Advances in Plastic & Reconstructive Surgery © All rights are reserved by Sukhbir Singh.

*Address for Correspondence: Dr. Sukhbir singh, Consultant Plastic and Cosmetic Surgeon, Resplendent the Cosmetic Studio, R-9, Greater Kailash part 1, New-Delhi-110048, INDIA, Tel: 91-9910391229; E-Mail: sukhi_1@yahoo.com

Received: February 27, 2018; Date Accepted: May 01, 2018; Date Published: May 10, 2019.

Sukhbir SinghConsultant Plastic and Cosmetic Surgeon, Greater Kailash part 1, New Delhi, India.

AbstractBackgorund: Nose has always been regarded as a sign of pride and beauty. It is an important part of facial aesthetics and need to be restored as part of overall facial rejuvenation. Surgical Rhinoplasty has always been the mainstay of treatment for patients seeking nasal contour improvements, but it is always associated with a longer recovery period whereas Hyaluronic Acid fillers not only give immediate results but with minimal or no downtime.

Methods: The aim of this retrospective study was to study the efficacy of HA Fillers for nasal contouring and improving aesthetic outcome with paradigm shift from surgical to non-surgical. All the patients irrespective of the gender wanting non - surgical improvements in nasal aesthetics were recruited for the procedure and study. All co-morbidities were ruled out and written informed consent was taken from all patients. The study was done at the author’s private clinic and all procedures were done by author himself using Juvederm Volift (Allergan Inc. Irvin, California) which is a HA filler. Various areas were assessed (dorsum, lateral wall of nose, tip and Alar region ) and correction done depending on the requirement. All the patients were followed by for a period of 6 months post procedure.

Results: 55 patients underwent nasal reshaping with HA fillers. No complications occurred in the above patients. Dorsal correction was the most common indication, followed by the tip and alar correction. The patients were highly satisfied in accordance with the Global Assessment Improvement Scale with both the results and very minimal downtime following the treatment.

Conclusion: HA fillers are very effective for nasal reshaping for patients not willing for rhinoplasty and even those with post rhinoplasty minor defects. They give immediate results with very minimal downtime. The author cautions that such injections should be done by doctors experienced in this field with thorough anatomical knowledge.

Keywords: Hyaluronic fillers (HA fillers); Dorsum; Tip; Ala; Nasal reshaping.

useful characterization of serotonin receptor subtypes in the treatment of

Research Article ISSN: 2572-6684

Injection Rhinoplasty in Indian Population: A Paradigm shift

Surgical Rhinoplasty has always been the mainstay of treatment for patients seeking nasal contour improvements and reshaping, but it is always associated with a longer recovery period whereas Hyaluronic Acid fillers not only give immediate results but with minimal or no downtime. Various injectables have been used such as calcium hydroxyl apatite and HA fillers. Nasal dorsal correction has been the most common indication for non-surgical nose reshaping, but in this article the author shall discuss about various areas of nasal aesthetics corrections.

Materials and Methods The author has been performing surgical rhinoplasty since last

ten years and since last 2 years there has been a preference for non-surgical nose reshaping primarily due to immediate results and very minimal downtime. Facial documentation with photographs is mandatory before nasal reshaping is done. Informed consent form is must and it should be stressed to the patients, that this is a temporary correction since HA degrades over time. In all the patients, Juvederm Volift (Allergan Inc. Irvin, California) HA filler was used for nose reshaping. The author earlier used Juvederm Ultra plus XC (Allergan Inc. Irvin, California) for nasal correction but has shifted to Juvederm Volift (Allergan Inc. Irvin, California) due to less downtime, smoothness of the filler, less hydration and higher cohesivity to achieve the desired result. All procedures were done in the author’s private clinic by the author himself.

Introduction Nasal reshaping whether surgically through rhinoplasty or non-

surgically with soft tissue fillers is always challenging. The surgeon needs to be very precise and accurate in his/ her injections. Thorough knowledge of the nasal anatomy is the basis to perform such procedu-res. According to the global statistics 2016 of American Society of Plastic Surgeons (ASPS) and International Society of Aesthetic Plastic Surgeons (ISAPS), out of 17.1 million cosmetic procedures performed, 15.4 million have been minimally invasive ones rather than surgical. Out of top 5 surgical procedures, nose reshaping is the 3rd commo-nest amongst surgical procedures. Soft tissue fillers was the second commonest amongst all minimally invasive procedures all over the world. Thus there is a clear paradigm shift from surgical to non-surgical aesthetic procedures. We donot have any Indian statistics on surgical or non-surgical procedures but the author has noted that in his practice also the demand for non-surgical procedures has increased many folds.

Adv Plast Reconstr Surg, 2019 Page 242 of 245

Sukhbir S. Injection Rhinoplasty in Indian Population: A Paradigm shift. Adv Plast Reconstr Surg, 2019; 3(1): 242-245.

