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Understanding Filler Implications for Rhinoplasty Plastic surgeon Mr Dario Rochira explains why dermal fillers can be contraindicated for closed preservation rhinoplasty and how practitioners can work together to ensure best patient outcomes Dermal fillers are widely used for non-surgical nose reshaping. Often, patients will present to clinic for this treatment because they are not ready for surgical interventions, are not suitable candidates for surgery, or, commonly, because they are interested in surgery, but want to try something more temporary first to see how they might feel about a more permanent solution. There are many complications that can arise with non-surgical nose reshaping using filler, which include, but are not limited to, skin necrosis and blindness.1,2 However, dermal fillers can also be responsible for a different complication if they are injected up to a year before the patient undergoes rhinoplasty. This is particularly so if the closed preservation rhinoplasty technique is used, which is what I focus this article on.3 I will explain why dermal fillers are contraindicated for closed preservation rhinoplasty, and how non-surgical aesthetic practitioners can work together with surgeons to ensure maximum patient care and successful outcomes.
Understanding closed preservation rhinoplasty Closed preservation rhinoplasty is a newer form of surgical rhinoplasty that preserves the structural and functional integrity of the tissues within the nose, including the cartilages, muscles, ligaments and bones. This technique preserves the nasal dorsum (bridge), unlike traditional rhinoplasty, which involves excision and removal of the dorsal bones and cartilage, as well as reconstructive technique. The reason why many patients opt for this is because the procedure is less invasive, less aggressive, has reduced bruising and swelling and results in less recovery time with more predictable results than traditional rhinoplasty. It also has a lower rate of revision Bone surgery.3,4,5 The basis and rationale of Key-stone area (mobile joint) this technique comes from Cartilage recent anatomical findings that relate the nasal anatomy to nasal aesthetics and surgical techniques.3,5 The most important and revolutionary finding is that the key-stone Figure 1: The key-stone area is the junction between the bony vault area (the junction between and the cartilaginous vault of the nasal bones and cartilages on dorsum (yellow circle).4 Image courtesy of Mr Dario Rochira. the dorsum) is a semi-mobile
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chondrosseous joint, which can be converted from convex to straight by resecting its underlying cartilaginous support (Figure 1).3,5 I have found that the endonasal approach (without any skin incision) is the best method, as the tip can also be reshaped from the inside leading to a less traumatic and less invasive operation, resulting in more controlled and predictable results.4,5 A further study conducted by Cakir et al. has demonstrated that a closed approach to the subperichondrial and subperiosteal dissection is associated with less swelling and bruising, preserving sensitivity and resulting in faster recovery.6
Why dermal fillers are contraindicated It is my experience that hyaluronic acid fillers injected into the nose last considerably longer than when they are injected in other areas of the face.7 Most practitioners inject the filler to the radix area (just below the glabella) in a deep plane, which is the layer just above the periosteum (sub-SMAS layer). This is important because when closed preservation rhinoplasty is performed, the dissection at the radix is carried out in the subperiosteal plane. As a result, any filler previously injected into this area may not be inspected or possible to remove. While it is relatively easy for a surgeon to remove any filler from the tip area as it is closer to the incision (Figure 2), it is a big Figure 2: Surgical removal of HAchallenge, if not impossible, to based filler injected into the tip 13 months before surgery. remove any filler from the radix area, particularly in a closed approach. The open approach (skin incision and elevation) may offer better visibility of the radix, however the removal of the filler is still a big challenge due to the thin skin of this area, resulting in potential skin irregularities or skin necrosis when removing the filler. This can create a poor aesthetic result following surgery. The patient may have a straight dorsum immediately after surgery, but over time, the previously injected filler will be absorbed, creating a residual hump or very deep and low radix (Figure 3).
Practitioners should be asking patients if their intention is to undergo surgery at a later date
Reproduced from Aesthetics | Volume 7/Issue 5 - April 2020
