**Five Fluorouracil, Hyaluronidase, and Triamcinolone in the Nasal Region**

Guillermo Blugerman, Diego Schavelzon and Gabriel Wexler

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62068

#### **Abstract**

Informed consent was obtained from the patients included in the chapter.

nose. *Plast. Reconstr. Surg*. 1988 ;82(1):48-57.

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*Surg*. 1999 Dec; 3 Suppl 4:S49-S52.

*Plast. Surg*. 1989;22(5):370-379.

toxin. *Dermatol Surg*. 2005;31(3):271-275.

[1] Letourneau, A., and Daniel, R. K. The superficial musculoaponeurotic system of the

[2] Aiach, G., and Levignac, J. La Rhinoplastie Esthetique. Paris: Masson edit. 1986;13-14.

[3] Griesman, B. Muscles and cartilages of the nose from the standpoint of a typical rhi‐

[4] Zide B.M. Nasal Anatomy: The muscles and tip sensation. *Aesthetic. Plast. Surg.* 1985;

[5] Carruthers J., and Carruthers A. Practical cosmetic BOTOX techniques. *J. Cutan. Med*

[6] Tamura B.M., Odo M.Y., Chang B., *et al.* Treatment of nasal wrinkles with botulinum

[7] Wright, W.K. Symposium: The supra-tip in rhinoplasty – A dilemma: II. Influence of

[8] Ham, K.S., Chung, S.C., and Lee, S.H. Complications of oriental augmentation rhino‐

[9] Cachay-Velasquez, H., and Laguinge, R. Aesthetic treatment of the columella. *Ann.*

[10] Cachay-Velasquez, H. Rhinoplasty and facial expression. *Ann. Plast. Surg*. 1992 ;28(5):

[11] Converse, J. M. (Ed.). *Plastic and Reconstructive Surgery*. Philadelphia: Saunders, 1964.

[12] De Souza Pinto, E.B., Da Rocha, R. P., Filho, W. Q., *et al*. Anatomy of the median part of the septum depressor muscle in aesthetic surgery. *Aesthetic Plast. Surg*. 1998;22(2):

[13] Rohrich, Rod J. Importance of the depressor septi nasi muscle in rhinoplasty: Ana‐ tomic study and clinical application. *Plast. Reconstruct. Surg*. 2000;105(1):376-383; dis‐

[14] Benedetto, Anthony V. Botulinum toxin in clinical medicine. *Clin. Dermatol*.

[15] Blugerman G, and Schavelzon D. Multiple Eccrine Hidrocystomas: a new therapeutic

option with Botulinum Toxin, *Dermatol. Surg*. 2003; 29(5):557-558.

surrounding structure and prevention. *Laryngoscope*. 1976;86(1):50-52.

plasty. *Ann. Acad. Med. Singapore*. 1983;12(2 Suppl):460-462.

**References**

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427-433.

111-115.

cussion 384-388.

2003;21(6):465-468.

pp. 702-703.

**Introduction**: The use of five fluorouracil (5 FU) as antifibrotic started in the 1960s, in the hands of ophthalmologists, to prevent adherence after glaucoma and pterigion surgery. In 1999, Fitzpatrick presented his experience in keloids and hypertrophic scars, making a great contribution to their treatment. Fibroblasts' main function is collagen synthesis; in vicious scar the amount of collagen is normal, but what is altered is the ratio between col‐ lagen subtypes. The use of triamcinolone, the previous standard treatment, produced dif‐ ferent degrees of atrophy and telangiectasias.

**Technique**: Infiltration is done in the center of fibrosis, weekly for the first month, then every 15 days until reaching the desired result. Softening, loss of volume and retraction are seen since the first session. Also pain and itching disappears.

**Histopathology**: Biopsy of treated scars has organized collagen fibers and less fibroblasts compared to nontreated scars.

**Clinical applications**: hypertrophic scars or keloids fixed to deep planes, "supratip" post-rhinoplasty fibrosis, post-rhinoplasty fibrosis (as preparation for other treatments), foreign body granulomas, and post-burn retractions. The use in supratip deformity when secondary to rhinoplasty fibrotic scar has proven very effective, and also as preparation for surgical (secondary rhinoplasty) and nonsurgical (bioplasty) procedures.

**Conclusion**: Our experience in the treatment of nasal scars, fibrosis, and retraction with 5 FU is favorable. The results of infiltration with 5FU, hyaluronidase and triamcinolone in low dose have clinical and histological demonstration of collagen synthesis reduction and reorganization of collagen cicatrizal fibers.

**Keywords:** Corticosteroids, fibrosis, fibrosis histopathology, fibrosis treatment, five fluo‐ rouracil, fibroblasts, foreign body granulomas, healing, hyaluronidase, hypertrophic scar, keloids, nasal aesthetics, nasal dermatology, nasal deformity, nasal reconstruction, postrhinoplasty fibrosis, burn sequelae, scar, scarring disorders, supratip deformity

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **1. Introduction**

Since Fitzpatrick [1] published his work with five fluorouracil (5FU) in 1999, we included it in our daily practice. The most frequent use of this drug is for treatment and prevention of hypertrophic scars, keloids, and foreign body granulomas [2].

The particular anatomy of the skin in each nasal subunit makes scarring process completely different among them (Fig. 1). The skin of the tip is thick, has follicular units, and sebaceous glands, whereas the dorsum skin is thin with almost no subcutaneous tissue. Because of these, the nasal tip skin reacts violently to injury, with an important inflammatory process and residual edema that generates unaesthetic deformities. The dorsum skin reacts softly to injuries, with light inflammation and scarring, but strong adherence to deep structures due to its thin composition. The etiologies of scarring in the nose are:


**Figure 1.** Anatomical structure of nasal tip and dorsum.

Fibroblasts' proliferation and migration play a major role in wound healing. Their main metabolic function is collagen, elastin, and proteoglycans synthesis. Fibroblasts' suppression in hypertrophic scars and keloids is essential since collagen synthesis is increased by 14% and 20%, respectively, compared to normal skin. Other studies show a higher amount of fibroblasts without significant increase in collagen synthesis but with altered proportions between collagen I, III, and IV. These studies also show an increased production of fibronectin by fibroblasts. The local increase of collagenase inhibitors has also been reported.

Local steroids have been the gold standard treatment for nasal inflammatory and fibrotic processes for years, but its use has important side effects and complications. Triamcinolone usually generates different grades of skin atrophy and telangiectasias in the nasal tip and ala.

5 FU is a citostatic antimetabolite drug that inhibits cell proliferation by:


**Figure 2.** Molecular structure of 5 FU.

**1. Introduction**

114 Miniinvasive Techniques in Rhinoplasty

**•** Congenital (angioma)

**Figure 1.** Anatomical structure of nasal tip and dorsum.

**•** Traumatic

**•** Surgical

**•** Infectious

**•** Implants

Since Fitzpatrick [1] published his work with five fluorouracil (5FU) in 1999, we included it in our daily practice. The most frequent use of this drug is for treatment and prevention of

The particular anatomy of the skin in each nasal subunit makes scarring process completely different among them (Fig. 1). The skin of the tip is thick, has follicular units, and sebaceous glands, whereas the dorsum skin is thin with almost no subcutaneous tissue. Because of these, the nasal tip skin reacts violently to injury, with an important inflammatory process and residual edema that generates unaesthetic deformities. The dorsum skin reacts softly to injuries, with light inflammation and scarring, but strong adherence to deep structures due to

Fibroblasts' proliferation and migration play a major role in wound healing. Their main metabolic function is collagen, elastin, and proteoglycans synthesis. Fibroblasts' suppression in hypertrophic scars and keloids is essential since collagen synthesis is increased by 14% and 20%, respectively, compared to normal skin. Other studies show a higher amount of fibroblasts

hypertrophic scars, keloids, and foreign body granulomas [2].

its thin composition. The etiologies of scarring in the nose are:

It has been proved in laboratory tests that 5 FU produces a slight reduction of collagen synthesis in normal fibroblasts but a drastic reduction in altered ones, as in Dupuytren illness [3]. Apparently, it also inhibits the collagen synthesis stimulation effect of TGF1 (transforming growth factor).

