Accepted: 29 November 2017

DOI: 10.1111/jocd.12482

MASTER CASE PRESENTATION

Polycaprolactone facial volume restoration of a 46-year-old

Asian women: A case report

Shang-Li Lin MD

Shang-Li Dermatologic & Aesthetic Clinic,

New Taipei City, Taiwan Summary
A 46-year-old Asian women was treated with a next-generation bioresorbable bios-
Correspondence
Shang-Li Lin, Shang-Li Dermatologic & timulatory polycaprolactone (PCL)-based dermal filler to restore facial volume loss.
Aesthetic Clinic, New Taipei City, Taiwan. Before- and after (12 weeks of follow-up)-treatment photographs were analyzed
Email: lslskin@gmail.com
and compared. In addition, before- and after-treatment contour images were
recorded using the VectraâXT 3D imaging system (Canfield Scientific, Inc.).
Improvement of facial volume in multiple tissue layers was observed at 4 and
12 weeks of follow-up. Total facial rejuvenation to correct descending soft tissue
with a PCL-based dermal filler was achieved through volume restoration in multiple
tissue layers of the face.

KEYWORDS
neocollagenesis, PCL, polycaprolactone, volumizing

1 | INTRODUCTION
Volume loss has been recognized as a major cause of facial aging,
and it occurs in multiple anatomical structures. By adequately volu-
mizing multiple layers of those anatomical structures by dermal filler
injection, it is possible to achieve treatment goals that are more sat-
isfying for the patients than correcting lines and folds in the face
alone. However, no two faces age identically, and there is no one
algorithm for the amount to be volumized in each face. Correlating
the observed and subjective aging signs with the possible relevant
anatomical compartments of volume loss is the key to a successful
and satisfactory treatment outcome.
A polycaprolactone (PCL)-based dermal filler has been introduced
to the esthetic market in 2010, representing a new class of biostimula-
tory dermal fillers with microspheres that are smooth and spherical-
shaped for optimal biocompatibility.1-3 The PCL-based dermal filler is
composed of 30% synthetic PCL microspheres suspended in a 70%
aqueous carboxymethylcellulose (CMC) gel carrier, and its safety and
efficacy has already been shown in several studies.4-6 Furthermore,
it not only acts as a filler with immediate volumizing effects, but also
stimulates the growth of new collagen (neocollagenesis) replacing
the volume loss.7,8 In this case study, the PCL-based dermal filler
was used to treat the descending soft tissue and contour defects of
a 46-year-old Asian women by total facial volume restoration in mul-
tiple tissue layers. The injection techniques and concepts were
derived from the recommendations of use for this product9 and
modified from the author’s previous experience of using the
injectable poly-L-lactic acid (PLLA).10
2 | MATERIALS AND METHODS
A 46-year-old women was treated 2 years before the current treat-
ment by the insertion of polydioxanone threads. The result from the
polydioxanone threads was unsatisfying and did not correct the folds
and the descending soft tissue in her face as desired. She therefore
expressed her preference for a biostimulatory product with an imme-
diate volumizing effect that lasts longer than 1 year. Considering the
needs of the patient and the volumizing characteristics of the PCL-
based dermal filler, this became the product of choice for her treat-
ment. Ten syringes (1 mL each) of the PCL-based dermal filler were
â; AQTIS Medical, Utrecht, the Netherlands). Each
used (Ellanse

----------------------------------------------------------------------------------------------------------------------------------------------------------------------
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in
any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2018 The Authors. Journal of Cosmetic Dermatology Published by Wiley Periodicals, Inc

