It can take months—and sometimes years—for nasal-tip edema to resolve after rhinoplasty, which can be challenging for patients and surgeons. Although various conventional modalities have been used to counteract edema, they are not successful for all skin types or in all situations.
With the advent of the Ultherapy Ulthera System (Ulthera, Inc., Mesa, Ariz.), the capability now exists to safely and reliably manipulate the contour of the skin to permit the skin to conform optimally to the underlying cartilaginous framework. Thus, the cartilage and skin can work in tandem to create a more ideal nasal-tip configuration.
During the past 18 months, the author has used Ultherapy to control edema and shape the nasal skin after rhinoplasty in 21 patients (19 women and two men, aged 22 to 66 years). Participants were required to have nasal skin types that typically are not amenable to conforming to underlying anatomical structures and thus would preclude an optimal result. The patients had previously undergone conservative attempts to reduce postoperative edema, which were not successful. All patients had been informed that Ultherapy is not a “proven” or U.S. Food and Drug Administration–approved modality for enhancing or expediting the results of rhinoplasty, but that it is U.S. Food and Drug Administration approved for facial skin tightening and brow elevation.
Ultherapy creates microthermal injury in the dermis and subdermis at depths of 1.5, 3, and 4.5 mm. Healing of these lesions, at the consistently spaced locations, leads to skin contraction, remodeling of scar tissue (revisional rhinoplasty), and, when desired, a degree of thermally induced subcutaneous fat loss.
The average number of treatments per patient was 2.1. The average time between rhinoplasty and the initial Ultherapy treatment was 3.22 years. Four nasal-tip skin types are anatomically limiting with respect to achieving optimal postrhinoplasty aesthetic results: large skin sleeve, thick skin sleeve, scarred skin sleeve, and C-shaped curvature. However, Ultherapy proved successful for three of these skin types (Figs. 1 through 3.) All patients were pleased with their result, as measured by a posttreatment survey, and there were no treatment-related adverse effects. Follow-up is ongoing to assess the durability of results, and a full clinical report is planned.
In the author's experience, Ultherapy has been particularly useful for patients who would typically be considered poor candidates for rhinoplasty because of the quality or quantity of their skin. The success achieved in the present series has led the author to use Ultherapy routinely in his practice to reduce tip edema following rhinoplasty.
Ultherapy's mechanism of action appears to be absolute shrinkage of the skin sleeve,1–3 renewal of the cutaneous structure including enhanced elasticity,4 and the ability to remodel scar tissue. Ultherapy also has been used successfully to reduce the size of silicone-injected lips nonsurgically. A proposed mechanism of action is remodeling of the silicone bead capsule.5
In postrhinoplasty patients, Ultherapy appears to “shrink wrap” the skin over the underlying cartilaginous framework. With this modality, rhinoplastic surgeons are able to control another anatomical element—the skin—to allow optimal sculpting of the central feature of the human face.
Andrew N. Kornstein, M.D.
Museum Mile Surgery Center, 1050 Fifth Avenue, New York, N.Y. 10028, [email protected]
The author has no financial interest to declare in relation to the content of this article. No funding was received for the preparation of this article.
Patients provided written consent for the use of their images.
1. White WM, Makin R, Barthe P, Slayton M, Gliklich RE. Selective creation of thermal injury zones in the superficial musculoaponeurotic system using intense ultrasound therapy. Arch Facial Plast Surg. 2007;9:22–29.
2. Hinz B. Formation and function of the myofibroblast during tissue repair. J Invest Dermatol. 2007;127:526–537.
3. Mulvaney M, Harrington A. Cutaneous trauma and its treatment. In: James WD, ed. Military Dermatology (Textbook of Military Medicine). Fort Detrick, Md: Department of the Army, Office of the Surgeon General, Borden Institute; 1994:143–156.
4. Suh DH, Shin MK, Lee SJ, et al.. Intense focused ultrasound tightening in Asian skin: Clinical and pathologic results. Dermatol Surg. 2011;37:1595–1602.
5. Kornstein AN. Ulthera for silicone lip correction. Plast Reconstr Surg. 2012;129:1014e–1015e.
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:
- Text—maximum of 500 words (not including references)
- References—maximum of five
- Authors—no more than five
- Figures/Tables—no more than two figures and/or one table
Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.
We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.