5 FU has been used for years in treatment of premalignant and malignant lesions of skin and mucosa due to its selective toxicity for dysplastic epithelium and fibroblasts. The first appli‐ cation of 5 FU was as an antifibrotic to prevent fibrous scarring after glaucoma surgery and to avoid relapse in pterigion surgery in the 1960s [4, 5, 6, 7, 8, 9]. In February of 1999, its use was reported to prevent fibrous adherence after tendon reconstructive surgery. One month after Fitzpatrick published his 7-year experience of over a thousand patients with 5 FU in hyper‐ trophic scars and keloids. This magnificent work encouraged our team to include it in our office with positive results. Since Lambros published his work in 2004 [10], our team also added hyaluronidase. This last is an enzyme that increases connective tissue permeability by hyaluronic acid hydrolysis. Hyaluronic acid is a polysaccharide of connective tissue and other specialized tissues as the umbilical cord and the vitreous humor. Hydrolysis is done between the C1of glucosamine and C4 of glucuronic acid. This reduces temporarily the intercellular cement viscosity, promoting diffusion of injected solution, exudates, and transudates facili‐ tating absorption.

Triamcinolone is a steroid; it diffuses through cell membranes binding with cytoplasmic receptors that are translocated to the nucleus generating the transcription of proteins that are responsible for their effects. It reduces tissue response to inflammation, reducing it symptoms without treating the specific cause. To do this it reduces the white blood cell (WBC) migration to the affected tissue. The most important effects are:


In the past 14 years, we have been using a preparation of 5FU, hyaluronidase, and triamcino‐ lone for the nasal area, and we have not had the complications and side effects observed with steroids monotreatment.

#### **2. Technique**

5 FU (Fluorouracil- Filaxis 500mg) is presented commercially as ampoules of 10 ml containing 50 mg per ml. Triamcinolone (Kenacort-A-BSM) is used in its acetonide form of 40mg/ml and is commercialized in ampoules of 1ml (Fig. 3). Hyluronidase (Unidasa Roux Ocefa) is com‐ mercialized in ampoules that contain 500 UI of testicular ovine freeze-dried powder hyaluro‐ nidase. We use 2.7 ml of 5 FU and 0.3ml of triamcinolone to reconstitute hyaluronidase (5 FU solution). For the application, a 0.3 or 0.5 ml Luer lock syringe and 30 G needle are preferred. This allows a better dosage and correct plane of infiltration. We have never used more that 0.5 ml of the solution in the nasal area per session. The infiltration is done with multiple punctures in the "heart" of the fibrotic lesion. In the first month, one session is done per week; then it is spaced to every fifteen days. The improvement is evaluated with three parameters: hardening reduction, loss of volume, and reduction of cutaneous retraction. Positive changes are observed since the first session, not only in the above parameters but also in aesthetics and pain–itching symptomatology. Some cases are complemented with kinesiology treatment in order to obtain a better functional and cosmetic result.

#### **3. Histopathology**

If after finishing the treatment a surgical procedure was needed to improve the result, the surgical piece was sent to the pathologist and compared to nontreated scarring tissue resec‐ tions. Results informed reduction of fibrosis and rearrangement of collagen tissue in the treated pieces. These results are illustrated in the images. In the tissue of the right side of the scar proliferation of fibrous tissue, great amount of fibroblasts and collagen fibers forming tangles Five Fluorouracil, Hyaluronidase, and Triamcinolone in the Nasal Region http://dx.doi.org/10.5772/62068 117

**Figure 3.** Commercial presentations of 5 FU and triamcinolone

Triamcinolone is a steroid; it diffuses through cell membranes binding with cytoplasmic receptors that are translocated to the nucleus generating the transcription of proteins that are responsible for their effects. It reduces tissue response to inflammation, reducing it symptoms without treating the specific cause. To do this it reduces the white blood cell (WBC) migration

**•** Inhibition of liberation of lysosomal enzymes and inflammatory mediators

**•** Reduction of blood concentration of T-cells, eosinophils, and monocytes

**•** Reduction of immunoglobulin binding with cellular receptors

**•** Reduction of capillary permeability and WBC adhesion to capillary endothelium

In the past 14 years, we have been using a preparation of 5FU, hyaluronidase, and triamcino‐ lone for the nasal area, and we have not had the complications and side effects observed with

5 FU (Fluorouracil- Filaxis 500mg) is presented commercially as ampoules of 10 ml containing 50 mg per ml. Triamcinolone (Kenacort-A-BSM) is used in its acetonide form of 40mg/ml and is commercialized in ampoules of 1ml (Fig. 3). Hyluronidase (Unidasa Roux Ocefa) is com‐ mercialized in ampoules that contain 500 UI of testicular ovine freeze-dried powder hyaluro‐ nidase. We use 2.7 ml of 5 FU and 0.3ml of triamcinolone to reconstitute hyaluronidase (5 FU solution). For the application, a 0.3 or 0.5 ml Luer lock syringe and 30 G needle are preferred. This allows a better dosage and correct plane of infiltration. We have never used more that 0.5 ml of the solution in the nasal area per session. The infiltration is done with multiple punctures in the "heart" of the fibrotic lesion. In the first month, one session is done per week; then it is spaced to every fifteen days. The improvement is evaluated with three parameters: hardening reduction, loss of volume, and reduction of cutaneous retraction. Positive changes are observed since the first session, not only in the above parameters but also in aesthetics and pain–itching symptomatology. Some cases are complemented with kinesiology treatment in order to obtain

If after finishing the treatment a surgical procedure was needed to improve the result, the surgical piece was sent to the pathologist and compared to nontreated scarring tissue resec‐ tions. Results informed reduction of fibrosis and rearrangement of collagen tissue in the treated pieces. These results are illustrated in the images. In the tissue of the right side of the scar proliferation of fibrous tissue, great amount of fibroblasts and collagen fibers forming tangles

to the affected tissue. The most important effects are:

**•** Inhibition of phagocytosis

116 Miniinvasive Techniques in Rhinoplasty

steroids monotreatment.

a better functional and cosmetic result.

**3. Histopathology**

**2. Technique**

is seen (Fig. 4). In the tissue of the left, treated with 5 FU solution, there are less fibroblasts, and the collagen fibers adopt a parallel disposition (Fig. 5).

**Figure 4.** Microscopic image of fibrosis without any infiltration treatment (left).

**Figure 5.** Microscopic image of fibrosis after infiltration with 5 FU (right).

## **4. Clinical applications**


#### **4.1. Hypertrophic scars or keloids fixed to deep planes**

The nose, being a mid-facial and projected structure, is exposed to trauma that leaves scarring sequels in the skin. Traumatic scarring if healed by second intention generates unaesthetic scars. The use of 5 FU, triamcinolone, and hyaluronidase for hypertrophic scars and keloids in the nasal area is in our hands more effective and safe than the use of steroids alone. When these scars are fixed to deep planes, the infiltration is done as preparation to subcision and then a filler as Polymethylmetacrilate (PMMA) is used to prevent the relapse of the adherence (Figs. 6 and 7).

**Figure 6.** Nasal tip scar after cartilage graft infection and extrusion. Frontal view before and after 5 FU injection and dermabration.

