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Treatment of HIV-Associated
     Facial Lipoatrophy

US FDA Pivotal Trial Results


                               1
FDA HIV Facial
                                           Lipoatrophy
                                                Study Design
 Initial Treatment            Follow-up Phase
 Phase



   4.7 cc 1.8 cc                 2.4 cc
Baseline    0 Months 3 Months     6 Months          12 Months             18 Months             30 Months
                                                                          12 months after touchup



                                                                      Follow-on Study
   Average Initial
      Volume
       6.5cc


                     •   Multi-center, prospective, open-label trial of 100 subjects at 3 sites:
                          –   Stacey Silvers, MD                New York, NY
                          –   Joseph Eviatar, MD                New York, NY
                          –   Michael Echavez, MD               San Francisco, CA
                     •   Grade 3 or 4 facial lipoatrophy
Efficacy Criteria
• Primary Endpoint:
  – Global Aesthetic Improvement Scale (GAIS)
    assessment at 3 months
• Secondary Endpoints:
  – GAIS assessment at 6 months
  – Cheek skin thickness at 3 and 6 months
Patient Demographics
   HIV-Associated Facial Lipoatrophy                                        Fitzpatrick Skin Type Scores n=100
    HIV-Associated Facial Lipoatrophy                                        Fitzpatrick Skin Type Scores n=100
         Severity Ratings n=100
          Severity Ratings n=100                                                               I
                                                                                                 I
                                                                                  VI                    II
                                      , I.,I., 0%
                                            0%                                                3%
                                                                                   VI                      II
                      IV.,
                                                                                               3%
                        IV.,            ,                                        17%                   13%
                     13%                                                          17%                   13%
                       13%
            ,
                               Type IV.
                ,
                                 13%
                                                                           V
                                                                II.,        V
                                                                   II.,
                                                    Type II.              13%
                                                               48%
                                                                           13%
                                                                48%
                                                     48%
                        Type III.
                         39%


                                                                                                                 III
 III.,
                                                                                                                   III
    III.,
39%                                                                                                             33%
  39%                                                                                                            33%
                                                                                  IV
                                                                                   IV
                                           ,
                                                                                 21%
                                               ,
                                                                                  21%

                    Balanced distribution of                                      Balanced distribution
                     lipoatrophy severity                                           of all skin types
GAIS Results
                                  Through 18 Months                                   91% of Patients
                                                                                         maintain
                     100% of Patients Improved through 12 Months                       Improvement


Very Much
                            26%                          7%                  31%                  10%
 Improved


    Much
                            72%                          86%                 53%                  44%
 Improved


                                                                                                  38%
 Improved                   2%                           7%                  16%


                                                                                                    9%
No Change
            --                                                 --

   Worse
            --                                                 --
                                                                                        --
                 3 Months             6 Months                  12 Months               18 Months
                   n=100                n=98                       n=98                    n=94
                                     (before touch up)         (6mo after touch up)   (12mo after touch up)
Representative Study Images



                                                 40 yo
                                                 Male
 Baseline               Month 6
                                              Total Volume
                                                 8.0 ml




Month 12             Month 18
                 (12 months after touch-up)
Representative Study Images



                                                41 yo
                                                Male
Baseline           Month 6
                                            Total Volume
                                              15.9 mL




Month 12          Month 18   (12 months after touch-up)
Representative Study Images



                                            50 year old
                                               male
Baseline           Month 6
                                           Total volume
                                             17.2 ml




Month 12          Month 18   (12 months after refinement)
Cheek Thickness Increase
                        Mean Cheek Thickness Measurement
                                                      10.0
                    Right Side                                                 Left Side
10.0

                                                       9.0
 9.0

                                                       8.0
 8.0

                                                       7.0
 7.0

                                                       6.0
 6.0

                                                       5.0
 5.0

                                                       4.0
 4.0


                                                       3.0
 3.0


 2.0                                                   2.0


 1.0                                                   1.0

 0.0                                                   0.0
       Baseline 3 Months 6 Months     12       18            Baseline   3 Months   6 Months   12 Months   18 Months
                                    Months   Months

                              p < 0.001                                             p < 0.001
Patient Satisfaction
                                 Through 18 Months
                              “Yes” at 3   “Yes” at 6   “Yes” at 12    “Yes” at
                               months       months        months      18 months
  Would you recommend
                                99%          99%          99%           99%
   Radiesse treatment?
Has the Radiesse treatment
                               100%         100%          100%          99%
  been beneficial to you?
Do you feel more attractive
                                98%          98%          98%           98%
    since receiving the
  Radiesse treatment?
Is your emotional wellbeing
                                91%          96%          97%           95%
   better since receiving
    Radiesse treatment?
    Do you have more
    confidence in your
                                98%          98%          99%           99%
appearance since receiving
 the Radiesse treatment?
Safety – Adverse Events

