FPSAM - Roundtable - 3

much blood flow and movement. This sort of longevity
is great. The patients do, however, need touchups.
Especially people who have the larger hump tend to
need a touchup, and people who have a lot of tip mobility with mouth movement tend to flatten their tips
faster. But the results are, on the whole, easily lasting
18 months. I do not advertise it this way because it is
intended to be a 1-year filler product, and I do not want
dissatisfaction. But I would say 18 months is reasonable for me and not uncommon in my experience.
Dr. Dayan: Sasha?
Dr. Rivkin: In my practice, it really depends on which
filler is being used. I primarily use Voluma for the
temporary procedure. I will tell people it is going to
last *1.5 years to 2 years, but I build into the procedure two touchup treatments, one at 1 month and the
other at 6 months. And I find that that really takes them
at least out to 1.5 years, and oftentimes 2 years.
The interesting thing is, I had recently a conversation with Chris Zoumalan, who was telling me that he
has done several surgical rhinoplasties in patients on
whom I had done injections on, and even years later,
he finds products in there.
And I do not know if any others on this panel have
seen that, as well. But it seems to last. The aesthetic
effect seems to fade, but the product is still in there for
quite a long time, even after the 2 years have gone by.
Dr. Dayan: Yes. I have had experiences wherein I
have gone into noses 1 to 3 years after surgery, and I
will find products in there. I think this is an interesting finding, and something that is not unusual.
Sebastian, do you have any comments on the product lasting longer in this area due to the anatomy?

Dr. Grunebaum: No, I do not think so.
Dr. Dayan: Columella, are you okay with alar
sidewalls or rims of the ala?
Dr. Grunebaum: It really depends on the circumstance. I will give you an example. Early alar, very
mild retraction after rhinoplasty, on a few occasions, I
have actually put the tiniest bit of filler to create a little
bit of a scar, and that has been really useful. So, again,
it depends on the indication. But I do not have a hard
and fast rule about where I will or will not treat. It is
more about the pathology.
Dr. Dayan: Kay, how about yourself?
Dr. Durairaj: I am not a big fan of columellar injections, and I do inject them, but I always hold my
breath. I am always concerned about lack of flow there,
especially from postsurgical patients who have had an
open rhinoplasty. So, for myself, I do not like to treat
the columella.
Dr. Grunebaum: I just want to interject and corroborate that. This is the thing that makes me hold my
breath the most of every single thing that I do in my
entire life. I do find it very nerve racking.
Dr. Dayan: All right, we are going to come back to
that when we talk about vascular occlusions. So, let
us keep this to relative anatomy or areas you will not
treat. Sasha, is there any area you will not treat?

Dr. Cotofana: Factors influencing a product's longevity are multiple: one of the reasons a product lasts
in its injected position is biomechanical stress. In the
mobile parts of the face, we know product longevity is
reduced, and is usually gone within 3 to 7 months. But
on the nose, where we have less biomechanical stress
because of less movement, a product lasts longer. This
is one of the reasons why products can sometimes last
longer than manufacturers or our own professional
experience tells us.
Another influencing factor is lymphatic outflow.
The lymphatic outflow on the nose is not as increased
and not as high as on the other areas of the face, like the
cheek or like the infraorbital area. This correlates with
your surgical findings wherein the product is visible
after > 1 year.

Dr. Rivkin: Yeah, so over the years, I have had people
ask me to treat a wide variety of areas of the nose.
I have treated most of these parts with a few exceptions. I treat the columella, but one of the areas I really
try not to treat is the sidewall of the columella. I will
get patients who complain, especially after surgery,
that their columella is asymmetric and they want to
make it look straighter. The skin in that spot is very
adherent and I have not had much success getting filler
in there, especially in postsurgical patients. The skin of
the alar base and the columellar footplate also does not
come up very well. That has not been very successful,
and it is really also simply that it does not work very
well. I have not been able to get a good cosmetic result
injecting those areas.
Some Asian patients want to create definition in the
lateral radix, which adds more of a Caucasian appearance to the lateral aspect of their nose. It is like creating
the upper aspect of the brow tip line. I have found that
creating this is tricky to do, and I try not to engage in that.

Dr. Dayan: Lisa, is there any part of the nose you
will not treat?

Dr. Dayan: Sebastian, are there any areas we
should avoid anatomically where you think the

ª 2020 by American Academy of Facial Plastic and Reconstructive Surgery, Inc.



FPSAM - Roundtable

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