In Amerika wordt gewaarschuwd voor een praktijk die in Europa niet ongewoon is. Bij nogal afwijkende neusvormen wordt de neus op ons continent blijkbaar niet alleen chirurgisch in model gezet, er kunnen ook permanente fillers aan te pas komen, zoals Radiesse en Artecoll om de neusvorm verder te verfraaien. Deze fillers kunnen in de huid nogal wat problemen (bobbels en celdood) geven, waardoor wederom een operatie nodig is om de boel te herstellen, en dat gaat dus juist vaak niet, omdat die permanente fillers heel moeilijk uit de huid te halen zijn, en al zeker niet zonder littekens en dan weer een plastisch chirurgische operatie, zo stellen artsen. Lees er hierondr meer over…
Overgenomen van de website Cosmetic medicine:
Surgical expert warns against 'nonsurgical' rhinoplasty without further research
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 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.
 Figure 1. A. Injectable filler material embedded in the dermis of the skin. B. Filler is removed, trying to avoid damaging the skin. C. Some surrounding soft tissue is removed with the material, which thins the skin. D. Most of the material is removed. |
SIGNIFICANT RISK The patient shown in Figure 1 underwent a rhinoplasty but had a persistently deviated nose. To compensate for this, the surgeon injected Radiesse into the depression in his nose to create a straighter appearance. The patient then came to our office seeking secondary rhinoplasty. The patient stated that his surgeon told him that he had only injected 0.2 cc of Radiesse and that it was likely completely resorbed. At the time of his revision surgery, his nose was full of very gritty material that damaged his skin and made the reconstruction significantly more difficult. The surgeon injected the material too superficially (into the dermis). A large amount of this material was removed, and all that remained was a severely thinned skin envelope (Figure 1). As a result, performing secondary rhinoplasty put this patient at risk for skin necrosis. Fortunately, the skin was not compromised, and he is healing uneventfully. However, if we had known there was going to be that much Radiesse in his nose, we would have denied him surgery due to the significant risk involved.
 Figure 2. A. Scarring of nasal skin is noted where filler was injected. B. Filler was removed leaving thinned skin in the area of resection. Note the blue hue to the skin. |
Because some of these fillers have been available in Europe and Canada prior to their introduction in the United States, we have seen these problems in our international patients for quite some time. Many of these patients had devastating deformities that could only be corrected by performing procedures that risk skin necrosis, scarring, deformity and infection.
 Figure 3. After a difficult two-stage operation with structural grafting, the patient did well. Preoperative views: A, C and E. One year postoperative views: B, D, and F. |
The patient shown in Figures 2 and 3 underwent treatment with a permanent injectable filler to correct a defect in her nose. The surgeon injected the material too superficially, resulting in scarring of the dermis. This resulted in chronic infections and severe scarring. We performed a two-stage secondary rhinoplasty to correct her problems. In the first stage, we used an open rhinoplasty approach and removed as much of the filler as possible without exposing her to even more risk of tissue compromise (Figure 2). At the conclusion of the case, the skin overlying the filler was very thin and blue indicating a compromised vascular supply. Although her skin survived, she had persistent erythema at the surgical site. In the second stage, which was performed over a year later, we performed a reconstructive rhinoplasty with costal cartilage grafting to regain appropriate contour. Two years after surgery, she has a natural-looking result but still has some scarring where the filler was removed (Figure 3).
We have shown two patients who have done well after undergoing removal of inappropriately placed injectable fillers. 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 is more likely to be successful. However, correction is much more complicated in patients in whom the filler was injected superficially because the skin often is adherent to the filler. In these patients, surgical correction is very risky, and the patients may be left with chronically damaged skin and scarring.
EVIDENCE-BASED RESEARCH NEEDED There is an urgent need for scientifically sound research that demonstrates the safety and efficacy of these materials in the nose. Scientific study may show that these fillers, when placed deeply against the bone and cartilage, are safe when used in the nose. Until then, it is prudent to use restraint when modifying the nose using unproven methods. A deformity in the nose can negatively influence the overall facial appearance and may result in a permanent deformity.
Dean M. Toriumi, M.D., is a professor in the Department of Otolaryngology – Head and Neck Surgery, and head of the Division of Facial Plastic & Reconstructive Surgery at the University of Illinois at Chicago.
A board-certified facial plastic surgeon specializing in rhinoplasty, blepharoplasty, rhytidectomy and several other cosmetic and reconstructive surgical procedures of the head and neck, he completed a five-year residency training program in Otolaryngology – Head and Neck Surgery at Northwestern University Medical School and has also completed two fellowships in facial plastic and reconstructive surgery.
He is a Past President of the American Academy of Facial Plastic and Reconstructive Surgery. Dr. Toriumi's primary interest is in aesthetic and functional rhinoplasty.
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