Prevention of Calcium Hydroxyapatite Nodules in the Neck With Use of Botulinum Toxin: A Case Report and Review of Anatomy and Pathophysiology.

[BACKGROUND] Calcium hydroxylapatite (CaHA) is a biostimulatory filler frequently used in a hyperdilute form to improve skin quality. While generally safe, nodule formation is the most common adverse event, particularly in dynamic areas.

[AIMS] To describe a case of delayed-onset CaHA nodules in the neck and review anatomical and procedural factors contributing to this complication, as well as prevention and management strategies.

[PATIENT] A 72-year-old woman underwent three sessions of hyperdilute CaHA injections to the neck, with recent or concurrent onabotulinumtoxinA injections. After the third treatment, which followed a longer interval since her last botulinum toxin injection, she developed multiple firm, non-tender nodules. A stepwise approach with intralesional saline injections-initially using needles and later a cannula-was implemented.

[RESULTS] Initial saline injections with small-gauge needles yielded minimal improvement. Transitioning to a 22G cannula enabled both saline delivery and mechanical disruption, resulting in complete resolution after five total treatments. The patient has remained recurrence-free for over 2 years.

[CONCLUSIONS] Nodule formation following CaHA injection is most often due to product aggregation, and is particularly common in dynamic areas with thin overlying skin. Combining treatment with botulinum toxin may reduce this risk by limiting movement. Other preventive strategies include using higher dilutions of CaHA, avoiding high-risk areas, and optimizing injection depth. When nodules do occur, mechanical disruption with a cannula combined with saline injection is a safe, effective, and minimally invasive first-line treatment.