J Cosmet Dermatol. 2018;1–5. wileyonlinelibrary.com/journal/jocd | 1

2 | LIN

syringe was premixed with 0.2 mL, 2% lidocaine before use.11 The
product was placed into the supraperiosteal (SP) plane by vertical
punctures with a 27G 1” needle (Figure 1). The amount injected was
2
determined by the surface areas to be treated using 0.2 mL/cm .
For superficial fat (SF) and deep fat (DF) placement, a retrograde
fanning technique was performed using 25G, 40 mm cannulas (Fig-
ure 1). The amount injected was also determined by the surface
areas to be treated, with each linear thread containing 0.1 mL/cm.
The treatment was carried out in the following sequence:
Upper face: right glabella (SP); right temple (SP); right brow (DF;
retro-orbicularis oculi fat, ROOF); right temple (DF; suprazygomatic
temporal fat and deep to temporalis fascia).
Midface: right zygoma and zygomatic arch (SP); right premaxillary
space and canine fossa (SP); right deep fat compartments of the mid-
face (DF; lateral suborbicularis oculi fat (SOOF), medial SOOF, buccal
extension of buccal fat, and suborbicularis oculi fat (DMCF)).
Lower face: preauricular area and mandibular angle (SF; temporal
lateral-cheek fat compartment); chin (SP); chin (DF); oral commissure
(DF). The left side of the face was treated by the same sequence in
similar anatomical structures, but differed in amount due to volume
loss differences.
The forehead (SP) and the nasal bridge (SP) were treated to cam-
ouflage the transition zone between the treated and the untreated
area to produce a more beautified contour. As the treatment goal of
this patient is to correct descending fat and contour defects caused
by volume loss in the deep fat compartments and the craniofacial
platform, the therapeutic end point for each third of the face is to
blanket the surface area to be treated, and a small extra amount of
the product can be focally added by the same techniques to reach
an ideal volumetric correction. A massage and molding of the pro-
duct was performed post-treatment.
3 | RESULTS
Immediately after and 1 week post-treatment, mild swelling and
edema of the face were observed, which resolved within 1 week
without intervention. There was no significant bruising due to deep
injections in relatively avascular anatomical structures with the use
of cannulas. Figure 2(1) shows the pretreatment images of the 46-
year-old women with several observed signs of facial aging
(Figure 2(1)). Twelve weeks post-treatment, images demonstrated a

(A) (B)

(C) (D)

F I G U R E 1 Procedure was carried out in several injection planes to achieve the best volumizing effect. A, and B show the supraperiosteal
plane and temporalis fascia injection locations. A total of 6.5 mL was injected in these planes. C, and D show the plane of the deep fat
compartments and the plane of superficial fat compartments. A total of 5.5 mL was injected in these planes
LIN | 3

F I G U R E 2 (1) Pretreatment images of the 46-year-old women demonstrated one of the most common types of Asian faces, with a
rounded face shape, thick subcutaneous tissue, and no significant hollowing. However, signs of facial aging due to volume loss in anatomical
supporting structures were noticeable on observation. The curvature of her lateral two-thirds of eyebrows reflected volume loss in the
temporal area and lack of support on the bilateral lateral upper quadrants of her bony orbits. Ptosis of her bilateral medial one-third of
eyebrows and glabellar flattening indicated loss of support in the medial upper part of the bony orbits and the overlying soft tissue. Signs of
aging in the medial parts of her midface included tear troughs, nasolabial folds, and loss of anterior projections, which all indicated volume loss
in supporting compartments such as premaxillary spaces, canine fossa, and deep fat pads of the midface. Asymmetrical volume loss in these
compartments on both sides of her face led to her jowls and a downward shift of soft tissue to a different extent on her cheeks. Lack of
support from the zygoma and zygomatic arches and volume loss in lateral temporal-cheek fat compartments could be noticed by observing the
contour of her lateral cheeks. In her lower face, chin retrusion, melomental folds, and drooping of oral commissures indicated loss of volume in
the chin, while sagging of her submental skin and the mild curved jawline indicated the possible age-related bone remodeling in the mandible
and loss of thickness in the overlying soft tissue. (2) Images of the patient that were recorded 12 wk post-treatment demonstrated a reverse
triangular shape of the face, indicating a more rejuvenated and beautified proportion. Volume restoration in the temporal area and the lateral
two-thirds of the orbits contributed to the curvature change and the lifting effect of eyebrows, which also subsequently improved the puffy-
looking upper eyelids observed in the pretreatment images. Volume change in the top of the eyebrows and glabella contributed to the more
lifted medial third of eyebrows and the improvement of glabellar flattening. The post-treatment images also demonstrated the improvement of
her tear troughs, anterior projections of her medial cheeks as well as the jowls, and downward shift of the soft tissue in the medial cheeks as a
result of volume restoration in the supporting fat compartments and an increase in surface area of the bony platform. Supraperiosteal
volumization on the bilateral zygomatic arches and zygoma as well as in the lateral temporal-cheek fat compartments contributed to the
improvement of the lateral cheek projections. The post-treatment image also showed improvement of the anterior projection, the shape and
proportion of the chin. A more defined and straightened jawline together with correction of descending submental fat was also observed in
the images due to volume restoration in multiple tissue layers of the lower face

