Pre-operative preparation

For any aesthetic procedure, it is important to carefully discuss expectations with each patient when planning treatment. An assiduous review of the patient’s medical history is also essential, with special emphasis on the patient’s use of prescription and non prescription medications, allergies, history of cold sores, presence of auto immune disorders, previous facial surgeries or dermal filler treatments, and whether the patient is pregnant or nursing. If the patient has a history of facial herpesvirus lesion, prophylactic antiviral therapy, e.g., aciclovir or valaciclovir, may be prescribed. For those with active lesions, treatment may be delayed.

Other topics that should be addressed with the patient include what to expect in terms of any discomfort that may occur during or after injection and possible adverse events, as well as the results that he or she can expect immediately after treatment and the likely durability of these results. Informed consent should be obtained. I advise patients to avoid any medications or supplements that might increase bleeding, e.g., salicylate drugs, nonsteroidal anti-inflammatory drugs, high doses of vitamin E, and certain herbs. There are also anecdotal reports of the use of Arnica montana , bromelain, and 1% vitamin K ₁ (phytonadione) cream as prophylaxis against bruising.

Before beginning the actual procedure, a washable marker or other non-permanent tool should be used to identify the injection site. Marking is best performed with the patient sitting upright, to take into account the effect of gravity on the facial contours. Pre-treatment photographs may be taken before and after the marking. A typical tray set-up for injection of CaHA is listed in Table 4.1 .

Anesthesia and other patient comfort measures

Appropriate use of anesthetics may enhance patient comfort during the injection of CaHA and other fillers. The choice of anesthesia technique depends largely on clinician and patient preference, as well as the site being treated. Options include infiltration anesthesia, nerve block anesthesia, topical anesthesia, the infiltration of tiny amounts of local anesthetic directly into the area, or some combination of these. I recommend marking the treatment site before anesthetic is administered, as infiltration may distort the skin surface and regional nerve block may have a blunting or effacing effect on creases and folds.

Injection technique

Injection technique and injection volumes for Radiesse® tend to be site dependent. Because of the relative viscosity of CaHA, a 27-gauge, -inch or -inch needle is recommended. Some physicians have reported use of a 28-gauge needle with a 27-gauge bore. (If lidocaine has been mixed with the Radiesse®, a 30-gauge needle can be used. If clogging occurs, simply change needles.) CaHA is usually injected at the subdermal plane, especially when being used to fill creases, wrinkles, and deep lines. It can be injected in the subcutaneous space superior to the periosteum, or placed on the periosteum if the intent is to augment the facial bony skeleton. Placement of CaHA on the periosteum will not stimulate bone growth in the area.

Depending on the area being treated, CaHA may be injected in a retrograde fashion using a linear, threading, fanning, and/or cross-hatching technique. For supraperiosteal placement a bolus or depot type of injection may be used, followed by massage or molding of material to desired effect. Injection volumes vary with the location of the treatment site, the size of the area being treated, and individual patient characteristics.

In my own experience, a lesser volume of CaHA than of hyaluronic acid and/or collagen may be required to provide the same degree of correction. Two studies in particular, published in late 2007, support the finding of smaller volumes in CaHA than in several other soft tissue fillers. Smith et al compared CaHA versus collagen for the nasolabial folds in a split-face study of CaHA versus collagen for the nasolabial folds and found that, on average, the collagen-treated sides of the face required twice the volume of material (2.35 mL) to produce optimal correction as compared to the CaHA-treated side (1.22 mL) (P < 0.0001) ( ). Another study found that approximately 30% less volume of CaHA gel was required for full correction of the nasolabial folds compared to a non-animal stabilized hyaluronic acid ( ).

It may be appropriate to massage the site to ensure that no palpable lumps are present. Some clinicians routinely mold the injected area post treatment; other clinicians reserve molding for correction of undesired shapes in an effort to avoid the amplification of edema and erythema that molding sometimes creates.

Post-procedure care

Post-treatment photos should be taken as soon as the injections have been completed and the washable markings removed. Additional photos should be taken at 3, 6, 9 and 12 months post injection.

Post-treatment care involves application of ice over the injection areas to reduce and limit tissue edema and ecchymosis. Some clinicians advise patients to remain upright for the remainder of the day and sleep with the head elevated to reduce the degree of edema. Patient follow up visits are typically scheduled 2–12 weeks post-injection to document any adverse effects and, if necessary, provide further treatments to refine results.