Procedure After thorough discussion with the patient and signing of the

consent form, pre- procedure pictures are taken for all patients – front view, lateral views, basal views. Deformities and the intended sites of injection are marked and local numbing cream containing lidocaine and prilocaine is applied to make the patient comfortable. After an interval of 45 minutes, the cream is cleaned , the injection sites are remarked. Patient is placed comfortably on the chair and injections are carried out at the intended sites.

Dorsum For Dorsum corrections, usually 2 or 3 points are injected directly

on the dorsum, needle directed at 45 degrees from the dorsum [figure 1], supraperiosteal level with care being taken to aspirate before and avoid large boluses. The author suggests to inject in small boluses only, less than .02 ml per site. Immediately after injection gentle moulding to be done. More filler can be added if required to get the desired result.

Figure 1: Illustration demonstrating the technique and angulation for Nasal dorsum correction.

TIP Tip correction is desired mainly for lifting the tip in case of parrot beak shaped nose (drooping tip) or to give it more definition and contour as in case of box nose shape. For Tip correction, the author places the needle directly on the nasal tip, needle placed obliquely to the lip axis at 45 degrees [figure 2] and injected at intradermal or subdermal level.

ALA Alar correction is indicated to correct deformities like difference in heights of both Ala or to reshape them. For Alar correction, the author places the needle directly on the alar areas requiring correction, needle directed at 45 degrees [figure 3] and injected at intradermal level.

There are few important steps to be followed during nasal injections to minimize the risk of complications, first and foremost is to always aspirate before injecting. It is also advisable to avoid big bolus injections and giving very small bolus. Anatomical knowledge

Figure 2: Illustration demonstrating the technique and angulation for Nasal Tip correction.

Figure 3: Illustration demonstrating the technique and angulation for Nasal Ala correction.

of safe plain of injection is very important. It is better to avoid over-correction and always keep hyaluronidase injection ready in case of an adverse event. After injection examine the skin well and always look out for blanching of skin if any. Post-procedure pictures are taken with same views as above. Patients are given the mirror for self- inspection and once they are satisfied, post procedure instructions are explained to them in detail with special emphasis on no massa-ging of the nasal injected area for at least 3-4 days. A follow up visit is scheduled after 3 weeks and touch up if required is done during this visit itself. All the patients were followed up for 6 months. A total of 0.6- 1 ml of HA filler was used in each patient.

Results HA fillers are now the preferred treatment options for patients

wanting non- surgical nose reshaping and even for those who have undergone surgical rhinoplasty but want slight corrections for uneven shape. HA fillers give immediate results with almost no downtime and happy clients as one can see in the pic [figure 4] below. For example in figure 4, we can see soon after the dorsum injections, its deviation is corrected and its lifted more than 30 degrees

Adv Plast Reconstr Surg, 2019 Page 243 of 245

Sukhbir S. Injection Rhinoplasty in Indian Population: A Paradigm shift. Adv Plast Reconstr Surg, 2019; 3(1): 242-245.

surgical anatomy of various vascular structures in and around the nose which can lead to adverse events. It’s important to know about the anatomy of facial artery and its course as it crosses the buccinator muscle and gives the angular artery on each side of the nose. Other important branches include the dorsal nasal artery, the lateral nasal artery, the alar branches and the various anastomosis which occur between various vessels. Most of these vessels are end arteries and even a drop of filler injected intravascularly can lead to blindness. Without adequate knowledge it’s easy to do more harm than benefit to the patient.

Though nasal fillers have become very common and more popular than Surgical Rhinoplasty, one ought to know what only surgical rhinoplasty can achieve and not fillers. Surgical rhinoplasty is the only method by which we can achieve nasal bony width reduction, correct severe traumatic and crooked noses, improve nasal breathing and address the nasal fractures with no risk for blindness. All these things are impossible to be corrected by fillers alone. But all this comes at the price of longer recovery periods, swelling which lasts for 6 weeks or more, residual deformities can still persist requiring further corrections and worsening of breathing problem can also occur.

HA fillers on the other hand are quick with minimal swelling with hardly any downtime and patient is back to his work almost immediately. HA fillers can also correct post rhinoplasty residual defects very easily. Though it seems very quick [1] and lucrative, the author warns of the risks associated with fillers even in experienced hands like vascular emboli and necrosis [2-6], vision loss [7-9], ocular ischemia [10], tyndall effect [11] and infection [1]. Vision loss or blindness is the most dreadful of all due to very close proximity of the neurovascular arcade.

The author suggests nasal fillers to be done only by experienced plastic surgeons with thorough knowledge of nasal anatomy and how to tackle any adverse event if it ever happens. Aspiration is always a must and it is advisable to inject very small bolus instead of large boluses. The author suggests to do retrograde injections rather than antegrade injections wherever required.

The plane of injection is very important. When we inject for dorsal correction we have to place injections supraperiosteally, for tip and alar rim intradermal injections need to be done. If any vascular compromise is suspected , protocol suggested by DeLorenzi [12] and others [13-15] is recommended.