reverse triangular shape of the face, indicating more rejuvenated
and beautified proportions (Figure 2(2)). In parallel, pretreatment
contour images of the face were obtained with the VectraâXT 3D
imaging system (Canfield Scientific, Inc.) (Figure 3, week 0). The
contour images recorded at 12 weeks post-treatment (Figure 3,
week 12) demonstrated contour changes after three-dimensional
volumization in multiple tissue layers with a change of facial shape
from a rounded one to a reverse triangular one. The contour
images showed changes in eyebrow spans and changes in the eye-
brow and glabellar contours coupled with improvement of the
drooping upper eyelids, all of which were in line with the effects
after volume restoration in multiple layers of the temples, brows,
and the glabella. A subtle contour change in the nasal dorsum
revealed the result of volumization along the nasal dorsum that
went well with the contour change of the glabella. The changes of
anterior projections in the midface as well as the improvement of
jowls were also well observed in the post-treatment contour
images. The change of chin shape and contour change in the
mandibular and submental areas indicated the results of volume
restoration in the lower face.
4 |
F I G U R E 3 For comparison and observation of contour changes, before (week 0) and after (week 12) images were recorded by the Vectra
3D imaging system
4 | DISCUSSION
Loss of contour definitions, downward shifts of soft tissue, and flat-
tening of anterior projections are common signs of aging caused by
volume loss in the deep fat compartments and by bone remodeling
in the process of facial aging. For volumes to be restored deep on
the bony surface and in the deep fat compartments, fillers with high
viscosity and elasticity are preferred to produce a good lifting effect.
In this case report, a 46-year-old Asian women was treated with a
next-generation bioresorbable biostimulatory polycaprolactone (PCL)-
based dermal filler to correct descending fat compartments and con-
tour defects caused by volume loss in the deep fat compartments
and the craniofacial platform, and to maximize the result using
10 mL of the product distributed in small amounts in multiple levels
LIN
of depth. Post-treatment facial images compared to pretreatment
facial images revealed a more reverse triangular shaped and in pro-
portion rejuvenated face with more widened temples and a more
pointed chin, coupled with the improvement of a downward shift of
soft tissue, which can be well observed in the contour images (gray-
scale photographs in Figure 3) of the restored anterior projections in
the frontal and 90-degree views. In the upper face, the images
demonstrated more beautified eyebrow shapes and a better contour
of the glabella, along with the vertically and horizontally lifting
effects in the eyebrows and eyelids, which can be attributed to volu-
mization in the ROOF. In the midface, a downward shift of the soft
tissue observed as ptosis of deep fat compartments and jowls was
corrected, coupled with a rejuvenated anterior projection after vol-
ume restoration in the premaxillary spaces and the deep fat
LIN
compartments. In the lower face, the images demonstrated improve-
ment in the definition of the jawline, downward shift of the soft tis-
sue, and a descent in submental fat. Chin projection and proportion
also demonstrated significant improvement along with the improve-
ment of melomental folds. Narrowing of the distance between the
eyebrows and the shape of the nasal dorsum were observed after
restoring the anterior projections in these areas.
The PCL microspheres of the product are homogeneously sus-
pended in the CMC gel carrier. The gel carries a high viscosity and
elasticity and provides an immediate filling effect to the treated area,
while the PCL microspheres stimulate the growth of collagen as the
