Comprehensive Radiesse Injection Training Certification for Buttlift

Introduction

This manual discusses the multilayered injection technique for Radiesse (Calcium Hydroxylapatite, CaHA) in buttocks enhancement, based on the latest research and practices. The procedure uses different dilutions of CaHA in various planes for a personalized, minimally invasive approach.

Understanding Radiesse for Buttocks Augmentation

Radiesse combines a volumizing component (carboxymethyl cellulose, CMC gel) and a biostimulating component (CaHA microspheres). This combination provides immediate volumization and subsequent biostimulation, resulting in collagen and elastin synthesis.

Patient Assessment

Indications

Suitable for patients seeking buttocks augmentation, treatment of asymmetry, cellulite, or increased self-confidence.

Ideal for those not suited for surgical augmentation, insufficient adipose tissue for lipotransfer, or sensitivity to anesthetics.

Patients may have a relatively low BMI with the following issues: cellulite, stretch marks, asymmetries, volume deficits, or skin laxity.

Contraindications

Severe Allergies: Not suitable for patients with a history of anaphylaxis or multiple severe allergies.

Hypersensitivity: Avoid use in patients with known hypersensitivity to any components of RADIESSE® (+), including lidocaine or amide-type anesthetics.

Bleeding Disorders: Contraindicated for patients with bleeding disorders.

Warnings

Vascular Risks: Injection into blood vessels can lead to serious complications like embolization, occlusion, ischemia, or infarction. Symptoms like vision changes, stroke signs, skin blanching, or unusual pain require immediate cessation of the injection and prompt medical intervention.

Inflammation or Infection: Do not use in areas with active skin inflammation or infection.

Overcorrection: Avoid overfilling to prevent excessive correction.

Lip Use: Safety and effectiveness in the lips are not established; nodules have been reported.

Short-term Reactions: Common reactions include bruising, redness, and swelling lasting less than 7 days.

Precautions

Practitioner Expertise: Should be used only by trained, experienced healthcare practitioners knowledgeable about injection anatomy.

Familiarity with Product: Practitioners should thoroughly understand the product and its usage.

Cannula and Needle Use: Specific cannula (27g, 40mm) and needle (25g) types have been evaluated for safety and effectiveness.

Radiopacity: CaHA particles are visible on CT Scans and plain radiography. Patients should be informed of this for future medical procedures.

Risk Discussion: Discuss all potential risks with patients, including signs and symptoms of complications.

Jaw Function: Jawline injections may temporarily affect jaw function.

Infection Risk: Follow standard precautions to minimize infection risks.

Medication Interactions: Increased bruising or bleeding risk in patients on medications like aspirin or warfarin.

Post-Treatment Procedures: Caution with procedures like laser treatment or chemical peeling following RADIESSE® (+) injections.

Long-term Safety: Not established in clinical trials.

Use in Specific Populations: Safety during pregnancy, breastfeeding, or in patients under 18 years is not established.

Keloid/Hypertrophic Scarring: Safety in patients prone to keloid formation or hypertrophic scarring is unknown.

Concomitant Dermal Therapies: Safety with other dermal therapies has not been evaluated.

Herpes Reactivation: Potential reactivation in patients with a history of herpes.

Drug Interactions and Periorbital Use: No studies on interactions with other drugs or implants; safety in the periorbital area is not established.

Sun/Heat Exposure: Advise patients to minimize exposure to sun or heat for 24 hours post-treatment.

Aseptic Technique: Ensure aseptic technique during injection sessions.

Single Patient Use: Do not resterilize or use if packaging is damaged. Avoid reusing needles.

Disposal: Dispose of syringes and needles as per medical and legal requirements.

Methemoglobinemia Risk: Assess risk-benefit for patients with congenital methemoglobinemia or those receiving methemoglobin-inducing agents.

Adverse Events

Ecchymosis

Edema

Erythema

Granuloma

Nodule

Pain

Pruritus

Soreness

Numbness

Contour irregularity

Tenderness

Irritation

Single Layer Injection Technique #1 (1:6 Dilution)

The choice of a 1:6 dilution for the product is primarily influenced by its ability to achieve a broader and deeper distribution in the treated area. This is particularly important for large tissue volumes, such as the buttocks, where extensive spread of the product is necessary to effectively stimulate the tissue. While higher dilutions may result in a reduced stimulation per unit volume of tissue, hyper dilute CaHA still effectively promotes the production of significant amounts of collagen and elastin. Although lower dilutions could potentially induce a greater stimulation of these proteins, you would need to use a greater quantity of the product to cover the same area.

Preparation

Material Preparation:
1. Draw 8.5 ml of normal saline into each 10 ml syringe.
2. Attach a Luer Lock transfer adapter to a 1.5 ml syringe of Radiesse and to the 10 ml saline-filled syringe.
3. Transfer Radiesse into the 10 ml syringe to create a 1:6 ratio of CaHA to saline.
4. After hyperdiluting to a 1:6 dilution, replace the empty Radiesse syringe with another 10 ml syringe.
5. Pass the Radiesse and saline solution between syringes 20 times for homogenization.
6. Repeat these steps until the desired number of syringes are prepared.
Anesthetic Preparation:
1. Draw 2 ml of 2% lidocaine with/without epinephrine into a 3 ml syringe using a 30 gauge needle.
Patient Preparation:
1. Have the patient stand upright for anatomical mapping.
2. Draw mapping lines on the buttocks based on the desired clinical outcome (shelf, hip dips, heart shape, projection).