• Typical Adverse Events Reported:
      •   Edema
      •   Ecchymosis
      •   Erythema
      •   Pruritis
      •   Pain
• No product related serious adverse events
• No Granulomas
• Most AE’s resolved within 1-2 weeks
% of Patients with Event




                    0%
                         10%
                               20%
                                     30%
                                           40%
                                                 50%
                                                       60%
                                                             70%
                                                                   80%
                                                                         90%
                                                                               100%
     Ed
       em
          a
Ec
   hy
     m
      os
         is

    O
     th
       er
          s
  Er
     yt
       he
         m
               a

       Pa
         in

    Pr
       ur
          it   is
H
 em
   at
        om
          a
                                                                                      ADVERSE EVENTS




G
 ra
   nu
     lo
       m
               a
    N
     od
       ul
         e
  In
    fe
       ct
         io
            n
  N
    ec
       ro
          si
            s
N
 ee
    dl
      e
                                                                                                       Safety – Adverse Events




         Ja
             m
HIV Lipoatrophy Study
                          Conclusions
• Radiesse is safe
  – No reports of serious adverse events
  – Minor AE’s resolved within 7 days
• Radiesse is effective
  – 100% of patients were improved through 12 months
  – > 90% of patients were improved through 18 months
    demonstrating 1 year longevity
  – All primary and secondary endpoints were met
  – > 90% patient satisfaction through 18 months
Radiographic Evaluation of
        Radiesse
Study Overview

• Objective: To assess the radiographic
  appearance of Radiesse when injected into the
  soft tissues of the face
• 58 patients treated in Vancouver, Canada by Dr.
  Alastair Carruthers
  – 28 patients: Long-term facial lipoatrophy (>12 Months)
  – 15 patients: Short-term facial lipoatrophy (<1 Month)
  – 15 patients: Short-term nasolabial fold (<1 Month)
• Images sent to blinded independent evaluators
  in New York, directed by Dr. Marc Liebeskind
Short-Term Facial Lipoatrophy
Pre-Injection     Immediately Post-Injection
                    Total Volume: 15.6 ml
Long-Term Facial Lipoatrophy
                                      Post-12 Month
        Pre-12 Month
                                        Injection
          Injection
Initial Volume Injected: 25.0 ml   Volume Added: 9.1 ml
Short-Term Nasolabial Folds
Pre-Injection            Post-Injection
                      Total Volume: 2.6 ml
No Obstruction of Underlying
              Structures
Common dental work results in interference
Radiographic Findings
                        Summary
• Radiesse is not consistently evident on X-ray
• Radiesse is clearly visible on CT Scan
  – Distinctly separate from bone
  – For facial soft tissue applications, Radiesse is visible
    bi-laterally (not typical of an adverse clinical finding)
  – Radiesse volume dissipates over time
• No evidence that Radiesse migrates
• Radiesse as a radiographic material does not
  pose a safety concern

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FDA HIV Lipoatrophy Trials with Radiesse in the United States