#### **4.2. "Supratip" post-rhinoplasty fibrosis**

**Figure 5.** Microscopic image of fibrosis after infiltration with 5 FU (right).

**•** Hypertrophic scars or keloids fixed to deep planes

**4.1. Hypertrophic scars or keloids fixed to deep planes**

**•** Post-rhinoplasty fibrosis (as preparation for other treatments)

The nose, being a mid-facial and projected structure, is exposed to trauma that leaves scarring sequels in the skin. Traumatic scarring if healed by second intention generates unaesthetic scars. The use of 5 FU, triamcinolone, and hyaluronidase for hypertrophic scars and keloids in the nasal area is in our hands more effective and safe than the use of steroids alone. When

**4. Clinical applications**

118 Miniinvasive Techniques in Rhinoplasty

**•** Foreign body granulomas

**•** Post-burn retractions

**•** "Supratip" post-rhinoplasty fibrosis

One of the most frequent complications of rhinoplasty is the healing fibrosis that is formed over time, known as "fibrous supratip." It can be the result of a badly executed rhinoplasty or defective healing process. It is very frequent among beginners and even experts still have this complication. There are many causes of supratip deformity and each demands a specific treatment. Bahman Guyuron [11] conducted a clinical and histological study to unmask the surgical causes of this deformity. This study shows that clinical supratip is observed in 9% of primary and 36% of secondary consults of rhinoplasty. In primary cases, the deformity is the result of: tip inadequate projection, caudal dorsum overprojection, lateral inferior cartilages cephalic orientation, or a combination of these. In secondary cases, the deformity is the result of: subcorrection or overcorrection of caudal dorsum, overresection of medial valve, subpro‐ jected tip, or a combination of these. The histophatological study of the supratip soft tissue demonstrated significant fibrosis in 14 of 16 secondary patients and 13 of 23 primary patients. The supratip deformity can be avoided through appropriate resection of caudal dorsum (in order not to leave dead space), nasal tip projection, and joining with stitches the subcutaneous tissue over the cartilages in the supratip area. When diagnosed early, if the tip has adequate projection and the supratip tissue can be collapsed by pressure, the elective treatment is compressive tape. If after 6 weeks the response is not positive, 0.2–0.4 ml of 5 FU solution is injected in the deep (Figs. 8 and 9) subcutaneous tissue. This infiltration can be repeated monthly until reaching the desired result. (The judicious use of 5 FU solution can help in most supratip deformities caused by fibrosis when the caudal septum and the tip cartilages are strong. If the cartilaginous frame is weak, infiltration will not solve the problem.)

**Figure 7.** Nasal tip scar after cartilage graft infection and extrusion. Lateral view before and after 5 FU injection and dermabration.

**Figure 8.** Fibrose supratip after previous procedure solve after 5 year with 0.3 ml of 5 FU single injection. Frontal view.

Infiltration can reduce a big supratip to a small one but with an important risk of skin atrophy.

Other authors such as Gruber [12] prefer to start with infiltration after 4–6 weeks of surgery, when most edema has disappeared. He uses 1–2 mg of triamcinolone (0.1–0.2 cc of triamcino‐ lone 10 mg/cc) in the supratip or other fibrous area. Pastorek [13] uses small steroids doses during and immediately after surgery, having excellent results in his hands. If a severe supratip deformity is the consequence of inadequate cartilage resection or subprojection of the tip, a surgical correction or bioplasty is needed. Sheen [14] suggested in 1979 that most supratip deformities were caused by caudal dorsum overresection. He proposed then the use of cartilage graft to correct this deformity.

**Figure 9.** Fibrose supratip after previous procedure solved after 5 years with 0.3 ml of 5 FU single injection. Frontal view. Lateral view.

**Figure 7.** Nasal tip scar after cartilage graft infection and extrusion. Lateral view before and after 5 FU injection and

**Figure 8.** Fibrose supratip after previous procedure solve after 5 year with 0.3 ml of 5 FU single injection. Frontal view.

Infiltration can reduce a big supratip to a small one but with an important risk of skin atrophy. Other authors such as Gruber [12] prefer to start with infiltration after 4–6 weeks of surgery, when most edema has disappeared. He uses 1–2 mg of triamcinolone (0.1–0.2 cc of triamcino‐ lone 10 mg/cc) in the supratip or other fibrous area. Pastorek [13] uses small steroids doses

dermabration.

120 Miniinvasive Techniques in Rhinoplasty

**Figure 10.** Patient with 3 previous rhinoplasties. Three applications of 5 FU solution were done.

Nowadays, it is widely accepted that healing fibrotic tissue formed to fill the dead space is the most frequent cause of supratip deformity post-rhinoplasty. But it was not until Guyuron's work that this was scientifically confirmed.

#### **4.3. Post-rhinoplasty fibrosis, as preparation for other treatments**

After several surgical procedures, the nose can be involved in different grades of fibrosis, turning the skin hard and inelastic. Before performing a secondary rhinoplasty or a bioplasty, we prefer preparing the area with some applications of the 5 FU solution, in order to soften the tissue (Fig. 10).

#### **4.4. Foreign body granulomas**

The use of fillers in the nasal area is a very popular method to correct slight deformities. There are many different materials and each of them produces a different degree of fibrotic reaction in the tissue. In most cases, this is a controlled reaction and leads to the expected result. But in some cases, an overreaction of patient immune system, bad application technique, or the chemistry of the material used provoke the formation of foreign body granulomas, resulting in unaesthetic deformities.

The use of triamcinolone in these cases can generate skin atrophy, thus turning the deformity more visible. When the filler used is hyaluronic acid, pure hyaluronidase should be infiltrated as stated by Brody [15] and Hirsch [16]. Infiltration is done with 100 UI in the area of hyaluronic acid excess (Fig. 11). This dissolves the acid, solving the fibrosis. When alloplastic materials were used, we preferred the 5 FU solution for infiltration because it does not have the side effects of steroids monotreatment. The application has a double effect, the pharmacological effect of the drugs, and the mechanical effect of disruption by the fluid pressure.

#### **4.5. Post-burn retractions**

The nasal skin usually gets affected in facial burns. The scarring retraction can deform the tip, ala, or both, stretching the nostrils. We use the 5 FU solution infiltration in these fibrous areas in order to increase the tissue elasticity and prepare them for secondary procedures as PMMA bioplasty or compound auricular graft.

#### **5. Complications**

The use of 5 FU solution, in young patients mostly, can cause tissue necrosis. This is relatively frequent in keloid treatment, resulting in ulcers or brown stains in the application spots. However, in the nasal region we have not observed this complication, mainly because of the low dosage. In this way, by using a progressive treatment instead of an aggressive one, side effects are kept to the minimum.

#### **6. Conclusions**

Nowadays, it is widely accepted that healing fibrotic tissue formed to fill the dead space is the most frequent cause of supratip deformity post-rhinoplasty. But it was not until Guyuron's

After several surgical procedures, the nose can be involved in different grades of fibrosis, turning the skin hard and inelastic. Before performing a secondary rhinoplasty or a bioplasty, we prefer preparing the area with some applications of the 5 FU solution, in order to soften

The use of fillers in the nasal area is a very popular method to correct slight deformities. There are many different materials and each of them produces a different degree of fibrotic reaction in the tissue. In most cases, this is a controlled reaction and leads to the expected result. But in some cases, an overreaction of patient immune system, bad application technique, or the chemistry of the material used provoke the formation of foreign body granulomas, resulting

The use of triamcinolone in these cases can generate skin atrophy, thus turning the deformity more visible. When the filler used is hyaluronic acid, pure hyaluronidase should be infiltrated as stated by Brody [15] and Hirsch [16]. Infiltration is done with 100 UI in the area of hyaluronic acid excess (Fig. 11). This dissolves the acid, solving the fibrosis. When alloplastic materials were used, we preferred the 5 FU solution for infiltration because it does not have the side effects of steroids monotreatment. The application has a double effect, the pharmacological

The nasal skin usually gets affected in facial burns. The scarring retraction can deform the tip, ala, or both, stretching the nostrils. We use the 5 FU solution infiltration in these fibrous areas in order to increase the tissue elasticity and prepare them for secondary procedures as PMMA

The use of 5 FU solution, in young patients mostly, can cause tissue necrosis. This is relatively frequent in keloid treatment, resulting in ulcers or brown stains in the application spots. However, in the nasal region we have not observed this complication, mainly because of the low dosage. In this way, by using a progressive treatment instead of an aggressive one, side

effect of the drugs, and the mechanical effect of disruption by the fluid pressure.

work that this was scientifically confirmed.

the tissue (Fig. 10).

122 Miniinvasive Techniques in Rhinoplasty

**4.4. Foreign body granulomas**

in unaesthetic deformities.

**4.5. Post-burn retractions**

**5. Complications**

bioplasty or compound auricular graft.

effects are kept to the minimum.

