Calcium hydroxylapatite: over a decade of clinical experience

Abstract

Background: Calcium hydroxylapatite is one of the most well-studied dermal fillers worldwide and has been extensively used for the correction of moderate-to-severe facial lines and folds and to replenish lost volume.

Objectives: To mark the milestone of 10 years of use in the aesthetic field, this review will consider the evolution of calcium hydroxylapatite in aesthetic medicine, provide a detailed injection protocol for a global facial approach, and examine how the unique properties of calcium hydroxylapatite provide it with an important place in today's market.

Methods: This article is an up-to-date review of calcium hydroxylapatite in aesthetic medicine along with procedures for its use, including a detailed injection protocol for a global facial approach by three expert injectors.

Conclusion: Calcium hydroxylapatite is a very effective agent for many areas of facial soft tissue augmentation and is associated with a high and well-established safety profile. Calcium hydroxylapatite combines high elasticity and viscosity with an ability to induce long-term collagen formation making it an ideal agent for a global facial approach.

Figures

Figure 1

Frontal concavity. The danger point (supraorbital foramen) is marked and should be avoided as there is a direct access to the intraorbital area. The cannula entry point is chosen at the temporal crest, lateral to the frontal concavity. The cannula is advanced through the muscle, through the galea aponeurotica and advanced in the glide plane between the galea and the periosteum of the frontal bone. Radiesse is deposited in retrograde linear threads.

Figure 2

Sunken temples. The danger zone is marked in red: Intravascular injection into the superficial temporal artery should be avoided while injecting with a needle. At the point of maximum depression, the needle is placed perpendicular to the skin and advanced slowly until contact with the periosteum is felt. Slow injection of small amounts of Radiesse will maximize safety. There is evidence of small arteries running over the periosteum so there is a theoretical risk of intra-arterial injection. Slow injection reduces the risk of retrograde displacement and embolization of intraorbital (including retinal) arteries. Low volume injection minimizes necrotic area. Due to supraperiosteal placement, the temporal muscle, which is connected by loose connective tissue, is hydrodissected from the periosteum.

Figure 3

Brow lift. The danger zone (supra orbital foramen) is marked in red. The entrance for the cannula is chosen at the tail of the brow. A multi-level approach is used with one or two retrograde linear threads at the dermal-subdermal junction and two additional retrograde linear threads at the periosteal plane on the orbital rim. With female patients in particular, care should be taken not to overcorrect here to avoid masculinization (max 0.15-0.2mL for the lateral brow).

Figure 4

Zygomatic area. The danger zone (infra-orbital foramen) is marked in yellow and the marking at the infra-orbital rim serves as a reminder of the cranial limit of this area. For the augmentation of the cheek, a two-point cannula technique is advised. As a general rule of thumb, the injections cranial to the alar-tragal line should be placed at the supraperiosteal level, whereas the injections below this line should be placed at the level of the dermal-subdermal junction. The first entry point is found between the superior and inferior demarcation of the zygomatic arch, immediately in front of the hair line. From this point, a vector line can be drawn to the oral commissure. At the intersection of the vector line and the alar-tragal line, the second entry point can be found. Left: Before with markings; middle: Before; right: After 1.5mL Radiesse in the cheeks.

Figure 5

Mandibular augmentation. As bone resorption is most apparent at the dorsum of the mandible, at the mandibular angle, the cannula entry point for mandibular augmentation should be placed at the dorsum of the mandibular angle. From there, the cannula should be advanced at the level of the dermal-subdermal junction to the pre-auricular area, from where a fanning technique can be used with diluted Radiesse for easier spreading of the product (in this case 0.8mL lidocaine per 1.5mL Radiesse). To enhance definition of the mandible, the first and last thread can be made with more volume (e.g., 0.2–0.3mL). Care should be taken to avoid placing Radiesse into the jowl fat compartment, as this can aggravate the aged appearance. To improve the mandibular area further, Radiesse can be placed in the marionette lines and mental crease via the pre-jowl sulcus entry point as shown. Left: Before with markings; middle: Before; right: After 1.5mL Radiesse in the jawline plus marionette lines.

Figure 6

Mentum augmentation. For augmentation of the mentum, a multi-level approach is generally used. In this case, a cannula was inserted at the pre-jowl sulcus entry point and advanced in both the supraperiosteal layer, as well as the junction between the dermis and subcutis. Augmentation was continued until the patient had a good Steiner Line. Left: Before with markings; middle: Before; right: After 1.5mL Radiesse in the mentum.