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Injection rejection

Article-Injection rejection

Key iconKey Points

  • A growing number of surgeons are injecting filler materials into patients' noses
  • This practice may result in complications that permanently damage the nasal skin

Dr. Toriumi
There is a potentially hazardous new practice evolving in rhinoplasty: a growing number of surgeons are injecting filler materials into patients' noses. Unfortunately, this may result in complications that permanently damage the nasal skin. Some of these patients present with problems such as chronic infection, pain, persistent redness, swelling and even permanent skin damage. A distressingly large number of these patients are unsuitable for surgery because the nasal skin is so damaged that surgical correction would risk severe deformity or skin necrosis. The most concerning phenomenon is that many generalists and surgeons are performing "nonsurgical" rhinoplasties. In these cases, semi-permanent or permanent injectable fillers are 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. The temptation of being able to perform a "nonsurgical" rhinoplasty may make this a more frequent occurrence and compromise the patient's ability to undergo rhinoplasty in the future. One can foresee a scenario in which patients who underwent a "nonsurgical" rhinoplasty may need to undergo complex reconstructive surgery to correct problems directly related to the filler injected into their nose.

INJECTION ISSUES There is a rapidly growing selection of injectable filler materials available in the U.S. Restylane and Juvéderm are hyaluronic acid derivatives and provide temporary contour changes, lasting approximately six months before resorbing. Many surgeons feel that this material is safe because, in other areas of the face, it is not permanent and has not been correlated with long-term problems. Unfortunately, in the nose, this does not appear to be the case. I have seen several patients who underwent Restylane injections and subsequently developed infections that permanently damaged the nasal skin envelope. These problems are more likely to occur in patients who underwent previous rhinoplasty, have a thin, compromised skin envelope, or have an alloplastic implant, such as MedPor or silicone, in their noses.

If a patient with healthy skin has a minor irregularity, Restylane and Juvéderm are reasonably safe options, as they will eventually resorb if injected correctly. However, the patient must understand that this correction is temporary, and the person who performs the injection must be careful to inject deeply against the bone or cartilage and avoid placing the filler in the dermis, as this can permanently damage the nasal skin. If the patient chooses to undergo secondary rhinoplasty before the material resorbs, the reconstruction will be more complicated and post-operative irregularities are more likely.

When performing secondary rhinoplasty, we try to create a smooth cartilage and bone structure. If the skin envelope is smooth and uniform, then the patient will likely have a smooth nasal contour. Conversely, if the nasal structure is smooth and uniform but the overlying skin envelope is irregular, the nose will likely be irregular. Improper injection of fillers can create a bumpy skin envelope, which increases the likelihood that the patient will have an irregular contour despite a proper reconstruction of the nasal framework. By using cartilage grafts, we can predictably reshape the nose only if the skin 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 complex enough without having to deal with these added variables.

Unlike their hyaluronic acid counterparts, Radiesse and ArteFill are much longer-lasting filler materials. Radiesse is composed of hydroxyapatite particles suspended in gel and can last two years or more. ArteFill is polymethylmethacrylate beads in a collagen suspension and is permanent. Many surgeons 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 too superficially, can result in permanent changes to the skin. Surgical removal of these materials is very difficult and puts the patient at high risk for permanent skin damage. One option is to leave the filler in the nose to avoid the risk of skin necrosis and proceed with the rhinoplasty. If the filler used is semi-permanent and surgery is undertaken before resorption is complete, this may ultimately leave the patient with a depression that had nothing to do with the reconstruction. Injectable fillers in the nose create so many variables that getting a good surgical outcome is much more difficult. These patients must accept multiple irregularities if they choose to undergo surgical correction.

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