Radiesse Reversal
Radiesse (calcium hydroxylapatite) cannot be dissolved like hyaluronic acid fillers, but can be mechanically removed using a grater-type microliposuction cannula technique when complications such as nodules, overcorrection, or vascular compression occur. 1
Understanding the Challenge
Radiesse is a semipermanent, biodegradable filler composed of calcium hydroxylapatite (CaHA) microspheres (30%) suspended in an aqueous carrier gel (70%). 2 Unlike hyaluronic acid-based fillers that can be enzymatically dissolved with hyaluronidase, the physical properties of CaHA make it impossible to chemically dissolve or reverse. 1
Indications for Removal
Consider mechanical removal in the following situations:
- Nodule formation (palpable or visible lumps) 1
- Overcorrection with excess material causing aesthetic concerns 1
- Vascular compression threatening tissue perfusion 1
- Anterior filler displacement with migration to unintended areas 3
- Chronic foreign body granulomatous inflammation 3
Mechanical Removal Technique
The established removal method involves mechanical debulking using a grater-type microliposuction cannula under negative pressure. 1 This technique has been validated in clinical practice with successful outcomes.
Step-by-Step Protocol:
Create access point: Use an 18-gauge needle to make a small incision near the excess filler 1
Prepare extraction device: Attach a 1-mm-diameter grater-type microliposuction cannula (such as Lipocube) to a 5-10 mL syringe 1
Apply negative pressure: Create suction by pulling back the syringe plunger 1
Perform mechanical removal: Insert the cannula under suction and use a back-and-forth reaming motion, starting at the base of the material and gradually moving toward the surface 1
Continue until desired effect: Remove material until the nodule is eliminated or overcorrection is adequately reduced 1
Ultrasound Guidance
Ultrasound imaging can be used to identify CaHA location before removal and confirm adequate extraction afterward. 1 This is particularly helpful for deeper deposits or when the extent of filler is unclear on palpation.
Timing Considerations
Removal can be performed either immediately at the time of injection if overcorrection is recognized, or months later when complications develop. 1 In the reported case series, successful removal was achieved both at the time of injection in two patients and 6 months post-injection in another patient. 1
Expected Outcomes
In clinical experience with this technique:
- No patients required repeat removal treatment 1
- Palpable nodules were completely eliminated 1
- Excess material was adequately removed in all cases 1
- One patient had a 1-cm buccal nodule successfully eliminated 1
Critical Limitations
This mechanical removal technique is NOT applicable to inadvertent intravascular injection of Radiesse. 1 Intravascular complications require immediate emergency management following standard protocols for filler-related vascular occlusion, including cessation of injection, aspiration attempts, hyaluronidase (though ineffective for CaHA), warm compresses, massage, and consideration of hyperbaric oxygen or other interventions to restore perfusion.
Surgical Excision Alternative
For severe cases with extensive anterior displacement or chronic inflammation, transconjunctival or transcutaneous surgical excision may be necessary. 3 In a case series of orbital Radiesse complications, two of four patients required formal surgical excision of the filler and infiltrated orbital fat. 3 Histopathologic examination revealed chronic foreign body granulomatous inflammation. 3
Prevention Strategies
The best approach is prevention through proper injection technique:
- Inject in small, calculated doses to prevent nodules or vascular occlusion 4
- Place product in the supraperiosteal space or deep subcutaneous layer, avoiding superficial placement 4
- Consider product reconstitution with lidocaine to improve rheology and reduce complications 4, 5
- Avoid injection in patients with multiple prior surgeries in the area, as tissue disruption and scarring may increase risk of filler displacement 3
Common Pitfalls
- Do not attempt enzymatic dissolution: No enzyme exists that can dissolve calcium hydroxylapatite 1
- Do not delay removal of symptomatic nodules: Early mechanical removal is more straightforward than waiting for chronic inflammation to develop 1, 3
- Do not use this technique for vascular occlusion: Intravascular injection requires different emergency management 1