Prevention and Management of Complications With a Hyaluronic Acid-Calcium Hydroxyapatite Hybrid Injectable

Abstract

Background: A ready-to-use hyaluronic acid-calcium hydroxyapatite (HA-CaHA) hybrid injectable has a dual mode of action for soft-tissue augmentation. Although previous studies have reported a favorable safety profile for HA-CaHA, there is a need for guidelines and recommendations based on real-world clinical experience for the management of complications associated with HA-CaHA.

Purpose: This publication provides guidelines and recommendations for the prevention and management of HA-CaHA-related complications. A case study example, treatment algorithms, and injection techniques are included to illustrate the management of complications.

Materials and methods: On January 25, 2023, 13 European physicians were invited to an advisory board meeting to discuss strategies for optimizing patient care, minimizing adverse events (AEs), and identifying data gaps for the prevention and management of complications with HA-CaHA.

Results: The management of a subset of AEs, including skin discoloration and edema, was discussed. Small group workshops also shared management algorithms for late noninflammatory adverse reactions, late inflammatory adverse reactions, localized vascular complications, and retinal vascular complications. Best practices for optimal injection techniques were discussed, and injection-technique protocols were developed for treatment sites. Treatment strategies for HA-CaHA-related complications are considered similar to treatment of those resulting from single-agent fillers, and knowledge of anatomy, aseptic technique, correct injection techniques, and appropriate posttreatment care is emphasized.

Conclusion: These recommendations on the management of HA-CaHA-related complications may serve as a reference for the broad range of clinicians using HA-CaHA hybrid injectable for different indications and can help optimize patient outcomes and safety.

Keywords: calcium hydroxyapatite; complications; hyaluronic acid; prevention.

Figure 1

Case photographs of a 58-year-old female patient before (A) and immediately after (B) treatment with hyaluronic acid–calcium hydroxyapatite (HA-CaHA) hybrid injectable in the pre-jowl sulcus using a 22-G cannula injected into the subdermal plane. A small area of redness was observed at the entry point of the needle. (C) Five months after HA-CaHA treatment and following bariatric surgery, a late noninflammatory adverse reaction, presenting as a nodule, was observed. The nodule was palpable but did not cause pain and was observed at the site of needle entry (marked here with a blue surgical marker). The nodule was treated with a localized 75-U injection of hyaluronidase and completely resolved. Photographs courtesy of R. Murthy.

Figure 2

Images of a 53-year-old female patient 2 months after treatment with hyaluronic acid–calcium hydroxyapatite (HA-CaHA) hybrid injectable at ck 5 (submalar/buccal area) and jw 4 (lower prejowl) using a 22-G cannula injected into the subcutaneous plane. The patient presented with inflammation at ck 5 resulting from HA-CaHA overcorrection. There was no pain, redness, or liquid collection. (A) Photograph of patient showing inflammation at ck5 and jw4. Areas 1, 2, and 3 correspond to the ultrasound images in B to D. (B−D) Ultrasound images corresponding to areas 1, 2, and 3 in A show a heterogenous pattern with anechoic/hypoechoic areas and inflammation. A heterogenous pattern with anechoic/hypoechoic areas is characteristic of normal healthy skin and demonstrates integration of HA, whereas a “coarse snow grain” pattern is due to the presence of CaHA. (B) Ultrasound image corresponding to area 1. 1. Epidermis, 2. Dermis, 3. Subcutaneous cellular tissue, 4. Fibrillar collagen area, 5. “Coarse snow grain” pattern, 6. Anechoic/Hypoechoic areas, 7. SLEB. (C) Ultrasound image corresponding to area 2. 1. Epidermis, 2. Dermis, 3. Subcutaneous cellular tissue, 4. Inflammation area, 5. “Coarse snow grain” pattern, 6. Anechoic/Hypoechoic areas, 7. SLEB. (D) Ultrasound image corresponding to area 3. 1. Epidermis, 2. Dermis, 3. Subcutaneous cellular tissue, 4. Inflammation area, 5. “Coarse snow grain” pattern, 6. High-density echogenic areas. Photographs courtesy of F. Urdiales-Galvez.

Figure 3

Management of skin discoloration.

Figure 4

Management of noninflammatory (A) and inflammatory (B) adverse reactions.,

Figure 5

Management of localized vascular complications.,,

Figure 6

(A) MD Codes anatomical associations, which are relevant to hyaluronic acid–calcium hydroxyapatite (HA-CaHA) treatment sites: ck, cheek; ck1, zygomatic arch; ck2, zygomatic eminence; ck3, anteromedial cheek; ck4, lateral lower cheek/parotid area; ck5, submalar/buccal area. jw, jowl; jw1, mandible angle; jw2, pre-auricular area; jw3, mandible body; jw4, lower prejowl; jw5, lower anterior chin. Adapted from De Maio 2021. Recommended HA-CaHA injection-site protocols: (B) the C approach, which includes the zygomatic arch, jaw ramus, and jawline; (C) the C-plus approach, which includes the aforementioned areas plus the submalar area and jowl; and (D) additional sites in the ck can be injected with HA-CaHA to achieve more lift.