Aesth Plast Surg
https://doi.org/10.1007/s00266-024-04071-5
ORIGINAL ARTICLES
An Innovative Treatment Using Calcium Hydroxyapatite for
Non-Surgical Facial Rejuvenation: The Vectorial-Lift Technique
Virginia Marcia Amaral1 • Helena Hotz Arroyo Ramos2 • Fernanda Aquino Cavallieri3 •
Mariana Muniz4 • Guilherme Muzy5 • Ada Trindade de Almeida6
Received: 13 January 2024 / Accepted: 9 April 2024
Ó The Authors 2024, corrected publication 2024
Abstract
Background The facial aging process entails alterations in
the volume, shape, and texture of all skin layers over time.
Calcium hydroxyapatite (CaHA) is a well-established safe
skin filler with unique properties to resolve some skin
alterations by stimulating neocollagenesis. The vectoral-lift
(V-lift) technique targets the global repositioning of facial
structures by addressing distinct anatomical injection
planes. It includes deep facial augmentation with Radiesse
PlusTM to retain ligament restructuring and superficial
subcutaneous enhancement with diluted Radiesse DuoTM.
Herein, we present cases that illustrate the use of this
approach.
Methods This pilot study enrolled 36 participants (33
women and three men; ages 37–68 years) in a Brazilian
clinical setting, and all patients underwent a single treat-
ment. Photographs were taken at rest, in frontal and oblique
views, before injection, and 90 days after treatment.
Results Treatment resulted in elevation of the upper and
middle face, notable improvements in the infraorbital
hollow, and adjustment of the mean facial volume.
& Virginia Marcia Amaral
dravirginiaamaral@gmail.com
1
IVA Medical Institute, Av. dos Bandeirantes 1518,
Belo Horizonte CEP: 30.315-032, Brazil
2
Vitória, Brazil
3
Rio de Janeiro, Brazil
4
São Paulo, Brazil
5
São Paulo, Brazil
6
Hospital do Servidor Público Municipal de São Paulo,
São Paulo, Brazil
FACIAL SURGERY
Conclusions The V-lift technique is a three-dimensional
pan-facial treatment that relies on ligament support and
face vectoring to obtain a lifting effect and facial contour
restoration. It encompasses deep facial augmentation
involving the use of Radiesse PlusTM for restructuring and
retaining ligaments and Radiesse DuoTM for superficial
subcutaneous enhancement. This approach targets a global
repositioning of the facial structures by addressing distinct
anatomical injection planes. It achieves a repositioning of
the overall facial anatomy without requiring a substantial
volumetric expansion.
Level of Evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Skin aging
Collagen
Plastic surgery

