Master Case Presentation

Blackwell Publishing
C A S E Inc
RE P O R T

Hand recontouring with calcium hydroxylapatite (Radiesse)®

Kenneth L Edelson, MD, FAACS
Private practice, New York City

Summary The aging hand is a common area of concern for many patients. Until recently, adequate
treatment options have been hampered by pain of injecting into the dorsum and,
post-injection, by the absence of longevity of treatment. In this article, we describe the
off-label use of the soft tissue filler calcium hydroxylapatite (CaHA; Radiesse) for hand
rejuvenation. The product is inherently biocompatible and, when placed in soft tissue,
induces neocollagenesis.
An alternative injection mixture of CaHA combined with lidocaine is described, as well
as the novel “bolus” injection technique. The CaHA-lidocaine emulsion reduces the pain
of injection to nearly none at all, improves the rheology of the procedure, and allows for
deposition of the product into the correct plane of tissue. The volume of CaHA injected as
well as the amount of lidocaine used for the mixture vary according to physician preference.
In our practice, 1.3 mL of CaHA combined with 0.5 mL lidocaine per hand usually
appears to be sufficient to improve the appearance of the atrophic dorsum of the hand.
Side-effects of CaHA (Radiesse), particularly in this off-label application, are minimal
and of short duration. The aesthetic result is immediate and generally persists for longer
than 6 months. As a treatment option, hand rejuvenation with CaHA (Radiesse) is a very
gratifying procedure both to the patient and to the physician.
Keywords: hand recontouring, hand rejuvenation, hand augmentation, calcium
hydroxylapatite, Radiesse

The great Irish playwright Oscar Wilde once said that “a
woman who tells you her age will tell you anything.”
Well, in his day, she didn’t have to! One could just
examine her hands. But today, with the technology of
hand recontouring, her secret is still safe.
The hands have always been problem areas for physicians
to rejuvenate, and a myriad of applications and techniques
have been used, both surgical and nonsurgical with
limited success. Until recently, no gratifying procedure
has been successful in producing the “wow” effect of
Botox on our wrinkles or intense pulsed light and lasers
on our vessels.
Correspondence: Kenneth L. Edelson, MD, FAACS. E-mail: docskin@aol.com
Accepted for publication November 20, 2008
When faced with the patient who is complaining of
the aging hand, textural changes including crepe-like
appearance, dryness, dyschromia, increased skin laxity,
volume loss giving the sunken in appearance with bones
tendons and veins becoming more apparent, most of
us would shy away from treatment because of the un-
satisfactory outcome, whether with fat or collagen or
even recently with hyaluronic acids. A combination of
both fractional nonablative, or ablative laser resurfacing
to address the epidermal defects, and the ideal subdermal
filling agent to correct the loss of skin elasticity, volume,
and wrinkling is needed to address the aging hand. Both
men and women can benefit from volume restoration and
can attain that plumper, more youthful appearance of
their earlier years with the right technique and product.
A panoply of dermal fillers exists in the aesthetic
marketplace. These have been well described in the 2008

