Soft tissue fillers offer a versatile, nonsurgical option for facial augmentation and contouring with a multitude of potential aesthetic applications.19 Volume loss and displacement of facial fat pads associated with ligament laxity cause skin drooping over a changing bony skeleton.20 Skin aging is related to increased activity of endogenous enzymes, among other factors, that promote the breakdown of collagen and elastin fibers.21,22 The properties of Radiesse provide it with substantial versatility and appropriateness for most aspects of facial rejuvenation, volume restoration, contouring, and skin tightening. In the authors’ experience, Radiesse diluted 1:1 can improve acne scars with minimal volume gain,23 and hyperdiluted use allows the health-care professional to offer patients more global treatment rather than local filling/volumization, as the product can be more easily spread on the skin, providing general skin tightening with progressive, natural, and discrete volume gains (Fig. 1).
Current Practice and Consensus Statements for Face Treatment
According to experts, the following guidelines for face treatment with CaHA were established. The product can be applied via retroinjection using cannulas and fanning or “asterisks” techniques with 2–4 entry points in each hemiface. With needles, the short linear threading technique is preferred (Fig. 2, Table 1). For face treatment, a dilution of 1:1 (1.5 mL of diluent) and usually 1 syringe per session are indicated (Table 1).
Neck and Décolletage
Rejuvenation procedures for the neck and décolletage have increased substantially in recent years. Although CaHA use for neck and décolletage treatment is off-label, its ability to induce extracellular matrix remodeling after subdermal injection may have a significant impact on reducing fine wrinkling, improving skin quality, and promoting local skin tightening.8,24 In one study,24 the authors described a technique for addressing horizontal neck lines by injecting hyperdiluted CaHA. Another trial7 evaluated the stimulating effects of diluted CaHA in subjects with skin laxity in the neck and décolletage. Twenty subjects received subdermal injections of CaHA with different dilutions of preserved saline at baseline and after 4 months according to skin thickness: 1:2 (normal skin), 1:4 (thin skin), and 1:6 (atrophic skin). Changes in skin mechanical properties were measured by ultrasound scanning and cutometry. Immunohistochemical data showed increased collagen and elastin production correlated with improved skin elasticity and pliability, as evaluated by cutometry, and ultrasound revealed increased dermal thickness. Subject and investigator satisfaction were high, and the procedure was well tolerated.
Current Practice and Consensus Statements for Neck Treatment
According to the experts, the following guidelines for neck treatment with CaHA were established. Product application can be performed by cannula via retroinjection with 3–5 entrance points (Fig. 3, Table 1). The short linear threading technique with a needle is an alternative technical option. For neck treatment, a dilution of 1:2 to 1:4 (3–6 mL of diluent) is usually indicated according to the patient’s skin thickness. Usually, 1 syringe per session is indicated (Table 1).
Current Practice and Consensus Statements for Décolletage Treatment
The following guidelines for CaHA décolletage treatment were established. It can be performed by the short linear threading technique with needle or via retroinjections with a cannula (Table 1). Generally, a dilution of 1:2 to 1:4 (3–6 mL of diluent) is indicated according to the patient’s skin thickness. Usually, 0.5–1 syringe per session is indicated (Table 1).
Buttocks and Thighs
Buttocks and thighs play an important role in maintaining or improving body contours. Individuals present with a wide range of complaints: generalized lipohypertrophy or lipohypotrophy, gluteal sagging, and cellulite-induced skin-surface irregularities, among other complaints.8,25–27 Increasing the strength and elasticity of the dermis and superficial fascia is an important aim when treating skin laxity and cellulite dimples. CaHA injections have unequivocally demonstrated collagen-stimulating properties and improvements in skin laxity in different aesthetic applications.12 When used with MFU, the biostimulatory effects of both treatments can be synergistic. One study12 evaluated the effects of MFU-V in combination with diluted Radiesse on cellulite appearance. Twenty women with cellulite and skin laxity on the thighs and buttocks were retrospectively enrolled. MFU-V was applied and immediately followed by subdermal CaHA injection (1.5 mL/buttock or thigh). Two independent evaluators reported statistically significant improvements 90 days after treatment for each item of the cellulite severity scale (P < 0.001). This combination treatment was considered effective for improving the appearance of cellulite and skin laxity. In the authors’ experience, the use of Radiesse alone (1.5 mL diluted with 6 mL of diluent) can also improve skin tightening and the appearance of cellulitis dimples.
Current Practice and Consensus Statements on Buttocks Treatment
The following guidelines for CaHA buttocks treatment were established. For buttocks skin laxity, the product can be applied with a cannula using the fanning or asterisks technique. The product should be applied mainly on the upper and lateral portions of the buttocks and on cellulite dimples (Figs. 4, Table 1). The short linear threading technique can also be used with needles. Usually, 1 syringe per buttock side per session is indicated. For buttocks skin laxity, the dilution may range from 1:1 to 1:4 (1.5–6 mL of diluent), whereas for cellulite dimples, lower dilutions (1:1 or 1:2) can be used (Table 1).
Current Practice and Consensus Statements on Thighs Treatment
The following guidelines for CaHA thigh treatment were established. The product can be applied to the inner and posterior thigh areas. The most frequently used technique for skin laxity is multiple cannula passages with fanning or asterisks injections (Table 1). The short linear threading technique can also be used with needles. Usually, 1 syringe per thigh area (inner or posterior) is indicated. The recommended CaHA dilution may range from 1:1 to 1:4 (1.5–6 mL of diluent) according to the degree of laxity (Table 1).
