Injectable Calcium Hydroxylapatite for Correction of Nasal Bridge Deformities
Minimally invasive procedures for aesthetic surgery have become widely popular, and facial soft tissue augmentation is one of the most common procedures. Various kinds of fillers have been used, and recently the use of calcium hydroxylapatite was extended to cosmetic facial procedures. This article presents the authors’ experience with primary and secondary nasal bridge correction using calcium hydroxylapatite (Radiesse).
This preliminary prospective study investigated the use of commercially available calcium hydroxylapatite (Radiesse) for correction of nasal bridge deformities. Calcium hydroxylapatite was injected on the plane of the periosteum in a retrograde fashion using a linear, threading, fanning, or crosshatching technique. The patients were followed for several months, with the outcome and side effects assessed both subjectively and objectively.
Patients showed a persistence of benefit up to 1 year during the follow-up period, with pleasing long-term results.
Calcium hydroxylapatite (Radiesse) is a useful injectable filler for correction of nasal bridge deformities. Further efficacy studies seem justified.
KeywordsCalcium hydroxylapatite Nasal bridge correction Radiesse
Facial soft tissue augmentation by injection has become increasingly popular as a minimally invasive option for patients seeking cosmetic facial enhancement. Various types of fillers have been used, and the use of calcium hydroxylapatite (Radiesse, BioForm Medical, San Mateo, CA, USA) was extended recently to cosmetic facial procedures.
Augmenting the contour of the nasal dorsum often is a major task: the greater the depression, the greater the difficulty. The use of autologous materials (e.g., cartilage or bone) requires a very invasive procedure with an inherent high resorption rate. On the other hand, the use of exogenous material (e.g., silicone) may result in a rejection reaction, in addition to the very invasive nature of this option.
Radiesse is a steam-sterilized, latex-free, nonpyrogenic, semisolid, cohesive, completely biodegradable deep and subdermal implant. The principle component of Radiesse is synthetic calcium hydroxylapatite, a biomaterial used for more than 20 years in orthopedics, neurosurgery, dentistry, and otolaryngology. Calcium hydroxylapatite is the primary mineral constituent of bone and teeth.
The semisolid nature of Radiesse is created by suspending calcium hydroxylapatite microspheres with a diameter of 25–45 μm (30%) in a gel carrier (70%) that consists primarily of sterile water and glycerin. The gel structure is formed by adding a small amount of sodium carboxymethyl cellulose. The gel is dissipated in vivo and replaced with soft tissue growth, whereas the calcium hydroxylapatite remains at the site of injections. The result is long-term yet nonpermanent restoration and augmentation [4, 7, 11].
Radiesse is Food and Drug Administration (FDA) approved for surgical reconstruction of bony defects, but it has been used recently as a soft tissue filler, particularly for the nasolabial fold, marionette lines, the prejowl sulcus, the chin, and the zygomatic eminence . When placed into soft tissue, Radiesse provides immediate correction. Over time, the carrier gel is gradually absorbed, and the calcium hydroxylapatite particles remain. The local histiocytic and fibroblastic response at the site appears to result in the production of new collagen around the microspheres.
Preclinical canine studies have demonstrated histologically progressive integration of collagen fibers in and around the calcium hydroxylapatite microspheres up to 78 weeks after implantation. Further studies have verified preclinical data by demonstrating dermal matrix integration in biopsy samples harvested from human volunteers . Interestingly, these histologic findings have been accompanied by evidence of maintained clinical improvement. The current study found no evidence of granuloma formation, ossification, or foreign body reactions at 1 month or 6 months.
Over time, calcium hydroxylapatite particles are broken down into calcium and phosphate ions via normal metabolic processes and eliminated through the body’s normal excretory processes. In one long-term animal study of the bladder neck, the particles remained intact at the site of injection throughout the entire 3-year study period . In vivo, durability depends on factors such as injection technique, site of material placement, and patient age and metabolism. The reported longevity of aesthetic correction in the face ranges from 10 to 14 months, with an average correction of 1 year in several studies [1, 3]. Other sources report correction longevity of 12–18 months [4, 8].
Materials and Methods
As with any cosmetic procedure, patient satisfaction can be optimized by keeping in mind certain treatment considerations and by discussing expectations carefully with each patient. The patient’s medical history should be reviewed, with a focus on drug use, allergies, history of cold sores, presence of autoimmune disorders, previous facial operations or dermal filler treatments, and whether the patient is pregnant or nursing. Patients also should be asked about their history of herpes virus infection. If active lesions exist, the treatment should be delayed, with prophylactic antiviral therapy (Acyclovir) prescribed for patients with a history of facial herpes virus . Medications that might increase bleeding (e.g., aspirin and nonsteroidal antiinflammatory drugs) should be interrupted at least 1 week before the procedure.
