Medical Aesthetic Rhinoplasty—Liquid Rhinoplasty

Introduction

Liquid rhinoplasty is a modern term used to describe the use of hyaluronic acid fillers to augment, contour, and reshape the external appearance of the nose. The types of defects involving a clinical problem and anticipated outcomes are described in Table 56.1 .

Case Reports

See Figs. 56.1–56.8 .

Background

Surgery remains the principle means by which to alter the shape of nose; however, the use of injectables to the nose (medical aesthetics) has come a long way since the era of using liquid silicone with its attendant problems of granuloma formation, silicone blocks with high risk of displacement, and coral derivates with the potential to resorb, in the 1960s and 70s. It is now common to use hyaluronic acid (HA) as the primary injectable filler to the nose, despite its limited longevity, and to use Botulinum toxin for excessively flaring nostrils, “bunny” lines, and glabella creases. Although contoured autologous cartilage grafts, silicone struts, and bone grafts are still the mainstay to surgically improve the congenital, ethnic, or traumatized nose, patients are becoming more savvy, and if an immediate and significant improvement can be achieved that could last for 2 years, a significant number will jump at the opportunity to avoid the expense, risks, and downtime associated with major surgery. HA injectables can complement treatment from surgical rhinoplasty. The ability to quickly and effectively improve an unwanted shape or postoperative filling defect should appeal to all and avoids the potential for disaster in the event of secondary rhinoplasty. The twenty-fold reduction in expense using HAs compared with surgical rhinoplasty is also appealing, especially to those not wanting a major change to the appearance of their noses.

The results from injecting HA can almost be predicted preinjection using smart phone apps that are currently available, which means that the patient can participate in deciding their immediate outcome. However, the oVio 360-degree camera (oVio Technologies, Implicitcare LLC, Newport Beach, California) is also an exceedingly useful tool in preoperative assessment, planning, and measuring outcomes and satisfaction scores ( Video 56.1 ).

Video 56.1 oVio 360-degree videos showing the value of good pre- and postoperative imagery in determining outcome in a patient. Identifying every patient’s individual problem, treating, and confirming a satisfactory outcome is also important for the clinician’s own appraisal process.

The volume of HA injected into nose will rarely exceed 1 mL, and nearly always is measured in the 0.1 to 0.2 mL bracket. The temptation to over-inject HA must be resisted because, although easily reversed with Hyalase, the reversal is uncomfortable, is an all-or-nothing effect, and may actually totally remove the HA, recreating the original defect. It is far better to inject the perceived correct amount initially and then add in more, if required, after a few weeks. The smaller the HA particle size within the filler, the shorter is its half-life, so if possible, the filler used for nasal contour must be of a thicker particle size for longevity of results. Juvederm 4 (Allergan, Irvine, CA) is the filler of choice for improving subcutaneous nasal contour defects, because it lasts for at least 2 years and subjectively, may actually have even more longevity. This anecdote presumes release of the tissues during the “hydrostatic” dissection of the injectate and the molded HA contributing, as a replaceable matrix, to a more permanent residual layer of autologous fibroblast activity and collagen, as the HA actually dissolves.

The initial results from HA injection are immediate and are generally well accepted, but swelling will disguise the true outcome over the first 72 hours. Swelling completely settles at about 2 weeks postinjection. No reversal should be entertained before the 2-week postinjection period has elapsed. No preinjection allergen testing is required and although there is risk of sepsis in the sebaceous thick-skinned nose, it is a rare event. Contraindications can include skin sensitivity to the local anesthetic agent contained in Juvederm. Topical antiseptics and antimicrobial soaps are all that are usually required for the “at risk of infection” nose in the pre-and postinjection period. Antibiotics are rarely indicated.

Injecting HA