Radiesse™ for Facial Rejuvenation

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Radiesse™ for Facial Rejuvenation

Radiesse for

Facial Rejuvenation

Lenora I. Felderman, MD

Cosmetic Technique

New products constantly are being developed to help ease the ravages of time and aging. One of these

is Radiesse, an injectable compound of calcium hydroxylapatite suspended in an aqueous gel. Radiesse

is an excellent filler for nasolabial folds, marionette lines, oral commissurae, and deep rhytides.

The technique for administering Radiesse is subdermal injection, most commonly at the junction of

deep dermis and subcutaneous tissue. On withdrawal of the syringe, small aliquots of material

are deposited uniformly along the plane. Subsequent injections may be made through the same

entry point.

Radiesse

COS

is considered a semipermanent filler.

DERM

Most recent clinical data have reported between 30%

and 100% correction at 1 year. In my clinical experience, correction duration of at least 1 year results in

high patient satisfaction. However, booster injections may be required during this period for patients

with deep defects. Regardless of the exact correction duration, this injectable compound holds promise

for long-term soft tissue augmentation of lines, depressions, scars, and facial defects.

Do Not Copy

With the increasing interest in cosmesis

and ongoing quest for a youth-

clinician should first identify the “problem” areas and select

When assessing the patient from an aesthetic perspective, the

ful appearance, products constantly products and procedures that would most effectively achieve

are being developed to minimize the desired cosmetic correction. For example, as an individual

ages, bone density loss combined with diminished skin

the ravages of time and aging.

These products include cosmeceuticals designed to mitigate

the effects of photoaging, fillers to soften furrows and signs of aging (eg, wrinkling, furrowing, sagging).

firmness and elasticity, as well as gravity results in telltale

wrinkles, agents to relax and immobilize facial muscles, Fortunately, products have been developed to help correct

and peels and lasers to smooth the complexion and eliminate

pigmentary and vascular changes. As a result, the introduced into the marketplace for aesthetic use, describe

these signs of aging. This article will examine products being

practitioner has been equipped with an extensive armamentarium

to help achieve facial rejuvenation.

appropriate use of Radiesse for facial rejuvenation.

the characteristics of the ideal facial filler, and focus on the

This influx of new products presents a challenge to the

physician (ie, which products to use in each circumstance).

Dr. Felderman is Clinical Assistant Professor of Dermatology,

Weill Medical College of Cornell University, New York, New York,

and Assistant Attending Physician, Division of Dermatology, New

York-Presbyterian Hospital/Weill Cornell Medical Center.

The author reports no actual or potential conflict of interest in

relation to this article.

EVOLUTION OF FACIAL FILLERS

The ideal filler should be nonallergenic, durable, easily

injected, user-friendly, cost-effective, and malleable

enough to provide a “natural” look and feel. In addition,

it should degrade naturally, require no reconstitution or

refrigeration, have a long shelf life, evoke minimal pain

on injection, require minimal downtime, and exhibit few

side effects.

VOL. 18 NO. 12 • DECEMBER 2005 • Cosmetic Dermatology 823

Copyright Cosmetic Dermatology 2010. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher.


Facial Rejuvenation

Since the introduction of injectable collagen in the late

1970s, a host of new soft tissue fillers has been developed

that provide temporary to semipermanent correction. These

fillers are malleable substances injected into the skin to

improve facial rhytides and deep lines of facial expression,

augment and enhance the size and shape of the lips, and

minimize facial defects, scarring, and imperfections. Each

filler has its own unique properties, allowing the physician

to choose the optimal agent for each patient thus enhancing

predictability and safety with minimal morbidity.

Longevity

Radiesse is considered a longer-lasting agent than collagen

COMMONLY USED FILLERS

and hyaluronic acid, with correction durations of up to

Dermal fillers in particular have been created to restore 2 years. The CaHA microspheres typically are degraded via

volume in a process known as soft tissue augmentation. 1 normal tissue metabolism into Ca 2+ and PO 3-

ions and do

Commonly used fillers include autologous fat, collagen, not calcify when implanted into soft tissue. 3 Longevity of

hyaluronic acid, poly-L-lactic acid, and, with increasing correction depends on many factors, including the patient’s

frequency, calcium hydroxylapatite (CaHA). These fillers age and ability to produce new soft tissue around the CaHA

are not permanent treatment solutions. The efficacy and implant and the relative dynamic motion of the area in

duration of correction depend on the individual properties

of each agent, the specific treatment site, and the tions are extended in static facial areas such as the nasal

which the implant is placed. For example, correction dura-

patient’s idiosyncratic

COS

metabolism of the product.

DERM

dorsum or malar area (18–24 months) compared with

those of motile areas such as the nasolabial folds and

RADIESSE

marionette lines (12–18 months).

