FPSAM - Roundtable - 5

EXPERT PANEL DISCUSSION
Dr. Dayan: Lisa?
Dr. Grunebaum: Kay said it better than I could have,
and I agree with her completely.
Dr. Dayan: I agree with both of you. I will do surgery on someone who has had previous filler. In
fact, many of my patients have had previous filler,
and they are becoming rhinoplasty patients. And
that is one of the great things about this.
But I will dissolve it. About a week beforehand I
will try to get it all out if I can before going to
surgery. I have seen it in there during surgery, and
it has not caused any difficulties with my rhinoplasty. Have you noticed any difficulties doing
rhinoplasty with filler in the nose?
Dr. Durairaj: I have not noticed any difficulties with
it. I am curious from everybody's perspective, do you
administer Hylenex when you notice it intraoperatively, or how do you wash it out?
Dr. Dayan: I suck it out. And I have had radix, too,
which is calcium hydroxyapatite, which I have had
to remove. The first time I saw that, I did not know
what it was. I have seen it and wondered, ''What is
this stuff in the nose?'' And then I figured out it was
calcium hydroxyapatite. I was a little concerned the
first time I saw that.
Dr. Durairaj: Yes. I mean, sometimes this filler is
injected somewhat incorrectly into the dermis, or it is
actually embedded in the tissue. So, it is one thing if
we have placed it in a relatively aponeurotic plane
where we can just flush it out. But we might need to
dissolve it, too, in certain instances.
Dr. Dayan: We all know that the nose is probably
the highest risk area for vascular occlusion or
blindness, and it is the reason why we are probably
all coming together on this to come up with best
practices, so we can try to reduce the risk for those
people who are out there treating the nose.
So, I guess I will start with something that is
kind of controversial: technique. Kay, do you
want to tell us a little bit about your technique,
how you inject, needle versus cannula, and does that
have an impact in your opinion on vascular occlusion? Also, where do you put your hands? Do you
occlude the vessels up near the orbit when you inject, or are there any other tricks you have?
Dr. Durairaj: My technique is generally to occlude
the vessels at the radix area, and I will use a needle
100% of the time. I rarely will use a cannula unless
someone has an implant that I want to be just above.
ª 2020 by American Academy of Facial Plastic and Reconstructive Surgery, Inc.

I think the needle gives me the most precise placement
of filler, and I think the millimeter changes that we do
with the injection rhinoplasty are necessary to be very
ultraprecise.
I like the ability to aspirate with the needle, and, yes,
I have gotten blood back on flashes with aspiration, so
that has given me some pause sometimes.
And my technique really is to stay exactly on the
midline, under the aponeurotic layer, directly on bone,
if possible, and to visualize and place filler like a
spreader graft placement. When I am coming to the tip
of the nose, I like to construct some beautiful points of
light.
I think with filler, it is all about light and shadows and
creating the illusion of slimming by placing a thin line
of filler in the midline, which is helpful, and then creating a nice tip breakpoint, as well as tip definition. So,
for me, the needle is the precise way to do that.
Dr. Dayan: Sasha?
Dr. Rivkin: I agree with Kay. I like to use needles
because they are very precise, and I think that gives
them a big advantage over cannulas in the nose. In
other areas, it is more a matter of preference. But I
think the needles in the nose really have the definite
advantage.
I use a backloaded 0.3 cc BD syringe, BD syringes,
0.33 cc BD syringe with a fixed 31-gauge needle.
These tiny syringes with a very small needle permit me
to be able to inject in amounts of 0.01 cc at a time,
which I find to be very useful for precision and safety,
especially in areas around the radix where the ophthalmic vasculature is close.
Studies have shown that to send an embolus that can
cause blindness, all you need is < 0.l cc of filler. So, I
feel that being able to inject very small quantities
keeps my patients safe.
I also occlude the vessels when we are injecting the
radix. I do very small pointed injections, and try to be
extremely precise with the depth so that the needle is
on the periosteum or perichondrium.
Dr. Dayan: Lisa, how about yourself?
Dr. Grunebaum: I agree with others. I am needle
only, and I use a small needle, usually a 30-gauge
needle, but I like the idea of using the BD 31-gauge
needles. Anatomy knowledge is especially critical in
this area. There is a tendency perhaps among novice
injectors to believe that superficial might be safer with
regard to large vessels. This may be true in some areas
of the face but not others. Again, familiarity with
specific nasal anatomy is paramount here.
So, again, in the radix, midline only on bone. And I
want to make sure that I continue to feel my needle on
5



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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