Calcium Hydroxylapatite (CaHA)

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Dr. Thomas Ackermann Practice

Calcium-Hydroxylapatit (CaHA) Biostimulator.
Firm contours without puffiness.

Many classic hyaluronic acid fillers attract water, which can make the face look doughy or unnaturally „puffy“ in the long run. Calcium-Hydroxylapatit (CaHA) works completely differently. It is based on bio-identical calcium hydroxylapatite (CaHA) and does not bind water. We use this extremely versatile preparation in my practice in two ways: Either pure for razor-sharp, firm facial contours (e.g., jawline) or highly diluted as a pure collagen booster to tighten wrinkled skin on the neck and décolleté.

The result: Maximum firmness and natural collagen regeneration in the deep layers.

Transparent medical treatment and billing according to GOÄ.

Premium Medical Standard:

No „Pillow Face“: Does not attract water, retains exact shape
Cell Regeneration: Stimulates the body’s own collagen and elastin
Specialist Level: Hyperdiluted technique for neck, décolleté & body

Bioregeneration · Collagen stimulation

Calcium Hydroxylapatite

Calcium hydroxylapatite consists of the same mineral components as bone — calcium and phosphate — in the form of microspheres suspended in an aqueous carrier gel. It works in two ways: the gel provides immediate volume, while the particles stimulate your own collagen production over months. The two are offset in time, and knowing this beforehand matters — otherwise the course of the result can look like a setback.

Immediate effectat the appointmentFrom the carrier gel — it recedes over the first few weeks.

Final result8–12 weeksOnce the newly formed collagen has replaced the gel component.

Duration of effectabout 12–18 monthsClinical experience; in a long-term study, some patients still showed improvement after 30 months.

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Classification

This material has two effects that don't happen at the same time — and that's where most misunderstandings arise. Right after injection, you see a result: that's the carrier gel. This gel is broken down over the following weeks, while the new collagen is only just forming. In between lies a phase where the result recedes before it comes back. This early volume loss is explicitly described in the literature — as a reason to explain the timeline beforehand, not as a flaw in the treatment. Anyone who doesn't know this calls, disappointed, in week four.

Dr. Thomas Ackermann's practice · Methodological stance

This material cannot be dissolved with hyaluronidase. What is placed, stays — until the body breaks it down. That's why I clarify beforehand, precisely, whether it's the right material for your findings, and when in doubt I default to hyaluronic acid, which can be reversed.

— Dr. med. Thomas Ackermann · Board-Certified Anesthesiologist

Mechanism of action

The course over two years

The microspheres are about 25 to 45 micrometers in size. What happens with them and with the carrier gel unfolds in five phases — and the second one is the one that needs to be discussed.

Phase	What happens	What you'll notice
Immediately	The aqueous carrier gel plumps the tissue	A visible result while still in the treatment chair
2–4 weeks	The carrier gel is broken down, the new collagen isn't there yet; the microspheres remain in place	The result recedes. The phase where patients become uncertain — it is expected and temporary
4–12 weeks	The particles activate connective tissue cells; type I and type III collagen forms	The result comes back, this time from your own tissue rather than gel
3–6 months	The new collagen stabilizes and functionally takes over the role of the carrier gel	The state you could call the treatment result
12–24 months	The mineral particles are slowly broken down by macrophages	The effect gradually fades; part of the structure can persist longer

For the classic application in nasolabial folds, long-term data over three years exist: 40% of treated folds were still rated as improved 30 months after the last treatment. That's a proportion, not a rule — the majority fell below it.

Common reasons patients come in

Does this sound familiar?

"I want contour, not fullness"

That's exactly what this material is for. It's placed deep at the bone and provides structure at defined points — cheekbone, jaw angle, chin. It's too firm for soft volumes and expressive areas of the face; hyaluronic acid is the right choice there.

"After four weeks it was almost gone again"

If you experienced this after an earlier treatment, it was probably not a treatment error but the course described above: the carrier gel breaks down faster than new collagen forms. What's usually missing isn't the material, but the explanation of this — and the follow-up appointment that accompanies this phase.

"The backs of my hands look older than my face"

The backs of the hands are a good and rarely offered indication. This is about balancing volume between the tendons and about skin tone — this material addresses both, and the region tolerates more than the face because it has little expressive movement.