Currently on the horizon for facial contouring and fold correction

is Radiesse (formerly known as Radiance FN). This of material laid down in a fanning or cross-hatching

The method by which Radiesse is injected (fine threads

pat-

product is derived from uniform microspheres of CaHA, tern) results in diffuse placement. Although CaHA is

measuring 25 to 45 µm and suspended in an aqueous carboxymethylcellulose

radiopaque, particle size combined with injection technique

renders

Do

gel. 2,3 Each component

Not

has been studied

and used extensively in implants and drug delivery clinical data have reported between 30% and 100% cor-

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the implant invisible on x-ray. Most recent

systems for many years, with applications in otolaryngology, rection with Radiesse at 1 year. 5 In my clinical experience,

dentistry, orthopedics, urology, and neurosurgery. 4 Although correction duration of at least 1 year yields high patient

Radiesse is not yet approved in the United States for facial satisfaction. Booster touch-up injections may be required

aesthetics, off-label use as a facial soft tissue augmentation

material has been gaining increasing popularity and recognition

within the medical community. Radiesse is an excellent

material for correcting nasolabial folds, marionette lines, oral

commissurae, and deep rhytides.

Radiesse exemplifies how a naturally occurring substance,

originally instituted for medical applications, evolved into

the realm of a cosmetic agent. For example, botulinum toxin

type A initially was indicated for blepharospasm. However,

the elimination of crow’s-feet surrounding the orbit was

noted during and after its injection. This observation served

as a springboard for the expansion and development of the

product for various cosmetic needs. The expansion of uses

for Radiesse has a similar history.

Mechanism of Action

On injection of Radiesse, the vehicle slowly starts to

degrade, and collagen deposition begins to occur around

the CaHA microspheres. This process results in tissue

expansion and anchoring and a consistency similar to that

of the surrounding tissue. Over time, the microspheres are

integrated into the surrounding soft tissue and naturally

conform without reaction or migration. Because of their

relatively large size, migration of CaHA particles from the

implant site has not been reported and is highly unlikely.

Furthermore, because the microspheres become integrated

into the new collagen and soft tissue, they essentially are

anchored into place and thus prevent movement over time.

during this period and are recommended for lasting correction

in patients with deep defects.

Treatment Sites

Facial sites best suited for Radiesse injection are the

nasolabial folds, marionette lines (Figures 1 and 2),

angles of the mouth, and deep wrinkles and furrows of

the perioral area. Studies have shown marked efficacy and

safety using Radiesse for HIV-associated facial lipoatrophy,

as well as in facial contouring of the jawline and

malar eminence. 2

Injection of other areas such as the tear trough/nasojugal

groove and lip mucosa has been studied. However, the

potential risks of side effects include lumpiness and nodule

formation. Fillers such as hyaluronic acid and collagen

are best suited for these areas.

Injection Technique

The technique for administering Radiesse is subdermal

injection, most commonly at the junction of deep dermis

824 Cosmetic Dermatology • DECEMBER 2005 • VOL. 18 NO. 12

Copyright Cosmetic Dermatology 2010. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher.


Facial Rejuvenation

Figure 1. Injection sites of Radiesse for treatment of nasolabial folds.

Figure 2. Injection sites of Radiesse for treatment of marionette lines.

and subcutaneous tissue. For correction of the nasolabial

folds, the needle usually is placed at the lip commissure,

entering the subdermal space at a 45º angle. The needle

bevel should be placed upward, with the needle advancing

forward, parallel to the dermis and slightly medial to the

fold toward the nasal alae. Injections should be slow, using

crosshatch may be used to help elevate the depression in

the angle of the mouth. These areas also should be

molded gently. If bleeding occurs at the injection site,

applying pressure for several minutes will allow adequate

time for hemostasis and may help prevent further ecchymoses

and hematoma formation. Placing ice packs on the

a retrograde

COS

technique. On withdrawal of the syringe,

DERM

treatment site before and after the procedure helps ease

small aliquots (typically 0.05 mL in volume) are deposited discomfort, swelling, and bruising.

uniformly along the plane. Injections should stop before

exit of the needle to avoid superficial deposition. Correction Ratio

Subsequent injections may be achieved through the same The correction ratio for Radiesse is approximately 1:1 (ie,

entry point, placing the material medial to the previous

thread. Further injection into the alar depression is

overcorrection should be avoided). 6 If necessary, the practitioner

should err on the side of undercorrection and have the

achieved

Do

via deposition of threads

Not

in a fanning motion to patient return

Copy

for touch-up treatment 2 to 4 weeks following

correct the depression in the canine fossa (Figures 3 and 4). initial treatment to complete the augmentation. Immediate

Molding should be performed to create smoothness, edema and erythema may occur postinjection, which may

ensure proper placement, and prevent lump formation. obscure the severity of the defect and amount of material

Molding is achieved by placing the thumb intraorally and required to produce the desired correction. In addition,

the index finger on the overlying

facial skin and gently massaging to

achieve evenness and symmetry.

Deposition of material in fine

threads rather than in a bolus also

greatly reduces any likelihood of an

irregular appearance.

