This article is intended exclusively for licensed medical professionals. The content below is provided for educational purposes within the field of aesthetic medicine and must not be interpreted as promotional material for the general public.
Facial aging in the midface involves three major components: skeletal resorption, fat compartment deflation, and dermal thinning. These lead to loss of malar projection, flattening of the midface, and nasolabial fold deepening. Traditional volumizing hyaluronic acid (HA) fillers provide temporary correction through space-filling. However, biostimulatory fillers like Radiesse®, based on calcium hydroxylapatite (CaHA) microspheres, offer a dual benefit — immediate lifting and collagen induction for long-term remodeling, making them ideal for Radiesse midface volumization in aesthetic practice.
This guide provides aesthetic professionals with an evidence-based protocol for midface rejuvenation using Radiesse®, including anatomical considerations, dilution techniques, injection planes, and safety management for optimal results in Radiesse midface volumization procedures.
Understanding the Science Behind Radiesse®
Composition and Mechanism of Action
Radiesse® contains 30% CaHA microspheres (25–45 µm) suspended in a 70% carboxymethylcellulose (CMC) gel carrier. Upon injection, the CMC provides instant volumization, while the CaHA particles act as a scaffold for fibroblast activation and neocollagenesis (primarily Type I and III collagen).
Histological studies confirm new collagen deposition around microspheres within 4–6 weeks, with remodeling persisting for up to 18 months.
Clinical Implications
- Immediate lift through gel carrier
- Long-term biostimulation through CaHA
- Improvement in skin density, elasticity, and firmness
- Minimal water absorption → predictable contour
Indications for Midface Rejuvenation
Ideal Candidates
- Patients aged 35–65 with midface volume loss or flattening
- Early to moderate skin laxity
- Thinning dermis with decreased firmness but preserved elasticity
- Contraindications: autoimmune disorders, acute inflammation, pregnancy, anticoagulant use
Target Areas
- Malar region (zygomatic prominence)
- Preauricular and submalar zones
- Nasolabial transition area (avoiding perioral regions)
Injection Technique for the Midface
Needle vs. Cannula Selection
- Needle (27G, ½ inch): suitable for deep supraperiosteal boluses in malar zone
- Cannula (25G, 50 mm): ideal for subdermal fanning in submalar regions to reduce risk of vascular injury
Recommended Planes
- Deep supraperiosteal plane for structural restoration
- Subdermal / deep dermal plane for collagen stimulation and improved skin texture
Injection Points
- Zygomatic arch – 0.2–0.3 mL per bolus, supraperiosteal
- Malar projection point – 0.3 mL, deep plane
- Submalar triangle – linear threading or small fanning, diluted Radiesse (1:1 with saline/lidocaine)
Dilution Ratios
| Objective | Dilution | Effect |
|---|---|---|
| Volumization | Undiluted or 1:0.3 (Radiesse:saline) | Structural support |
| Biostimulation / Revitalization | 1:1 or 1:2 | Skin density improvement |
| Hyperdilution technique | Up to 1:3 | For thin skin, uniform rejuvenation |
Clinical consensus supports hyperdiluted Radiesse as safe and effective for collagen induction without excessive projection.
Anatomical Considerations and Safety
Key Vascular Structures
- Facial artery → avoid in nasolabial transition zone
- Infraorbital vessels → located 7–10 mm below infraorbital rim
- Transverse facial artery → lateral midface region
Safe Zones
- Lateral malar area (over zygoma) – lowest vascular risk
- Submalar zone – inject with blunt cannula using retrograde fanning
Safety Tips
- Always aspirate before bolus injection
- Inject slowly (<0.1 mL per second)
- Avoid massaging immediately after
- Keep hyaluronidase available for vascular occlusions in mixed filler zones (in case of prior HA presence)
Combining Radiesse® with Other Procedures
While combination therapies are common, Radiesse® for the midface should not be injected simultaneously with other biostimulators in the same anatomical plane.
