TABLE 1.

Radiesse injection protocol for a global face approach

TREATMENT AREA	BENEFITS	INJECTION PROTOCOL	SAFETY CONSIDERATIONS
Frontal concavity (parallel and superior to eyebrows)	Reduces skeletonized appearance, restores youthful frontal convexity and contributes to brow lift	Mark frontal concavity prior to injection. Inject only at the subgaleal/ supraperiosteal plane	Facial nerve, supraorbital/supratrochleal nerve and arteries. Cannula technique is advised starting from temporal crest
Temporal concavity	Restores oval of the face, reduces skeletonized appearance and contributes to lift of lateral brow	Submuscular/supraperiosteal/subdermal injection protocols	Submuscular injection protocol: for Radiesse, aspiration before injection is not a reliable test to avoid intravascular injection as the filler inside the needle will be too viscous to allow blood to enter the syringe. Therefore, multiple boluses are injected in the submuscular/supraperiosteal plane. With the needle tip gently touching the periosteum, the chance of intra-arterial injection is minimized. Injector should remain on periosteum during entire injection. Slow bolus injection minimizes risk of retrograde arterial migration of product and low volume of bolus (0.1-0.2mL per bolus) minimizes risk of necrosis as only a small area could be blocked and will allow for collateral perfusion. Subdermal injection protocol: venous network, superficial temporal artery. Advisable to use blunt cannulas. Injectors often choose to dilute according to the FDA dilution protocol (0.3mL lidocaine for a 1.5mL Radiesse syringe)
Brow lift	Lifts brow, reduces lateral hooding	Submuscular/supraperiosteal or subcutaneous/dermal injection at the level of the lateral brow to the peak/middle of the brow. Needle or cannula technique. Our technique is only for supraperiosteal placement, as vascular entry/cannulation is too much of a risk in this area.	Venous plexus, supraorbital artery and nerve, intraorbital area. Avoid masculinization of the female brow: limit volume. A cannula is advised to avoid intravascular injection. If a needle is used, inject with: 1) low volume, 2) low pressure, 3) retrograde in an area where there are no large arteries—the dermal/subdermal plane of the area from the peak to the tail of the brow; more medially from the peak, direct arterial connections to the intra-orbital area are present (supraorbital artery, supratrochlear artery). Also avoid deep injection to prevent intra-arterial injection. Advocate no more than 0.3mL total volume to brow in a single injection sitting
Zygomatic area	Restores V-shape of the face, restores youthful cheek convexity, lifts sagging soft tissues, reduces lower lid lag, and reduces tear trough (without treating the latter).	Multilevel approach: Needle or cannula technique. Cannula: 2-point technique: Zygomatic arch entry point and medial zygoma entry point Above alar-tragal line: Inject only at the periosteal level. Below alar-tragal line: Inject more “superficially” (meaning dermal/subdermal junction)	Infraorbital foramen; lymphatic drainage, infraorbital fat compartments, malar edema. Proper patient selection is necessary, for example, care should be taken when treating patients with fat bags. Assess for any asymmetry of the zygomatic arches in each patient. Augmentation of the midface in individuals with herniated fat pads may help to reduce the appearance of fat pads. However, care should be taken not to inject into the Arcus Marginalis, as this may result in protrusion of the fat, and development of “white bangers” as Radiesse aggregates and becomes visible through the skin. Note: Avoid injection of product directly into a fat pad, as fat pads are quite vascular. Advocate injection only over periosteum and lightly mold when complete
