Understanding Filler Implications for Rhinoplasty

By Mr Dario Rochira / 09 Apr 2020

Plastic surgeon Mr Dario Rochira explains why dermal fillers can be contraindicated for closed preservation rhinoplasty and how practitioners can work together to ensure best patient outcomes

Dermal fillers are widely used for non-surgical nose reshaping. Often, patients will present to clinic for this treatment because they are not ready for surgical interventions, are not suitable candidates for surgery, or, commonly, because they are interested in surgery, but want to try something more temporary first to see how they might feel about a more permanent solution.

There are many complications that can arise with non-surgical nose reshaping using filler, which include, but are not limited to, skin necrosis and blindness.1,2 However, dermal fillers can also be responsible for a different complication if they are injected up to a year before the patient undergoes rhinoplasty. This is particularly so if the closed preservation rhinoplasty technique is used, which is what I focus this article on.3

I will explain why dermal fillers are contraindicated for closed preservation rhinoplasty, and how non-surgical aesthetic practitioners can work together with surgeons to ensure maximum patient care and successful outcomes.

Understanding closed preservation rhinoplasty

Closed preservation rhinoplasty is a newer form of surgical rhinoplasty that preserves the structural and functional integrity of the tissues within the nose, including the cartilages, muscles, ligaments and bones. This technique preserves the septum, unlike traditional rhinoplasty, which involves excision and removal of the septum and reconstruction using bone and cartilage.

The reason why many patients opt for this is because the procedure is less invasive, less traumatic, has reduced bruising and swelling and results in less recovery time with more predictable results than traditional rhinoplasty. It also has a lower rate of revision surgery. The benefits of closed preservation rhinoplasty over the traditional forms of rhinoplasty is a reduced risk in complications, is a little less aggressive and produces more predictable results than traditional approaches.3,4,5

The basis and rationale of this technique comes from recent anatomical findings that relate the nasal anatomy to nasal aesthetics and surgical techniques.3,5 The most important and revolutionary finding is that the key-stone area (the junction between nasal bones and cartilages on the dorsum) is a semi-mobile chondrosseous joint, which can be converted from convex to straight by resecting its underlying cartilaginous support (Figure 1).3,5

Figure 1: The key-stone area is the junction between the bony vault and the cartilaginous vault of the dorsum (yellow circle).4 Image courtesy of Mr Dario Rochira.

I have found that the endonasal approach (without any skin incision) is the best method, as the tip can also be reshaped from the inside leading to a less traumatic and less invasive operation, resulting in more controlled and predictable results.4,5

A further study conducted by Cakir et al. has demonstrated that a closed approach to the subperichondrial and subperiosteal dissection is associated with less swelling and bruising, preserving sensitivity and resulting in faster recovery.6

Why dermal fillers are contraindicated

It is my experience that hyaluronic acid fillers injected into the nose last considerably longer than when they are injected in other areas of the face.7

Most practitioners inject the filler to the radix area (just below the glabella) in a deep plane, which is the layer just above the periosteum (sub-SMAS layer).

This is important because when closed preservation rhinoplasty is performed, the dissection at the radix is carried out in the subperiosteal plane. As a result, any filler previously injected into this area may not be inspected or possible to remove.

While it is relatively easy for a surgeon to remove any filler from the tip area as it is closer to the incision (Figure 2), it is a big challenge, if not impossible, to remove any filler from the radix area, particularly in a closed approach.

Figure 2:  Surgical removal of HA-based filler injected into the tip 13 months before surgery.


The open approach (skin incision and elevation) may offer better visibility of the radix, however the removal of the filler is still a big challenge due to the thin skin of this area, resulting in potential skin irregularities or skin necrosis when removing the filler.

This can create a poor aesthetic result following surgery. The patient may have a straight dorsum immediately after surgery, but over time, the previously injected filler will be absorbed, creating a residual hump or very deep and low radix (Figure 3).

Figure 3: Patient presents with a dorsal hump and asks for a non-surgical nose-reshaping to make the dorsum straight-looking (A). Filler in injected to the radix (B). Closed preservation rhinoplasty is performed without dissolving the filler previously injected and not seen during surgery (C). Hump ‘recurrence’ after the filler is absorbed over time (D).4 Images courtesy of Mr Dario Rochira.


Therefore, if this type of operation is scheduled within a year (or the patient has indicated that they are interested in surgical interventions), the injection of filler to the radix should be avoided.8 Alternatively, the filler should be dissolved using hyaluronidase one month before the surgery. It is most surgeons’ opinion that this hyaluronidase procedure should be carried out by the treating aesthetic practitioner as they know what and where the filler was injected, which should produce the best outcome for the patient.

Recommendations

As mentioned, patients often present to non-surgical aesthetic professionals to address shape concerns with their nose as a trial before surgical interventions. With this in mind, I believe that practitioners should be asking patients if their intention is to undergo surgery at a later date. Practitioners then have a responsibility to educate the patient that closed preservation rhinoplasty should be no less than one year after the filler is injected, or one month after the filler has been dissolved with hyaluronidase.

In the ideal scenario, non-surgical aesthetic practitioners should also make the patient’s records available to the treating surgeon. The records should include detailed treatment notes on type of filler used, injection plane and technique, amount of filler injected and treated areas, date and signature, as well as before and after images. The surgeon can then make a full, accurate assessment of the native nasal anatomy of the patient and plan the surgical steps accordingly.

It should be noted that, in my experience, it is very common for patients not to even remember the name of their previous practitioners; perhaps the procedure was performed abroad, they simply don’t want to give details or don’t want me to contact the practitioner. I have also previously written to the practitioners, but without answer. A good relationship and communication between the surgeon and the aesthetic practitioner is always encouraged.

A further recommendation is that more studies are still needed to establish guidelines on the best time frame between filler injections and rhinoplasty, especially given the wide range of different fillers currently on the market. 


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