Non-surgical Rhinoplasty with Hyaluronic acid Fillers: Predictable Results Using Software for the Evaluation of Nasal Angles
Adriano Santorelli & Sergio Marlino
Aesthetic Plastic Surgery
ISSN 0364-216X
Aesth Plast Surg
DOI 10.1007/s00266-019-01579-z
However,comparedwithotherareasoftheface,there remainsarelativelackofevidenceregardingtheoptimal products,techniquesandindicationsforsafeandeffective nasalreshapingwithHAfillers.
TheVycrossTM portfoliooffillerscanbeusedacrossa widerangeoffacialareas.Theseproductscontainvarying concentrationsofHA(10%highmolecularweight;90% lowmolecularweight)toachievedifferentphysicalpropertiessuitablefordifferenttreatmentapplications[5].Their safetyandefficacyhavebeendemonstratedinanumberof clinicaltrials[4, 6–13].However,tothebestofour knowledge,noprospective,multicenter,randomizedtrials oftheVycrossrangehavespecificallyfocusedontreatment ofthenose.Hence,forthemoment,one/two-center,nonrandomizedstudiesremainthekeydataresourcefornasal reshapingwithVycrossfillers[14–16].Thesehavelargely reliedonsubjectivemeasuresofefficacy,suchassatisfactionscales.ThepresentstudyaimedtoassesstheefficacyandsafetyofnosereshapingtreatmentwithVycross HAfillers,usingalicense-freesoftwareknownas‘Face Master’toobjectivelymeasureanthropometricfacial parameters[17].
MaterialsandMethods
StudyDesignandPatients
Thiswasaprospective,open-label,single-centerstudyof consecutivepatientsundergoingnon-surgicalnasal reshapingwithinjectablefillers.TreatmentswereperformedaspartofasingleepisodeofcarebetweenMarch 2017andDecember2018.Thestudywasconductedin accordancewiththeDeclarationofHelsinki,andallsubjectsprovidedwritteninformedconsent.
Eligibleindividualswerefemalesandmalesaged C 17yearswishingtoimprovetheaestheticappearanceof theirnose,forwhomnon-surgicalreshapingwasconsideredappropriate.Patientselectionwasbasedprimarilyon theprofileofthenose:idealcandidateswerethosewith lowroot,nasalhump,orhypo-projectedtip.Allpatients wererequiredtohaverealisticexpectationsofwhatcould beachievednon-surgically,andtounderstandthatfiller treatmentwould increase theoverallsizeofthenose.For thisreason,patientswhoconsideredtheirnosetobetoo largewereexcluded.
Otherexclusioncriteriaweretwoormoreprevious rhinoplasties,previousfillertreatmentwithinthepast 3months,allergytoanyofthestudyproducts,excessive sundamage,wound-healingproblems,pregnancy,or breastfeeding.
Patientsincludedinthisanalysishadaminimumof 12monthsoffollow-up(exceptforonepatientwithonly 11monthsoffollow-up).
Procedures
Allstudysubjectsweretreatedinthenosewitheither VYC-20(Voluma ;20mg/mLHA)orVYC-17.5(Volift ;17.5mg/mLHA)fromtheVycrossrangeofHAbasedproducts(Allergan,Dublin,Ireland).VYC-20was usedasthedefaultfiller,owingtoitshighG’characteristics;VYC-17.5waspreferredonlyinpatientswhoneededverysmallcorrections,orwhowereconcernedabout theprocedureandwantedto‘test’itusingaproductwitha shorterdurationofeffect.
Theareasinjectedwerethebonydorsum,cartilaginous dorsumand/orcolumella,asperinvestigatorjudgmentof clinicalneed.Thegoaloftreatmentwaslinearimprovementintheprofile.