**4.3. Post-rhinoplasty fibrosis, as preparation for other treatments**

Through this chapter, we have presented our experience in the treatment of scars, fibrosis, retractions, and deformities over the nasal skin. The results of our 14-year experience with 5 FU solution (5 FU, triamcinolone, and hyaluronidase) have the histopathological demonstra‐ tion of effectiveness in collagen fibers synthesis reduction and fiber rearrangement, thus explaining the positive clinical effect.

#### **Author details**

Guillermo Blugerman1\*, Diego Schavelzon1 and Gabriel Wexler2

\*Address all correspondence to: blugerman@centrosbys.com

1 Plastic Surgery Department of Centros ByS,Centros B&S de Excelencia en Cirugía Plástica, Argentina

2 Universidad Nacional del Nordeste, Argentina

#### **Conflict of interest**

The Authors declare no conflict of interest. Informed consent was obtained from patients included in the chapter.

#### **References**


## **Auxiliary Procedures in the Nasal Skin**

Guillermo Blugerman, Diego Schavelzon, Gabriel Wexler and Roberto Schale

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62067

#### **Abstract**

[7] Lee D.A., Shapourifar-Tehrani S., Kitada S. The effect of 5-fluorouracil and cytara‐ bine on human fibroblasts from Tenon's capsule. *Invest Ophthalmol Vis Sci.*

[8] Schellini Silvana A. Uso do 5-fluorouracil no intra-operatório da cirurgia do pterígio.

[9] Acali Augustine et al. Decrease in adhesión formation by a single application of 5Flu‐ orouracil after flexor tendon injury. *Plast Reconstr Surg*.1999;103(1):151-158.

[10] Lambros V. The use of hyaluronidase to reverse the effects of hyaluronic acid filler.

[11] Guyuron, Bahman. Supratip deformity: A closer look. *Plast Reconstr Surg*.

[12] Gruber, Ronald P. MD. Supratip deformity: A closer look by Bahman Guyuron, MD, Louis DeLuca, MD, and Richard Lash, MD. *Plast Reconstr Surg*. 2000 105(3):

[13] Pastorek, N. Surgery of the Nasal Tip. Presented at the Dallas Rhinoplasty Symposi‐

[15] Brody, H.J. The use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyalronic acid misplacement. *Dermatol Surg*. 2005;31(8 Pt

[16] Hirsch R.J. Correcting superficially placed of Hyaluronic Acid. *Skin Aging*. 2007;15

[14] Sheen, J.H. A new look at supratip deformity. *Ann Plast Surg*. 1979;3(6):498-504.

1990;31:1848-1855.

124 Miniinvasive Techniques in Rhinoplasty

2000.105(3):1140-1151.

1152-1153.

1):893-897.

(1):36-38.

*Arq Bras Oftalmol*. 2000 63(2): 111-114.

*Plast Reconstr Surg*. 2004; 114(1):277.

um, Dallas, Texas, March, 1999.

**Dermabrasion:** This is a procedure that removes epidermis and superficial dermis in order to stimulate neo formation of collagen, elastic fibers, and ves‐ sels. **Radiofrequency:** The equipment can be regulated in ablative or nonabla‐ tive (heat in dermis results in collagen fibers contraction) mode. The main effect is contraction and remodeling of collagen fibers. **Chemical peels:** Most used products are: retinoic acid, alpha hydroxy acids, trichloroacetic acid, phenol, and resorcinol. Superficial and mid peels are indicated in pigmented lesions and fine wrinkles. Deep wrinkles need a deep peel. **External nasal lift‐ ing:** As we age, flaccidity and solar damage in nasal skin turns the tip down‐ ward, and its classical correction (rhinoplasty) deepens the nasal dorsum wrinkles. Incisions and skin resection is planned in the nasoglabellar area. **Subnasal lifting:** An open nasolabial angle creates disequilibrium between the lip and nose in the central face. A buffalo horn like resection in the im‐ plantation of the nasal ala in the lip solves this angle, restoring the loss bal‐ ance. **Treatment of vascular lesion with luminic energy:** Here we present our experience with nasal vascular lesions in the last 15 years. **Treatment of nasal vascular lesions through thermocoagulation with radiofrequency:** This tech‐ nique is indicated in vascular lesions smaller than 3 mm of diameter, and punctiform lesions as rubi nevus and telangiectasias. **Hair removal with LA‐ SER or IPL:** The hairs anagen period of the nasal tip and vestibule gets lon‐ ger as people age, turning hair to be unaesthetic.

**Keywords:** Chemical peels, dermabrasion, external nasal lifting, gravitational wrinkles, IPL in nasal area, LASER in nasal area, minimal invasive nasal procedure, nasal aesthet‐ ics, nasal aging, nasal dressings, nasal hair removal, nasal tip ptosis, nasal vascular le‐ sions, nasal wrinkles, nasolabial proportions, nonablative radiofrequency, phenol peel, radiofrequency in nasal area, selective photothermolysis, subnasal lifting

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **1. Introduction**

With aging, the nasal skin suffers the same changes as the rest of the face skin. The fact that it is medial and projected over the frontal plane makes it more vulnerable to sun radiation, having a greater risk of photoaging, preneoplastic and neoplastic lesions. As years go by, skin loses collagen fibers, elastic fibers, and subcutaneous tissue, losing volume and support. In this chapter, minimal invasive procedures for the solution of nasal skin aesthetic issues will be presented.

Caucasian thin skin tends to develop wrinkles earlier, while thicker skins develop them later. Women's skin is thinner and that is why it looks older than in a man of the same age. Smoking and sun exposure are main factors that contribute to the early development of wrinkles and sulcus. The use of heavy glasses over a long period of time can lead to skin sliding off the nasal bridge, creating wrinkles over the lateral wall of the nasal pyramid. In some cases, the material of glasses has generated chronic dermatitis.

Basically there are two types of wrinkles:


Expression wrinkles originate in mimic muscles activity, especially those superficial ones with insertions in skin around lip and eyes. The sphincter muscles such as the orbicularis oculi and orbicularis oris have mainly skin insertions and have a major function in expressing anger, worry, concentration, and other moods.

Gravity forces in any part of the face form the gravitational lines. As time passes, skin gets loose, falling over the forehead, brows, lids, nose, cheek, and neck. There is an important individual variation during this process. In the presence of atrophied skin, the aging process is faster.

As a general rule, expression wrinkles can be treated through external softening procedures or BOTOX®, and gravitational wrinkles with suspension procedures, fillers, or external lifting. There is a great amount of fillers: autologous or heterologous, absorbable or permanent. To stimulate the production of collagen, elastic fibers, and vessels, the superficial excision of epidermis and dermis can be used, creating a controlled lesion, that when healed leaves a more juvenile skin. This can be done through mechanical, chemical, physical, or electrical methods.

#### **2. Mechanical methods: Dermabrasion**

Dermabrasion is a very well-known technique [1] that was initially used for the treatment of unaesthetic scars (accidents, surgery, acne) and dysplastic lesions [2]. This procedure can be done with electrical instruments with abrasive tips of diamond or steel that spin at high speeds (Fig. 2) or water sandpaper previously sterilized (Fig. 1).

**Figure 1.** Materials employed in manual dermabration (left).

**1. Introduction**

126 Miniinvasive Techniques in Rhinoplasty

be presented.

of glasses has generated chronic dermatitis.

Basically there are two types of wrinkles:

worry, concentration, and other moods.

**2. Mechanical methods: Dermabrasion**

(Fig. 2) or water sandpaper previously sterilized (Fig. 1).

**1.** Expression wrinkles

is faster.

