FPSAM - Roundtable - 2

EXPERT PANEL DISCUSSION
not think that the procedure will make them prom
queen. But I will treat patients from 12 years old and up.

visions and nothing quite enhances them as well as a
little touch of filler in just the right places.

Dr. Dayan: Lisa, will you treat patients younger
than 18?

Dr. Dayan: Okay, so, Lisa and Sasha, can you
both chime in with your thoughts on patients who
had previous rhinoplasty. Will you treat these patients?

Dr. Grunebaum: I will treat patients who are under
the age of 18 as well if I see that their motivation is
reasonable and they are mature.
Dr. Dayan: I tend to treat patients who are a little
bit older. I rarely treat patients under 16 years, and
I try to push patients or encourage patients to undergo a surgical option if that is something they are
considering.
Sebastian, is there anything we should know with
the anatomy that could affect our indications or
who we choose to do surgery on?
Dr. Cotofana: One of the important things regarding
the nose is that the nose is arranged in layers, from
superficial to deep: skin, superficial fat, nasal superficial musculo-aponeurotic system (SMAS) including
the nasalis muscle, loose areolar tissue, and the periosteum, or perichondrium. These layers are very important to find your safer plane, because the majority
of the vessels are located subdermally in the superficial fatty layer (layer 2). If the patient has previously
had any surgical intervention or any other procedure
on the nose, this layer arrangement is altered. When
performing nonsurgical rhinoplasty, you might have
experienced difficulties with getting the needle or
cannula into a safer plane; this also affects the aesthetic outcome.
Dr. Dayan: So, treating a patient who has had a
previous surgery is a relative contraindication?
Does everyone agree with that? Kay, do you want to
offer your opinion regarding whether you would
consider someone having had a previous rhinoplasty a relative contraindication? Does it alter
your treatment plan?
Dr. Durairaj: I do consider it a relative contraindication. I definitely ask these questions as part of my history
taking, and I also seek to learn who did the rhinoplasty,
how many revisions they have had and whether there
was any facial trauma, and whether they have implants.
They definitely will educate patients if they have an
increased risk of vascular occlusion, if there is scar tissue, or if there is abnormal vasculature, and I am extra
conservative with the amount of filler used because I
think that you get some occlusive symptoms, too, from
putting in too much filler too quickly.
But with that said, I still do a lot of injection rhinoplasties on postsurgical patients, and in fact they are
some of the happiest because they have had two re2

Dr. Grunebaum: I would favor not using the term
''relative'' or anything to do with contraindication
when they have had previously rhinoplasty. I think it is
too strong.
I think if a patient has had a previous rhinoplasty, is
a reason for pause and a reason for consideration and
any planned procedures should be done by injectors
who have advanced surgical and postsurgical knowledge, and that does not necessarily mean you have to
be a surgeon. However, I think it is a little too strong to
use the word ''contraindication.'' I am curious how
others feel about that.
Dr. Dayan: I think that is a good point.
Dr. Rivkin: I totally agree. I think that is a really good
point because in the right hands, the risk of adverse
events with filler injection in these postsurgical patients is less than what they would be subjected to with
surgical revision rhinoplasty. Revision nonsurgical
rhinoplasty must be done by someone who knows
what they are doing, and is not really only an advanced
injector, but also an advanced nonsurgical rhinoplasty
injector.
I agree with Kay that these are some of the happiest
patients in my practice because usually they have been
dreaming about these changes for many years. They
often feel that they look unnatural after their surgery,
and with a few injections you make them look completely natural. They are usually extremely, extremely
happy.
Dr. Dayan: So I would agree with that, as well. All
right, So, Lisa, how long do you tell the patient it is
going to last when you put the fillers in? And I guess
it matters what kind of filler you are using, too.
Dr. Grunebaum: It does matter which kind of filler
you are using. I think it also matters where you are
putting it. I would estimate about a little bit longer in
general, but I usually establish a ballpark of around 6
months.
Dr. Durairaj: I would say in my practice that filler is
lasting longer than that. Eighteen months is not unusual, and this week I saw someone who came back at 2
years whose nose is different from the baseline original
pretreatment nose. So, I think that the filler has a very
long shelf life there, just lack of mobility and not that
ª 2020 by American Academy of Facial Plastic and Reconstructive Surgery, Inc.



FPSAM - Roundtable

Table of Contents for the Digital Edition of FPSAM - Roundtable

FPSAM - Roundtable - Cover1
FPSAM - Roundtable - Cover2
FPSAM - Roundtable - i
FPSAM - Roundtable - ii
FPSAM - Roundtable - 1
FPSAM - Roundtable - 2
FPSAM - Roundtable - 3
FPSAM - Roundtable - 4
FPSAM - Roundtable - 5
FPSAM - Roundtable - 6
FPSAM - Roundtable - 7
FPSAM - Roundtable - 8
FPSAM - Roundtable - 9
FPSAM - Roundtable - 10
FPSAM - Roundtable - Cover3
FPSAM - Roundtable - Cover4
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