44 © 2009 Wiley Periodicals, Inc. • Journal of Cosmetic Dermatology, 8, 44–51

 Hand recontouring with calcium hydroxylapatite® • K L Edelson et al.
ASDS guidelines publication.1 Zyderm Collagen, our
original filler since 1982, and the gold standard for more
than two decades, and Zyplast followed by Cosmoderm
and Cosmoplast didn’t work well because of the con-
sistency, flow characteristics, and lack of longevity. The
filler was injected into the atrophic areas but it did not
cover the objectionable structures or their color. These
fillers also did not flow the way we needed them to. Lumps
and bumps were also the norm with the aforementioned
fillers. In brief, none of these products worked especially
well because of the consistency of the product, its flow
characteristics (rheology), and the relative absence of
longevity.
Harvested fat has also been used by some physicians.
However, the large bore needles required for injection
often left unsightly puncture marks for a while. More
importantly, the results were modest at best, and short
lived. In addition, there is the unavoidable second surgical
procedure of harvesting the fat that is required which
is both time consuming, requires a slightly painful, un-
comfortable injection of anesthetic, the additional prowess
at liposuction, and is fraught with all the possible adverse
side effects and complications that we are all familiar
with: bruising, infection, and scarring.
Advantages of calcium hydroxylapatite for
treatment of the aging hand
Fortunately in 2007, Florida dermatologists Mariano
Busso (Coconut Grove) and David Applebaum (Boca
Raton) articulately reported off-label clinical experiences
using calcium hydroxylapatite (CaHA; Radiesse, BioForm
Medical, San Mateo, CA) for hand recontouring.2 The
experiences involved addition of lidocaine to the existing
Radiesse compound. (Radiesse was approved in later
2006 for treatment of severe lines and wrinkles of the face
such as nasolabial folds as well as treatment for human
immunodeficiency virus–associated facial lipoatrophy.)
As a result, pain of treatment was reduced to nearly none,
with immediately pleasing results to his patients – and in
one treatment session.
Part of the success behind Dr Busso’s approach likely lies
in the physical characteristics of Radiesse. The product
consists of CaHA microspheres, 25 to 45 μm in diameter,
in a carboxymethyl cellulose carrier gel. The CaHA is
identical to the component found in human bone. The
carrier gel disperses within weeks, leaving behind the
calcium microspheres. It does not induce osteogenesis
when placed in tissue but laboratory studies show neocol-
lagenesis extending out to 72 weeks.3
Realizing the unique characteristics of Radiesse, reading
about its use in the hand, and seeing it used at live
© 2009 Wiley Periodicals, Inc. • Journal of Cosmetic Dermatology, 8, 44– 51
workshops, one had to wonder why it would work when
others have failed. Radiesse (CaHA) is a unique laboratory
manufactured filler with the appropriate density, con-
sistency, color, and rheologic characteristics, and on
paper seemed to be the answer for hand recontouring.
Physicians needed a substance that could not only fill in
the atrophic areas of the dorsum of the hand, but due to
its opacity, could conceal the color of the veins and
tendons as well. Radiesse is white and opaque, is of the
right viscosity, flows extremely smoothly, and has a
manageable extrusion force. It simply seems to be the
ideal filler for hand rejuvenation at this point in time.
After one treatment session, patients appear to be
“wowed” by the dramatic effect of Radiesse on rejuvenat-
ing the hands. As you watch the technique performed,
one is literally taken aback. After the bolus of Radiesse is
spread out under massaging fingers over the entire
surface of the dorsum of the hand, the unsightly structures
that bothered the patient are no longer visible. Within
30 min, you can painlessly give the patient hands that
bring them back to their youth. The introduction of both
nonablative and ablative fractional lasers and this
ideal filling substance has made hand rejuvenation and
recontouring a very accepted modality for the cosmetically
oriented physician to consider.
Technique of injection of CaHA into the hand
Water seeks its own level, and when allowed to, with a
little help from a massaging hand, so does Radiesse. This
is the premise of the basic technique of recontouring the
hands with Radiesse. Contrary to the technique we have
all been taught and have used since the advent of Zyderm
in 1982, hand recontouring requires a totally different
technique of “bolus” injection followed by vigorous
massage, allowing the Radiesse to fill in where it is
needed. It is a new technique for all of us, as we have
always filled in lines and furrows with a constantly
moving needle ejecting product as we either withdrew or
introduced our needle and allowed the product to remain
where deposited. In this new technique, we allow our
product to have a “nodding” acquaintance with its initial
injection site and quickly relocate it to where it is needed
with steady vigorous massage.
Preparing the Radiesse-Lidocaine mixture
Prior to injecting Radiesse into the hands, it is
homogenized with 0.5 cc of 2% plain lidocaine. The 1.3-
mL Radiesse Luer-Lok syringe is attached via a Rapid Fill
Luer-Lok to Luer-Lok connector (Baxa, Englewood, CO)
to a 3-mL Luer-Lok syringe containing the 0.5-mL of
45
Hand recontouring with calcium hydroxylapatite® • K L Edelson et al.

Table 1 Representative treatment products for the aging hand.

Product category Duration of effect*† Advantages Disadvantages

Autologous fat
CaHA (Radiesse®)
Collagen [bovine]
(Zyderm®, Zyplast®) [human]
(CosmoDerm®, CosmoPlast®)
Hyaluronic acids (Juvederm™,
Restylane®, Perlane®)
Poly L-lactic acid (Sculptra®)
Widely variable, from
4 months to more than
12 months
Approximately 12–15 months
Approximately 2–3 months
Approximately 6–9 months
Approximately 18–24 months
Biocompatibility, potential
neovascularization
Biocompatibility, collagen proliferation,
immediate correction, no
overcorrection needed, minimal pain
Long history of use in US aesthetics
No testing required
Wide variety of products available
Sustained collagenesis after a few
weeks post-injection
Harvesting required, not amenable
to patients with lipodystrophy,
does not conceal structures
Time required for mixing with
lidocaine
Skin testing for hypersensitivity
reactions, does not conceal
structures
Visibility of papules, color not
easily blended into skin of dorsum,
Tyndall effect, does not conceal
structures
Multiple treatments often
necessary, does not conceal
structures

*Facial areas (scant literature on longevity in hand), †ASDS Guidelines.

