FPSAM - Roundtable - 6

the bone and be aware if it pulls up or anything like that.
It can be easy for an injector to not realize that they are
moving away from their initial chosen depth. Now, it is
an important thing to remember to continually reassess
yourself so you know where you are. I have a lot of
opportunity to train residents and new injectors, and part
of the reason that we are doing this is to help educate.
So, again, alar rim is going to be a much more superficial, tip is intermediate, and then, again, on bone,
continually feeling like I feel bone with my small needle.
Dr. Rivkin: There is controversy about whether to
aspirate or not. I tend to be on the nonaspiration side of
the debate and I try to take what I call ''universal
injection precautions.'' I inject slowly and with low
pressure. I am always moving my needle while I am
injecting. I use clean technique and tiny needles. I find
that these precautions keep my patients safe.
There was recently a consensus article talking about
blindness and fillers, and they actually recommended
against aspiration. I have nothing against the practice,
but I worry when aspiration is the only safety precaution that people use. I believe that it can give injectors, especially those without a lot of experience, a
sense of false security. I think that other precautions
should be taken as well.
Dr. Dayan: I agree. I am going to ask Sebastian to
weigh in on that in a second because he has some
insight that I think is important. My techniques, to
round out all our techniques, are different than
those of the three of you. I use only 22-gauge cannulas. Rarely do I use a needle. On rare occasions, I
will. I will go down to the bone. But 99% of the time
I will use a large-bore cannula.
I have a specific technique. I call it a ''five-point''
technique. I put a little drop of local on the radix, on
the supratip, on the tip, and then at the columellar
base. And then I inject the radix area first. I fill it up.
And then I make a second injection, a port, at the
supratip, and I place a cannula in the midline, and
fill in the radix and the dorsum to get a streamlined
appearance of the dorsum. Then I will go in between
the tip, between the medial crural footplates, down
to the nasal spine and withdraw as I inject filler to
give like a columellar strut. And then I will fill in the
tip with a small port over the top, once again, for the
most part using only a 22-gauge cannula.
And that has been my technique. I have my
assistant cover the area where I believe the supratrochlear artery enters into the orbit, so hopefully compressing that, or the area where I believe
it is going to be in a confluence with the trochlear artery. I will try to protect that area. I do not
know whether it really works, and we will get
Sebastian's input on that. And that is my technique.

Afterward, I pretty much do not put anything on
their nose. I let them go as they look right there.
Most people are happy right away.
So, postoperatively, what do you do when the
patients leave? And then, Sebastian, I really want
you weigh in here on the anatomy and your input on
technique that is safest. So, Lisa, post-treatment, do
your patients leave the office?
Dr. Grunebaum: I have them wait a minimum of 15
minutes to watch for any other untoward effects, and
then afterward, they would be with me-like you,
nothing else.
Dr. Dayan: Sasha?
Dr. Rivkin: Yes, I put arnica cream on, wait for 15
minutes, and then take it off. If there are any concerns,
I will do warm compresses, massage, etc. But if there
is no concern, then the patients can simply leave.
Dr. Dayan: Kay?
Dr. Durairaj: I recommend that patients avoid
wearing glasses or anything that could put pressure on
the bridge of their nose for the first 2 weeks after
surgery, avoid putting their face in a massage pillow,
and avoid sleeping on their face.
And if I feel that they have any kind of tip redness or
just increased activity, I will give them 40 mg of
prednisone to take that night, just because I think the
swelling can lead to some avoidable vascular symptoms. Then I instruct them on what to look for in terms
of color changes.
Dr. Dayan: Okay, so have any of you seen vascular
necrosis or impending necrosis of the nose?
Dr. Rivkin: Yes.
Dr. Dayan: So have I. I have treated some patients
following vascular occlusive events in the nose.
Fortunately, it has not been any patients I have
treated, but I have had other areas of the face where
I have seen vascular compromise after I treated
them. However, since I have gone to large bore 22gauge cannula, I have not seen it.
And Sebastian, I would love for you to weigh in
here a little bit, because I know you have done an
extensive amount of work on vascular necrosis and
the anatomy of the nose. And oftentimes, the anatomy of the nose is not like it is in the textbooks, at least
that is my impression when I get into the nose. So, can
you comment and share your thoughts on the anatomy of the nose and injection techniques and how we
can reduce the risk for an impending necrosis?
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
FPSAM - Roundtable - 7
FPSAM - Roundtable - 8
FPSAM - Roundtable - 9
FPSAM - Roundtable - 10
FPSAM - Roundtable - Cover3
FPSAM - Roundtable - Cover4