Plastic surgeons need an injectable soft tissue filler that is reliable, nonallergenic, and long-lasting. In January 2003 I began injecting patients with Radiance (BioForm, Inc., Franksville, WI), a mixture of calcium hydroxylapatite (30%) and polysaccharide gel (70%). The polysaccharide gel is very white, which makes Radiance inappropriate for the dermis. Radiance has a long shelf life (no refrigeration required), and it is reputed to last 2 to 7 years once injected, though the longest clinical follow-up to date is 2.5 years.

Between January and October 2003, I injected 130 patients with a total of at least 190 1-mL syringes of Radiance. Here I present my short-term experience, including methods for injection and placement, problems with some specific areas (lips), areas where it works reasonably well, and (4) how to overcome certain limitations of the material.

Lips

I injected Radiance into the lips (mostly the upper lips) of 28 patients using bilateral infraorbital blocks and mental blocks, if needed, for the lower. I placed the injectable in the center of the orbicularis muscle using 2 lateral injections with a 27- or 25-gauge 1.5-inch needle across the midline, injecting on withdrawal (Figure 1). Ecchymosis developed in several patients as a result of the needle’s piercing the labial artery. When the injections were too posterior, the lips protruded too much. If the injection was too close to the mucosa inferiorly, the lip had a bump when the patient smiled. This bumpiness and aberrant placement occurred in about 40% of patients whose lips were injected with Radiance ( Figure 2). In a few, the bumps disappeared or improved after 8 weeks. In at least 11, I had to make a vertical slit with an 18-gauge needle, then use the needle to carve out some of the material, which was firmly attached to the muscle. In short, an extremely high percentage of patients undergoing lip augmentation required secondary work, and in others, the palpability of the implant by the tongue was problematic. The lower lip, which required only 1 needle stick for the central two-thirds, had fewer problems. All of the problems resolved with time or removal, which required only a small nick.

The material is injected into the center of the orbicularis lip muscle. Multiple injections with a short needle tended to be less effective than single long strips laid down with a longer (1.5-inch) 25- or 27-gauge needle. The lower lip usually required 1 injection for the middle two-thirds and had fewer problems. The upper lips required 1 or 2 strips and light massage. I am not sure whether the massage actually caused some of the bumps. It is helpful to watch the syringe gauge as you pull out; you must stop short of the exit, or you get a little bump. Blocks are always used, followed by cool compresses.

The bumps that commonly occur in the lips either decrease in the 8 weeks following the procedure or require removal with a vertical nick and partial excision, which works well.

In some reconstructive cases, Radiance is excellent (Figure 3), and for certain problems, such as cleft whistle deformities, it is a very good short-term answer. For the patient seeking cosmetic lip improvement, the material works only fairly well, presenting problems in my experience that were frequently troublesome and counterproductive, although treatable. I have yet to inject the white roll to provide a “little ridge,” as a few have suggested, because I would like to avoid more lip problems. From a technical standpoint, there is a certain learning curve. When I injected too deeply, the correction was minimal. For those lips that got a fair to good augmentative correction, the material was definitely palpable 3 to 4 months or longer after augmentation, and some of the result was lost. I am going to try a few variations in my technique in an attempt to reduce the nuisance problems, but in my view, Radiance is not the lip “answer.”

Nasolabial folds

I performed injections of the nasolabial folds in 70 patients after administering an infraorbital block that anesthetizes the folds at least to the commissures. If the depressions exceeded the commissure, I passed the needle, always subdermally, from the lowest point of fill and accordionated the tissue on the needle to the upper fold. Sometimes I injected the folds below the commissure level in isolation, explaining to the patient that it would hurt a bit. The pain was never so bad that any patient told me to stop. Then I placed a finger cot on each of my index fingers for the intraoral side, flattening the material or massaging it enough to flatten any bumpiness.

The average nasolabial folds required about l mL. Some deeper folds required more, especially in men, for whom the process was more expensive. Most patients were happy with the result, although several reported that they noted no real difference after 8 weeks. I probably injected too deeply, which minimized the result. Figure 4 depicts a typical patient. Massage helps flatten the material and it must be done postinjection ( Figure 5).