Figure 1 Radiesse with Lidocaine using the Baxa connector. Figure 2 Radiesse-lidocaine mixture with 1.3-mL Radiesse and
0.5-mL 2% plain lidocaine.

lidocaine (Fig. 1). The use of a 3-mL Luer-Lok syringe is
ideal for the homogenization process, as one can generate
a high extrusion pressure required for the proper
admixing of the two liquids. At this point, there is an
important “pearl” that needs to be passed on to the
reader: make sure you prime the Baxa connector with
lidocaine prior to making the connection; otherwise, you
will be very surprised when you attempt to first apply
pressure to the plunger of the syringe and the Radiesse
doesn’t flow, but instead, the plunger moves down
without product emerging from the needle tip, the result
of air in the mixture. The Radiesse is first injected into the
syringe containing the lidocaine and then the mixture is
admixed back and forth for several minutes until there is
a completely smooth airless composition to the filler–
lidocaine mixture (Fig. 2). There is no magic number for
this process, but a very recently published journal article
by Busso et al. speaks about 10 passes as sufficient.4 The
addition of the anesthetic favorably changes the viscosity
and extrusion force of the filler, and delivers a more
malleable mixture that is less viscous and therefore
requires a smaller extrusion force.

46 © 2009 Wiley Periodicals, Inc. • Journal of Cosmetic Dermatology, 8, 44–51

 Hand recontouring with calcium hydroxylapatite® • K L Edelson et al.

Where to inject
Careful injection site selection can considerably limit the
amount of bruising. Before injecting, carefully examine
the hand to ensure selection of an area devoid of any veins
or tendons. The imaginary line of bolus injection(s) is
midway between the dorsal crease of the wrist and the
metacarpophalangeal joints, bound laterally by the fifth
metacarpal and medially by the second metacarpal. This
boundary can be modified of course depending on the
injector’s judgment regarding the location of the defects
to be filled.

How to inject
The patient should be comfortably seated on an exam Figure 4 Injecting and forming bolus of Radiesse mixture (0.5-mL
table with the hands extended in front of them preferably bolus) in the areolar plane.
resting on a Mayo stand covered with a soft pillow,
adjusted to the height of the patient’s knees, allowing
gravity to have the desired effect on the defects to be
corrected. The skin must be tented in order to separate it
from the underlying veins and tendons (Fig. 3). Entry is
into the areolar plane, which is located between the
superficial fascia and the subcutaneous fat. The thumb
and forefinger of the noninjecting hand or a smooth
forceps is used to lift the skin and create the entry point
in the center of the tent (Fig. 3). With a 27-gauge by 1/2-inch
(or the new 28-gauge with 27-gauge inner lumen) needle
attached to the prefilled Radiesse syringe, inject between
two and four boluses of product across the previously
described area of the dorsum of the hand, refilling the
syringe when necessary. The average bolus amount is
about 0.2–0.5-mL of CaHA emulsion (Figs 4–6). Table 2
gives a step-by-step, at-a-glance guide to this procedure. Figure 5 Injected bolus prior to closed-fist massage.

Figure 3 Tenting of the skin technique. Figure 6 Injected bolus prior to closed-fist massage.

