The ENTific Centre
Rhinoplasties with injectable fillers are very popular in Asia and are used extensively. The advantages of injection rhinoplasty include:
Short learning curve for clinicians
Minimal tooling necessary
Local anesthetic procedure
Quick operative time
Per-operative client defined endpoint
Minimal postoperative downtime for patient
The idea of a simple local procedure with immediate results is very attractive to the Asian clients. Furthermore the down time is minimal; this minimizes the social exposure and questioning that some Asian clients may not welcome as plastic surgery on the nose remains a taboo in some Asian communities. The traditional injectables e.g. silicone gel and Teflon paste are generally falling out of favor due to their associated and recognized complications. The newer synthetic NASHA and PAAG injectables are increasingly being used. The skill-training time required for a clinician is very short and hence, many general practice clinicians have embraced this practice. Coupled with the marketing forces, this area of rhinoplasty has increased significantly.
The injection rhinoplasty technique depends primarily on:
- the desired aesthetic result and
- the injectable filler used.
It can be employed either as:
- a primary injection rhinoplasty procedure to augment the nose or
- as a secondary procedure to enhance a surgical rhinoplasty result (see Figures 3a-c)
- as a secondary procedure to "salvage" aesthetic complications of septoplasty or rhinoplasty (see Figures 4a-c)
After adequate local anesthesia (topical EMLA and infra-orbital nerve block) and antiseptic cleansing of the face, the injectable is delivered into the subdermis or deeper, to augment the radix, dorsum and tip accordingly. A primary advantage of this approach is that the client can view the surgery in progress to help the surgeon define his/her own aesthetic endpoint. There will undoubtedly be tissue edema associated with the injection, which may add to the augmentation inadvertently. Hence a review of the patient a week after the procedure would be wise for any further touch-ups as required.
In the authors 'opinion (GS & FW), we prefer to start by injecting onto the deep supraperiosteal plane with depots of filler to augment the nose and to raise the radix and dorsal profile. These depots of injection are kept in the desired augmented midline and paramedial injections are very judiciously taken to minimize the width of the augmentation. This is to ensure that the augmented soft tissue remains narrower in width. This is more in keeping with the usual Asian aesthetics of petiteness, and even whilst augmenting the nose, this illusion of petiteness is maintained. A judicious and smaller amount of subdermal injectable fills can then be added accordingly thereafter.
We preferred this in contrast to described subdermal fern leaf or reticular pattern injection techniques. These more superficial subdermal depot techniques would certainly create a stronger and more rigid soft tissue dorsum envelope. However it also adds to the nasal width which detracts from the Asian nasal concept of petiteness.
The surgeon and patient should also note that injection rhinoplasty techniques do not confer any functional advantage for the patient whatsoever as it does not inherently improve structural rigidity or structural width of the nasal framework. Furthermore as elastic tissue forces and gravity begin to exert their influence on these injected filler depots, the injected compartmentalized gel has to take on a more spherical shape to better resist these compressive forces. Hence from an aesthetic point of view, the result would be more an appearance of rounded fullness and rounded edges at these augmented areas. It would not be entirely possible to achieve a sharp and definable edge that would highlight the nasal contour as one can get from more rigid surgical implants e.g. ePTFE (Gore-Tex) or porous polyethylene (Medpor) implants.
Whilst simple, injection rhinoplasty is not without its risks. These include:
- Soft tissue infection
- Soft tissue necrosis
- Hypersensitivity reaction to the specified injectable filler
- Capsule formation
- Granuloma formation
- Ocular complications
- Complicated surgical revisions due to deep fibrosis
Management of these complications would include removal of the injectable filler, antibiotic therapy and supportive treatment as necessary. The removal of these fillers is not simple. The injectable depots would be intimately distributed in the fibrous tissue of the nose and surrounded by inflamed scar tissue. Complete removal is preferred in any complicated injection rhinoplasty and an open approach rhinoplasty may be deemed necessary to facilitate this.
Choice of injectable
There are many available injectable fillers on the market and can be broadly considered under the following category:
Autologous injectables e.g. autologous fat
Reversible NASHA injectables e.g. Restylane, Juvederm
Permanent injectables e.g. Teflon paste, silicone gel, PAAG
Autologous fat is naturally preferred but the unpredictability of fat globule survival rates and donor site morbidity remain issues for the patient. Autologous fat harvesting, whilst relatively simple with specialized harvesting needles and centrifuge, adds to the cost of the procedure which may be prohibitive in some Asian clinical settings.
Permanent injectables are often preferred by patients who select injection rhinoplasty as their choice of treatment. This obviates the need for repeat injections every nine to twelve months. From a point of view of complications, all synthetic injectables carry similar risks of infection with more specified hypersensitivity and granuloma formation specific to the product used.
In the authors' opinion (GS, FW), reversible injectables should not be disregarded. Their advantage lies in their reversibility and can be outlined as below:
- A reversible injectable is a good first line rhinoplasty trial that helps the patient to ultimately understand what they want and the personal and social implications of their facial enhancement trial. This is true even when simulated postoperative pictures have been employed in the counseling process. For the next treatment session, they can then deliberately choose to use a second permanent injectable, to convert to a surgical implant approach or not to undertake any future rhinoplasties.
- An unsatisfactory aesthetic result or over-injection will not last
- An overenthusiastic young client, eager for a rhinoplasty, will not have cause to regret for a lifetime if a reversible injectable is offered as the first injectable line of filler
- If there are signs of sluggish / lack of capillary refill due to inadvertent over-injection of NASHA, impending dermal and soft tissue necrosis is a risk. Especially prevalent areas are the nasal tip and areas of thin skin. Immediate aspiration removal of the NASHA with injection of hyaluronidase can be implemented.
The caveat to injection rhinoplasty is that some subdermal scarring will invariably occur in the injected tissue planes. This can complicate future rhinoplasty surgery and make them unpredictable and more difficult to do. Clients should be advised accordingly.
Silicone implants have been traditionally used to augment Asian noses. They remain in use today as these implants are relatively inexpensive. Silicone nasal implants are available as:
Free-form silicone implants (carved from silicone blocks by the surgeon)
Pre-formed silicone implants
These implants (see Figure 5) are shaped either as L-shaped struts (which provide for dorsal height, more tip projection and caudal septal extension) or as I implants (which provide primarily for dorsal height augmentation and some tip projection) as in Figure 6.
Silicone implant surgery is usually performed under local anesthesia. Depending on the implant type and the aesthetic outcome, these implants can be inserted through a marginal or rim incision. These implants are then placed into a pocket made just superficial to the dorsal nasal framework. For the L-strut implants, a pocket just caudal to the caudal septum is also fashioned for the shorter component of the L strut (see Figure 7). An intercartilaginous incision can also be used with a retrograde approach to establish any caudal septal pocket as necessary.
Pre-formed implants have a beautifully carved and smooth surface finish, and are the ideal silicone implants. In Asia where clients are price-sensitive, free-form silicone implants are more economical. Free-form silicone implant surgeons should be careful to ensure a smoothly carved implant especially for clients with thinner skin of the nasal dorsum (see Figure 8). This guarantees that silicone surface irregularities do not show nor are they easily palpable.
Implant infection and extrusion rates are well reported in the literature (Pak, Tham). Longer term extrusion of silicone implants can be minimized by ensuring adequate soft tissue coverage of the implants and implant placement with minimal soft tissue tension.