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Calcium Hydroxylapatite

Medically reviewed by Last updated on Oct 13, 2020.


(KAL see um hi DROKS el AP a tite)

Index Terms

  • CaHA

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Implant, Subdermal:

Radiesse: (0.8 mL, 1.5 mL)

Radiesse Plus: (0.8 mL, 1.5 mL) [contains lidocaine hydrochloride 0.3%]

Brand Names: U.S.

  • Radiesse
  • Radiesse Plus

Pharmacologic Category

  • Cosmetic Agent, Implant
  • Skin and Mucous Membrane Agent, Miscellaneous


Subdermal injection may decrease the depth of facial wrinkles or correct volume loss in dorsum of hands.

Use: Labeled Indications

Facial wrinkles: Subdermal implantation for correction of moderate to severe facial wrinkles and folds, such as nasolabial folds, and also intended for restoration and/or correction of the signs of facial fat loss (lipoatrophy) in patients with HIV.

Hand augmentation: Subdermal implantation to correct volume loss in the dorsum of the hands.


Hypersensitivity to calcium hydroxylapatite or any component of the formulation; severe allergies manifested by a history of anaphylaxis or history or presence of multiple severe allergies; bleeding disorders.

Radiesse Plus: Additional contraindication: Known hypersensitivity to lidocaine or anesthetics of the amide type.

Dosing: Adult

Facial wrinkles: Subdermal: Inject as required for cosmetic result (treatment volume varies based on indication/location); repeat treatment may be administered. Use a 1:1 correction factor. Do not overcorrect (overfill) a contour deficiency.

Hand augmentation: Subdermal: Inject in small boluses (0.2 to 0.5 mL per bolus [maximum: 0.5 mL per bolus]) as required for cosmetic result (number of injection points varies); maximum volume per hand: 3 mL. Repeat treatment may be administered (retreatment with volumes >1.6 mL/hand per treatment session may result in increased adverse events). Use a 1:1 correction factor. Do not overcorrect (overfill) a contour deficiency.

Dosing: Geriatric

Refer to adult dosing.


Open the foil pouch by tearing at the notches (marked 1 and 2), and remove the syringe from the foil pouch. There is a small amount of moisture normally present inside the foil pouch for sterilization purposes; this is not an indication of a defective product. A new injection needle may be used for each syringe, or the same injection needle may be connected to each new syringe.

The needle must be tightened securely to the syringe and primed with calcium hydroxylapatite injectable implant. Slowly push the syringe plunger until calcium hydroxylapatite injectable implant extrudes from the end of the needle. If leakage is noted at the Luer fitting, it may be necessary to tighten the needle, or to remove the needle and clean the surfaces of the Luer fitting, or, in extreme cases, replace both the syringe and the needle. Refer to manufacturer’s labeling for detailed instructions.

Radiesse: Lidocaine 2% may be mixed in the syringe; add 0.11 mL or 0.26 mL of lidocaine 2% to the 0.8 mL or 1.5 mL calcium hydroxylapatite syringe, respectively. Refer to manufacturer’s labeling for detailed instructions.


Subdermal: Do not inject into blood vessels or veins or tendons in the hand. Local or topical anesthesia may be used at the injection site. Avoid passing through scar tissue and cartilage, if possible. Insert needle at approximately a 30-degree angle to the skin. Advance the needle into the subdermis; slowly inject the implant material in linear threads while withdrawing the needle. Continue placing additional lines of material until the desired level of correction is achieved; do not overcorrect. The implant material should be completely surrounded by soft tissue without leaving globular deposits. The injected area may be massaged as needed to achieve even distribution of the implant.

The needle should slide under the dermis; if significant resistance is encountered when pushing the plunger, move the needle slightly or change the injection needle. Needle jams are more common with needles smaller than 27 gauge. To help avoid needle breakage, do not attempt to straighten a bent needle; discard it and complete the procedure with a replacement needle.

Hand augmentation: Immediately after injection, cover injection site with sterile gauze and have patient sit on hand to warm implant while the contralateral hand is being treated. After contralateral hand is treated, cover with gauze and have patient sit on it. Remove gauze from initial hand, have patient make a fist and gently massage dorsum of hand to spread evenly; repeat with contralateral hand.


Store between15°C and 32°C (59°F and 90°F). Do not use if the expiration date has been exceeded. Do not use the calcium hydroxylapatite injectable implant and lidocaine 2% mixture later than 2 hours after mixing.

Syringes are packaged for single patient use. Do not resterilize. Do not use if the package is opened or damaged or if the syringe end cap or plunger is not in place.

Drug Interactions

There are no known significant interactions.

Test Interactions

Radiography: Calcium hydroxylapatite particles are radiopaque and are visible on CT scans and may be visible on standard radiography.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Incidences based on patient's diaries on days 1 to 3 postinjection of calcium hydroxylapatite.