**2.** Gravitational wrinkles

With aging, the nasal skin suffers the same changes as the rest of the face skin. The fact that it is medial and projected over the frontal plane makes it more vulnerable to sun radiation, having a greater risk of photoaging, preneoplastic and neoplastic lesions. As years go by, skin loses collagen fibers, elastic fibers, and subcutaneous tissue, losing volume and support. In this chapter, minimal invasive procedures for the solution of nasal skin aesthetic issues will

Caucasian thin skin tends to develop wrinkles earlier, while thicker skins develop them later. Women's skin is thinner and that is why it looks older than in a man of the same age. Smoking and sun exposure are main factors that contribute to the early development of wrinkles and sulcus. The use of heavy glasses over a long period of time can lead to skin sliding off the nasal bridge, creating wrinkles over the lateral wall of the nasal pyramid. In some cases, the material

Expression wrinkles originate in mimic muscles activity, especially those superficial ones with insertions in skin around lip and eyes. The sphincter muscles such as the orbicularis oculi and orbicularis oris have mainly skin insertions and have a major function in expressing anger,

Gravity forces in any part of the face form the gravitational lines. As time passes, skin gets loose, falling over the forehead, brows, lids, nose, cheek, and neck. There is an important individual variation during this process. In the presence of atrophied skin, the aging process

As a general rule, expression wrinkles can be treated through external softening procedures or BOTOX®, and gravitational wrinkles with suspension procedures, fillers, or external lifting. There is a great amount of fillers: autologous or heterologous, absorbable or permanent. To stimulate the production of collagen, elastic fibers, and vessels, the superficial excision of epidermis and dermis can be used, creating a controlled lesion, that when healed leaves a more juvenile skin. This can be done through mechanical, chemical, physical, or electrical methods.

Dermabrasion is a very well-known technique [1] that was initially used for the treatment of unaesthetic scars (accidents, surgery, acne) and dysplastic lesions [2]. This procedure can be done with electrical instruments with abrasive tips of diamond or steel that spin at high speeds

**Figure 2.** Equipment for high-speed dermabrasion (right).

The results of dermabrasion are very gratifying and comparable to chemical or LASER abrasion (Fig. 3). It is important not be aggressive if inexperienced because deep abrasion leave unaesthetic scars. Most frequent complication is wound infection with bacteria or herpes, with which the wound deepens and permanent scars appear.

**Figure 3.** Dermabrasion with diamond tip.

**Figure 4.** Blood bed and hemostasis after silver nitrate action.

In most patients, after dermabrasion we apply silver nitrate 10% over the blood bed. As a complement to the treatment, biologic dressings can be used as plasma rich in platelets (PRP), to avoid fluid loss and accelerate the healing process[3] (Figs. 4 and 5).

The procedure can be repeated after four to six months. This is the elective treatment in initial rhinophyma.

**Figure 5.** Preoperative, and process until the elimination of crusts left by silver nitrate.

#### **3. Electric methods: Radiofrequency**

For treatment with radiosurgery, an electronic transistorized device that produces radiofre‐ quency waves is used [4]. This can be regulated to produce an ablative or nonablative treatment (a selective heating of the deep dermis promoting collagen fibers contraction). For the ablative treatment, we use a Surgitron 4.0 MHz of Ellman equipment with special needles and hand piece that adapt to the defect we need to correct. For the nonablative treatment, we use a Radiage hand piece, allowing us to stretch the skin without surgery (Fig. 6).

The most used radiofrequency nonablative treatment is done with Thermage equipment that produces monopolar capacitive radiofrequency. This system produces:


**Figure 4.** Blood bed and hemostasis after silver nitrate action.

**Figure 3.** Dermabrasion with diamond tip.

128 Miniinvasive Techniques in Rhinoplasty

rhinophyma.

In most patients, after dermabrasion we apply silver nitrate 10% over the blood bed. As a complement to the treatment, biologic dressings can be used as plasma rich in platelets (PRP),

The procedure can be repeated after four to six months. This is the elective treatment in initial

to avoid fluid loss and accelerate the healing process[3] (Figs. 4 and 5).


**Figure 6.** Ellman radiofrequency equipment.

The size and characteristics of the hand piece make its use in the nasal area difficult but using in the neighboring skin, a tightening effect is obtained in the nose.

Another equipment with which we have a positive experience is Accent of Alma Lasers that allows monopolar and bipolar modes, and has hand piece more adequate for the nose.

## **4. Chemical methods: Chemical peel**

There are many ways to stimulate skin regeneration with acids. Taking into account the deepness of the lesions we need to treat, we choose different products to obtain a superficial, mid, or deep peel. Most used products are:


**•** Resorcinol

Superficial and mid peels are useful for treating pigmented lesions and fine wrinkles of the nasal dorsum and tip, but in the presence of deep wrinkles a deep peel is needed.

Baker-Gordon [5] formula with phenol has been the most popular deep peel in the world, but the solution instability has the risk of provoking vicious scars. That is why we prefer a commercial formula known as Exoderm [6]. This formula, created by Yoram Fintsi [7] is a modification of the Baker formula with a neutralization system. In this way, it does not transgress the basal membrane of the skin, having lesser chances of heart or kidney toxicity (Fig. 7). The formula is composed of:


**Figure 7.** Commercial presentation of exoderm.

The principal indications are:


The size and characteristics of the hand piece make its use in the nasal area difficult but using

Another equipment with which we have a positive experience is Accent of Alma Lasers that allows monopolar and bipolar modes, and has hand piece more adequate for the nose.

There are many ways to stimulate skin regeneration with acids. Taking into account the deepness of the lesions we need to treat, we choose different products to obtain a superficial,

in the neighboring skin, a tightening effect is obtained in the nose.

**•** Alpha hydroxy acids, found in milk, fruits, and sugar (glycolic acid)

**4. Chemical methods: Chemical peel**

**Figure 6.** Ellman radiofrequency equipment.

130 Miniinvasive Techniques in Rhinoplasty

mid, or deep peel. Most used products are:

**•** Trichloroacetic acid (TCA)

**•** Phenol, in different concentrations

**•** Retinoic Acid, synthetic derived of vitamin A

**Figure 8.** Pre- and postexoderm treatment.


It is fundamental to clean the skin with acetone before applying phenol to remove the skin's sebaceous content. Sedation is recommended to avoid the burning sensation. When treating the frown, nasal dorsum or tip, we must include the entire aesthetic unit. Usually, we apply the product and wait for the frosting effect, which indicates epidermal proteins denaturing. Then we evaluate if more product is needed in the entire area or just deeper lesions. The treated area can be left open in contact with air or with an occlusive bandage. If the last is done, it has to be removed the next day. After this, we use a bismuth-based healing powder, which forms a green crust that adheres to the area for approximately seven days. On day six, the patient must start using liquid vaseline to remove the crusts.

If the indication was appropriate and the procedure correctly done, positive results are expected (Fig 8). Erythema can last for eight weeks and in white skins or atrophied skins even longer. Labial herpes, heart arrhythmia, and kidney failure are absolute contraindications for this procedure. The most frequent complications are milia (a very marked line between treated and untreated skin), hyperpigmentation, hypopigmentation, and labial herpes.

#### **5. External nasal lifting**

When the skin quality, laxity, or nasal deformity cannot be corrected with the exposed methods, a surgical external nasal lifting is needed. Aging in the face affects each and every aesthetic area [8]. The central situation of the nose in the facial frame and its importance in the facial profile make it a subject of frequent consultation in patients seeking rejuvenation.

In the nose, skin alterations caused by the lack of elasticity, excessive looseness, and solar damage, causes an increase in the length of the cutaneous coverage resulting in tip ptosis. These patients, generally over their seventies, have an inelastic skin with horizontal wrinkles in the nasal bridge and lateral walls. By placing with our fingers the tip in the right position wrinkles deepen and increase significantly. In these cases, suspension techniques or fillers are useless to solve the problem. For this reduced amount of patients, in which the noninvasive procedures have poor results, we recommend the external nasal lifting, using techniques previously described for reconstructive procedures [9].

**Figure 9.** Picture of external nasal lifting surgical procedure.

#### **5.1. Patient selection**

**•** Pigmented lesions and keratoacanthoma

**Figure 8.** Pre- and postexoderm treatment.

132 Miniinvasive Techniques in Rhinoplasty

must start using liquid vaseline to remove the crusts.