Dermatology
Aesthetics
Calcium hydroxyapatite

Biostimulation
Introduction
Minimally invasive procedures have gained popularity
because of their shorter downtime, absence of visible scars,
and potential for corrective action if the outcomes deviate
from initial goals [1]. Consequently, procedural strategies
that account for facial shape, structure, proportions, and the
impact of aging on facial esthetics have become focal
points of esthetic medicine research [2]. Recent studies
have focused on refining the placement of soft tissue fillers
on the face, thereby augmenting both results and safety
while utilizing less volume of the product for superior and
natural final outcomes [3].
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It is speculated that the injection of collagen biostimu-
lators around the adhesion areas and retaining ligaments of
the face promotes contracture, causing a suspension effect
by acting as anchors and, as a result, elevating the tissues
and improving the lifting effect [4–6]. This occurs because
the facial retaining ligaments serve as pivotal anchoring
points for both the superficial musculoaponeurotic system
(SMAS) and the overlying dermis onto the deep fascia and
periosteum [7].
Moreover, there is a lack of studies that address the
physiology and mechanics of non-surgical repositioning of
the retaining ligaments of the face with collagen biostim-
ulators [4, 5, 8]. Calcium hydroxyapatite (CaHA) is a well-
established and safe dermal filler with unique properties
that enhance the mechanical properties of the skin. It
stimulates collagen and elastin production, angiogenesis,
and the proliferation of dermal cells [9]. However, there is
a lack of studies in the literature that address the physiol-
ogy and mechanics of non-surgical repositioning of
retaining ligaments of the face with CaHA injections.
In this study, we aim to introduce a technique that
employs CaHA-based dermal filler based on the principles
of periligamentar subMAS layer redensification and face
vectoring. The technique aims to attain lifting effect and
restore facial contours.
Materials and Methods
Study Design
This pilot study included 36 participants in a clinical set-
ting. The analysis involved thirty female participants and
three males, with an age range of 37–68 years. All patients
received a single treatment, and all procedures adhered to
the ethical guidelines outlined in the Declaration of Hel-
sinki, as revised in the year 2000.
Patient Selection and Documentation
For this study, women and men aged 35 years and older
were selected if they exhibited midface deflection. Indi-
viduals were excluded if they had received hyaluronic acid
(HA) fillers, neuromodulators, or biostimulators in the
previous 6 months, or if they planned to undergo any other
facial enhancement procedures such as fillers, chemical
lipolysis injections, energy-based devices, or surgeries in
the coming months. Extremely thin patients, those with
very heavy faces, or individuals with a surgical indication
were also excluded. All participants provided written
(signed) informed consent.
Photographs were taken at rest, in frontal and oblique
views before calcium hydroxylapatite (CaHA) injection
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Aesth Plast Surg
(Day 0) and 90 days after treatment (Day 90), using the
same camera (Canon EOS T5i with 50 mm f/1.8 STM
lens), lighting, and distance parameters..
Injection Techniques
To facilitate anatomical subdivision and delineation, the
treated regions were categorized as follows: temporal
(from the temporal line to the upper edge of the zygomatic
arch), zygomatic (covering the zygomatic arch region),
masseteric (extending from the lower edge of the zygo-
matic arch to the masseteric parotid region), orbital,
infraorbital, and mandibular regions (spanning from the
pre-jowl sulcus area to the angle of the mandible area).
Participants were clinically evaluated for skin laxity,
ptosis of subcutaneous fat, and shadow lines correlated
with ptosis of ligaments. Injection of different CaHA for-
mulations (Radiesse LidocaineTM and Radiesse DuoTM)
was carried out according to the need for facial restruc-
turing: Radiesse LidocaineTM was used in the subSMAS
layer, Radiesse DuoTM was administered to superficial
areas, while a combination of Radiesse LidocaineTM and
Radiesse DuoTM was used for restructuring of facial liga-
ments (Fig. 1).
All participants of this study were administered a total
of two syringes each of Radiesse LidocaineTM and two
syringes each of Radiesse DuoTM, diluted with 0.5 mL of
2% lidocaine, by following the proposed 6-step technique
utilizing microcannulas.
The 6-Step Technique
Step 1: Markings and Delimitations of the Regions
for Treatment
We delimited the following areas of medial superior
injection: temporal region (temporal line to upper edge of
the zygomatic arch); zygomatic region (zygomatic arch);
masseteric parotid region (lower edge of the zygomatic
arch to a rectangular area of 2–3 cm in the masseteric
parotid region); and the ligament transition areas (infraor-
bital and zygomatic/malar areas).
We delimited the following lower injections areas: the
mandible angle region; the pre-jowl regions; and the planes
of injection (Fig. 2).
Step 2: Solution Preparation
The contents (1.5 mL) of a single Radiesse DuoTM syringe
were mixed with 0.5 mL of 2% lidocaine by employing a
direct connector or a female-to-female Luer-lock connec-
tor, resulting in a total volume of 2 mL per syringe.
Aesth Plast Surg

Fig. 1 Injection areas in the

subcutaneous and
supraperiosteal facial planes. 1:
Radiesse Duo injection areas in
the subcutaneous plane aim to
create a vector to lift the face. 2:
Radiesse Lidocaine injection
areas in the supraperiosteal
plane. 3: Radiesse Lidocaine
injection areas in the
subcutaneous plane

Fig. 2 Facial mapping for a series of injections. Top line: Markings and delimitations of the regions for treatment. Bottom line: The injection
sequence comprising Radiesse Duo (first syringe), Radiesse Lidocaine (second syringe), Radiesse Duo (third syringe), and Radiesse Lidocaine
(fourth syringe)