© 2009 Wiley Periodicals, Inc. • Journal of Cosmetic Dermatology, 8, 44– 51 47

Hand recontouring with calcium hydroxylapatite® • K L Edelson et al.
Figure 7 Partial massage of bolus into the dorsum.
Table 2 Steps of in-office procedure for treatment of the aging hand*.
1 Combine Radiesse with lidocaine, using a Luer-Lok connector for
the Radiesse syringe and a 3-mL syringe containing 0.5 mL of 2%
plain lidocaine.
2 Identify the areas of treatment, usually between the second and
fifth metacarpals, from the dorsal crease of the wrist to the
metacarpophalangeal joints.
3 Isolate the area of treatment with skin tenting between thumb and
forefinger of non-injecting hand, or forceps.
4 Using a 27-gauge, 1/2-inch needle, inject the boluses of CaHA–
lidocaine mixture into the areolar plane between the subcutaneous
layer and superficial fascia of the hand as needed.
5 Have the patient make a fist of the injected hand, then firmly
massage mixture to disperse.
6 Schedule follow up with patient in 2 to 4 weeks; repeat treatment
for any areas missed during initial visit.
*Adapted from Busso M, Applebaum D. Hand augmentation with
Radiesse® (calcium hydroxylapatite). Dermatol Ther. 2007; 20:
315–317.
Post-injection hand massage
At this point, massaging – the quintessential element of
relocating the product to its needed destination – is begun
(Fig. 7). Have the patient make a tight fist. To relieve
friction and enhance the process, apply a liberal amount
of Aquaphor or white petrolatum to the dorsum. Begin
pushing the boluses, one at a time, distally, laterally, and
medially, so that the bolus is flattened and spread as far as
possible. Care should be taken not to encroach upon the
metacarpophalangeal joints or the medial and lateral
dorso–palmar junctions; product is not intended for these
areas. After completing treatment of the first hand, have
48
the patient sit on that hand while you treat the other
hand. It will help in the smoothing out process as well as
add to hemostasis if needed. In the event of a hematoma,
have the patient hold pressure firmly for 5–10 min and
proceed to begin treating the contralateral hand. When
the other hand is completed, go back and complete the
“bruised” hand. Each hand usually requires between one
and two 1.3-mL Radiesse syringes. Radiesse is also
available in the 0.3-mL syringe, should a full 1.3-mL
syringe not be needed for the second syringe.
Post-treatment care
After treatment is completed apply ice packs to the hands.
The patient leaves the office with the disposable pack,
using it for as long as it stays cool. Use of the ice pack will
help reduce some of the possible swelling. The patient
should be told to carry on with normal activities
beginning the following day. Schedule the patient for
follow-up in 2 weeks, and if at this time there are skip
areas noticed, you can fill them in using the 0.3-mL
Radiesse syringe mixed with 0.12-mL of 2% lidocaine.
Adverse events
Because it is a compound identical to that found in bone,
Radiesse has high biocompatibility and low adverse event
risks. Adverse events in published studies have been few and
of short duration.5–8 They include ecchymosis, erythema,
and occasional edema, when used in facial applications other
than the lips. In general, the diluted product described for
off-label use in the hands is even more forgiving. Clinical
experiences with treatment of the aging hand suggest that
adverse events in this area are infrequent and not severe.
In recent personal communications, however, there have
been some anecdotal reports of hand swelling lasting up
to 7-10 days.
Results
Figures 8–11 represent a 45-year-old female patient who
received 1.3 mL of Radiesse mixture per hand during
the initial visit and did not have a touch-up performed.
Figures 12–16 represent a 58-year-old female patient
who also received 1.3 mL of the Radiesse mixture in each
hand and returned for a touch-up of the left hand only
with 0.3-mL Radiesse at week 8.
Discussion
As with every new technique in surgery, refinements
and modifications are the rule as time goes on. New
© 2009 Wiley Periodicals, Inc. • Journal of Cosmetic Dermatology, 8, 44–51
 Hand recontouring with calcium hydroxylapatite® • K L Edelson et al.

Figure 8 A 45-year-old female patient prior to treatment. Figure 11 Same patient 12 weeks post-treatment.

Figure 9 Same patient 2 weeks post-treatment with 1.3-mL Figure 12 A 58-year-old female patient pre-treatment (Pianist!).
mixture in each hand.

Figure 13 Same patient 2 weeks post-treatment with 1.3-mL

Figure 10 Same patient 8 weeks post-treatment. Radiesse mixture for each hand.

