Journal of Clinical and Aesthetic Dermatology

APR 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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40 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY April 2018 • Volume 11 • Number 4 R E V I E W for a successful procedure. Although there is no definitive evidence for an ideal filler for use in the nasal region, hyaluronic acid has been increasingly used due to its longevity and rheological properties compared to other fillers. 1 In our experience, hyaluronic acid is safe when the minimum quantity of the product needed for the patient is injected with a blunt-tip cannula. As opposed to a surgical procedure, we have the ability to perform nonsurgical rhinoplasty as many times as necessary due to the absorbability of hyaluronic acid. In secondary rhinomodulations, hyaluronic acid injection should be done with caution and following a clinical evaluation that considers tissue distensibility and structural architecture. If tissue distensibility and structural architecture are greatly altered, it is not advisable to continue with the remodeling. Although these components are generally not significantly altered, the injection should still be done carefully and with the minimum quantity of the product due to the distortion of the local anatomy after the surgical rhinoplasty. Corrections that aim to reduce bone, cartilaginous, or soft tissue structures are not possible with this method. In addition, it should be noted that nasal remodeling using hyaluronic acid will increase the structures and proportions due to the volumizing effect of the fillers. Ideal nose shapes. The measurements of an ideal nose have been recorded since antiquity. Despite the variations over time, the mathematics and the way of calculating the ideal nose shape have not changed —only the standards of beauty. For the Greeks, a high radix is seen as beautiful, while among Brazilians, a low radix is the ideal profile. 6 Procedural categories. Use of hyaluronic acid for nonsurgical rhinoplasty filling can be broadly divided based on three indications: dorsum enlargement, dorsum correction, or tip projection. 7 The increase of the dorsum is indicated in patients who have a concave dorsum with a hump, producing an unrectified dorsum. Increasing the nasal tip is indicated in cases requiring the correction of bifid tips or for local projection. The filling of the collumellar-labial angle is indicated in cases of low or fallen nasal tip, short columella, or bulging nasal dorsum. This procedure is equivalent to the insertion of a columellar structure in surgical rhinoplasty. 1 Recognizing complications. The recognition of ischemia, the most dangerous complication, is critical. Signs of pallor, livedo, and/or local pain during or immediately after the procedure should be treated immediately with the application of hyaluronidase. When performing the procedure, all structures of the nose—including the thicknesses and properties of the skin and soft tissue and the size, shape, and strength of the cartilage and bone—should be taken into account in order to avoid complications. CONCLUSION Nonsurgical rhinoplasty requires further study in order to determine its safety and efficacy. 8 The nose is a region of complex anatomy, comprising several different tissues, and the use of hyaluronic acid in this area requires expert practice and technique. For this reason, careful evaluation of the nasal surgery site, with measurements of the ideal nasal proportions, is fundamental to ensure optimal and safe use of the filler. The use of hyaluronic acid can either be used as a concomitant or alternative procedure to rhinoplasty, and is emerging as an effective solution for minor corrections. This technique for minor corrections might improve patient satisfaction because immediate results can be seen following the procedure. The clinician must always consider not only the risk of complications, but also the severity of potential complications, and carefully weigh the aesthetic benefits of nasal injectables against any potentially devastating risks. REFERENCES 1. Daher JC. Columellar rhinoplasty: a new vision with the use of solid silicone. Rev Bras Cir Plást (Impr). 2010;25(3):450–457. Article in Portuguese. 2. Furtado IR. Nasal morphology - harmony and proportion applied to rhinoplasty. Rev Bras Cir Plást. 2016;31(4):599–608. Article in Portuguese. 3. Augusto GG, Shiro T, Serra GG, et al. Aesthetic comparison of the ideal nasal radix height in a Brazilian population. Braz J Otorhinolaryngol. (Impr). 2011;77(3):334–340. Article in Portuguese. 4. Neligan PC. Analysis and nasal anatomy. Plastic Surgery. Philadelphia, PA: Elsevier; 2012: 373–386. 5. Aston SJ, Steinbrech DS, Walden JL. Aesthetic Plastic Surgery. Philadelphia, PA:Elsevier;2012:437. 6. Augusto GG, Shiro T, Serra GG, et al. Aesthetic comparison of the ideal nasal radix height in a Brazilian population. Braz J Otorhinolaryngol (Impr). 2011;77(3):334–340. 7. Youn SH, Seo KK. Rhinoplasty evaluated by anthropometric analysis. Dermatol Surg. 2016;42(9):1071–1081. 8. Wang LL, Friedman O. Update on injectables in the nose. Curr Opin Otolaryngol Head Neck Surg. 2017;25(4): 307–313. JCAD

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