Step 3: Injection Technique for the First Syringe
of Radiesse DuoTM
The first access point was located immediately lateral to
the transition region, fixed face to mobile face, at the
zygomatic region for treatment of the temporal region, and
refinement in the infraorbital region.
To treat the temporal region, we injected 0.8 mL of the
solution per side using a 23G blunt cannula to cover the
entire area. Employing retrograde linear injection or ret-
rograde fanning techniques within the subcutaneous
superficial layer, we proceeded from the posterior bound-
ary to the orbital margin, targeting the temporal adhesion
ligament and the upper edge of the zygomatic arch.
For the treatment and enhancement of the ligament
adhesion regions (temporal ligament adhesion region and
from the lateral orbital adhesion to the lateral orbital
thickening), as well as the infraorbital area (orbicular
retaining ligament), we utilized the same entry point. We
injected 0.2 mL of the solution per side using a 23G blunt
cannula, employing multiple retrograde micro boluses
(Fig. 1). It is advisable to gently massage the treated area
immediately after the injection regimen to ensure uniform
CaHa distribution.
Step 4: Injection Technique for the First Syringe
of Radiesse LidocaineTM
For treating the zygomatic region, the same entry point was
employed as mentioned above. A volume of 0.45 mL of
Radiesse LidocaineTM per side was injected using a 23G
blunt cannula along the juxtaperiosteal plane (subSMAS),
encompassing the entire zygomatic area. Additionally,
0.3 mL per side was injected at the malar region, following
a juxtaperiosteal plane (around the zygomatic cutaneous
ligament), employing a retrograde linear injection

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technique with micro boluses in the deep layer (Fig. 1). A
gentle massage of the treated area immediately post-in-
jection is recommended to ensure a uniform CaHa
distribution.
Step 5: Injection Technique for the Second Syringe
of Radiesse DuoTM
The second entry point was established just lateral to the
region of transition between the fixed and mobile aspects of
the face and was positioned approximately 3 cm beneath
the lower border of the zygomatic arch. This access point is
employed for treating the masseteric parotid region as well
as the ligament transition areas (infraorbital and the
zygomatic/malar region).
A second access point was utilized to treat the masse-
teric parotid region and involved the injection of 0.6 mL of
the solution per side using a 23G blunt cannula, employing
retrograde linear injection or retrograde fanning tech-
niques. A gentle massage of the treated area immediately
post-injection ensured a uniform CaHa distribution.
For the refinement of the ligament transition areas (in-
fraorbital and zygomatic/malar regions), the same access
point as above was employed, to administer 0.1 mL of the
solution per side with a 23G blunt cannula, utilizing mul-
tiple retrograde micro boluses. As before, a gentle massage
of the treated area immediately following the injection
regimen aids in an even CaHa distribution.
The third access point was positioned lateral to the
mandibular cutaneous ligaments to treat the pre-jowl
regions and mandibular angle regions.
For the treatment of the pre-jowl region within the mental
sulcus, the third access point is employed. This involves
injecting 0.3 mL of the solution per side using a 23G blunt
cannula, utilizing anterograde and/or retrograde linear injec-
tion, or anterograde and/or retrograde fanning techniques at the
subcutaneous layer. A gentle massaging of the treated area
immediately post-injection ensured an even CaHa distribution.
Step 6: The Injection Technique for the Second Syringe
of Radiesse LidocaineTM
For an improved outcome, the lower face can be treated with a
focus on repositioning the mandibular ligament through inter-
ventions in both the pre-jowl and lateral mandible regions.
To administer the mandible treatment, the same access
point as mentioned above was employed. We injected
0.45 mL of the solution per side at the lateral mandible
region and 0.3 mL per side at the pre-jowl region using a
23G blunt cannula. We employed anterograde and/or ret-
rograde linear injection or anterograde and/or retrograde
fanning techniques. Following the procedure, a gentle
massage of the treated area ensures even CaHa distribution.
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Aesth Plast Surg
Results
The 36 patients reported subjective improvement in skin
quality and repositioning of the midface at the 90-day
evaluation. Twenty-eight experienced swelling in the first
48 hours, and they were advised to enhance post-procedure
facial massage, leading to spontaneous symptom relief.
Four patients developed swelling after 48 hours and were
instructed to use prednisone 20 mg for 3 days, resulting in
symptom remission. Three patients complained of persis-
tent pain in the malar region for 20 days and were advised
to use analgesics for symptom control. Two patients
developed small nodules due to product accumulation,
which resolved after intranodular saline injection followed
by local massage. No infectious or vascular adverse effects
were observed.
Herein, we present cases that illustrate the use of this
approach.
The overall improvements in facial laxity and contour
90 days after the V-Lift procedure are presented in Figs. 3,
4, 5, 6, and 7.
Case 1 (Fig. 3) involved a woman with complaints of
facial laxity and loss of facial contour. Ninety days after
the 6-step V-lift injection regimen, it was possible to note
restoration of the global positioning of the facial tissues
with better positioning of the eyebrow, enhancement of the
zygomatic malar layers redensification points and attenu-
ation of the nasolabial, mental and labiomental folds with
significant elevation of the lip commissure.
In Case 2 (Fig. 4), we present a lady with a ‘‘heavy’’
face, with a saggy appearance of the whole face and deep
markings at the malar region. Ninety days after the V-lift
injections, it was possible to discern attenuation of the
grooves and amelioration of global face complaints.
In Case 3 (Fig. 5), we present a woman with skin laxity,
loss of facial contour and a ‘‘sad mouth’’ appearance.
Ninety days after the V-lift procedure, a restoration of the
global positioning of the face with better positioning of the
eyebrows was observed, as well as an enhancement of the
zygomatic malar layers redensification points, attenuation
of the nasolabial, mental, and labiomental folds, and a
significant elevation of the lip commissure.
Discussion
The depletion of anatomical tissues is a consequence of the
aging process observed throughout the layers of facial soft
tissue (Fig. 6), and in addition to skeletal changes
[2, 10–14].
The role of the retaining ligaments in the process of
facial aging is not well defined [10]. Some authors believe
Aesth Plast Surg

