Physician's severity rating scores for patients treated with calcium hydroxylapatite to the lower one-third of the face. Scores were determined using the Dayan Severity Rating Scale throughout the course of treatment; 5.0, extreme; 4.0, severe; 3.0, moderate; 2.0, mild; 1.0, absent.
Mean improvement scores as judged by physicians and patients. Mean improvement scores, according to the Global Aesthetic Improvement Scale (GAIS), of patients treated with calcium hydroxylapatite, as judged by physicians and patients before treatment and at 3, 6, and 12 months following optimal correction: 5.0, very much improved; 4.0, much improved; 3.0, improved; 2.0, no change; 1.0, worse.
A patient treated with calcium hydroxylapatite to the lower one-third of the face. A, Pretreatment; B, posttreatment at 6 months; and C, posttreatment at 12 months.
Dayan SH, Lieberman E, Larimer K. High-Volume Calcium Hydroxylapatite Filler to the Lower One-Third of the Face. Arch Facial Plast Surg. 2009;11(2):140-147. doi:10.1001/archfaci.11.2.145
Many of today's cosmetic patients desire the maximum aesthetic result with the least amount of downtime and expense. Nonsurgical, minimally invasive cosmetic treatments are increasing at a substantial rate. Calcium hydroxylapatite (CaHA) was one of the first fillers to be used for “volumizing” the face as an alternative to surgical intervention. Filling the cheeks and prejowl sulcus lifts the cheeks and camouflages dependent jowls, creating a more youthful appearance. Surgical practices have appropriately begun to incorporate more filling and less aggressive pulling during facial procedures.
The CaHA product Radiesse (BioForm Medical Inc, San Mateo, California) is a synthetic material approved by the US Food and Drug Administration for treating facial lines and wrinkles such as nasolabial folds. Correction and patient satisfaction can be expected for about 1 year following treatment. Some reports are now espousing persistence beyond 1 year.1,2 To determine the efficacy of CaHA, we hypothesized that complete correction of the lower one-third of the face, specifically, the nasolabial folds, prejowl sulcus, oral commissure grooves, and marionette lines, by filling with CaHA would lead to an acceptable satisfaction rate at 1 year in many patients who were seeking facial rejuvenation.
This study was conducted in a private practice ambulatory facial plastic surgery center in Chicago, Illinois, over a 16-month period. A total of 20 patients underwent CaHA treatment to the lower one-third of the face for soft-tissue augmentation. All 20 patients were women and ranged in age from 46 to 72 years (mean age, 56 years). Calcium hydroxylapatite was injected into the nasolabial folds, labiomandibular grooves (prejowl sulcus), marionette lines, oral commissure grooves, and chin.
Patients returned for a follow-up visit 2 weeks after their treatment. If complete correction was not achieved then a “touch-up” treatment was recommended using the same technique to achieve complete correction. The mean dosage of initial treatment was 4.9 cm3 (range, 3.2-6.5 cm3). Half of the patients (n = 10) received only 1 treatment during the study, whereas the other half (n = 10) required touch-up treatment to obtain optimal results. The mean dosage of touch-up treatment was 1.4 cm3 (range, 0.75-2.25 cm3). Patients returned at 3, 6, and 12 months after the initial treatment for 5 view photographs, a subjective questionnaire, and a severity rating by the primary investigator.
Improvement was assessed using the Dayan Severity Rating Scale, wherein low scores designate absent creases and high scores reflect extreme rhytids. Wrinkle severity scores demonstrated marked improvement at 2 weeks after optimal treatment and remained improved throughout the 1 year of follow-up (Figure 1).
Physician assessment and patient satisfaction was also measured using the Global Aesthetic Improvement Scale (Figure 2). On the one hand, physician ratings revealed 100% improvement ratings at 3 months and 89% and 48% improvement at 6 and 12 months, respectively. On the other hand, patient perception of improvement upheld even better results, whereby 77% of patients continued to rate themselves as improved or better at 1 year, attesting to the value of CaHA soft-tissue fillers. Photographic evidence of long-term efficacy is demonstrated with frontal views before treatment and 6 and 12 months after treatment (Figure 3). In addition, the subjective questionnaire demonstrated that overall patient satisfaction rated improved, much improved, or very much improved in 95%, 89%, and 76% of patients at 3, 6, and 12 months, respectively, comparing favorably to other reports using fillers and CaHA.1- 3
A nonsurgical alternative to face-lifting is desired by many of our patients. In this report, we identify a minimally invasive method leading to facial rejuvenation in our patient population at 1 year following treatment.
Many of the patients in this study were candidates for surgical rejuvenation but for a myriad of reasons were not ready to undergo a surgical procedure. Instead of turning these patients away and counseling them to return when they were ready for surgery, a nonsurgical alternative solution was offered that met many of their facial rejuvenating goals.
In this study, compared with previous reports, placement of the product was deep in the subdermal tissues and along the bony structures. This allows for the overlying soft tissues to be filled and lifted en bloc. Calcium hydroxylapatite has the advantage that it can be molded once placed deeply along the bony structures, an effect that has led to less edema and bruising and a better tolerated treatment. Finally, this study demonstrates that long-term efficacy and patient satisfaction depend on complete correction. A satisfying facial rejuvenation and wrinkle improvement can be achieved for up to 12 months with placement of high-volume CaHA to the lower one-third of the face.
Correspondence: Dr Dayan, Dayan Facial Plastic Surgery, 845 N Michigan Ave, Ste 923 E, Chicago, IL 60611 (Sdayan@drdayan.com).
Author Contributions: Dr Dayan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Dayan and Larimer. Acquisition of data: Dayan and Larimer. Analysis and interpretation of data: Dayan and Lieberman. Drafting of the manuscript: Dayan, Larimer, and Lieberman. Critical revision of the manuscript for important intellectual content: Dayan and Lieberman. Statistical analysis: Lieberman. Obtained funding: Dayan and Larimer. Administrative, technical, and material support: Dayan and Larimer. Study supervision: Dayan and Larimer.
Financial Disclosure: None reported.
Funding/Support: This study was funded by a research grant from BioForm Medical Inc (Dr Dayan).
Additional Information: Radiesse soft-tissue filler was provided by BioForm Medical Inc.