Important to know

What this treatment is not

Not reversible. Unlike hyaluronic acid, this material cannot be removed with hyaluronidase. If placement is unfavorable, waiting for resorption is the only option. If reversibility matters to you, hyaluronic acid is the right material — I'd rather say that beforehand than afterward.
Not a universal material. For lips, tear trough and perioral fine lines, it is too firm and sits too visibly close to the surface. These regions belong to hyaluronic acid at the appropriate cross-linking.
Not a stable immediate result. What you see on treatment day is the carrier gel. The result recedes temporarily before rebuilding over eight to twelve weeks. If you want to be treated for an event in four weeks, choose a different material.
The diluted application is an off-label use. For the neck, décolleté and upper arms, the material is used heavily diluted to treat skin quality rather than volume. The international consensus recommendations explicitly describe this approach as an off-label use with preliminary evidence. You'll receive separate written information about this.
Not a substitute for a lift. With pronounced skin laxity, a surgical procedure is the anatomically correct approach. Structure at defined points does not replace tightening.

Indication

Where it fits — and where it doesn't

Region	Assessment	Approach
Cheekbone and mid-face	Good indication	Deep placement directly at the bone; structural support rather than broad-area fullness
Jawline and chin	Good indication	Contouring along the mandible, projection at the chin; this material carries well here
Backs of the hands	Good indication	Balancing volume between the tendons; an expressively quiet region with low risk
Neck, décolleté, upper arms	Possible, diluted · off-label	Heavily diluted application for skin quality. Separate written information, conservative expectations
Lips	Not suitable	Too firm, too expressive an area
Tear trough and perioral fine lines	Not suitable	Very thin skin; visibility and irregularities are the leading risk here

This practice also offers the hybrid bio-stimulator with an added hyaluronic acid component, poly-L-lactic acid for broad-area buildup, and polynucleotides for skin quality. Combining materials by area is often more sensible than using one material for the whole face.

Safety

What can occur

Observation	Frequency	Management
Swelling, redness, bruising	common	3–7 days, self-limiting
Firmness in the treated area	occasional	Usually resolves; checked at the follow-up appointment
Visible irregularity from too-superficial placement	rare	Avoidable through injection depth and dilution; correction only possible to a limited extent
Nodules or granulomas	very rare	Not observed in the three-year follow-up of 102 patients
Vessel occlusion from intravascular injection	very rare	The serious emergency with any filler treatment. Emergency protocol and equipment are in place

The consensus recommendations note that too-superficial injection of the less diluted material is associated with more adverse events in thinner and darker skin. This informs the choice of dilution and layer here — it's why the technique is set individually rather than by a fixed scheme.

Why this practice

A material with no way back calls for a different approach to risk.

With hyaluronic acid, a vessel occlusion is an emergency with an antidote. Here, no such antidote exists. That's why, near vessels, treatment is preferentially done with a blunt microcannula, aspiration is performed before injection with a needle, and where anatomy requires it, injection is done under ultrasound guidance.

As a board-certified anesthesiologist with an additional qualification in emergency medicine, managing complications is my core specialty, not a side responsibility. This practice also treats complications and second opinions from other practices — including cases involving non-reversible materials.

And the least dramatic but most effective part: the timeline is explained beforehand and accompanied at the follow-up appointment after four to six weeks — precisely during the phase when the result temporarily recedes. That costs one extra appointment and prevents the misinterpretation that otherwise leads patients to switch materials unnecessarily.

How your treatment works

Assessment and indication. Findings, goals, and the question of reversibility. If reversibility matters or the region is expressive, this is where we switch to hyaluronic acid. Written consent, with separate information on the off-label nature of diluted application.
Anesthesia. Numbing cream, with additional local anesthesia or nerve block for deeper placement.
Placement. Deep at the bone at defined points, using a microcannula or fine needle depending on the region. Near vessels, a blunt cannula and aspiration; ultrasound guidance where anatomy is unclear.
Shaping. Gentle external shaping, cooling. Written aftercare instructions for the following days.
Follow-up after 4–6 weeks. The most important appointment: this is where the temporary recession sits, and this is where it's assessed whether more material is needed or whether collagen buildup closes the gap. Adding more is possible — taking it back is not.

The next step

First, the question of the right material.

Whether this material fits or hyaluronic acid is the better choice is decided by the findings. Herzogenaurach, twelve minutes by car from Erlangen.

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Frequently asked questions

Why does it look worse after four weeks than right afterward?

Because you're seeing two different things. The result on treatment day comes from the carrier gel, which is broken down within a few weeks. The new collagen forms more slowly, leaving a gap in between. This early volume loss is described in the literature and is the reason for the follow-up appointment — not a sign that the treatment didn't work.

How long does the effect last?

Based on clinical experience, about twelve to eighteen months. The most robust long-term observation comes from a study of nasolabial folds with 102 patients followed over time: 40% of treated folds were still rated as improved 30 months after the last treatment — considerably less than shortly after treatment, but measurable. A number for your specific case would be a claim.

Can it be removed again?