**5. External nasal lifting**

It is fundamental to clean the skin with acetone before applying phenol to remove the skin's sebaceous content. Sedation is recommended to avoid the burning sensation. When treating the frown, nasal dorsum or tip, we must include the entire aesthetic unit. Usually, we apply the product and wait for the frosting effect, which indicates epidermal proteins denaturing. Then we evaluate if more product is needed in the entire area or just deeper lesions. The treated area can be left open in contact with air or with an occlusive bandage. If the last is done, it has to be removed the next day. After this, we use a bismuth-based healing powder, which forms a green crust that adheres to the area for approximately seven days. On day six, the patient

If the indication was appropriate and the procedure correctly done, positive results are expected (Fig 8). Erythema can last for eight weeks and in white skins or atrophied skins even longer. Labial herpes, heart arrhythmia, and kidney failure are absolute contraindications for this procedure. The most frequent complications are milia (a very marked line between treated

When the skin quality, laxity, or nasal deformity cannot be corrected with the exposed methods, a surgical external nasal lifting is needed. Aging in the face affects each and every aesthetic area [8]. The central situation of the nose in the facial frame and its importance in the facial profile make it a subject of frequent consultation in patients seeking rejuvenation.

and untreated skin), hyperpigmentation, hypopigmentation, and labial herpes.

**•** Rhinophyma

The ideal candidates for this procedure are those with nasal tip ptosis caused by excessive skin looseness. These patients have usually important photoaging and are in their sixties or seventies.

#### **5.2. Procedure**

The main objective is to produce a shortening of the nasal length by resecting a block of skin over the nasal SMAS [10]. First, the skin to be removed is marked in ellipsoidal or inverted U form in the nasal bridge dorsum at the level of the medial canthus. Local infiltration is done with 1% Lidocaine with 1:100000 adrenalin in the nasal dorsum and the depressor septi nasi. The marked skin is resected respecting the SMAS plane [11]. After that we elevate a SMAS flap with inferior pedicle and we dissect below it until reaching the supratip area (Fig. 9). The SMAS flap is fixed to the periosteum of the nasofrontal joint with Nylon 5-0. Hemostasis is done. Closure is done deep with separated stitches of Monocryl 4-0 and superficial with a continuous intracuticular suture with Monocryl 4-0. Finally, to reduce the risk of relapse, a myotomy of the depressor septi nasi is done through a small incision in the nasal vestibule or through an intraoral approach [12, 13].

**Figure 10.** Before and after (8 years) external nasal lifting through previous scar. Frontal view.

We use occlusive bandage with micropore tape and thermomoldable plastic.

In general, the scar is acceptable from the aesthetic point of view and patients have a high degree of satisfaction with the procedure.

#### **5.3. Conclusions**

Nasal external lifting is a minimal invasive procedure, easy and fast to execute, without major complications. The combination with other facial rejuvenation surgical procedures does not increase significantly the surgical times (Figs. 10 and 11).

**Figure 11.** Before and after (8 years) external nasal lifting through previous scar. Lateral view.

## **6. Subnasal lifting**

Closure is done deep with separated stitches of Monocryl 4-0 and superficial with a continuous intracuticular suture with Monocryl 4-0. Finally, to reduce the risk of relapse, a myotomy of the depressor septi nasi is done through a small incision in the nasal vestibule or through an

**Figure 10.** Before and after (8 years) external nasal lifting through previous scar. Frontal view.

degree of satisfaction with the procedure.

increase significantly the surgical times (Figs. 10 and 11).

**5.3. Conclusions**

We use occlusive bandage with micropore tape and thermomoldable plastic.

In general, the scar is acceptable from the aesthetic point of view and patients have a high

Nasal external lifting is a minimal invasive procedure, easy and fast to execute, without major complications. The combination with other facial rejuvenation surgical procedures does not

intraoral approach [12, 13].

134 Miniinvasive Techniques in Rhinoplasty

A over-open nasolabial angle creates disharmony between the nose and the lip, generating an unaesthetic appearance of facial features. For patients with this problem we use the subnasal lifting technique, a simple, minimal invasive procedure and one of rapid recovery. It can be done under local anesthesia, reducing the nasolabial angle (treating the depressor septi nasi), shortening the upper lip, and the vermilion is everted. A great number of men request for this surgery.

**Figure 12.** Buffalo horn design for skin resection.

Marking is in the form of a buffalo horn and it must be kept inside the external limit of implantation of the nasal ala to avoid visible scars (Fig. 12). Local anesthesia is done through infiltration with 1% lidocaine with adrenalin 1:100000. The resection is done following the markings, as in Fig. 13. Skin and subcutaneous tissue are resected, taking care, mainly in men, not to leave follicular units of the mustache to avoid future cystic lesions. The depressor septi nasi is treated under direct vision according to their strength, by complete or partial resection. Hemostasis is done. Skin is closed with deep and superficial stitches of Monocryl 5/0. Micro‐ pore tape is applied. Even when this technique acts mostly in the upper lip, the effect is also seen in the nose, creating a new nasolabial balance (Figs. 13 and 14).

**Figure 13.** Before and after subnasal lifting. Frontal view.

**Figure 14.** Before and after subnasal lifting. Observe the nasolabial angle.

#### **7. Treatment of nasal vascular lesions with luminous energy**

#### **7.1. Introduction**

nasi is treated under direct vision according to their strength, by complete or partial resection. Hemostasis is done. Skin is closed with deep and superficial stitches of Monocryl 5/0. Micro‐ pore tape is applied. Even when this technique acts mostly in the upper lip, the effect is also

seen in the nose, creating a new nasolabial balance (Figs. 13 and 14).

136 Miniinvasive Techniques in Rhinoplasty

**Figure 13.** Before and after subnasal lifting. Frontal view.

**Figure 14.** Before and after subnasal lifting. Observe the nasolabial angle.

Nasal vascular lesions are a common cause of consultation in a plastic surgery clinic. For their study, a complete clinical history is important to make the correct diagnosis and, subsequently, the correct treatment. The population that requests the removal of these lesions is growing, so we must select the best method available to minimize side effects. Nowadays, the most used methods for the treatment of these lesions are radiofrequency and luminous energy.

Vascular lesions are classified into:

	- **◦** Hemangioma
	- **◦** Venous malformations
	- **◦** Port wine stains or nevus flammeus
	- **◦** Lymphangiomas
	- **◦** Telangiectasias
	- **◦** Venous lakes
	- **◦** Poikiloderma
	- **◦** Cherry angiomas
	- **◦** Pyogenic granuloma
	- **◦** Rubi nevus
	- **◦** Kaposi sarcoma
	- **◦** Unspecified erythema
	- **◦** Rosacea

In general, congenital lesions have origin in vascular endothelium, arterial, venous, capillary, or lymphatic. Most frequent locations are face, neck, and extremities, but it can be located in any part of the body. They are noticed at birth or in the first weeks of life and suffer involution during childhood.

Acquired lesions are vascular dilatations, usually venous, frequently localized in face and lower extremities. There are important factors that predispose to nasal vascular lesions:


Different equipments are used according to the origin, nature, location, size, and depth of the lesion. It is important to know the working principles of these equipments in order to take the best advantage possible of them.

#### **7.2. Luminous emission physical principles: History**

Two centuries ago, only luminous emission was known. Physicists such as Newton were the first to recognize the wavy characteristic of light. Years later, they discovered that different colors corresponded to different wavelengths. In 1903, N.R. Finsen was awarded the Nobel Prize for the treatment of vulgar lupus with ultraviolet light, initiating a new field in medicine: Photomedicine. The work published by Einstein in 1917 about the controlled management of light waves was the fundamental knowledge for working with LASERS. It was not until 1933 with the discovery of optical fiber that scientists started working in microwave amplification. In 1951, this technique was patented by Fabrikant, a Russian physicist, and the year after the first equipment was built called MASER (microwave amplification by stimulated emission of radiation). In 1958, Schawlow and Townes [14] published their work in microwave amplifi‐ cation by stimulated emission of radiation bringing two new concepts: monochromatic light and coherent light. In 1960 [15], the first Ruby LASER was installed in the Cincinnati Univer‐ sity. The first medical use of LASER was in ophthalmology. From there it had an exponential growth, reaching almost every field in medicine, with a great variety of equipments with different wavelength, frequency, and energy.

#### **7.3. Physical aspects of light and LASER radiation**

The transportation of energy in the form of particles generates waves with an electrical component and a magnetic one, resulting in electromagnetic radiation [16]. As these particles vary in their energy load, they have different wave length and frequency, thus completing the electromagnetic spectrum. Light is not more than electromagnetic radiation, transmitted by particles called photons, in the visible emission spectrum that has a wavelength between 300 and 700 nm.

