Aesthetic Nasal Corrections with Hydroxylapatite Facial Filler

Sir: Conventional surgery likely remains the treatment of choice for patients who require extensive aesthetic facial changes. However, injectable soft-tissue fillers are increasingly being seen as an acceptable product option in certain patients seeking subtle results. One area of promise for facial fillers is in correction of minor nose defects. In such cases, fillers appear to provide more “real-time” results, and are not characterized by extensive swelling and the prolonged recuperative periods sometimes found in rhinoplasty. Many products have been described as “soft-tissue substitutes.”1 Regardless of the product, the ideal characteristics of soft-tissue filling material have been identified. They include filler longevity, biocompatibility, low adverse event profile, and a reasonable cost-benefit ratio.1,2 Synthetic calcium hydroxylapatite may offer many of the desirable facial filler properties. Radiesse (BioForm Medical, San Mateo, Calif.) is a sterile, latex-free, nonpy-rogenic, subdermal implant composed of synthetic calcium hydroxylapatite microspheres (25 to 40 μm in diameter) suspended in an aqueous gel carrier of glycerin and sodium carboxymethylcellulose. The gel structure dissipates and the calcium hydroxylapatite remains in the injection site.1,3,4 To improve aesthetic appearance, different anatomical regions were injected: the frontonasal angle, dorsum, nasal tip, and nasolabial angle. The average volume injected was 0.87 cc. All patients were injected once or twice. The suggested maximum volumes for each of the nasal regions were as follows: frontonasal angle, 1 cc; dorsum, 0.5 cc; tip, 0.5 cc; and nasolabial angles 1.5 cc (Fig. 1).Fig. 1.: (Left) Preinjection view shows lack of tip projection as a result of primary aesthetic conventional rhinoplasty. (Right) With injection of 0.5 ml of Radiesse, a projected nasal tip was achieved and aesthetic appearance was improved.Patients with one or more of the following conditions were excluded from the study: acute or chronic nasal infection, existing keloidal scars, history of systemic collagen diseases, severe bleeding disorders, nasal respiratory impairment, and unrealistic expectations. Aesthetic results remained for 24 months without significant changes. As temporary adverse effects, there were two cases of ecchymosis and one case of hematoma. No systemic reactions were seen during the stated follow-up period. A patient satisfaction survey revealed 86 percent acceptance (n = 23 of 25), for very good results. With regard to other compounds, some considerations can be mentioned. Due to the many reported adverse effects and complications, liquid silicone should not be accepted. Permanent fillers have the disadvantage of being difficult to remove if the desired results are not achieved. Gryskiewicz3 describes the use of AlloDerm for minor nasal defects, when corrections of less than 3 mm are needed. Although he achieved very good, lasting, 5-year results, that technique is different from injecting fillers. In contrast to the short duration of other fillers, such as hyaluronic acid, synthetic calcium hydroxylapatite may offer long-lasting effects and serve as a viable alternative. Calcium hydroxylapatite particles have been used successfully for some time in urology as a bulking agent for incontinence treatment. Histological studies have shown that the carboxymethylcellulose is completely absorbed after 12 months and that the calcium hydroxylapatite particles remain surrounded by connective tissue.1,3,4 Although classic surgical rhinoplasty remains the treatment of choice for primary and secondary nasal deformities, calcium hydroxylapatite filler can be consider a good alternative to be injected only by plastic surgeons. Patricio F. Jacovella, M.D.