MIAMI BEACH Cosmetic enhancement with Radiesse is technique dependent, and three experts shared their clinical tips to optimize success with this filler at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Radiesse (calcium hydroxylapatite, BioForm Medical) is manufactured as synthetic microspheres that are suspended in a resorbable aqueous gel.

Calcium hydroxylapatite provides immediate results and is versatile, moldable, and longer lasting than some other filler products, said Dr. Susan H. Weinkle, who is with the University of South Florida in Tampa.

The product's gel carrier degrades in 36 months for 70% of patients, she said.

During this time, new collagen formation is ongoing. "If you avoid the temptation to retreat patients at 6 months when the gel drops, you will see continued improvement," said Dr. David J. Goldberg of the department of dermatology at Mount Sinai School of Medicine in New York.

A meeting attendee wanted to know how to choose between Radiesse, Restylane (Q-Med), and Sculptra (Sanofi-Aventis).

"A lot has to do with what you think will benefit the patient more. If they need a lot of volume, I would go with Sculptra," Dr. Weinkle said. "If they have deep nasolabial folds and [deep wrinkles in] the chin area, I would use Radiesse. There are a lot of considerations, including longevity and cost. With Radiesse, you can have immediate correction, but with Sculptra you cannot promise that."

Radiesse can fill nasolabial folds and marionette lines, but the product is generally not recommended for the glabellar area or lips. Any long-acting filler can cause nodules in the lips, Dr. Goldberg said.

"Success is very technique dependent. This is not a filler to start with," Dr. Weinkle added.

"I get a lot of questions about what needle to use with which filler. Start with what the company recommends," said Dr. Marta Rendon of the University of Miami.

"For smaller areas, use a shorter needle and 27-Gthe product will flow nicely," Dr. Goldberg said. "I use mostly the longer needles for nasolabial folds. This stuff is thicker, so you need to push harder. If you do that with Juvederm [Allergan], all the material will be gone right away."

Anesthesia is recommended before the procedure. "Let's be honest, it hurts. It is thicker [than some other fillers]. It's a 25-G needle," Dr. Weinkle said. "Use anesthesia and keep the patient as comfortable as possible."

Dr. Goldberg does a block with 1% lidocaine without epinephrine, and Dr. Rendon blocks with 2% lidocaine without epinephrine.

Inject a small amount of Radiesse on the way in and lay it down retrograde as you pull the needle out, Dr. Weinkle suggested.

Remember to stop injecting as you pull the needle out, Dr. Rendon said. "You don't want to bring out the product. My tip here is to use the blunt end of a Q-tip to push it back in."

"Here is another little pearl," Dr. Rendon said, "The hardest corner to correct is the nasolabial fold just above and lateral to the corner of the mouth. Tent the skin to lift the corner when you inject, and be careful not to inject too superficially."

Place your finger inside the mouth when you first start injecting, Dr. Goldberg said, to feel the material going in. "Early on I injected it right through into the mouth," he said. "Patients will tell you they can taste a granular substance. It doesn't harm them, but you have to start over."

It is important to fill just below the corner of each side of the mouth, Dr. Weinkle said. "I put my finger inside the mouth and mold it right away."

Be careful not to overcorrect the patient's face, she pointed out. "I tell patients there is more where this came from."

A meeting attendee asked about the cost to physicians. "It's actually cost effective. Originally, it was $500 for 1.3 cc, and about a year ago, the company reduced the price to $298 per 1.3-cc syringe. Now that the price has come down, it's much more affordable," Dr. Weinkle said.

The range of what dermatologists charge patients ranges from $500 to $3,000 across the country. Dr. Goldberg said, "It's longer acting, so I think it's fair to charge more for this, compared to what you are charging for hyaluronic acid."

Patient follow-up is essential. "I stress the importance of seeing the patient back at 2 weeks. If they are unhappy with results, you want to be the one to know," Dr. Weinkle said. "I've learned that the 0.3 cc [syringe] is nice for topping off someone who comes back for a touch-up."

Dr. Goldberg and Dr. Weinkle are consultants for BioForm Medical and Dr. Rendon is on the company's advisory board.

Expert Tips Can Improve Results With Radiesse