Chances are, you’re familiar with Radiesse. Since gaining FDA approval in 2006, some 6 million syringes of the filler have been injected deep in the skin, to restore lost volume and correct facial wrinkles and folds. Radiesse is frequently used to smooth smile lines, lift sunken cheeks, plump hands, and strengthen jawlines.
Recently, however, dermatologists and facial plastic surgeons have started using Radiesse in a unique way, by diluting (or when the ratio is 1:2 or higher, hyperdiluting) it with saline or lidocaine and injecting it more superficially, to address concerns related to skin texture and laxity—think fine wrinkles, crepiness, acne scars, and cellulite as well as saggy skin. It’s being used on the face, neck, chest, arms, abdomen, legs, and buttocks.
“I love this technique,” says Dr. Jessie Cheung, a board-certified dermatologist in New York City and Chicago. “We’re not adding volume, but we see the skin tighten and shrink and become smoother.”
Radiesse vs. diluted Radiesse—what’s the difference?
A little refresher course on Radiesse: unlike hyaluronic acid (HA)–based filling materials like Juvéderm and Restylane, Radiesse works by stimulating your body to make collagen, the protein that plumps skin and keeps it smooth. The filler is made up of microspheres of calcium hydroxyapatite (CaHA), a substance also found in bones, that are suspended in a gel.
Like HA fillers, Radiesse works immediately to improve the treated area. But over time, the gel is fully absorbed and the body metabolizes the CaHA microspheres, leaving behind your own natural collagen, which lasts for 18–24 months. “In its unaltered form, Radiesse holds up well against gravity, which makes it an excellent filler for areas requiring a significant amount of structure and/or that are impacted by strong muscles, like the cheeks and jawline,” explains Dr. Heidi Waldorf, a board-certified dermatologist in Nanuet, New York, who was on the consensus panel that determined the preliminary guidelines for using hyperdiluted Radiesse.
Depending on how much Radiesse is diluted, the material has a mild volumizing effect, at best. Instead, it creates the equivalent of a gel mesh. “This initially holds an area more taut, but over time, it acts primarily as a biostimulator to improve the tone and texture and even tighten skin,” explains Dr. Waldorf. She uses it most commonly for the cheeks, neck, and chest in patients who have severe “solar elastosis,” or damaged collagen and elastin from sun exposure.
Tighten and smooth, from the neck down
This technique has been used in Europe for a few years, but it’s catching on more in the U.S. and should be widely adopted in 12–18 months, says Dr. Steven Weiner, a facial plastic surgeon in Santa Rosa Beach, Florida. He’s particularly a fan of using diluted Radiesse to treat “off-face” areas that weren’t being addressed completely with other modalities and “now can be treated with significant improvement, with minimal to no downtime and [few to no] risks.”
He uses it mostly for necks, on patients with mild to moderate laxity, as part of his Tri-NECK-ta treatment, which also includes Dysport (a botulinum toxin); Genius (radiofrequency microneedling, or RFM); or laser resurfacing. “I often inject Radiesse in the neck in combination with the Genius to improve wrinkles and skin integrity, and it actually tightens the skin, with or without RFM,” he says. Indeed, in one small study on the neck and décolletage, injections of diluted Radiesse stimulated significant amounts of collagen. The treatment, researchers concluded, was very effective for skin tightening in both areas.
Related: Hyaluronic Acid vs. Biostimulatory Fillers: What to Know Before You Get Injected
How diluted is diluted Radiesse?
Many experts have developed techniques for diluting CaHA, in ratios of anywhere from 1:1 to 1:6. Dilutions can be adjusted, depending on the thickness of a patient’s skin and the degree of tissue laxity, to ensure smooth placement. If not properly diluted, the material can look bumpy, especially if it’s injected too superficially. In one study where hyperdiluted Radiesse was used on the neck, researchers injected different dilutions based on skin thickness: 1:2 (normal skin), 1:4 (thin skin) and 1:6 (severely “atrophic” or aged skin).
Diluted Radiesse is injected with a cannula or needle, with or without topical anesthetic, depending on whether Radiesse or Radiesse (+), which contains the anesthetic lidocaine, is used. Several injection techniques are used: for skin laxity, multiple cannula passages are made in patterns that resemble a fan or an asterisk. The material can also be injected in short, linear “threads.”
As a bonus, the dilution eases the filler delivery for the injector. It also reduces filler thickness and facilitates its even spread, encouraging skin stimulation through more direct contact with tissues and minimizing unevenness.
As with any filler injection, there can be a variable amount of bruising and swelling, which normally lasts up to a week. “Although uncommon because of the thinning of the product, if a bump is seen or felt after swelling and bruising have resolved, it can be camouflaged with other filler or broken up with injection and massage,” says Dr. Waldorf.
When injecting diluted Radiesse, less is more to prevent excess swelling, especially when using higher dilutions, says Dr. Waldorf. For instance, when treating the neck, she’ll often use one syringe of Radiesse and then have the patient return in two to four weeks for another treatment.
The “add-on” effect
Diluted Radiesse can be used alone, “but harder-to-treat concerns, like the neck, chest, and arms, invariably do best with a combination approach,” explains Dr. Waldorf. She says diluted Radiesse is a great adjunct to other tightening and resurfacing procedures, like Ultherapy, Thermage, and Fraxel, because they work together to improve dermal collagen. “Think of combination therapy like assembling an outfit—each piece of the outfit does something different, and together they make the look.”
That said, in one study that evaluated the effectiveness of diluted Radiesse used by itself to tighten skin in the upper arms and abdomen, skin thickness significantly increased after a single treatment and 90% of participants and physicians rated the areas very much improved.
Diluted Radiesse is frequently also combined with traditional Radiesse injections. “Most patients want the straight filler effect,” says Dr. Cheung. “Spackling” or “frosting,” as she called treatment with diluted Radiesse, is additional. “You see the effects of the regular filler immediately and then see the collagen that diluted Radiesse stimulates after about a month,” Dr. Cheung explains. “Patients look good from the filler right away, then come back and say their skin looks tighter [and] smoother and that they look a little more lifted.”
How much diluted Radiesse is needed, and what does it cost?
Radiesse is available by the syringe, and, according to the current practice guidelines, treatment typically requires one to two syringes. The face and neck each usually require a single 1.5cc syringe per session, while the chest requires a half to a full syringe. The buttocks require one syringe per cheek (for cellulite and sagging skin), and the thighs need one syringe per thigh area (inner or outer). The abdomen requires two syringes, one each for the upper and lower half. The knees and elbows require one syringe in total (half on each side), and the arms usually need between a half and a full syringe per arm. Usually, two sessions for fillers are necessary, spaced one or two months apart.
Depending on what’s being treated, the treatment may be repeated at six months or a year. Preliminary research shows that results with diluted Radiesse may last up to two years.
The average cost paid for Radiesse by RealSelf members is $1,050 per treatment.
How to find a provider
If you’re interested in investigating treatment with dilute Radiesse, be aware that this is not an FDA-approved indication for the filler. It’s also a more advanced procedure. “Many basic injectors aren’t as comfortable with Radiesse as they are with the HA fillers, because HA can be dissolved and Radiesse can’t be,” notes Dr. Waldorf, who advises patients to seek out a board-certified core cosmetic injector who’s familiar with the range of injectables available in the U.S. “We may not all choose to use every one, but we know how to do it,” she says. Be sure to have a discussion with the provider about all your treatment options and the pros and cons of each.