A body-vectoring technique using CaHA injections demonstrated notable reductions in skin flaccidity and increases in skin density and thickness in the abdomen and thighs 5 weeks after 1 treatment session.28 In 2017, Lapatina and Pavlenko29 evaluated the effectiveness of hyperdiluted CaHA for skin tightening in a case series of 10 women with skin laxity in the abdomen using ultrasound. CaHA diluted 1:4 with saline solution was injected subdermally using the linear threading technique, and the authors concluded that CaHA improved skin elasticity and increased abdominal dermal thickness after only a single treatment.
Current Practice and Consensus Statements of Abdomen Treatment
The following guidelines for CaHA abdomen treatment were established. Product application can be performed by both cannulas (the fanning or asterisk technique) and needles (short linear threading) with distribution across 4 abdominal quadrants (Fig. 5, Table 1). The short needle linear threading technique is particularly indicated for the periumbilical region. Product dilution can range from 1:1 to 1:4 (1.5–6 mL of diluent). Usually, one syringe is indicated for the upper abdominal region and another one is required for the lower half per session (Table 1).
As part of the natural aging process, the skin elasticity and firmness of the upper arms begin to decrease, increasing the visibility of some signs of aging, such as loose-hanging skin and fine wrinkles. In a prospective study,15 30 subjects received CaHA injections to the upper arms (1.5 mL/arm/visit) at 2 separate visits 1 month apart. Four months after the second treatment, flaccidity and volume showed significant improvements, with 77% of the subjects rating the improvements as good or great. In another study,29 improved skin elasticity of the arms was observed by cutometry after hyperdiluted 1:2 CaHA injection using the short linear threading technique (Fig. 6).
Current Practice and Consensus Statements on Arm Treatment
The generally recommended technique is retroinjection with a cannula with 2–4 fanning injections distributed along the inner arm (Fig.7, Table 1). Usually, 0.5–1 syringe per arm is indicated per session. The preferred dilution range is from 1:2 to 1:4 (3–6 mL of diluent) (Table 1).
Knees and Elbows
The knees and elbows show increased laxity with age. Although no clinical studies are available regarding CaHA treatment of these areas, in the authors’ experience, the local aged appearance can be improved by CaHA-generated collagen stimulation.
Current Practice and Consensus Statements on Knee Treatment
Product application can be performed via retroinjection with fanning with a cannula or by the short linear threading technique with needles. Treatment is suggested mainly for the region located above the patella. The recommended dose per session is 1 syringe in total (half per side) (Fig. 8, Table 1). No consensus was reached on the dilution used for the knees, but the authors presented their experiences with different dilutions ranging from 100% (1.5 mL) to 400% (6 mL).
Current Practice and Consensus Statements on Elbow Treatment
According to the experts, the following guidelines for CaHA elbow treatment were established. Product application can be performed by injecting the product with the short linear threading technique with a needle. The treatment is suggested mainly for the superior region of the elbow using 1 syringe in total (half per side) per session (Table 1).
Postprocedure, Adverse Events, and Follow-up Instructions
Exposure of the treated area to excessive sun and heat should be minimized for approximately 24 hours. A cold pack can be used to minimize tenderness, swelling, and bruising. During the treatment session, the treated area may need to be massaged to ensure that the CaHA is distributed evenly.30 If nodules develop, they can be treated with lidocaine or saline followed by vigorous massage. Nodules that do not resolve may respond to a series of ≥3 injections of 5-fluorouracil, triamcinolone, and lidocaine or 5-fluorouracil and lidocaine.31 Based on an extensive literature review of 5,081 treatments with CaHA by Kadouch,1 the product appears to have a good safety profile. In this study,1 45% of the reported nodules occurred in dynamic areas of the face. The current data suggest that if dynamic areas of the face were avoided, the incidence of CaHA nodules would be substantially lower. For facial augmentation, although some concerns about tissue necrosis and serious complications such as embolization have been noted in the literature, no vascular compromise has been observed by the authors on their practice and by Kadouch. However, caution should be the rule when treating the face and the high risky areas like the glabellar region and nose should be avoided. Regarding effect duration, it may depend on many factors, such as the patient’s age and metabolism, and the relative dynamic motion of the area in which the implant is placed. Published data show CaHA treatment results lasting up to 18–24 months.32
Current Practice and Consensus Statements
After an initial treatment cycle, one maintenance session is suggested within a range of 12–18 months. After the procedure, massage should be immediately performed by the physician to evenly distribute the product in the treated area. The patient can also be instructed to massage the injection site area 2 times a day for 3–7 days (Table 1).
Radiesse® (CaHA) is associated with a high and well-established safety profile and is a very effective agent for soft tissue augmentation of different face and body areas. The rising popularity of minimally invasive aesthetic procedures for the face over the last decade has led to greater demands for body rejuvenation interventions to minimize discrepancies between body and face appearance. The characteristic of Radiesse of long-term collagen stimulation reflects its substantial versatility. This consensus provides recommendations for the use of hyperdiluted CaHA as a biostimulatory agent for face and body rejuvenation and to improve skin quality and firmness.
The authors wish to thank Jessica Notario for providing medical writing and editorial assistance on behalf of Springer Healthcare.
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Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
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