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Dean Toriumi, M.D.


Emerging Issues In Rhinoplasty

 
Nasal Injectable Fillers Causing Damage
 
There is a new phenomenon developing in rhinoplasty. Many patients are getting injectable filler materials injected into their noses. This is creating an entirely new set of problems for rhinoplasty patients. I am seeing many of these patients in my office with devastating problems. Patients are presenting with such complications as chronic infection, pain, persistent redness and swelling, and even permanent skin damage. Many of these patients are not able to undergo corrective surgery because their skin is damaged so severely that surgical correction would risk severe deformity or skin necrosis/loss.

There are numerous new injectable filler materials available for use in the United States. Restylane and Juvederm are hyaluronic acid derivatives and provide temporary contour changes. The hyaluronic acid filler materials last for approximately 6 months before dissolving away. Many surgeons feel this material is safe as it is not permanent, will go away, and not cause long term problems. Unfortunately, this is not always the case. Patients with thin skin are at much higher risk for problems associated with injectable filler materials. I have seen several patients who underwent Restylane injections by their surgeon and subsequently developed infections that permanently damaged the skin envelope of their nose. These problems occurred in patients who already had a thin compromised skin envelope or had an artificial implant in their nose.

If a patient has a minor irregularity and would like a temporary correction, Restylane or Juvederm is a reasonably safe option as it will eventually resorb and go away if injected correctly. The person who performs the injection must be cautious to inject deeply against the bone or cartilage and avoid injecting into the dermal layer, as this can permanently damage the skin envelope. If the patient undergoes secondary rhinoplasty before the material resorbs, the reconstruction will be more complicated and postoperative irregularities are more likely.

When I perform secondary rhinoplasty, I try to create a smooth cartilage and bone structure under the skin envelope. If the skin envelope is smooth and uniform, then the patient will likely have a good outcome with a smooth nose. If the nasal structure is smooth but the overlying skin envelope is irregular, the nose will be irregular. Filler materials can create this type of bumpy skin envelope that makes it more likely that the patient will have an irregular nose even though I may have performed a near perfect reconstruction of the nasal structure. By using cartilage grafts, we can do amazing things with reshaping the nose as long as the skin envelope is in good condition. Presence of an irregular skin envelope makes corrective surgery exponentially more difficult and in some cases makes getting a good outcome unlikely. Secondary rhinoplasty is hard enough without having to deal with these added variables.

There are also a new group of semi-permanent and permanent injectable filler materials such as Radiesse and ArteFill. Radiesse is hydroxyapatite particles suspended in a gel and lasts two years or more. ArteFill is polymethylmethacrylate beads in a collagen suspension that is permanent. Most who use these materials state that if injected deeply below the skin there is little risk to the patient. The problem with both of these materials is that they last for a long period of time and if injected more superficially, there will likely be permanent changes to the skin envelope. Surgical removal of these materials when placed superficially is very difficult and puts the patient at high risk for permanent skin damage or necrosis. One option is to leave the injectable filler material in the nose to avoid the risk of skin necrosis. The problem with leaving the injectable in the skin is that the skin envelope may be bumpy, resulting in multiple irregularities even after revision surgery. Another potential problem is that the filler material may eventually resorb, leaving the patient with a depression that has nothing to do with the reconstruction. The bottom line is that the presence of an injectable filler material creates numerous variables in the surgery that makes getting a good outcome much more difficult. These patients will be forced to accept multiple irregularities if they choose to undergo surgical correction.

The patient shown below underwent a rhinoplasty and was left with a deviated nose. The surgeon injected Radiesse into the depression in his nose to create a straighter appearance. The patient then came to see me for secondary rhinoplasty. His surgeon told him that he had only injected 0.2 cc of the material and the Radiesse was likely gone. When I performed his revision surgery, his nose was full of this very gritty material that damaged his skin envelope and made the reconstruction exponentially more difficult. The surgeon injected the material in a more superficial layer of the skin envelope. I removed a large amount of this material that left a severely thinned skin envelope. I put this patient at risk for skin necrosis at the site that I removed the Radiesse. Fortunately, the skin did not necrose, and he is healing nicely. However, if I knew there was going to be that much Radiesse in his nose, I would have denied him surgery due to high risk for skin necrosis.

 

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Some of these filler materials have been available in Europe and Canada for many years. I have been treating patients from Europe and Canada with problems from injectable fillers for several years. Many of these patients had devastating problems that could only be corrected by performing procedures that risk skin necrosis, scarring, deformity and infection.

The patient shown below underwent treatment with a permanent injectable filler material to fill a defect in her nose. The surgeon injected the material in a superficial layer of her skin resulting in scarring of the dermal layer. She was having chronic infections and severe scarring from the injectable filler material. I performed a two stage secondary rhinoplasty to correct her problems. In the first stage I performed an open rhinoplasty approach and removed as much of the filler material that I could do safely. Her skin at the site of the resected filler material was very thin and blue indicating a compromised vascular supply. Fortunately she did not necrose her skin, but she did have long term redness in the skin at that site. In the second stage, I performed a reconstructive rhinoplasty with costal cartilage grafting. Two years after surgery, she is finally looking relatively good but still has some scarring at the site of the resection of the filler material.

 

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I have shown two patients who have done well after undergoing resection of injectable filler materials. I have not had any skin necrosis in my patients because I am very careful when I remove the filler materials. Additionally, I am not operating on most of these patients with filler materials in their nose. If the filler was injected deeply and the skin moves freely over the site of the filler material, then surgical correction is much safer and can be very successful. I am turning away patients who underwent superficial injections with the skin adherent to the filler material and telling them that correction is too risky. These patients are left with the consequences of having a damaging filler material reside in their nose.

The most concerning phenomenon is that many dermatologists, generalists and surgeons are performing non-surgical rhinoplasties. In these cases, semi-permanent or permanent injectable filler materials are being injected into the nose to make long lasting contour changes. Some of those who are performing the injections are not rhinoplasty surgeons and may have little if any understanding of the nasal anatomy and nasal aesthetics. I have seen many patients treated by such physicians with severe nasal skin envelope problems such as infection, swelling, pain, permanent redness and deformity. Unfortunately, many of these patients cannot be helped because correction of the problem requires resection of the filler material. Resection puts these patients at severe risk of permanent skin damage in the form of intense redness or skin necrosis, leaving a hole in their nose. Additionally, we do not know the long term effects of such materials on the nasal skin envelope.

There is an intense need for scientifically sound research that demonstrates the safety and efficacy of these materials in the nose. Scientific research may show that these filler materials when placed deeply against the bone and cartilage are safe when used in the nose. The nose is a very important structure of the face that greatly influences the overall facial appearance. Caution should be taken when doing anything that could potentially damage the nose and leave the patient with a permanent deformity.

 

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