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10/24/2011
Injectables serve as nonsurgical option for beautifying the nose
Injectables do not replace rhinoplasty, but they offer a viable alternative for those interested in nasal reshaping who are unwilling to undergo surgery, say Vince Bertucci, M.D., and Jean-Franois Tremblay, M.D.
Injectables serve as nonsurgical option for beautifying the nose

Fillers can address minor nose deformities
Exam should be performed from frontal view, laterally and from basal view
Ideal patient for nasal reshaping with filler has thicker skin to help conceal injected material
International report Injectables do not replace rhinoplasty, but they offer a viable alternative for those interested in nasal reshaping who are unwilling to undergo surgery, say Vince Bertucci, M.D., and Jean-Franois Tremblay, M.D.


Dr. Bertucci

"With careful patient selection and proper technique incorporating knowledge of anatomy, treatment with fillers or botulinum toxin can produce satisfying aesthetic results with acceptable safety and less downtime and cost than rhinoplasty," says Dr. Bertucci, consultant dermatologist, Women's College Hospital, Toronto, and medical director, Bertucci MedSpa, Woodbridge, Ontario.

Indications, evaluation


Nonsurgical nose reshaping with fillers can address minor deformities, including insufficient projection of the nasal tip, flattening of the nasal root, humps and bumps, and concavities, but it cannot correct more significant bony and cartilaginous abnormalities. Injections of botulinum toxin can help to minimize the appearance of nasal expression lines such as transverse rhytids between the brows and nasal "bunny lines," as well as to reduce alar flare and nasal tip droop.

Dr. Tremblay describes a systematic approach for assessing patients seeking nasal reshaping with injectables. The first step involves asking patients what bothers them so that the physician can understand their dislikes and expectations.


Dr. Tremblay

"Letting patients talk for a few minutes will give you a perception of their notion of an ideal nose and help to identify whether they have body dysmorphic thoughts. Among patients having body dysmorphic issues, the rate of cosmetic complaints about the nose is higher than for any other part of the anatomy," says Dr. Tremblay, associate professor of dermatology, University of Montreal, Quebec, and medical director, MdIME Aesthetic Clinique, Montreal.

The next step is to get an overall picture of the nose in terms of obvious irregularities, skin quality, color and thickness, and general shape, including asymmetry issues, size and concordance with the rest of the facial features.

"The ideal nose cannot be defined for any given individual without taking into consideration the rest of the facial features. The nose should be well-balanced and harmonious with the rest of the face, but the perception of the ideal nose also depends on gender, and there are cultural variations," Dr. Tremblay says.

An examination should be done from a frontal view; laterally to assess projection; and from a basal view that helps to understand facial anomalies underlying the features requiring correction.

Next, physicians should validate their first impressions against aesthetic standards for various parameters, including the size of the nose relative to the rest of the face, the alar and bony base widths, amount of columellar show, the relationship of the lips to the nasomental line and the sizes of the mentocervical, nasofrontal and nasolabial angles.
Selection issues

Dr. Bertucci says hyaluronic acid (HA) products and calcium hydroxylapatite (CaHA; Radiesse, Merz) are the most commonly used fillers in the nose. With the HAs, there is the advantage of reversibility and the opportunity to select from a variety of products with different rheologic properties.

"For example, one of the more fluid HA products (Juvderm, Allergan; Restylane, Medicis) may be used for correcting a supratip structural deficiency," Dr. Tremblay says.


Adds Dr. Bertucci, "For nasal root augmentation, a more viscous product such as Perlane (Medicis) might be used."

CaHA may offer greater longevity and is potentially associated with less edema because it is not hydrophilic but it is not reversible.

"Considering the swelling that occurs after an HA injection, be conservative initially with the amount of filler used and plan to re-evaluate the patient after edema has subsided to determine if further touch-up is necessary," Dr. Tremblay says.

Novices to fillers for nasal reshaping should also choose patients without a history of rhinoplasty, as alterations in cartilage, bone, soft tissue and vasculature after that surgery may increase the risk of an ischemic event with filler injection.

In addition, the ideal patient for nasal reshaping with a filler will have thicker skin that will provide better concealment of the injected material. The thickness of the nasal skin varies, however, in different areas of the nose as well as between individuals. In general, the skin is thinner in the mid-nose and thicker in the proximal and distal portions, so that injections into the mid-nose require particular care with technique.

Dr. Bertucci advocates a conservative injection technique when first treating a patient, with a total volume of up to approximately 0.5 mL. He also stresses the importance of immediate manipulation to mold the filler to the desired shape and position.

"Be sure you massage well after the injection to avoid focal protrusions or nodules," he says.

Complications

Aside from cosmetic issues arising from improper injection technique and typical injection-related sequelae (pain, redness, bleeding, ecchymosis, hematoma), filler injections can potentially result in more serious complications, including ischemia, necrosis or embolization from inadvertent intravascular injection, as well as biofilm formation and infection.

Risks of necrosis and embolization are highest when injecting in the glabellar region and less when treating over the nasal dorsum and sidewall, Dr. Bertucci says.

"Know the anatomic danger zones, consider aspirating before injecting, don't overfill so as to avoid external vascular compression, and consider use of HAs which are reversible but also make sure to have a protocol ready for treating HA-induced ischemia," he says.

Other considerations for preventing complications and achieving good results include injecting slowly while watching for blanching and proper placement, as well as molding after injection to create a smooth appearance and avoiding overcorrection.

Disclosures: Dr. Bertucci has been a consultant and investigator for Allergan, Medicis and Merz. Dr. Tremblay reports no relevant financial interests

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