Multiplane Hyaluronic Acid Rhinoplasty

Abstract

Sir:FigureHyaluronic acid injection rhinoplasty is a low-risk procedure that provides instant improvement. Normally, hyaluronic acid is injected into the deep dermis or subcutaneously.1 However, it might cause local area swelling and filler material shifting. The authors performed multiplane hyaluronic acid injection rhinoplasty in 50 patients from 2009 to 2011 and obtained satisfactory results. The hyaluronic acid used is Restylane-2 (Q-Med, Uppsala, Sweden). The needle is inserted at a 30- to 45-degree angle following aspiration to avoid arterial embolism and local area necrosis.2,3 Linear threading and multiple injection-site techniques were used, depending on the area and volume required for correction.1 Simulating silicone nasal augmentation techniques,4,5 the authors sequentially inject the filler under the nasodorsal fascia, on the perichondrium, and between the alar cartilages. During injection, pressure was applied on both sides of the dorsum to avoid filler spreading. Additional filler material can be administered as needed. In our case, patients were injected with 1 to 1.5 ml of filler material. Because hyaluronic acid tends to absorb nearby moisture and swell, physicians should always follow the “less rather than more” principle to avoid dorsum overelevation (Figs. 1 and 2).Fig. 1: Multiplane injection method: I, under the nasodorsal fascia; II, on the perichondrium; and III, between both sides of the greater alar cartilage.Fig. 2: A patient is shown before (left) and after (right) injection.The follow-up period ranged from 8 to 12 months. The duration of effect of Restylane was between 6 and 10 months (average, 8.5 months). Most of the patients were pleased with the result. Only one patient was unsatisfied and complained about an “uneven surface on nasal dorsum,” which could have been caused by improper technique during the procedure. A 21-year-old woman presented with a minor nasal hump deformity. One milliliter of Restylane was distributed evenly on the nasal dorsum area (0.3 ml under the nasodorsal fascia, 0.3 ml on the perichondrium, and 0.4 ml on the tip). Injection into the correct plane of the nose is the key to successful treatment. Traditionally, hyaluronic acid was injected into the deep dermis, with material shifting often occurring because of low surrounding tissue density. Therefore, we inject filler material into specific planes according to different anatomical features of different parts of the nasal dorsum: under nasodorsal fascia at the bony dorsum area, on the perichondrium at the nasal cartilage area, and between the alar cartilages at the nasal tip area. The rigidity of these structures can help pressurize the filler material, thereby restraining it at designated places and providing a vividly natural appearing result. At the same time, material shifting and local area swelling are avoided. The effect of hyaluronic acid (Restylane) usually lasts approximately 6 to 8 months following injection into the deep dermis. The effect of hyaluronic acid on our patients treated with the multiplane injection technique was 6 to 10 months, which is similar to that of injection into the deep dermis. This indicates that injecting hyaluronic acid using our method does not affect its duration of effect. As a microinvasive rhinoplasty technique, hyaluronic acid injection is a simple procedure with minimum downtime and instant improvement, and is suitable for those who are reluctant to undergo surgery yet need nose correction. Despite its advantages, accidental injection into the bloodstream causing arterial embolism and local skin necrosis2 is still an issue. Thus, injecting filler material into different planes, where few branch vessels are present, can greatly reduce the risk of arterial embolism and skin necrosis. We believe that with the combination of careful preoperative planning and proficient skill, the multiplane hyaluronic acid injection technique can lead to more harmonious results and greatly improves patient satisfaction. Ke Xue, M.D. Cheng-An Chiang, M.D. Kai Liu, M.D., Ph.D. Bin Gu, M.D., Ph.D. Qingfeng Li, M.D., Ph.D. Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Affiliated to School of Medicine, Shanghai Jiao Tong University, Shanghai, China DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. PATIENT CONSENT The patient provided written consent for the use of her image.