Fig. 3 Timeline of treatment

comprising Day 0 (D0; day of
treatment) and Day 90 (D90; 90
days after treatment) time-
points for a patient who
underwent the V-lift technique.
A generalized improvement of
the shadows of the face,
restoration of the zygomatic
arch and malar region,
attenuation of nasolabial lines,
and elevation of the angle of the
mouth can be observed 90 days
after completion of the V-lift
technique

Fig. 4 Timeline of treatment

comprising Day 0 (D0; day of
treatment) and Day 90 (D90; 90
days after treatment) time-
points for a patient who
underwent the V-lift technique.
A generalized improvement of
face shadows, restoration of the
zygomatic arch, attenuation of
the malar mound with
restoration of the malar region,
attenuation of nasolabial lines,
and elevation of the pre-jowl
area can be observed 90 days
after completion of the V-lift
technique

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 Aesth Plast Surg

Fig. 5 Timeline of treatment

comprising Day 0 (D0; day of
treatment) and Day 90 (D90; 90
days after treatment) time-
points for a patient who
underwent a V-lift technique.
Note the global repositioning of
tissues with the resulting softer
facial expression

Fig. 6 A comparison of a young and aging face showing the three-dimensional aging process. Left: A schematic representation of the face of a
young woman with well positioned anatomical layers. Right: A schematic representation of an aging face with changes in the positioning of
ligaments due to the gravitational weight of anatomical compartments determined by aging

that the loosening of the retaining ligaments results in the
descent of the soft tissue that they normally support
[12, 15, 16]. Other groups postulate that ligaments retain
their relative strength, while the surrounding tissues
experience a loss of support and subsequently descend over
these ligaments that remain relatively stable in their posi-
tion, leading to the formation of grooves [7, 17, 18].
In any case, age-related alterations in facial bone and
skin are widely recognized. The ongoing and lifelong
remodeling of the bony framework, coupled with the
loosening of the skin, leads to the distortion of ligament
attachment points and their adhesions to the skin. This, in
turn, impacts the neighboring structures supported by these
ligaments, as the changed position and trajectory of the
ligaments create a ripple effect [19, 20].
For these reasons, approaches that focus exclusively on
facial volume restoration often yield esthetically unsatis-
factory outcomes because they require larger additional
volumes to achieve noticeable results in the superficial
layer [21]. Cong et al. [5] described a method that differs

