Understanding Filler Complications for Rhinoplasty

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

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

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

Bone

Key-stone area (mobile joint)

Cartilage

Figure 1: The key-stone area is the junction between the bony vault and the cartilaginous vault of the dorsum (yellow circle). 4 Image courtesy of Mr Dario Rochira. predictable results than traditional rhinoplasty. It also has a lower rate of revision surgery. 3,4,5 The basis and rationale of this technique comes from 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 area (the junction between nasal bones and cartilages on the dorsum) is a semi-mobile 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 challenge, if not impossible, to Figure 2: Surgical removal of HAbased filler injected into the tip 13 remove any filler from the radix months before surgery. 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

Filler B

Filler Dorsal hump

D

Filler absorbed the filler is absorbed over time (D). 4 Images courtesy of Mr Dario Rochira. Therefore, if this type of operation is scheduled within a year (or the patient has indicated that they are interested in surgical Alternatively, the filler should be dissolved using hyaluronidase one month before the surgery. It is most surgeons’ opinion that this hyaluronidase procedure should be carried out by the treating aesthetic practitioner as they know what and where the filler was injected, which should produce the best outcome for the patient. Recommendations As mentioned, patients often present to non-surgical aesthetic professionals to address shape concerns with their nose as a trial before surgical interventions. With this in mind, I believe that practitioners should be asking patients if their intention is to undergo surgery at a later date. Practitioners then have a Straight-look dorsum

Dorsal hump responsibility to educate the patient that closed preservation rhinoplasty should be no less than one year after the filler is injected, or one month after the filler has been dissolved with hyaluronidase. In the ideal scenario, non-surgical aesthetic practitioners should also make the patient’s records available to the treating surgeon. The records should include detailed treatment notes on the type of filler used, injection plane and technique, amount of filler injected and treated areas, date and signature, as well as before and after images. The surgeon can then make a full, accurate assessment of the native nasal anatomy of the patient and plan the surgical steps accordingly. It should be noted that, in my

Figure 3: Patient presents with a dorsal hump and asks for a non-surgical nose-reshaping to make the dorsum straight-looking (A). Filler is injected to the radix (B). Closed preservation rhinoplasty is performed without dissolving the filler previously injected and not seen during surgery (C). Hump ‘recurrence’ after experience, it is very common for patients not to even remember the name of their previous practitioners; perhaps the procedure was performed

interventions), the injection of filler to the radix should be avoided. 8 abroad, they simply don’t want to give details or don’t want me to contact the practitioner. I have also previously written to the practitioners, but without answer. A good relationship and communication between the surgeon and the aesthetic practitioner is always encouraged. A further recommendation is that more studies are still needed to establish guidelines on the best time frame between filler injections and rhinoplasty, especially given the wide range of different fillers

currently on the market.

If this type of operation is scheduled within a year or the patient has indicated that they are interested in surgical interventions, the injection of filler to the radix should be avoided

Mr Dario Rochira is a plastic surgeon, practising on Harley Street, with more than 15 years’ experience in cosmetic surgery. He trained at the Catholic University of Rome and is a member of the BAPRAS and ISAPS. Mr Rochira’s main interest is rhinoplasty and he was the first specialist in plastic surgery to offer preservation rhinoplasty, which is a type of rhinoseptoplasty, into his practice in the UK. Qual: MD

REFERENCES

1. Kim DW, Yoon ES, Ji YH, Park SH, Lee BI and Dhong ES, “Vascular complications of hyaluronic acid filler and the role of hyluronidase in management, Journal of Plastic and Reconstructive Aesthetic

Surgery, Vol 64 (2011), 1590-1595. 2. McKeown DJ, “The risk of blindness following non-surgical Rhinoplasty”, Jo urnal of Plastic and

Reconstructive Aesthetic Surgery, Vol 66, (2013), e238. 3. Rollin K Daniel, “The Preservation Rhinoplasty: a new Rhinoplasty Revolution”, Aesthetic Surgery

Journal, Vol 38 (2018), 228-229. 4. Baris Cakir, Yves Saban, Rollind Daniel, Peter Palhazi, Preservation Rhinoplasty (Istanbul, 2018). 5. Yves Saban, Rollin K Daniel, Roberto Polselli, Maria Trapasso and Peter Palhazi, “Dorsal Preservation:

The push down technique reassesed”, Aesthetic Surgery Journal, Vol 38 (2018), 117-131. 6. Baris Cakir, Ali Riza Oreroglu, Teoman Dogan and Mithat Akan, “A Complete Subperichondrial

Dissecation Technique for Rhinopasty with management of the nasal ligaments”, Aesthetic Surgery

Journal, Vol 35 (2012), 564-574. 7. Per Hedén, Nasal Reshaping with Hyaluronic Acid: An Alternative or Complement to Surgery,

Plastic and Reconstructive Surgery Global Open, 2016. <https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC5142491/> 8. Johnson ON and Kontis TC, “Nonsurgical Rhinoplasty”, Facial Plastic Surgery, Vol 32 (2016), 500-6.