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Utilization of Aquamid as a Filler for Rhinoplasty in Orientals

Yagi, Yoichi M.D.; Kato, Kentaro M.D.; Murakami, Daisuke M.D.; Misaki, Kojiro M.D.; Ota, Mitsuya M.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 26e-28e
doi: 10.1097/PRS.0b013e318194d1e9
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Sir:

In Japan, Aquamid (Contura S.A., Montreux, Switzerland) has been used for 5 years, mainly as a facial filler. We have also used this filler for rhinoplasty for 4 years. To the best of our knowledge, there is no precise report concerning the application of Aquamid to the Oriental nose and the subject has not been published in any textbooks. In this article, we discuss the injection technique, analysis for determining the appropriate and satisfactory dose of Aquamid, and related complications encountered, especially for rhinoplasty.

The height of the Oriental nose is lower than that of the Caucasian nose in general. We Japanese have longed for a high nose. Injection therapy is a very easy method of achieving this desire without undergoing an invasive surgical approach. We have treated 1816 patients with this method. Follow-up has ranged from 2 to 3 years. Our longest recorded follow-up is 3.5 years. The average injection dose was 2.126 ml (Table 1). Under local anesthesia, the injection layer is the deep subcutaneous layer on the nasal bone periosteum; after injection, manual manipulation via hand massage is effective in obtaining a favorable contour and lining of the nose (Fig 1).

Table 1
Table 1:
Relationships between Number and Dosage
Fig. 1.
Fig. 1.:
Patient shown before and at 1.5 years after treatment. Three milliliters of Aquamid was administered to the patient's nose.

The rate of complications was 0.11 percent (two of 1816 patients). After treatment, we applied gentamicin ointment to the treatment site and administered oral antibiotics for 3 days. Facial cleansing and the use of cosmetics were authorized for the next morning. During the study, there was one case of infection and one case of ischemic change. The patient with the infection recovered with oral antibiotics. The patient with transient ischemic change showed signs of ischemia when 1% xylocaine with epinephrine was administered as local anesthetic to the patient's nasal dorsum. From the day of treatment to the next day, she felt pain and abnormal sensation in the proximity of the right nasal ala. The color gradually changed to pale with a congestive appearance, and the nose finally became erythemic in appearance (Fig. 2). We postulated that the vasoconstrictive effects of epinephrine and the pressure of the filler on the marginal subcutaneous tissues resulted in vascular compromise. Thus the final outcome was a transient ischemic change. The patient's nose returned to normal 2 weeks after the event.

Fig. 2.
Fig. 2.:
We speculate that this ischemic change resulted from congestive or vascular compromise to the right ala and nasal dorsum 5 days after treatment. Only 1 ml of Aquamid was administrated to her nose for augmentation. A nerve block was performed with 1% xylocaine with epinephrine. We believe that epinephrine's vasoconstrictive action and the pressure of the filler on the marginal subcutaneous circulation caused the ischemic state.

When used to augment the bridge of the nose, solid implants look and feel unnatural. The skin overlying the implant can appear unnaturally shiny. If the nose sits slightly to the left or right, the solid implant will follow this direction. The flexibility of Aquamid allows this direction to be corrected so that the nose can be properly centered.1 In cases of nasal humps, the hump can easily be “masked” by simply injecting Aquamid above and below it.2 The silicone prosthesis is suitable for nasal tip and columellar augmentation, so use of the filler is mainly for augmentation of the nasal root and dorsum. In terms of producing a higher nasal bridge, rhinoplasty using Aquamid gel is an innovative way of achieving the same aesthetic result as obtained with the conventional surgical method for a selected group of patients.

Extra precaution must be exercised for Aquamid administrations to the nasal tip, because the nasal skin of Orientals is extremely hard and thick; after treatment the nasal tip will appear to be rounder than anticipated by the patient or go against the patient's wishes for a sharper nasal tip appearance with fillers. On the other hand, administration of an excessive amount of Aquamid to the thin layer of the subcutaneous tissue of pale-skinned and thin patients will result in dark discoloration of the injection site and the gel may become visible through the nasal skin.

We have not experienced any allergic reaction to Aquamid or granuloma lesions as compared with hyaluronic acid treatment.3–5 Therefore, higher biocompatibility is expected to be guaranteed and complications are rare.

Yoichi Yagi, M.D.

Kentaro Kato, M.D.

Daisuke Murakami, M.D.

Kojiro Misaki, M.D.

Mitsuya Ota, M.D.

Tokyo Aoyama Clinic

Aesthetic Plastic Surgery

Minami, Aoyama

Tokyo, Japan

REFERENCES

1. Doggett C. A new nose: Instantly. Australian Cosmetic Surgery Magazine 2004;24:73.
2. Peterson L. Nose job without surgery. Australian Cosmetic Surgery Magazine 2004;24:48.
3. Lemperle G, Rullan PP, Gauthier-Hazan N. Avoiding and treating dermal filler complications. Plast Reconstr Surg. 2006;118:92S–107S.
4. Coleman SR, Plastic Surgery Educational Foundation DATA Committee. Cross-linked hyaluronic acid fillers. Plast Reconstr Surg. 2006;117:661–665.
5. Grossman LK. Hyaluronic acid gel fillers: Hypersensitivity reactions. Aesthetic Surg. 2005;25:403.

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