Mandibular augmentation	Restores mandibular definition, reduces jowl, pre-jowl sulcus, and marionette lines	2-point cannula technique. Mandibular angle: Placement at dermal/subdermal junction for skin tightening and redefining mandible. Point (depot) technique at the mandibular angle may help to define the lateral jaw, especially in older patients and those with poorly defined definition from face to neck, and contribute to curvilinear mandibular sweep. Pre-jowl sulcus entry point: Multilevel technique (dermal/ subdermal junction plus supraperiosteal placement). Supraperiosteal placement to augment masseter projection	Mandibular angle: Facial arteries; avoid placing product into jowl, as that might aggravate jowling. Parotid gland Pre-jowl sulcus entry point: Mental foramen, avoid placing product into mucosa and muscle as intramuscular injection can lead to nodule formation Pre-jowl sulcus (PJS) injection Palpate edge of mandible and position finger under edge of mandible to prevent inadvertent tracking of product interiorly upon injection Select PJS insertion point (antero-superior to the mandibular edge, mid PJS defect), advance needle down to periosteum being aware of bevel opening Inject aliquot of product (up to 0.4mL) to periosteum in the direction you wish to augment the pre-jowl sulcus concavity: Example: if injecting on the lateral edge of the concavity, have the bevel opening facing medially. May reposition needle to change bevel opening and flow of product, depending on visual endpoint/desired correction. Example: after the first bolus is placed, it is not uncommon to reposition the bevel opening to face superomedially in order to place a smaller bolus to complete the desired correction/augmentation. May add subdermal threads if collagenesis is desired over the pre-jowl sulcus aspects Gently pinch and mold to further contour jaw line Angle of jaw (AOJ) injection Parotid gland—Avoid injection into this gland, which lies within the lateral cheek fat medial to the ear. Cheek laxity can cause ptosis of the gland into the injection area. Advocate supraperiosteum placement with minimal massage to avoid retrograde tracking into needle track. If placing a few subdermal product threads, care should be exercised to stay immediately subdermal to avoid inadvertent injection into the parotid. Masseter muscle—Product placement should be below this muscle Facial artery—Palpate this artery medial to the masseter muscle in the antigonal notch along the inferior edge of the mandible. Nicking this artery is a common cause of increased bruising in the area Facial nerve—This nerve runs through the parotid gland. Avoid injection in or near the parotid gland Palpate angle of the jaw and outline with a skin pencil. Palpate the facial artery located immediately anterior to the masseter muscle. May have patient clench their jaw to palpate the anterior edge of masseter. Mark this area with an “X” to indicate a non-injection area. Mark the desired locations to place aliquots on the angle of the jaw Suggested aliquot locations: Near the angle of the jaw, slightly anterior to the angle of the jaw, superior overlying the inferior portion of the ramus. Note any asymmetry pre-injection Position thumb under edge of mandible and use fingers of noninjecting hand to push soft tissue structures up and off the mandibular edge to prevent inadvertent tracking of product interiorly or into the parotid gland upon injection Select insertion point for aliquot nearest the angle of the jaw by rolling finger to locate slight concavity. At a 90 degree angle to the skin, advance needle down to periosteum and place an aliquot of product (up to 0.5mL) A total of 0.7-2.95mL of Radiesse has been used to treat each AOJ, depending on correction desired Place next aliquot just superior to first along the lateral edge of ramus. Aliquot volume should decrease as additional aliquots are placed Third aliquot may be placed medial to angle site. Care should be taken to avoid the antigonal notch, facial artery, and nerve May place linear threads in the subdermal plane for contouring between aliquots. Gently pinch and mold to further contour jaw line and smooth product
Mentum augmentation	Reduces marionette lines, restores convexity of mentum, balances the face with Steiner’s line (joins soft tissue pogonion to the midpoint between subnasal and nasal tip; the lips should touch this line)	Multi-level approach: submuscular at the periosteum of the mentum and dermal/subdermal junction. 1-point cannula technique	Submental artery. Avoid injecting in the oral mucosa, so supraperiosteal injection only when injecting submuscularly. Typical injection is subdermal. Care must be taken when injecting to periosteum at this level, given the product may show or surface to the lower gingival sulcus immediately following injection (physician thought he/she was lower than the gingival sulcus and was not). Total volume injected during a single treatment session is often around 0.5mL per side