The author earlier used Juvederm Ultra plus XC (Allergan Inc. Irvin, California) for nasal correction but has shifted to Juvederm Volift (Allergan Inc. Irvin, California) as it is a highly cross linked filler which increases its cohesiveness and creates less hydration leading to lower downtime and swelling. The deformities can be corrected to maximum extent in a single sitting. The author suggests to review the patient after 3 weeks and do any touch up if required.

Conclusion HA fillers offers a great hope for clients opting for non-surgical

nasal reshaping. Though it is quick and almost no downtime but at the same time over aggressive treatment to be avoided for nasal fillers due to its risks involved as mentioned above including blindness. The author suggests only highly skilled specialists to do nasal injections so as to minimize the risks and improve the overall outcomes and achieve a high GAIS score.

and left ala shows deformity correction with height equalization.

Figure 4a: Pre-procedure pic showing dorsal deviation with depression and left Alar deformity with decreased height.

Figure 4 b: Post-procedure pic showing dorsal straightening with left Alar defo-rmity corrected with height equalization.

Though the author has never faced a complication with nasal fillers, but has faced positive aspirate in 3 of the 55 patients, hence aspiration is mandatory when contemplating nasal fillers since even a drop is enough to cause adverse events including blindness. The Global Aesthetic Improvement Scale (GAIS) is a 5- point scale rating global aesthetic improvement in appearance, compared to pretrea-tment, as judged by the investigator. The rating categories are “worse,” “no change,” “improved,” “much improved,” and “very much improved.” GAIS was measured for each treated area at baseline and during follow-up (14,30 and 180 days), with results compared to the baseline pretreatment photographs. 51/55 patients gave a GAIS score of very much improved and 4/55 gave a score of much improved.

Discussion Nasal fillers is an effective treatment option for patients seeking

nonsurgical nasal contouring and reshaping. It is also excellent for post rhinoplasty clients who seek minimal correction for residual deformities. But the author wants to caution and the need to know the

Adv Plast Reconstr Surg, 2019 Page 244 of 245

Sukhbir S. Injection Rhinoplasty in Indian Population: A Paradigm shift. Adv Plast Reconstr Surg, 2019; 3(1): 242-245.

References

9. Kim EG, Eom TK, Kang SJ. Severe visual loss and cerebral infarction after injection of hyaluronic acid gel. J Craniofac Surg. 2014; 25:684–686. [Crossref]

10. Kim YJ, Kim SS, Song WK, et al. Ocular ischemia with hypotony after injection of hyaluronic acid gel. Ophthal Plast Reconstr Surg. 2011; 27:e152– e155. [Crossref]

11. Fernandez EM, Mackley CL. Soft tissue augmentation: a review. J Drugs Dermatol.2006; 5:630– 641. [Crossref]

12. DeLorenzi C. Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 2014; 34:584–600. [Crossref]

13. Narins RS, Jewell M, Rubin M, et al. Clinical conference: management of rare events following dermal fillers–focal necrosis and angry red bumps. Dermatol Surg. 2006; 32:426–434. [Crossref]

14. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events andtreatment approaches. Clin Cosmet Investig Dermatol. 2013; 6:295–316. [Crossref]

15. Beleznay K, Humphrey S, Carruthers JD, et al. Vascular compromise from soft tissue augmentation: experience with 12 cases and recommendations for optimaloutcomes. J Clin Aesthet Dermatol. 2014; 7:37–43. [Crossref]

following cosmetic hyaluronic acid injection. JAMA Ophthalmol. 2013; 131:1234–1235. [Crossref]

He MS, Sheu MM, Huang ZL, et al. Sudden bilateral vision loss and brain infarction8.

1. Heden Per. Nasal Reshaping with Hyaluronic Acid: An alternative or complement to surgery. Plast Reconstr Surg Glob Open. 2006 Nov; 4(11):e1120. [Crossref]

2. Grunebaum LD, Bogdan Allemann I, Dayan S, et al. The risk of alar necrosisassociated with dermal filler injection. Dermatol Surg. 2009; 35:1635–1640. [Crossref]

3. Inoue K, Sato K, Matsumoto D, et al. Arterial embolization and skin necrosis of thenasal ala following injection of dermal fillers. Plast Reconstr Surg. 2008; 121:127e–128e. [Crossref]

4. Kim SG, Kim YJ, Lee SI, et al. Salvage of nasal skin in a case of venous compromise after hyaluronic acid filler injection using prostaglandin E. DermatolSurg. 2011; 37:1817–1819. [Crossref]

5. Menick FJ. Aesthetic and reconstructive rhinoplasty: a continuum. J Plast ReconstrAesthet Surg. 2012; 65:169–1174. [Crossref]

6. Sung HM, Suh IS, Lee HB, et al. Case reports of adipose-derived stem cell therapyfor nasal skin necrosis after filler injection. Arch Plast Surg. 2012; 39:51– 54. [Crossref]

7. Kim SN, Byun DS, Park JH, et al. Panophthalmoplegia and vision loss aftercosmetic nasal dorsum injection. J Clin Neurosci. 2014; 21:678–680. [Crossref]

Adv Plast Reconstr Surg, 2019 Page 245 of 245