Before injection, the patient should be informed about what to expect in terms of any discomfort that may occur during or after injection, possible side effects, the result that the patient should expect immediately after treatment, and the durability of correction. Each patient should give a signed consent.
In the current study, standardized photographs were obtained before the injection, and the areas of required augmentation were delineated with a marker. Topical anesthesia with Emla cream was used.
Due to the relative viscosity of calcium hydroxylapatite, a 27-gauge needle was used to inject the filler on the plane of the periosteum. The filler, which will not stimulate bone growth in the area, was injected in a retrograde fashion using a linear, threading, fanning, or crosshatching technique. The injection volumes varied with the individual patient characteristics. After the injection, external molding of the filler was achieved by gentle massage.
Photographs were taken after the procedure, and ice was placed immediately on the injected areas to reduce and limit tissue edema and ecchymosis. An external nasal splint was applied and kept in place for a few days to avoid displacement of the filler. The common side effects of the procedure were redness, swelling, and bruising. These resolved relatively soon (1–2 weeks) after the injection procedure. Bruising and swelling can be minimized by treating the tissue with care and taking time to provide necessary cosmetic augmentation.
No nodules or granuloma formation were visible nor migration of filler to other parts of the face. No immediate or delayed allergic reactions were observed.
Volume enhancement is rapidly becoming an indispensable component of modern cosmetic surgery. According to our clinical experience, the correction of nasal bridge deformities using injectable calcium hydroxyapatite is ideal for the patient who is not yet inclined to procedures involving surgery and equally useful for patients who have already undergone rhinoplasty.
Augmenting the contour of the nasal dorsum often is major task: the greater the depression, the greater the difficulty .The use of autologous materials (e.g., cartilage or bone) requires a very invasive procedure with an inherent high resorption rate. On the other hand, the use of exogenous material (e.g., silicone) may result in a rejection reaction, in addition to the very invasive nature of this option.
Calcium hydroxylapatite (Radiesse) injections can be used as a primary option or as a secondary procedure to correct some of the defects that may appear after rhinoplasty. Our experience also has shown calcium hydroxylapatite to be safe. This observation is borne out by the clinical literature, which demonstrates that the most common adverse events associated with the material are similar to those observed with other fillers. These adverse events tend to be short lived and resolve without treatment. Importantly, there is no evidence of granuloma formation or osteogenesis when calcium hydroxylapatite is placed in soft tissue. A recent study confirmed that the use of calcium hydroxylapatite does not interfere with the interpretation of radiography .
The preliminary results indicate that natural improvements in the shape of the nasal bridge are possible using calcium hydroxylapatite injections. This approach offers a very practical and efficient alternative to the more usual invasive surgical procedures. It is highly recommended for reconstructive secondary and tertiary nasal bridge deformities in cases involving skin that may not tolerate further surgical intervention.
- 1.Busso M, Karlsberg PL (2006) Check augmentation and rejuvenation using injectable calcium hydroxylapatite (Radiesse). Cosmet Dermatol 19:583Google Scholar
- 2.Carruthers A, Liebeskind B, Carruthers J, Forster BB (2008) Radiographic and computed tomographic studies of calcium hydroxylapatite for treatment of HIV-associated facial lipoatrophy and correction of nasolabial folds. Dermatol Surg 34(Suppl 1):S78–S84Google Scholar
- 3.Felderman LI (2005) Radiesse for facial rejuvenation. Cosmet Dermatol 18:823Google Scholar
- 4.Goldberg DJ (2006) Calcium hydroxylapatite: fillers in cosmetic dermatology. Informa UK Ltd, Abingdon, EnglandGoogle Scholar
- 5.Graivier MH, Bass LS, Busso M, Jasin ME, Narins RS, Tzikas TL (2007) Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations. Plast Reconstr Surg 120(Suppl):55S–66SGoogle Scholar
- 6.Hubbard W (2002) BioForm implants: durability. Bioform, Inc, FranksvilleGoogle Scholar
- 7.Hubbard W (2003) BioForm implants: biocompatibility. Bioform, Inc, FranksvilleGoogle Scholar
- 8.Jansen DA, Graivier MH (2006) Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft tissue augmentation. Plast Reconstr Surg 118(Suppl.):22SGoogle Scholar