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Aesth Plast Surg
Fig. 7 A schematic representation of the repositioning of the
cutaneous ligaments leading to a suspension effect
from the augmentation of facial fat compartments in that it
was not intended to restore the volume of the deflated fat
compartments, but to achieve a vertical tissue displace-
ment, that is, a lifting effect. Our technique is based on the
concept that injecting CaHa around the regions of adhesion
and retaining ligaments of the face triggers the reposi-
tioning of the cutaneous ligaments, resulting in a suspen-
sion effect. These ligaments effectively serve as anchoring
points for the SMAS and the dermis, overlying the deep
fascia and periosteum (Fig. 8) [8]. The role of CaHa in
improving the mechanical characteristics of the skin has
been broadly reported, as it stimulates collagen and elastin
production, angiogenesis, and dermal cell proliferation [8]
that could be an advantage of the present technique, as it
could offer layers redensification.
The facial retaining ligaments are robust, deep, and
fibrous connections that stem from the periosteum or the
deep facial fascia. These ligaments traverse facial layers
perpendicularly, anchoring into the dermis. Attenuation of
the retaining ligaments at all levels reduces the quality of
fixation of the layers (5). Hence, three-dimensional facial
repositioning interventions encompass the vertical adjust-
ment of these ligaments. This approach directly counteracts
Fig. 8 Biomechanical subMAS layer redensification mechanisms and vectorization of the facial ligaments implement the global repositioning of
the face as a mechanism of pulleys interconnected by the superficial musculoaponeurotic system (SMAS) and superficial temporal fascia
the detrimental impact of negative weight vectors gener-
ated by the aging process on the face [22]. This concept can
be elucidated through the ‘‘torch’’ theory, where the
robustness of CaHA collagen biostimulator enables the
elevation of facial structures (Fig. 9). Movement/Moment/
Torque is a mathematical variable that scales the direction
of movement based on the balance of forces. Conditioned
by the vectors that depress or elevate the face, the liga-
ments must be evaluated as lever arms that have a fixed
origin (bone) and a mobile insertion point (skin). It is
necessary to consider the ligament as a lever arm, its
position being directly influenced by deep repositioning
(subMAS layer redensification—without distension/en-
largement of the compartment) and superficial reposition-
ing (vectoring with gain in skin quality) through the
superficial suspension force of the SMAS, considering the
zygomatic arch as the bone support point. Thus, the posi-
tive (counterclockwise) direction of the torque was directly
influenced by the vector force and the angle related to the
origin or axial point of rotation (Fig. 9).
The objective of the technique is to address the liga-
mentous origin through the redensification of underlying
tissues by injecting calcium hydroxylapatite (CaHa) in the
justaperiosteal plane (subSMAS). In the subdermal plane,
the goal is the potential stretching of superficial ligamen-
tous fibers through the supposed vectorization implemented
by neocollagenesis. Therefore, the focus is not on the
ligament itself as a specific target, but rather on its terri-
tory. While the study did not include imaging examinations
for all patients, we had the opportunity to assess the
injection planes in a patient who underwent a CT scan for
another reason (Fig. 10), 21 days after CaHa injection in
the midface and bilateral temples. Since CaHa is radio-
paque, the injection plane of the product could be visual-
ized according to the described technique.
For this reason, we consider the Radiesse line to be a
valuable treatment instrument for the profile of patients
who aim for three-dimensional face repositioning and
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 Aesth Plast Surg

Fig. 9 A schematic
representation of the planes of
injection, vectors and direction
of injection of different types of
CaHA, according to study
objectives and definition of
facial planes