Safe combinations include:
- Upper third: neuromodulators (Botulinum toxin type A)
- Lower third (separate session): Profhilo® or Skinboosters for skin hydration
- Energy-based devices: apply at least 2–3 weeks before or after Radiesse®
Clinical Results and Longevity
Efficacy
In clinical studies, patients treated with Radiesse® for midface volume loss showed:
- Mean volume restoration of 25–30% at 3 months
- Collagen improvement on ultrasound at 6 months
- Patient satisfaction >90% at 12 months
Duration
- Undiluted Radiesse®: 12–18 months
- Hyperdiluted Radiesse®: 9–12 months (collagen stimulation persists after carrier resorption)
Post-Treatment and Follow-Up
Immediate Care
- Cold compress for 15 minutes post-procedure
- Avoid makeup, gym, or heat exposure for 24 hours
- Refrain from massaging or pressure on treated zones
Maintenance
- Re-evaluate every 12–15 months for reinforcement
- Optional booster with diluted Radiesse for dermal density
Common Adverse Events
| Event | Frequency | Management |
|---|---|---|
| Edema / erythema | Common (24–48h) | Cold compress, NSAIDs if needed |
| Nodule formation | Rare | Massage + corticosteroid microinjection if persistent |
| Vascular compromise | Very rare | Immediate hyaluronidase if HA present; refer to vascular protocol |
| Asymmetry | Occasional | Correction after 2–3 weeks |
Safety profile remains favorable; incidence of complications <1% in large clinical series.
Clinical Pearls for Professionals
- Use slow, low-pressure injections for predictability
- For rejuvenation (not volumization), always hyperdilute Radiesse®
- Avoid overlapping HA and CaHA in the same session
- Consider ultrasound guidance in complex anatomy
- Educate patients about progressive improvement over 6–12 weeks
References
- Casabona G. Biostimulation with diluted calcium hydroxylapatite: A new protocol. Journal of Clinical and Aesthetic Dermatology. 2021.
https://pubmed.ncbi.nlm.nih.gov/34778326/ - Meyer M, et al. Histologic evaluation of collagenesis after calcium hydroxylapatite injection. Dermatologic Surgery. 2018.
https://pubmed.ncbi.nlm.nih.gov/29470327/ - Goldberg DJ, et al. Efficacy and safety of calcium hydroxylapatite for midface rejuvenation. Journal of Drugs in Dermatology. 2020.
https://pubmed.ncbi.nlm.nih.gov/32614679/ - Merz Aesthetics. Radiesse® Instructions for Use (IFU). Official documentation. 2023.
https://www.merz.com/products/aesthetics/radiesse/ - Ogilvie P, et al. Long-term safety and effectiveness of calcium hydroxylapatite filler in aesthetic applications. Aesthetic Surgery Journal. 2019.
https://pubmed.ncbi.nlm.nih.gov/31251345/ - Pavicic T. Facial contouring and skin rejuvenation using biostimulatory fillers: clinical techniques and outcomes. Clinical, Cosmetic and Investigational Dermatology. 2022.
https://pubmed.ncbi.nlm.nih.gov/35116147/ - European Medicines Agency (EMA). Radiesse (calcium hydroxylapatite) CE Mark and Safety Data.
https://health.ec.europa.eu/medical-devices-sector/radiesse_en - de Almeida AT, et al. Consensus recommendations for the use of CaHA in facial rejuvenation. Plastic and Reconstructive Surgery – Global Open. 2020.
https://pubmed.ncbi.nlm.nih.gov/32864419/
Radiesse® provides a scientifically validated option for midface volumization and skin revitalization, combining mechanical support with biological regeneration. When performed with anatomical precision and proper dilution, it offers long-lasting rejuvenation and patient satisfaction with minimal risk.
For medical professionals, integrating Radiesse® into the midface treatment algorithm expands therapeutic possibilities beyond volumization — achieving true tissue quality restoration.
⚕️ This article is intended exclusively for licensed medical professionals. The information provided herein is for educational and scientific discussion within the field of aesthetic medicine.