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Hyperdilute Radiesse®

By Jill Charles, MSN, CNP

There are two proteins that every aging adult could benefit from in some way or another: collagen and elastin. We start slowly losing collagen and elastin after we reach 30 years of age, which contributes to fine lines and wrinkles, volume loss and skin laxity. While the aesthetic industry has endless options available to address these concerns, the use of biostimulatory treatments provide the opportunity to turn back time. Neurotoxins and dermal fillers produce quicker results than some of the biostimulatory options, however results are temporary. By stimulating the formation of new collagen and elastin, the skin appears fuller, smoother, more plump and hydrated. Who wouldn’t want to prevent the inevitable signs of aging?

For the purpose of today’s post, we will be discussing Hyperdilute Radiesse® as an option for a biostimulatory treatment. Radiesse® is a dermal filler manufactured by Merz Aesthetics and is the first and only filler in the United States made of Calcium Hydroxylapatite (CaHA) as opposed to Hyaluronic Acid (HA). Radiesse® is made up of approximately 30% CaHA and 70% sodium carboxymethylcellulose gel carrier. Upon injection, the gel carrier corrects the desired treatment area immediately. The CaHA integrates into the tissue creating a scaffolding that stimulates collagen and elastin. With time, the gel carrier absorbs and is replaced by new collagen and elastin to promote healthier, more youthful skin. The G’ of Radiesse® (viscosity and elasticity) is far superior compared to other dermal fillers which makes it a wonderful product to use for deep placement to improve structure and support.


Histology slides demonstrate deposition of new collagen around CaHA microspheres over an extended period of time. Collagen fibers stain red, while other tissue elements appear more yellow.1

Now that we have given a little background on Radiesse®, you may be wondering the purpose of diluting a product that has incredible lifting effects. While Radiesse® is a shining star for creating chiseled cheeks and jawlines, sometimes our goal is more to improve the overall health and appearance of the skin itself. That is where biostimulation and Hyperdilute Radiesse® come into play! Diluting Radiesse® using bacteriostatic sterile saline and lidocaine significantly reduces the G’ which means we lose the ability to immediately lift and correct. Instead, we are capitalizing on the biostimulatory effects of Radiesse® to address fine lines and wrinkles, skin laxity and volume loss.

Treatment areas go beyond the face and neck. There have been Current Practice and Consensus Statements established to include décolletage, buttocks, thighs, arms, abdomen, knees and elbows. Certainly the approach will change depending on your treatment area, for example if you are wanting to restore lost volume in the face and improve fine lines, it would be recommended to use a tighter dilution (1:1 ratio) in order to maintain some of the filling properties, as well as biostimulation. Another example would be treatment of the abdomen to address skin laxity, using a very diluted material that will not add volume (1:4 ratio) but help produce collagen and elastin to tighten the abdominal tissue.Regardless of the area being treated, the technique remains quite similar aside from the amount to be given, patient need and ratio used. A blunt-tip cannula is used to evenly distribute the diluted material in a retrograde fashion across the treatment area. Injections occur at different depths within the dermis depending on treatment area, and the ratio selected is based on patient need. It is recommended to complete a series of at least 3 treatments, 4-6 weeks apart for an optimal outcome. The process of neocollagenesis does not happen overnight and therefore it is important to prepare your patient that results will be gradual. The peak time frame for maximum collagen production is typically 3-6 months post-treatment. Due to the progressive improvement that we see with biostimulation, patient selection is crucial. For those looking for immediate results, the provider should consider a different treatment approach. It is important for patients to understand and have patience with the process. As for potential side effects, bruising and swelling should be expected. The bruising tends to happen most at the entry point that is used to gain cannula access. Swelling occurs not only from local tissue inflammation but also due to the volume of fluid being placed into the tissue, not only Radiesse® but also the diluent. Post-procedure, the swelling is most prominent but will improve over the next 1-3 days as the body absorbs and mobilizes the fluid. To date, there have been no reported vascular occlusions after the use of diluted/hyperdiluted Radiesse®. Below is a chart demonstrating different ratios/cannula depth based on treatment area.



Radiesse® has been a long-standing dermal filler used in aesthetics to restore lost volume, structure and support which happen as a result of the aging process. When used in the hyperdilute form, the process of neocollagenesis results in the production of collagen and elastin and therefore can address a different set of concerns such as fine lines and wrinkles, volume loss and skin laxity. While hyperdilute Radiesse® is a fantastic option for solo treatment, when used in conjunction with other modalities such as neurotoxins, dermal filler, medical-grade skin care and medical devices, the patient will reap tremendous benefit and decelerate the signs of aging.References

  1. Berlin AL, Hussain M, Goldberg DJ. Calcium hydroxylapatite filler for facial rejuvenation: a histologic and immunohistochemical analysis. Dermatol Surg. 2008;34(suppl 1):S64-S67.
  2. de Almeida AT , Figueredo V, da Cunha ALG, et al. Consensus recommendations for the use of hyperdiluted calcium hydroxyapatite (Radiesse) as a face and body biostimulatory agent. Plast Reconstr Surg Glob Open.2019;7(3):e2160.
  3. Goldie K , Peeters W, Alghoul M, et al. Global consensus guidelines for the injection of diluted and hyperdiluted calcium hydroxylapatite for skin tightening. Dermatol Surg.2018;44(Suppl 1):S32-S41.
  4. Merz Aesthetics.


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