The luminous system includes radiation with a wavelength between 200 and 1000000 nm, from ultraviolet to infrared. Most part of the radiation comes from the sun. So, radiation can be either natural (solar radiation) or artificial (LASERS and lamps). Both have emission in ultraviolet, visible, and infrared spectrum. The emission process can be coherent (LASER) or not coherent (solar light, lamps, LED).

#### **7.4. LASER radiation**

**•** Chronic treatments with steroids

Different equipments are used according to the origin, nature, location, size, and depth of the lesion. It is important to know the working principles of these equipments in order to take the

Two centuries ago, only luminous emission was known. Physicists such as Newton were the first to recognize the wavy characteristic of light. Years later, they discovered that different colors corresponded to different wavelengths. In 1903, N.R. Finsen was awarded the Nobel Prize for the treatment of vulgar lupus with ultraviolet light, initiating a new field in medicine: Photomedicine. The work published by Einstein in 1917 about the controlled management of light waves was the fundamental knowledge for working with LASERS. It was not until 1933 with the discovery of optical fiber that scientists started working in microwave amplification. In 1951, this technique was patented by Fabrikant, a Russian physicist, and the year after the first equipment was built called MASER (microwave amplification by stimulated emission of radiation). In 1958, Schawlow and Townes [14] published their work in microwave amplifi‐ cation by stimulated emission of radiation bringing two new concepts: monochromatic light and coherent light. In 1960 [15], the first Ruby LASER was installed in the Cincinnati Univer‐ sity. The first medical use of LASER was in ophthalmology. From there it had an exponential growth, reaching almost every field in medicine, with a great variety of equipments with

The transportation of energy in the form of particles generates waves with an electrical component and a magnetic one, resulting in electromagnetic radiation [16]. As these particles vary in their energy load, they have different wave length and frequency, thus completing the electromagnetic spectrum. Light is not more than electromagnetic radiation, transmitted by particles called photons, in the visible emission spectrum that has a wavelength between 300

The luminous system includes radiation with a wavelength between 200 and 1000000 nm, from ultraviolet to infrared. Most part of the radiation comes from the sun. So, radiation can be either natural (solar radiation) or artificial (LASERS and lamps). Both have emission in ultraviolet, visible, and infrared spectrum. The emission process can be coherent (LASER) or not coherent

**•** Pregnancy

**•** Infections

**•** Estrogen supplements

138 Miniinvasive Techniques in Rhinoplasty

best advantage possible of them.

**7.2. Luminous emission physical principles: History**

different wavelength, frequency, and energy.

**7.3. Physical aspects of light and LASER radiation**

**•** Alcohol

**•** Rosacea

and 700 nm.

(solar light, lamps, LED).

The word LASER [17] is an acronym of light amplification by stimulated emission of radiation. The characteristics of this light emission are: coherence, monochrome, directionality, intensity, and polarization. Basically, a LASER is composed by an energy source, an active medium whose molecules are exited (solid, liquid, or gas), and an amplifying system. The LASER is named after its active medium:


Reflecting surfaces, as mirrors, which have a multiplicative effect and direct photons, com‐ poses the amplifying system.

#### **7.5. Effects of light emission in tissue**

According to Grothus-Drayer law, the tissues are affected when they absorb the light, trans‐ forming it into thermal and biochemical energy. There is a long list of published investigations about the interaction between light and tissues. From the optical point of view, tissues are heterogeneous, so five effects can occur when an electromagnetic light hits them:


There is a great variation in medical application of LASERs because many different structures can be aimed with different equipments. There are some mathematical models that try to predict the light distribution among tissues. One of these is the Kubelka-Munk model, which provides information regarding the percentage of absorbed energy in different depth of tissue, according to tissue composition, attenuation coefficient, and absorption and dispersion phenomenon. These measurements and parameters are the fundamentals of selective photo‐ thermolysis and absorption of cellular photoreceptors.

#### **7.6. Selective photothermolysis**

In 1983, Anderson and Parish [18] discovered the light selective destruction of a structure known as chromophore or target, with minimal effects in neighboring tissue. This is based on the Thermal Relaxation Time, that is, the time necessary to reduce by 50% the maximum temperature obtained in the destruction of the structure. The effects will depend on the interaction of the following factors:


This mechanism is the foundation for the treatment of different lesions: pigmented, vascular, tattoos, tissue renovation, cutaneous remodeling, and hair removal. Through specific chro‐ mophores, as melanin and oxihemoglobin, light is absorbed provoking radical changes in tissue. The luminous effects can be classified in four groups:


Not all LASERs can produce these effects, and some noncoherent light sources, such as intense pulsed light (IPL), can produce some. Up to here, we have resumed the common characteristics of light emission equipments, coherent and noncoherent. Also the physics behind the LASER has been exposed in order to know which equipment to use according to the lesion structure that is being treated. In our practice, we have these equipments since 1998; in this chapter, we will share our experience in the treatment of nasal vascular lesions with:


The nasal vascular lesions that we have treated in the last 15 years include: plane angioma (cavernous, lobular, senile, serpinginous), facial telangiectasias, erythema, rosacea, and rubi nevus. A detailed clinical history is done taking into account the following:


#### **7.7. Technique**

**•** Wavelength

**•** Not thermal

**•** Type of lesions

**•** History of the lesions

**•** Previous treatments

**•** Pictures of the lesions

**•** Personal history **•** Family history

**•** Medication

**•** Type of skin

**•** Phototype **•** Localization

**•** Exposition time

**•** Fluency (or energy density)

140 Miniinvasive Techniques in Rhinoplasty

tissue. The luminous effects can be classified in four groups:

**•** Thermal, vaporization, and coagulation, most known and used

will share our experience in the treatment of nasal vascular lesions with:

**•** Polaris Syneron Diodo 780–980 nm combined with radiofrequency

nevus. A detailed clinical history is done taking into account the following:

**•** Electromechanic or photoacoustic: photodisruption

**•** Photoablation, mainly used in ophthalmology

**•** Deka Smartepil Nd YAG 1064nm

**•** Fotona XP Max Nd YAG 1064nm

This mechanism is the foundation for the treatment of different lesions: pigmented, vascular, tattoos, tissue renovation, cutaneous remodeling, and hair removal. Through specific chro‐ mophores, as melanin and oxihemoglobin, light is absorbed provoking radical changes in

Not all LASERs can produce these effects, and some noncoherent light sources, such as intense pulsed light (IPL), can produce some. Up to here, we have resumed the common characteristics of light emission equipments, coherent and noncoherent. Also the physics behind the LASER has been exposed in order to know which equipment to use according to the lesion structure that is being treated. In our practice, we have these equipments since 1998; in this chapter, we

The nasal vascular lesions that we have treated in the last 15 years include: plane angioma (cavernous, lobular, senile, serpinginous), facial telangiectasias, erythema, rosacea, and rubi The preparation for the treatment is common for any equipment. Pictures of the area are taken. The equipment is programmed with the correct parameters to treat a specific lesion. Both, the patient and the doctor, must wear protective glasses.

For the treatment of nasal telangiectasia small spot LASERs are preferred; with IPL it is harder to adapt the hand piece to the treatment. It is important to check after the first shot the response in the vascular walls and skin covering the vessel. According to that response, parameters are adjusted in order to obtain the best result with least collateral damage. Cooling the skin is not recommended because it causes vasoconstriction, removing oxihemoglobin (the aimed chromophore) from vessels (Fig. 15). This is a very extensive mistake, and we think it is because doctors or technicians use the same methodology as for other applications (hair removal, facial rejuvenation, tattoo removal) with fixed chromophores (melanin, ink) in which cooling is very effective in reducing pain and side effects. Once finished with the treatment, an immediate effect is observed; this percentage of improvement is written down in the clinical history, together with the equipment used and the parameters.

**Figure 15.** Nd:YAG LASER in nasal telangiectasia.

#### **7.8. Parameters**

According to the device equipments characteristics and the treatment to perform, they are used with different forms of energy, fluency, and pulse duration. The equipments we will discuss are the ones we have been using in the last 15 years, and the parameters are useful just for reference since each patient has a different requirement. The following data are for nasal telangiectasias. It is important to know, as treatment background, that limits of oxyhemoglobin absorption are between 418 and 577 nm, with a pulse duration of 10–20 ms.

