The most critical modification of PLLA injection of these sites is the hyperdilution of the product (>7 mL per vial) and extended product hydration (>1 wk).
Calcium hydroxylapatite (CaHA), composed of synthetic CaHA microspheres suspended in an aqueous carboxymethylcellulose gel carrier, was introduced in 2006 as a dermal filler for facial wrinkles and folds25 and was approved for hand rejuvenation in 2015.48–53 Although CaHA fillers are generally well tolerated, they can produce increased injection-site reactions and granuloma formation when compared with HA fillers54,55 and should be utilized by experienced injectors in the appropriate applications.56,57
The recent introduction of longer lasting HA fillers with greater lifting power in the context of residual inflammatory scarring in surgical areas previously treated with CaHA injections has led to a shift in CaHA applications. The authors’ preference is to use CaHA specifically for the volumization of deep supraperiosteal regions that are not dissected during standard surgical rejuvenation of the face and for subcutaneous hand rejuvenation.
The ideal patient presents with discrete volume loss requiring volumetric augmentation, rather than superficial line filling. Either needles or cannulas can be used. Ideal zones for supraperiosteal injection are mental protuberance, prejowl sulcus, temporal fossa, mandibular angle, and alar bases. The most critical modification of CaHA injection of these sites is the blending of the product with normal saline or lidocaine and epinephrine (in a 0.02–1:1 ratio) to soften its rheological properties and increase ease of injection. The authors recommend microbolus injections (0.1–0.3 mL) to avoid overfilling as CaHA dissolution cannot be achieved with hyaluronidase.
CaHA has distinct advantages over the other fillers in the hand because of its white color that provides a concealing effect over veins and tendons and its malleability.58 The authors recommend the use of blended CaHA for hand volumization with lidocaine 1% to 2%, 0.1 to 1 mL per CaHA syringe, to decrease pain and viscosity58–66 (Table 7). Either needles or cannulas may be safely65 utilized, with the benefit of a single entry point with cannulas. (See video, Supplemental Digital Content 11, which demonstrates hands Radiesse cannula injection, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRSGO/A343.) Increased adverse effects are associated with higher volumes injected.60 The authors agree with the current recommendations not to exceed 3 mL of CaHA per hand60 (Table 7).
The field of facial aesthetics has evolved dramatically over the past 2 decades. Our increased understanding of 3-dimensional structural volume restoration in combination with the continuous development of novel injectable products with distinct properties has stimulated this evolution. Consequently, it has become critically important to understand not just the basic technical approaches to volumization and neuromodulation but more importantly the unique nuances of patients’ tissues in relation to innate product characteristics and the potential to modify the latter to match the former. Blending or “customizing” injectable products with anesthetic agents or other diluents can often result in a better outcome for complex areas, such as the periorbital and perioral areas, hands, and décolletage.
In addition, recent patient-perceived outcome data suggest that product customization may be important in specific patient populations. For example, older patients may perceive more of a benefit from full neuromodulator correction, whereas men and younger women may prefer undercorrection.8 Recent novel data confirming differential strain reduction patterns among the 3 neurotoxins further support customized treatments within and between patients.9 The authors reviewed current FDA-approved injectables and described how, through clinical experience, product modification can produce safe and natural results with excellent patient outcomes. We provided our recommendations for subtle alterations in product profiles in discrete anatomic sites for both inexperienced and experienced injectors. The incorporation of these customized techniques will enable cosmetic practitioners to produce refined individualized results for the increasingly discerning cosmetic patient population.
Complications and adverse events with injectables can be prevented in most cases. Nevertheless, every patient is advised of these uncommon events and most accept the risk by affixing their signature to consent (Table 8).
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