Figure Not

Figure Not

Needle gauge sizes used for

Available Online

Available Online

administering Radiesse range from

25 to 30 mm. My preference is

a 27-gauge, 1.5-inch needle for

nasolabial folds and a 27-gauge,

1-inch needle for marionette lines,

angles of the mouth, and deep perioral

rhytides. A shorter needle (one

A

B

half to 1 inch) is preferred for

greater control when injecting

Figure 3. Patient before (A) and 24 months after (B) nasolabial fold treatment with Radiesse.

Patient received 1.4 mL initially and then 0.6 mL at touch-up. Photograph courtesy of Miles

Graivier, MD (North Atlanta Plastic Surgery Center, Georgia). Reprinted with permission from

smaller areas. Marionette lines also

Cosmet Surg Times (Special Report). August 2004:14,17. Cosmetic Surgery Times® is a copyrighted

are injected slightly medially, and a

publication of Advanstar Communications Inc. All rights reserved. 5

fanning technique or subdermal

VOL. 18 NO. 12 • DECEMBER 2005 • Cosmetic Dermatology 825

Copyright Cosmetic Dermatology 2010. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher.


Facial Rejuvenation

Figure Not

Available Online

Figure Not

Available Online

Figure 4. Patient before (A) and 14 months after (B) nasolabial fold treatment with 1.2 mL

of Radiesse. Photograph courtesy of Miles Graivier, MD (North Atlanta Plastic Surgery

Center, Georgia). Reprinted with permission from Cosmet Surg Times (Special Report). August

2004:14,17. Cosmetic Surgery Times® is a copyrighted publication of Advanstar Communications

Inc. All rights reserved. 5 A B

Anticipating Side Effects

Antiviral prophylaxis in individuals

with a history of herpes simplex is

recommended. Because of the variability

of effect achieved with topical

anesthetics, administration of intraoral,

infraorbital, and mental blocks

with 1% lidocaine is recommended.

Corrective makeup can be of significant

benefit during the immediate

postprocedural period, and supplements

such as arnica and bromelain

may be useful. Occasionally when

patients experience severe swelling,

a short course of oral corticosteroids

may be indicated.

CONCLUSION

The treatment options available

for soft tissue augmentation have

grown significantly in the past

20 years. However, not all products

are appropriate for treating all areas.

The skilled practitioner must assess treatment sites and

COS DERM

administering a local anesthetic may result in temporary

asymmetry, which may make injection more difficult. “It is select products that are appropriate for each specific

advisable to fully correct each area because swelling may not

allow touchup to the area at the end of the session.” 7

area. Radiesse holds promise as a viable treatment option

for long-lasting soft tissue augmentation of facial lines

Do Not

and contours,

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rhytides, depressions, and scars.

Advantages and Disadvantages

The advantages of Radiesse as a filler substance are its REFERENCES

longevity, nonimmunogenicity, injectability, and long 1. Alibhai H. The brave new world of facial dermal fillers. Aesthetic

Buyers Guide. 2005:48-52.

shelf life without the need for reconstitution or refrigeration.

Practitioners will gain confidence in administering associated facial lipoatrophy with Radiance FN (Radiesse).

2. Comite SL, Liu JF, Balasubramanian S, et al. Treatment of HIV-

Radiesse once the product becomes more widely used. Dermatol Online J. 2005;10(2):2. Available at: http://www.dermatology.

Possible disadvantages are pain on injection, variable

edema, erythema, and ecchymoses. Discontinuing blood

cdlib.org/102/therapy/HIV/comite.html. Accessed September 1, 2005.

3. Tzikas TL. Evaluation of the Radiance FN soft tissue filler for facial

soft tissue augmentation. Arch Facial Plast Surg. 2004;6:234-239.

thinners and anticoagulants (eg, warfarin, clopidigrel,

4. Hubbard W. Bioform implants: biocompatibility. Franksville, Wisc:

aspirin, non-steroidal anti-inflammatories) prior to treatment

can minimize bruising. In addition, several vitamin 5. Jesitus J. Radiesse effective intermediate filler: corrects variety of

Bioform Medical Inc; 2003.

and nutritional supplements (eg, gingko biloba, Saint- cosmetic problems, though durability disappoints. Cosmet Surg

John’s-wort, vitamin E, lutein) may have anticoagulant Times (Special Report). August 2004:14,17.

6. Sklar J, White SM. Radiance FN: a new soft tissue filler. Dermatol

effects. As noted previously, Radiesse may not be an optimal

filler for certain areas (eg, lip mucosa, tear trough/ 7. Busso M. Soft tissue augmentation with Radiance FN. Aesthetic

Surg. 2004;30:764-768.

nasojugal groove, temple).

Trends Technol. 2003;2(3).


826 Cosmetic Dermatology • DECEMBER 2005 • VOL. 18 NO. 12

Copyright Cosmetic Dermatology 2010. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher.

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