Priortoinjection,theskinwasassessedforanyactive bacterialorviralinfections.Patientswerepositionedwith theirheadparalleltotheground,andthetreatmentarea wasdisinfectedwithchlorhexidine.Treatmentwasperformedwitha27Gneedleandbeganwithtwosuperficial microbolusinjectionsintothedomeofthetipofthenose fromthebaseofcolumella.Withoutremovingtheneedle, toreducepainandimprovepatientcomfort,itwasthen turnedthrough180 andpusheddeepertotheboneinthe nasalspinewithabolusgiventosupportthenasaltip. Typically,thissecondinjectionusedthelargestamountof filler.Athirdinjectionwasmadeintothedorsum,afew millimetersfromthehump,givenasabolusdeeptothe bone.Topreventvascularadverseeventsresultingfromthe proximityoftheangularartery,thespacelateraltothe injectionsitewasclosedusingtwofingersofthelefthand, avoidingdislocationoftheproduct.Ifrequired,afinal injectionwasgivenparalleltothecartilaginousseptum fromtheattachmentoftheseptumtothenasalbone,in linearretrogradefromthetiptothenasalbone.Carewas takentoavoidovercorrection;nomorethan1mLoffiller wasusedforanypatient.Aftertreatment,astrongmassage wasperformedatthenasaltiptocheckthecolorationof theskinandavoidischemiaormajorhematoma.Icewas neverused,becausethenoseisaterminalareaandcold temperaturesincreasetheriskofnecrosis.Touch-upwas allowedat14–30dayspost-treatmentifdeemednecessary bytheinvestigator.
Standardizedphotographsweretakeninfrontalprojection,three-quarterprofile,andfullprofile,bothpre-treatmentandat1monthpost-treatment.Photographswere capturedinaccordancewiththerecommendationsofthe developersofFaceMaster[17].Inparticular,thecamera waspositionedataround1.0–1.5mfromthesubject,ona
Fig.2 Calculationofnasalanglespre-andpost-treatment.A 27-year-oldwomanbefore(a, b)and1monthafter(c, d)treatment with0.7mLofVYC-20inthecolumella(baseandpoint).Images a and c showthecalculationofnasofrontalangle,and b and d show
Discussion
ThisstudydemonstratedtheefficacyandsafetyofnonsurgicalnasalreshapingwithVycrossHAfillersinacohort ofrelativelyyoungpatients(meanageunder30years)ata singlecenter.Asexpected,changeswerevisibleprimarily inprofileratherthanfrontalview.Objectiveassessmentsof nasofrontalandnasolabialanglesweremadeusingafree software[17],whichdemonstratedclinicallysignificant increasesinbothanglesaftertreatment(Figs. 1, 2 and 3). Meanchangeswerearound3.5 ,butincreasesofupto12 wereevidentinsomeindividuals.
Meannasolabialangleincreasedfrom85.3 to88.5 afterfillertreatment.Inapreviousstudybasedonassessmentbymultipleraters(bothcliniciansandnon-clinicians),itwasproposedthatthemostaesthetically appealingnasolabialangleisaround93.4 –98.5 inmen
thecalculationofnasolabialangleusingtheFaceMastersoftware. Nasofrontalangleincreasedfrom147.6 to148.2 ,andnasolabial angleincreasedfrom89.2 to93.6
and95.5 –100.1 inwomen[18].Hence,thetreatment receivedinthepresentanalysisshiftedpatientssubstantiallyclosertothisaestheticideal.
TheFaceMastersoftwaretoolusedtocalculatethese angleswasdevelopedtosimplifytheprocessofmeasuring anthropometricfacialparametersandhasbeenshownto calculatefacialanglesaccuratelytowithin0.1 [17]. Althoughthesemeasurementscanbemademanually, accuracycanbeproblematicandtime-consumingto achieve.