  • 1. Treatment of HIV-Associated Facial Lipoatrophy US FDA Pivotal Trial Results 1
  • 2. FDA HIV Facial Lipoatrophy Study Design Initial Treatment Follow-up Phase Phase 4.7 cc 1.8 cc 2.4 cc Baseline 0 Months 3 Months 6 Months 12 Months 18 Months 30 Months 12 months after touchup Follow-on Study Average Initial Volume 6.5cc • Multi-center, prospective, open-label trial of 100 subjects at 3 sites: – Stacey Silvers, MD New York, NY – Joseph Eviatar, MD New York, NY – Michael Echavez, MD San Francisco, CA • Grade 3 or 4 facial lipoatrophy
  • 3. Efficacy Criteria • Primary Endpoint: – Global Aesthetic Improvement Scale (GAIS) assessment at 3 months • Secondary Endpoints: – GAIS assessment at 6 months – Cheek skin thickness at 3 and 6 months
  • 4. Patient Demographics HIV-Associated Facial Lipoatrophy Fitzpatrick Skin Type Scores n=100 HIV-Associated Facial Lipoatrophy Fitzpatrick Skin Type Scores n=100 Severity Ratings n=100 Severity Ratings n=100 I I VI II , I.,I., 0% 0% 3% VI II IV., 3% IV., , 17% 13% 13% 17% 13% 13% , Type IV. , 13% V II., V II., Type II. 13% 48% 13% 48% 48% Type III. 39% III III., III III., 39% 33% 39% 33% IV IV , 21% , 21% Balanced distribution of Balanced distribution lipoatrophy severity of all skin types
  • 5. GAIS Results Through 18 Months 91% of Patients maintain 100% of Patients Improved through 12 Months Improvement Very Much 26% 7% 31% 10% Improved Much 72% 86% 53% 44% Improved 38% Improved 2% 7% 16% 9% No Change -- -- Worse -- -- -- 3 Months 6 Months 12 Months 18 Months n=100 n=98 n=98 n=94 (before touch up) (6mo after touch up) (12mo after touch up)
  • 6. Representative Study Images 40 yo Male Baseline Month 6 Total Volume 8.0 ml Month 12 Month 18 (12 months after touch-up)
  • 7. Representative Study Images 41 yo Male Baseline Month 6 Total Volume 15.9 mL Month 12 Month 18 (12 months after touch-up)
  • 8. Representative Study Images 50 year old male Baseline Month 6 Total volume 17.2 ml Month 12 Month 18 (12 months after refinement)
  • 9. Cheek Thickness Increase Mean Cheek Thickness Measurement 10.0 Right Side Left Side 10.0 9.0 9.0 8.0 8.0 7.0 7.0 6.0 6.0 5.0 5.0 4.0 4.0 3.0 3.0 2.0 2.0 1.0 1.0 0.0 0.0 Baseline 3 Months 6 Months 12 18 Baseline 3 Months 6 Months 12 Months 18 Months Months Months p < 0.001 p < 0.001
  • 10. Patient Satisfaction Through 18 Months “Yes” at 3 “Yes” at 6 “Yes” at 12 “Yes” at months months months 18 months Would you recommend 99% 99% 99% 99% Radiesse treatment? Has the Radiesse treatment 100% 100% 100% 99% been beneficial to you? Do you feel more attractive 98% 98% 98% 98% since receiving the Radiesse treatment? Is your emotional wellbeing 91% 96% 97% 95% better since receiving Radiesse treatment? Do you have more confidence in your 98% 98% 99% 99% appearance since receiving the Radiesse treatment?
  • 11. Safety – Adverse Events • Typical Adverse Events Reported: • Edema • Ecchymosis • Erythema • Pruritis • Pain • No product related serious adverse events • No Granulomas • Most AE’s resolved within 1-2 weeks
  • 12. % of Patients with Event 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Ed em a Ec hy m os is O th er s Er yt he m a Pa in Pr ur it is H em at om a ADVERSE EVENTS G ra nu lo m a N od ul e In fe ct io n N ec ro si s N ee dl e Safety – Adverse Events Ja m
  • 13. HIV Lipoatrophy Study Conclusions • Radiesse is safe – No reports of serious adverse events – Minor AE’s resolved within 7 days • Radiesse is effective – 100% of patients were improved through 12 months – > 90% of patients were improved through 18 months demonstrating 1 year longevity – All primary and secondary endpoints were met – > 90% patient satisfaction through 18 months
  • 15. Study Overview • Objective: To assess the radiographic appearance of Radiesse when injected into the soft tissues of the face • 58 patients treated in Vancouver, Canada by Dr. Alastair Carruthers – 28 patients: Long-term facial lipoatrophy (>12 Months) – 15 patients: Short-term facial lipoatrophy (<1 Month) – 15 patients: Short-term nasolabial fold (<1 Month) • Images sent to blinded independent evaluators in New York, directed by Dr. Marc Liebeskind
  • 16. Short-Term Facial Lipoatrophy Pre-Injection Immediately Post-Injection Total Volume: 15.6 ml
  • 17. Long-Term Facial Lipoatrophy Post-12 Month Pre-12 Month Injection Injection Initial Volume Injected: 25.0 ml Volume Added: 9.1 ml
  • 18. Short-Term Nasolabial Folds Pre-Injection Post-Injection Total Volume: 2.6 ml
  • 19. No Obstruction of Underlying Structures Common dental work results in interference
  • 20. Radiographic Findings Summary • Radiesse is not consistently evident on X-ray • Radiesse is clearly visible on CT Scan – Distinctly separate from bone – For facial soft tissue applications, Radiesse is visible bi-laterally (not typical of an adverse clinical finding) – Radiesse volume dissipates over time • No evidence that Radiesse migrates • Radiesse as a radiographic material does not pose a safety concern