© 2009 Wiley Periodicals, Inc. • Journal of Cosmetic Dermatology, 8, 44– 51 49

Hand recontouring with calcium hydroxylapatite® • K L Edelson et al.
Figure 14 Same patient 8 weeks post-treatment with a touch-up
using 0.3-mL Radiesse mixture for only left hand done at 4 weeks
post-initial treatment.
Figure 15 Same patient at 20 weeks post-initial treatment.
approaches to the same technique give rise to slight
revisions and adjustments leading to a better outcome.
The original technique described by Busso was a single
voluminous bolus of an entire syringe of Radiesse and
lidocaine, which was then spread out over the hand.
Some physicians prefer large-volume bolus approach;
others believe it is less advantageous than the multiple,
smaller-volume bolus approach.
The volume of lidocaine remains an open question as
well. The original volumes of lidocaine with the single
bolus injection were much smaller (0.10-mL per 1.3-mL
Radiesse) than the volumes found in many clinical
settings today (0.23 to 2.0 mL per syringe). In many
personal communications, I have determined that a larger
volume of lidocaine is preferred for optimum results.
These volumes have ranged from 0.12 to 2.0 mL of
50
Figure 16 Same patient at 28 weeks post-initial treatment.
lidocaine per 1.3-mL syringe of Radiesse. A mixture of
0.5 mL of 2% lidocaine per 1.3-mL Radiesse syringe and
0.12 mL for the 0.3-mL Radiesse syringe appear optimal.
There are several reasons why these two volumes are the
volumes of choice. In the first place, considerably less
hand swelling occurs when 0.5 mL of lidocaine is used
compared to 2.0 mL. In addition, this volume enhances
product flow and makes massage of injected mixture
relatively easy. However, the most important reason is
longevity and the convenience issue for the patient. Much
less product is used with higher dilutions, and therefore,
the correction may not endure as long as with smaller
dilutions. Busso’s recent paper states “physicians have
reported that they see no significant decrease in durability
for media diluted with lidocaine”.4 At this point, controlled
clinical trials would be needed to determine that dilution
with lidocaine does not negatively affect longevity of
Radiesse correction, not only in the hands, but for all
applications.
This issue of higher dilutions and possible decreased
durability can easily be addressed, but it means more
procedures at the 2-week follow-up than necessary.
Follow-up sessions should address the missed areas that
are inevitable, not retreating areas where the “excess”
© 2009 Wiley Periodicals, Inc. • Journal of Cosmetic Dermatology, 8, 44–51
 Hand recontouring with calcium hydroxylapatite® • K L Edelson et al.
lidocaine has been absorbed. Another refinement that
is helpful is the use of a smooth forceps to create the
subsequent tents that might be needed. Once the emollient
has been applied to the skin, a gloved hand on greasy skin
will not be able to create the tent.
Summary
Past experiences with products for treating the aging
hand have met with limited success. These products –
harvested fat, collagen, and hyaluronic acids – have
disadvantages for placement in the hands for contouring
enhancements. Foremost among these is the brevity of
duration, usually less than 3 months, and the inability of
all of the other fillers to conceal the objectionable
structures of the aging hand. CaHA appears well suited
for consideration as a product for recontoruing of the
hand, with a duration of effect of 6 months or longer.
Unlike other areas where there is not a lot of muscle
activity, the hand’s muscles and tendons are constantly
moving, creating the friction which accelerates product
breakdown. (Of note is the fact that one of the patients
shown is a piano player.) This of course is in contrast to
more static treatment areas where we experience much
greater longevity of correction. Perhaps the single most
important and unique characteristic of Radiesse that
makes it ideal for hand recontoruing is its opacity, the
trait that enables the concealment of the undesirable
structures of the aging hand. Radiesse is also clinically
unchanged in its physical characteristics by the addition
of lidocaine, allowing for painless treatment.
© 2009 Wiley Periodicals, Inc. • Journal of Cosmetic Dermatology, 8, 44– 51
References
1 Guidelines Task Force: Alam M, Gladstone H, Kramer EM et al.
ASDS guidelines of care: injectable fillers. Dermatol Surg
2008; 34: S115–48.
2 Busso M, Applebaum D. Hand augmentation with
Radiesse® (calcium hydroxylapatite). Dermatol Ther 2007;
20: 315–7.
3 Berlin AL, Hussain M, Goldberg DJ. Calcium hydroxylapatite
for facial filler rejuvenation: a histologic and
immunohistochemical analysis. Dermatol Surg 2008;
34: S64–S67.
4 Busso M, Voigts R. An investigation of changes in physical
properties of injectable calcium hydroxylapatite in a carrier
gel when mixed with lidocaine and with lidocaine/
epinephrine. Dermatol Surg 2008; 34: S16–24.
5 Tzikas TL. A 52-month summary of results using calcium
hydroxylapatite for facial soft tissue augmentation. Dermatol
Surg 2008; 34: S9–15.
6 Carruthers A, Liebeskind M, Carruthers J, Forster BB.
Radiographic and computed tomographic studies of calcium
hydroxylapatite for treatment of HIV-associated facial
lipoatrophy and correction of nasolabial folds. Dermatol Surg
2008; 34: S78–84.
7 Moers-Carpi M, Vogt S, Martinez Santos B, Planas J,
Rovira Vallve S, Howell DJ. A multicenter, randomized trial
comparing calcium hydroxyalaptite to two hyaluronic acids
for treatment of nasolabial folds. Dermatol Surg 2007; 33:
S144–51.
8 Sadick NS, Katz BE, Roy D. A multicenter, 47-month study of
safety and efficacy of calcium hydroxylapatite for soft tissue
augmentation of nasolabial folds and other areas of the face.
Dermatol Surg 2007; 33: S122–7.
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