FaceMasterisconvenienttouse,extractinganthropometricparametersfromstandardtwo-dimensionaldigital photographsofpatients.Resultscanbeexportedto appropriatespreadsheetsand/ordatabases.Thedesigners ofthesoftwaresuggestthat,tooptimizeperformance, photographsshouldbetakenatearlevelatadistanceof around1.0–1.5mfromthepatient;lightsourcesshouldbe
5.GoodmanGJ,SwiftA,RemingtonBK(2015)Currentconcepts intheuseofVoluma,Volift,andVolbella.PlastReconstrSurg 136:139S–148S
6.Philipp-DormstonWG,EcclestonD,DeBoulleKetal(2014)A prospective,observationalstudyofthevolumizingeffectofopenlabelaestheticuseofJuve ´ derm VOLUMA withLidocainein mid-facearea.JCosmetLaserTher16:171–179
7.Philipp-DormstonWG,HiltonS,NathanM(2014)Aprospective,open-label,multicenter,observational,postmarketstudyof theuseofa15mg/mLhyaluronicaciddermalfillerinthelips. JCosmetDermatol13:125–134
8.HumphreyS,CarruthersJ,CarruthersA(2015)Clinicalexperiencewith11,460mlofa20-mg/mL,smooth,highlycohesive, viscoushyaluronicacidfiller.DermatolSurg41:1060–1067
9.RaspaldoH,ChantreyJ,BelhaouariLetal(2015)Lipand perioralenhancement:a12-monthprospective,randomized, controlledstudy.JDrugsDermatol14:1444–1452
10.CalvisiL,GilbertE,ToniniD(2017)Rejuvenationoftheperioral andlipregionswithtwonewdermalfillers:theItalianexperience withVycrossTM technology.JCosmetLaserTher19:54–58
11.GeronemusRG,BankDE,HardasBetal(2017)Safetyand effectivenessofVYC-15L,ahyaluronicacidfillerforlipand perioralenhancement:one-yearresultsfromarandomized,controlledstudy.DermatolSurg43:396–404
12.LiD,WangX,WuYetal(2017)Arandomized,controlled, multicenterstudyofJuvedermVolumaforenhancementofmalar volumeinChinesesubjects.PlastReconstrSurg139:1250e–1259e
13.MonheitG,BeerK,HardasBetal(2018)SafetyandeffectivenessofthehyaluronicaciddermalfillerVYC-17.5Lfornasolabialfolds:resultsofarandomized,controlledstudy.Dermatol Surg44:670–678
14.LiewS,ScampT,deMaioMetal(2016)Efficacyandsafetyofa hyaluronicacidfillertocorrectaestheticallydetractingordeficientfeaturesoftheAsiannose:aprospective,open-label,longtermstudy.AesthetSurgJ36:760–772
15.RausoR,ColellaG,ZerbinatiN,SaltiG(2017)Safetyandearly satisfactionassessmentofpatientsseekingnonsurgicalrhinoplastywithfiller.JCutanAesthetSurg10:207–214
16.BertossiD,LanaroL,DorelanSetal(2019)Nonsurgical rhinoplasty:nasalgridanalysisandnasalinjectingprotocol.Plast ReconstrSurg143:428–439
17.OzkulT,OzkulMH,AkhtarRetal(2009)Asoftwaretoolfor measurementoffacialparameters.OpenChemBiomedMethods J2:69–74
18.ArmijoBS,BrownM,GuyuronB(2012)Definingtheideal nasolabialangle.PlastReconstrSurg129:759–764
19.PrantlL,BrandlD,CeballosP(2017)Aproposalforupdated standardsofphotographicdocumentationinaestheticmedicine. PlastReconstrSurgGlobOpen5:e1389
20.BertossiD,CavalliniM,CirilloPetal(2018)Italianconsensus reportontheaestheticuseofonabotulinumtoxinA.JCosmet Dermatol17:719–730
21.MohamedWS,El-ShazlyMM,El-SonbatyMAH,EloteifyMM (2013)Objectiveversussubjectiveassessmentforrhinoplasty. EgyptJPlastReconstrSurg37:73–79
22.deMaioM,DeBoulleK,BrazAetal(2017)Facialassessment andinjectionguideforbotulinumtoxinandinjectablehyaluronic acidfillers:focusonthemidface.PlastReconstrSurg140:540e–550e
23.McCleveDE,GoldsteinJC(1995)Blindnesssecondaryto injectionsinthenose,mouth,andface:causeandprevention.Ear NoseThroatJ74:182–188
24.RayessHM,SviderPF,HanbaCetal(2018)Across-sectional analysisofadverseeventsandlitigationforinjectablefillers. JAMAFacialPlastSurg20:207–214
25.HeydenrychI,KapoorKM,DeBoulleKetal(2018)A10-point planforavoidinghyaluronicaciddermalfiller-relatedcomplicationsduringfacialaestheticproceduresandalgorithmsfor management.ClinCosmetInvestigDermatol11:603–611
26.JasinME(2013)Nonsurgicalrhinoplastyusingdermalfillers. FacialPlastSurgClinNAm21:241–252
27.JohnsonON3rd,KontisTC(2016)Nonsurgicalrhinoplasty. FacialPlastSurg32:500–506
28.WangLL,FriedmanO(2017)Updateoninjectablesinthenose. CurrOpinOtolaryngolHeadNeckSurg25:307–313
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