No, not enzymatically. Hyaluronidase only works on hyaluronic acid. If placement is unfavorable, waiting months for resorption is the only option. This is the key difference from hyaluronic acid and the reason treatment here errs toward placing less rather than more — adding more is always possible at the follow-up appointment.

How safe is the material?

The long-term data are reassuring: in the group of 102 patients followed for three years, no late-onset adverse events occurred — no nodules, no granulomas, no infections. That doesn't replace care during injection, because the relevant residual risk is vessel occlusion, and that depends on technique, not the material.

What is the diluted application for the neck and décolleté?

Here the material is diluted much more heavily and introduced more superficially across the area — the goal isn't volume but skin quality and tightening. The 2018 international consensus recommendations describe this approach as an off-label use with preliminary evidence and note that further studies are needed. I offer it while also telling you that the evidence here is weaker than for the classic application.

How much material is used?

Typically 1.5 to 3.0 ml per session at structural points; different amounts and dilutions apply for the hands and broad areas. The amount is determined by findings and isn't sold as a package in advance — the follow-up appointment decides whether more is added.

How does it differ from the hybrid preparation?

The hybrid bio-stimulator additionally contains hyaluronic acid. Its volume component bridges the phase where the carrier gel is already gone and the collagen isn't there yet — making the course more even. This exact idea was tested in a study using a mixture of both materials. Which variant fits depends on how important a consistently stable interim result is to you.

Is there downtime?

Usually not. Redness, swelling and occasional bruising resolve over three to seven days; a normal workday the next day is typical. Skip sport, sauna and heat on treatment day. Please mention blood-thinning medication beforehand.

Which product do you use?

A medical device approved in Germany, based on calcium hydroxylapatite. I don't name brand names of injectable medical devices on the website — that's a requirement of German medical advertising law, not reticence about the substance. You'll learn the manufacturer, composition and batch documentation in the consultation.

What does the treatment cost?

Physician services are billed under the German fee schedule for physicians (GOÄ) based on the services actually provided, plus the material according to the amount used. What applies in your case is broken down at the initial consultation.

Evidence base

What the studies show

Bass LS et al., 2010. Calcium hydroxylapatite for treatment of nasolabial folds: long-term safety and efficacy results. Aesthet Surg J 30(2):235–238. PMID 20442101. Extension phase of a randomized pivotal trial: 102 of the original 117 participants were followed for up to 39 months. 40% of folds were still rated as improved at least 30 months after the last treatment. No late-onset or long-term adverse events occurred — no nodules, granulomas or infections. The source for the duration-of-effect and safety figures on this page.
Goldie K et al., 2018. Global Consensus Guidelines for the Injection of Diluted and Hyperdiluted Calcium Hydroxylapatite for Skin Tightening. Dermatol Surg 44 Suppl 1:S32–S41. PMID 30358631. An international expert panel on diluted application for the face, neck, décolleté, arms and body. The recommendations explicitly describe this approach as an off-label use with preliminary evidence and name bruising, swelling, pain and induration as adverse events. They explicitly warn against too-superficial injection of less diluted material in thinner and darker skin.
Chang JW et al., 2020. Facial Rejuvenation Using a Mixture of Calcium Hydroxylapatite Filler and Hyaluronic Acid Filler. J Craniofac Surg 31(1):e18–e21. PMID 31403504. A study of 25 patients with histological review after six months. The starting point of the work is the observation that rapid resorption of the carrier gel before collagen formation begins can cause early volume loss — the basis for the timeline explanation on this page. Tissue samples showed increased collagen bundles without signs of inflammation.
Massidda E, 2023. Starting Point for Protocols on the Use of Hyperdiluted Calcium Hydroxylapatite for Optimizing Age-Related Biostimulation and Rejuvenation of Face, Neck, Décolletage and Hands: A Case Series Report. Clin Cosmet Investig Dermatol 16:3427–3439. PMID 38050476. A case series of 50 patients with varying dilution ratios: improvement in skin thickness, laxity and fine lines in 95% of 30–40-year-olds, 80% of 40–60-year-olds, and 70% of those over 60. A case series without a control group — an indication of an effect, not proof of efficacy.
Amaral VM et al., 2024. An Innovative Treatment Using Calcium Hydroxyapatite for Non-Surgical Facial Rejuvenation: The Vectorial-Lift Technique. Aesthetic Plast Surg 48(17):3206–3215. PMID 38714538. A pilot study of 36 patients on a technique combining deep placement at the ligament structures with superficial diluted application. Shows what the result with this material depends on: the layer and position, not the amount introduced.

The strength of evidence is unevenly distributed: for the classic application in folds, there is randomized data with long-term follow-up. For the diluted application for skin quality, there are consensus recommendations, case series and pilot studies — indications, not proof. This distinction belongs in the consultation, and that's why it's here too.