Cardiovascular: Edema (29%; maximal edema may occur on days 4 to 7 and may persist for up to 4 weeks)

Central nervous system: Pain (19%; may persist for up to 4 weeks)

Dermatologic: Erythema (33%; may persist up to 4 weeks), ecchymoses (14%; maximal ecchymosis may occur on days 4 to 7), pruritus (13%)

Infection: Infection (1% to >5%)

Local: Injection site reaction (13%; includes muscle tenderness, numbness, contour irregularity, and skin irritation; may persist for up to 4 weeks)

<1%, postmarketing, and/or case reports (includes long-term effects up to 3 years after treatment): Abscess, alopecia, application site reaction (exposed material, over injection, under injection, superficial injection, product displacement), bleeding at injection site, blepharoptosis, bullous pemphigoid, cold intolerance, dark circles, dizziness, double vision, eczema, facial wrinkling, flu-like symptoms, granuloma, hematoma, herpes simplex infection (including reactivation), hordeolum, hyperpigmentation (upper lip), hypersensitivity reaction, hyperventilation, inflammation, ischemia, localized blanching, nausea, nodule, pallor, paralysis, residual mass at injection site, scarring, skin blister, skin cyanosis, skin discoloration, skin necrosis, skin texture changes, tachyphylaxis, thrombosis, tingling sensation, urinary tract infection, venous obstruction


Concerns related to adverse effects:

• Injection-site reactions: Transient injection-site reactions lasting <7 days, including bruising, redness, and swelling, have been observed. Coadministration of medications that may prolong bleeding (eg, aspirin, warfarin) may cause increased bruising or bleeding; use with caution.

• Vascular occlusion: Vascular occlusion may occur following intravascular injection, resulting in infarction or embolism and subsequent ischemia, necrosis, or scarring. Intravascular injection in the face has produced rare serious adverse events, including temporary or permanent vision impairment, blindness, cerebral ischemia or cerebral hemorrhage (leading to stroke), skin necrosis, and damage to underlying facial structures. Do not use in vascular rich areas (eg, glabella, nose). Vascular occlusion of the lips, nose, or glabellar or ocular region has been reported. Discontinue use immediately if changes in vision, signs of stroke, blanching of skin, or unusual pain during or shortly after the procedure occur.

Disease-related concerns:

• Disorders of the hand: Use with caution in patients with autoimmune disease affecting the hand, hand implants, Dupuytren contracture, history of hand tumor, vascular malformations, Raynaud disease, and risk for tendon rupture; has not been studied.

• Fitzpatrick skin types IV-VI: Use with caution in patients with Fitzpatrick skin types IV-VI; may have increased risk in difficulty performing tasks following injection into the dorsum of the hand.

• Herpes: Treatment may result in herpes reactivation in patients with a history of herpetic eruption.

• HIV: Patients with HIV should only be treated by health care providers with expertise in the correction of volume deficiencies in these patients.

• Skin infection/inflammation: Patients with an active skin infection or inflammation in or near the treatment area should not undergo treatment until the inflammatory or infectious process has been controlled. Treatment carries a risk of infection; utilize standard aseptic precautions during treatment.

Dosage form specific issues:

• Radiesse Plus: Assess the risk versus benefit in patients with congenital methemoglobinemia, patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency, and patients receiving concomitant treatment with a methemoglobin-inducing agent.

Other warnings/precautions:

• Appropriate use: Safety and efficacy has not been established in patients with severe loss of fatty tissue with visible veins and tendons. Safety in patients with increased susceptibility to keloid formation and hypertrophic scarring has not been studied. Concomitant use with epilation, ultraviolet radiation, or laser, mechanical, or chemical peeling procedures has not been studied; there is a risk of inflammation at the implant site if these concomitant procedures are performed, especially prior to complete healing of the skin. Patients should minimize strenuous activity and exposure of the treatment area to extensive sun or heat for 24 hours or until any swelling and redness has resolved.

• Appropriate use: Hand augmentation: The effect on hand function is unknown. Avoid injection into veins or tendons; may weaken or cause tendons to rupture or cause embolization or thrombosis. Use in the dorsum of the hand may result in swelling; remove rings prior to treatment and until swelling has resolved. Adverse events may occur that last >14 days. Temporary difficulty performing activities may occur with injection into the dorsum of the hand; nodules, bumps, or lumps in the dorsum of the hand may last up to 1 year. Higher volume injections are associated with increased bruising; volumes >3 mL per hand in a treatment session have not been studied; retreatment with volumes greater than ~1.6 mL per hand in a treatment session may result in increased adverse events (eg, redness, pain, swelling, difficulty performing activities). Treatment for >1 year has not been studied.

• Appropriate use: Facial wrinkles: Contours should not be overfilled; facial wrinkles should gradually improve over several weeks following treatment. Safety and efficacy for use in the lips and periorbital area have not been established; nodules have been reported when injected into the lips. Treatment for >3 years has not been studied.

• Experienced physician: Should be administered by an experienced health care provider who has appropriate training, experience, knowledge of anatomy at injection site, and knowledge of aseptic technique.

Reproductive Considerations

Women of reproductive potential who were not using effective contraception were excluded from clinical trials.

Pregnancy Considerations

Reproduction studies have not been conducted. Pregnant women were excluded from clinical trials.

Patient Education

What is this drug used for?

• It is used to lower the number of wrinkles and skin folds on the face.

• It is used to help with fat or volume loss in certain areas of the body.

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

• Injection site pain, redness, or swelling

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• Weakness on 1 side of the body, trouble speaking or thinking, change in balance, drooping on one side of the face, or blurred eyesight

• Severe injection site irritation

• Numbness or tingling

• Pale skin

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.

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