Procedure

Site Preparation:
1. Clean each insertion site with an antiseptic wipe.
2. Inject 1 ml of lidocaine at each insertion point using a 3 ml syringe. If using Radiesse (+), additional lidocaine may not be necessary.
Cannula Insertion:
1. Use an 18 gauge needle to create an insertion site hole.
2. Insert an 18 gauge cannula attached to the 10 ml syringe of HDR CaHA into the subdermal plane of the glute.
3. Ensure the cannula is in the correct plane by checking for resistance during side-to-side movement.
HDR CaHA Injection:
1. Begin each procedure by injecting a 6 ml bolus of HDR CaHA at the mapped location.
2. Retrograde the remaining 4 ml of HDR CaHA towards the insertion point.
3. Slowly withdraw the cannula, leaving a small portion inserted.
4. Replace the empty syringe with a pre-mixed 10 ml syringe of HDR CaHA.
5. Reinsert the cannula and inject the next 6 ml bolus, leaving a 2 cm gap from the last bolus.
6. Retrograde the remaining 4 ml towards the insertion site.
7. Repeat these steps until the desired area is fully treated.
Post-Injection Care:
1. Apply pressure using gauze for up to 3 minutes at the insertion point to stop any leakage.
2. Cover the injection site with Tegaderm once bleeding and product exudation have stopped.

Shape-Specific Augmentation Techniques

Shelf Pattern:
1. Aim for increased superior projection.
2. Position the insertion point centrally on the x-axis and slightly above the midline on the y-axis.
3. Place five evenly-spaced boluses along the top of each glute, advancing the cannula superiorly.
4. Retrograde the remaining 4 ml of HDR CaHA towards the insertion point.
Hip Dips Pattern:
1. Aim to increase lateral projection for a rounder appearance.
2. Position insertion points centrally on both x and y axes.
3. Distribute boluses laterally, advancing the cannula towards the hip dips.
4. Retrograde the remaining 4 ml of HDR CaHA during withdrawal towards the insertion point.
Heart Shape Pattern:
1. Aim for a bottom-heavy outcome in glutes with excess skin laxity or volume need.
2. Lay boluses in the inferior portion of the glute.
3. Follow a similar retrograde approach as in previous patterns.
Projection Pattern:
1. Aim for rounding out and correcting the overall appearance of the glutes.
2. Use the same centrally-located insertion point.
3. Place 6 ml boluses in a complete circle around the glute.
4. Deposit 4 ml of HDR CaHA via retrograde deposition to correct all surrounding areas and create outward volume.

Multilayered Injection Technique #2 (1:1/2/4 Dilution)

Comprehensive Assessment

Focus on three key aspects: shape, sagging, and cellulite (specifically in women). The shape is categorized into four types:

A-Shape: More fat in the lateral upper thigh and less in the lateral upper hip.
V-Shape: Fat predominantly in the upper lateral hip area, minimal in the lateral upper thigh.
Short Square Shape: Equal height and width.
Round Shape: Excess fat in the center of the buttocks.

Sagging is assessed on a scale from no skin laxity to very severe skin laxity.

Cellulite is graded from none to severe, characterized by visible nodules, elevations, and discomfort.

Tailored Evaluation

This phase involves prioritizing patient concerns based on clinical findings, such as roundness, cellulite, and sagging. This combined assessment helps in identifying the primary focus for treatment and influences the quantity of filler used. For example, if the patient has a V shaped buttock, many syringes of filler will be required to create an A shaped buttock.

Customized Marking and Dilution

Each buttock is segmented into four quadrants, with each quadrant marked based on the patient’s desire.

Standardized dilutions and injection planes are as follows:

Cellulite: 1:1 dilution, injected into the superficial subcutaneous layer. The 1:1 dilution, intended for the hypodermis and its septa, is more concentrated and targets cellulite. The cannula is introduced at a 15 to 30-degree angle for this dilution.
Shape/Volume: 1:2 dilution, targeted at the deep subcutaneous layer. A 1:2 dilution is injected into the connective tissue and fascia at a 30 degree angle. This approach aims for effective neocollagenesis and structural support, potentially lifting and volumeizing the area.
Sagging: 1:4 dilution, focused on the subdermal layer. For a 1:4 dilution, CaHA particles are evenly dispersed in the subdermal layer to enhance skin quality, using a cannula angled at 15 degrees.

These dilutions are designed to target different layers, enhancing outcomes through multilayered injection and stimulating neocollagenesis.

Pre-mix a solution of 25% of 1% lidocaine and 75% normal saline under sterile conditions.

Dilution	Radiesse	Lidocaine/Saline Mix
1:1	1.5mL	1.5mL
1:2	1.5mL	3mL
1:4	1.5mL	6mL

Combo Treatment for Cellulite:

For cellulite treatment, a 22G cannula is used in a fan-like motion, supplemented by direct injections with a 27G needle in each depression. To define shape or address sagging, the solution is injected at varying depths and dilutions as per the standardized protocol.

Post-Procedure Care

Advise patients to avoid pressure on the treated area, strenuous activities, and submersion in water for at least 48 hours.

Recommend oral nonsteroidal anti-inflammatory medications as needed.

Keep Tegaderm in place for 48 hours post-procedure.

Perform active circular massage twice a day for the seven days following the procedure

Managing Complications

Common adverse events include bruising, swelling, and soreness at the injection site.

Serious complications like granulomas or vascular occlusions are rare but possible.

Have protocols in place for managing both serious and non-serious adverse events.

Conclusion

The HDR CaHA offers a customizable, patient-specific approach for buttocks augmentation. This minimally invasive procedure provides immediate volumization and long-term biostimulation, resulting in a natural-looking, symmetrical, and enhanced buttocks contour. The technique is adaptable for various clinical outcomes and is an effective alternative to surgical procedures.