gel is gradually degraded. By placing the product deeply on the bone,
it is possible to increase the surface area of bony platform that holds
the soft tissue envelop covering above it, and by placing the product
in a fanning and crosshatching fashion, the product in threads
restores volume in the supporting fat compartments as scaffolds,
and further, to correct the descending superficial fat compartments
above them, to achieve a rejuvenated proportion of the face. As
opposed to the PCL-based dermal filler, the injectable PLLA is recon-
stituted in sterile water before injection. As the water is quickly
absorbed by the body, the total injected volume decreases, which
could lead to a relatively high rate of nodule formation due to parti-
cles moving close to each other. In conclusion, total facial rejuvena-
tion to correct descending soft tissue with the PCL-based dermal
filler was achieved through volume restoration in multiple tissue layers.
While the above results show the effectivity of the PCL-based dermal
filler, it would also be interesting to show its effectivity compared to
other dermal fillers in a future comparative study. Also, based on
previous studies,9,12 the above volume restoration results with the
PCL-based dermal filler at 12 weeks follow-up are expected to be
long-lasting; however, this has to be investigated in a follow-up study.
ACKNOWLEDGMENTS
The consent and the permission of the provided figures have been
fully granted by the patient.
CONFLICT OF INTEREST
The author has no conflict of interest or financial ties to disclose.
| 5
ORCID
Shang-Li Lin http://orcid.org/0000-0003-4249-6852
REFERENCES
1. Laeschke K. Biocompatibility of microparticles into soft tissue fillers.
Semin Cutan Med Surg. 2004;23:214-217.
2. Nicolau PJ. Long-lasting and permanent fillers: biomaterial influence
over host tissue response. Plast Reconstr Surg. 2007;119:2271-2286.
3. Morhenn VB, Lemperle G, Gallo RL. Phagocytosis of different partic-
ulate dermal filler substances by human macrophages and skin cells.
Dermatol Surg. 2002;28:484-490.
4. Galadari H, van Abel D, Al Nuami K, et al. A randomized, prospec-
tive, blinded, split-face, single-center study comparing polycaprolac-
tone to hyaluronic acid for treatment of nasolabial folds. J Cosmet
Dermatol. 2015;14:27-32.
5. Moers-Carpi MM, Sherwood S. Polycaprolactone for the correction
of nasolabial folds: a 24-month, prospective, randomized, controlled
clinical trial. Dermatol Surg. 2013;39(3 Pt 1):457-463.
6. Figueiredo VM. A five-patient prospective pilot study of a polycapro-
lactone based dermal filler for hand rejuvenation. J Cosmet Dermatol.
2013;12:73-77.
7. Kim JA, Van Abel D. Neocollagenesis in human tissue injected with a
polycaprolactone-based dermal filler. J Cosmet Laser Ther.
2015;17:99-101.
8. Nicolau PJ, Marijnissen-Hofste  J. Neocollagenesis after injection of a
polycaprolactone based dermal filler in a rabbit. Eur J Aesth Med Der-
matol. 2013;3:19-26.
9. de Melo F, Nicolau P, Piovano L, et al. Recommendations for volume
augmentation and rejuvenation of the face and hands with the new
generation polycaprolactone-based collagen stimulator (Ellanse â). Clin
Cosmet Investig Dermatol. 2017;10:1-10.
10. Fitzgerald R, Vleggaar D. Facial volume restoration of the aging face
with poly-l-lactic acid. Dermatol Ther. 2011;24:22-27.
11. de Melo F, Marijnissen-Hofste  J. Investigation of physical properties
of a polycaprolactone dermal filler when mixed with lidocaine and
lidocaine/epinephrine. Dermatol Ther. 2012;2:13.
12. Bae B, Lee G, Oh S, Hong K. Safety and long-term efficacy of
forehead contouring with a polycaprolactone-based dermal filler.
Dermatol Surg. 2016;42:1256-1260.
How to cite this article: Lin S-L. Polycaprolactone facial
volume restoration of a 46-year-old Asian women: A case
report. J Cosmet Dermatol. 2018;00:1–5. https://doi.org/
10.1111/jocd.12482