volume to be injected in each quadrant. The injection area is cleaned with chlorhexidine or equivalent.

Anaesthesia (1% lidocaine) is injected with a dermal bleb into the cannula entry points.

The injection area is undermined with 10ml of 1% lidocaine injected with a 22G 70mm or 18G 70mm cannula in a retrograde fanning technique subdermally. No more than 4.5mg per kg lidocaine 1% should be injected in total.

The reconstituted PLLA is injected subdermally using a linear withdrawal fanning technique with only retrograde injections, working in quadrants around the clock face, an 18G 70mm cannula in threads of 0.5m-1mll with per linear thread.

RESULTS

Results from the treatment usually take 30-60 days. Patients can be involved in how many procedures they require due to the stepwise approach of this treatment.

Typically final results are achieved with two to three sessions, with two to four vials of Lanluma X.

MAINTENANCE

If maintenance is required, I would usually advise one session annually.

CASE STUDY

Vicky is a 36-year-old female patient with a healthy lifestyle and a BMI of 22.3. She attended the clinic for consultation, requesting a non-surgical bottom enhancement to help with the shape of her bottom so that she can feel more comfortable in tight dresses and leggings. Below are Vick’s results at 12 weeks from one session of treatment with four vials of Lanluma X. The improvement in shape, volume and skin texture is clearly visible.

CONCLUSION

In conclusion, the launch of Lanluma, a PLLA approved for body treatments, provides a valuable treatment option for patients seeking a natural-looking enhancement to buttock volume or improvement to the shape or skin texture of the buttocks.

As a trainer for Sinclair Pharma, Dr Karim has been treating with Lanluma in the buttocks since before its launch in February 2021. The product is living up to its early promise, and now she has had a year of using it in practice, she is building a body of evidence of its effectiveness.