Fig. 10 Face CT scan showing

CaHa injection in the zygomatic
arch in the subSMAS plane
(justaperiosteal) and in the
temporal region in the
subcutaneous plane

progressive results without subsequent volumetric gains, as
there is less hydrophilic effect compared to hyaluronic
acid; thus, a stable overall esthetic outcome is attained.
Only a small volume is needed for this ligament injection
technique, and the 23G blunt cannula was chosen due to
the possibility of accessing the desired layers (suprape-
riosteal and subdermic).
Site 1 was placed in the temporal ligamentous adhesion
region to lift the tail of the eyebrow, and site 2 was placed
in the region of the lateral orbital thickening to reduce
ptosis of the lateral canthus. Injections at the two sites had
a lifting effect on the periorbital region, as early ptosis of
the eyebrows and lateral canthi could be partly reversed in
a subtle manner, restoring a youthful appearance. As for
the midface, site 3 and site 4 targeted the zygomatic
retaining ligament and zygomatic cutaneous ligament,
respectively, to augment the midfacial soft tissue. The apex
of the cheekbone intensely reflected light, and the length of
the lower eyelid seemed to decrease due to the interplay of
light and shadow, contributing to a visual lifting effect.
CaHa injections at these two sites would also affect the soft
tissue of the anteromedial midface, so that the nasolabial
fold would be simultaneously effaced. In the lower face,
the nasolabial fold and the pre-jowl sulcus were also
reduced by the injections at sites 5 and 6, corresponding to
the regions of the maxillary and mandibular ligaments,
respectively. Therefore, injecting at the sites corresponding
to the actual ligament areas could effectively enhance the
redensification effect of the subSMAS layer, simultane-
ously reducing facial grooves and alleviating the signs of
aging. Upon completion of the treatment, which involves
lifting the upper and middle face, significant enhancements
were noted in the infraorbital hollow and the repositioning
of the overall facial volume. Moreover, this treatment has
the ability to restore volume, tissue resilience, and harmony
within the modiolus region, marionette zone, and pre-jowl

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Aesth Plast Surg
sulcus. The main point of this technique involves attaining
natural outcomes following facial procedures by using less
volume and shortened distances. These natural-looking
results play a pivotal role in enhancing patient satisfaction
and bolstering self-assurance as natural outcomes have the
potential to alleviate the stigma often associated with
cosmetic procedures [22–24].
This study has certain limitations. It is based on sub-
jective observations made by the authors, a factor that
warrants consideration when interpreting the presented
data. Future investigations should explore the histological
and mechanical characteristics of the ligaments following
treatment with collagen biostimulators. This could be
achieved by incorporating a control group, employing
randomized selection, and utilizing objective outcome
measures. Furthermore, studies encompassing a broader
participant pool and a prolonged postoperative timeline are
imperative for a more comprehensive understanding. A
prospective study is warranted to quantify the improvement
in facial aging achieved through the Radiesse V-Lift
technique. This study should incorporate control groups,
implement blinding methodologies, and employ objective
outcome measures.
Conclusion
We present the preliminary results of a three-dimensional
injection technique known as the V-lift technique, which
utilizes calcium hydroxylapatite (CaHA) collagen bios-
timulators to address the signs of aging. The V-lift tech-
nique was well-tolerated, yielding enduring subjective
results attributed to the stimulation of collagen and elastic
fiber deposition (collagenesis). However, more robust
studies are needed to substantiate these concepts.
Funding Medical writing support was provided by Merz Brazil, in
accordance with Good Publication Practice guidelines.
Declarations
Conflict of interest A.R.T. de Almeida has been a consultant to
Allergan Inc. and Merz and has participated in clinical trials for
Allergan and Galderma. Mariana Muniz is a medical consultant and
speaker for Merz Aesthetics. The authors declare no potential con-
flicts of interest with respect to the research, authorship, or publica-
tion of this article.
Human and Animal Rights This article does not contain any studies
with human participants or animals performed by any of the authors.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as
long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons licence, and indicate
if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless
indicated otherwise in a credit line to the material. If material is not
included in the article’s Creative Commons licence and your intended
use is not permitted by statutory regulation or exceeds the permitted
use, you will need to obtain permission directly from the copyright
holder. To view a copy of this licence, visit http://creativecommons.
org/licenses/by/4.0/.
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