MASTER CASE PRESENTATION Use of calcium hydroxylapatite in the upper third of the face: Retrospective analysis of techniques, dilutions and adverse events Jani A. J. Van Loghem 1 MD Aesthetic Medicine Centre, Amsterdam, The Netherlands Correspondence: Jani A. J. Van Loghem, MD, Aesthetic Medicine Institute, Falckstraat 51, 1017 VV Amsterdam, The Netherlands (hello@janivanloghem.com). Summary Calcium hydroxylapatite (CaHA) is a commonly used soft tissue filler for aesthetic facial improvement, in particular for the lower and mid‐face. The golden standard for upper facial filler indications is hyaluronic acid (HA) injection. In this report we investigate the safety, efficacy and complication rates after injections of CaHA to the upper third of the face using a variety of different techniques. This was a retro- spective analysis performed on patients who had received CaHA in 2016 and 2017 at various dilutions in the upper third of the face (frontal area, eyebrows and tem- poral hollows) using a number of injection techniques and both blunt‐tipped cannu- las as well as sharp needles. Records of adverse events and side effects were studied. Seventy patients had been injected with CaHA in the upper third of the face. There were 36 treatments to the frontal area, most with a cannula in the sub- galeal space with standard dilution of CaHA (16.7% lidocaine containing epinephr- ine). There were 13 treatments to the brow, mostly with a cannula and multilevel technique, and 66 treatments to the temporal hollows, mostly with a cannula in the interfascial space with standard CaHA dilution. No serious complications were recorded. CaHA was effective and well‐tolerated for a range of upper‐face indica- tions. More (prospective) research is required to further determine the value of CaHA treatments in these areas. KEYWORDS brow lift, calcium hydroxylapatite, frontal concavity, soft tissue fillers, temporal hollows 1 | INTRODUCTION The use of biostimulatory products in aesthetic medicine has been growing steadily over the past years, and in 2017, calcium hydroxy- lapatite (CaHA, Radiesse ® ; Merz North America, Inc, Raleigh, NC, USA) had risen to 10th position on the 2017 American Society of Aesthetic Plastic Surgery statistics list for most‐used nonsurgical modalities in the United States (from 11th position in 2016). 1 Calcium hydroxylapatite offers a number of advantages over hya- luronic acid (HA) fillers, as summarized in Table 1. Due to the high viscoelastic properties of the nondiluted product, it can be used for lifting, volumizing, contouring, and treating folds in the face. It is a long‐lasting, biodegradable product that stimulates fibroblasts and neocollagenesis, thereby forming new tissue that consists of the patient’s own collagen and elastin fibers. In clinical practice, CaHA is not a product for novice injectors as there is currently no reversing agent available, and in less experi- enced hands, HA fillers may be a better choice as hyaluronidase can effectively dissolve most HA products in a matter of hours. There are, however, satisfactory ways for treating CaHA overcorrections and nodules should they arise, which generally consist of redistribu- tion methods with massage, injection of saline, and injection of ster- ile water. 2 A recent report also documents the effective use of a combination of dexamethasone, triamcinolone, and 5‐fluorouracil for the resolution of CaHA nodules. 3 Received: 13 April 2018 | Accepted: 25 June 2018 DOI: 10.1111/jocd.12733 J Cosmet Dermatol. 2018;1–6. wileyonlinelibrary.com/journal/jocd © 2018 Wiley Periodicals, Inc. | 1