#### *7.8.1. Deka Smartepil II*

With this equipment, there is a great variety of spots, we generally use a 2 mm one, wavelength of 1064 nm, maximum energy of 150 J/cm2 , pulse duration of 16 mseg, with time between pulses up to 300 mseg. Up to 7 mm spots can be used that allow higher fluency up to 200 J/cm2 , but in this area of the face we do not recommend it.

#### *7.8.2. Polaris Syneron ELOS*

This is the only equipment, in our practice, that allows luminous energy treatment simulta‐ neously with radiofrequency. Its power source is a diode, which produces a wavelength between 780 and 980 nm. Luminous energy can be used between 10 and 140 J/cm2 , and radiofrequency between 10 and 100 J/cm2 with a spot of 5 x 5 mm.

#### *7.8.3. Fotona XP II*

This is an Nd-Yag LASER, with a wavelength of 1064 nm, maximum energy of 120 J/cm2 , pulse duration between 5 and 200 mseg, and a 20 mm spot. This is the same equipment as for endolaser treatment of varicose veins (Fig. 16).

**Figure 16.** LASER FOTONA XP.

After the treatment is finished, cooling of the skin is done with ice or gel packs for a few minutes.

Apart from the mentioned equipments, there are others with the ability to produce selective photothermolysis:


#### **7.9. Posttreatment indications**

reference since each patient has a different requirement. The following data are for nasal telangiectasias. It is important to know, as treatment background, that limits of oxyhemoglobin

With this equipment, there is a great variety of spots, we generally use a 2 mm one, wavelength

This is the only equipment, in our practice, that allows luminous energy treatment simulta‐ neously with radiofrequency. Its power source is a diode, which produces a wavelength between 780 and 980 nm. Luminous energy can be used between 10 and 140 J/cm2

This is an Nd-Yag LASER, with a wavelength of 1064 nm, maximum energy of 120 J/cm2

duration between 5 and 200 mseg, and a 20 mm spot. This is the same equipment as for

with a spot of 5 x 5 mm.

up to 300 mseg. Up to 7 mm spots can be used that allow higher fluency up to 200 J/cm2

, pulse duration of 16 mseg, with time between pulses

, but

, and

, pulse

absorption are between 418 and 577 nm, with a pulse duration of 10–20 ms.

*7.8.1. Deka Smartepil II*

142 Miniinvasive Techniques in Rhinoplasty

*7.8.2. Polaris Syneron ELOS*

*7.8.3. Fotona XP II*

**Figure 16.** LASER FOTONA XP.

of 1064 nm, maximum energy of 150 J/cm2

radiofrequency between 10 and 100 J/cm2

endolaser treatment of varicose veins (Fig. 16).

in this area of the face we do not recommend it.

Indications and precautions are common for most equipments. Erythema can be experienced in the first hours and cooling devices usually solve it. The treated area should not be exposed to sun light, and tanning beds are forbidden for ten days after the treatment. Solar protection factor (SPF) over 40 should be used. If the patient has not experienced any complications, the treatment is repeated after day 21 until erasing of the lesion.

#### **7.10. Side effects and complications**

Complications of this treatment almost never end in permanent sequel. The most frequent side effect is erythema, which usually lasts between 6 and 48 hours after the treatment, disappearing spontaneously.

Vesicles of 1–3 mm can appear in the treated area; this is because vessels are very superficial, thus transmitting heat to the skin, or responding to an excess in the energy used. They usually heal spontaneously in few days. Steroid healing creams are recommended and sun exposure is forbidden.

The most serious complications are hypertrophic scars and keloids, but in the nasal area atrophic and hypopigmented scars are more frequent.

In the last years, there has been an important reduction of complications rate due to a better knowledge of this technology and of the biological response to it.

Prevention is essential: correct patient choice, avoiding tanned skins, complete knowledge of the equipment, and periodical equipment technical services. Constant training is necessary for personnel using the equipments. Following these principles, complications are reduced to a minimum, and the treatment turns safe and efficient.

Absolute contraindications for this treatment are:


#### **7.11. Conclusions**

The technical advances in LASER technology have made possible the treating of most skin vascular lesions. With the increase in energy density, wavelength, exposition time, the association of these parameters, and the added effect of radiofrequency, these equipments are entering every field of medicine. Constant training is needed in order to apply new technolo‐ gies with a safety margin for patients.

#### **8. Definitive hair removal with laser or IPL**

The follicular units of the nasal tip have an anagen period that enlarges with age, thus growing a thicker hair as the years go by. The same occurs with hair in the nasal vestibule, which is highly unaesthetic. Changing some parameters in the mentioned equipments, melanin can be aimed as chromophore. So, based on the selective photothermolysis principle, follicular units from the nasal tip, ala, and vestibule can be eliminated. Five to six sessions with a 45–60 days interval are needed in order to obtain a permanent reduction in the number of active follicles using LASER or IPL. The patient should not be tanned during the treatment in order to avoid burns and hypopigmentation.

#### **9. Radiofrequency thermocoagulation of nasal vascular lesions**

Radiofrequency (RF) is another type of energy that has been used to alter skin connective tissue. Its use in medicine has a history of more than 70 years, but recent equipments can deliver the energy selectively to the deep dermis and subdermis. In the late 1990s, equipments were adapted for skin ablation, generating plasma at different deepness of skin. Recently, this technology was reconfigured for nonablative use in aesthetic medicine. The impact of RF on skin depends on the tissue impedance (Ohms), the RF power (Watts), the exposition time (seg), and the electrode configuration.

The radiofrequency thermocoagulation technique allows erasing vascular punctate lesions smaller than 3 mm such as Ruby nevus, cuperosis, small varicose lesions, and telangiectasia. The treatment is based on the thermal effect of a high-frequency wave that is focused in a fine needle. The varicose lesion disappears instantly, leaving a wheal that is replaced later by crusts. A disposable Teflon-coated nickel or gold needle of 0.075 mm diameter is used (Fig. 17). This reduces chances of allergic reactions, and thermal diffusion.

The treatment can be performed in a private office; it usually lasts for 15–10 min, and the posttreatment indications are similar to the ones mentioned for LASER. Topical anesthesia creams or cooling devices can be used in order to reduce pain during the procedure.

**Figure 17.** Needles used for radiofrequency cauterization of nasal telangiectasia.

**•** Low platelets level

144 Miniinvasive Techniques in Rhinoplasty

**7.11. Conclusions**

**•** Convulsive syndrome triggered by light

The technical advances in LASER technology have made possible the treating of most skin vascular lesions. With the increase in energy density, wavelength, exposition time, the association of these parameters, and the added effect of radiofrequency, these equipments are entering every field of medicine. Constant training is needed in order to apply new technolo‐

The follicular units of the nasal tip have an anagen period that enlarges with age, thus growing a thicker hair as the years go by. The same occurs with hair in the nasal vestibule, which is highly unaesthetic. Changing some parameters in the mentioned equipments, melanin can be aimed as chromophore. So, based on the selective photothermolysis principle, follicular units from the nasal tip, ala, and vestibule can be eliminated. Five to six sessions with a 45–60 days interval are needed in order to obtain a permanent reduction in the number of active follicles using LASER or IPL. The patient should not be tanned during the treatment in order to avoid

Radiofrequency (RF) is another type of energy that has been used to alter skin connective tissue. Its use in medicine has a history of more than 70 years, but recent equipments can deliver the energy selectively to the deep dermis and subdermis. In the late 1990s, equipments were adapted for skin ablation, generating plasma at different deepness of skin. Recently, this technology was reconfigured for nonablative use in aesthetic medicine. The impact of RF on skin depends on the tissue impedance (Ohms), the RF power (Watts), the exposition time (seg),

The radiofrequency thermocoagulation technique allows erasing vascular punctate lesions smaller than 3 mm such as Ruby nevus, cuperosis, small varicose lesions, and telangiectasia. The treatment is based on the thermal effect of a high-frequency wave that is focused in a fine needle. The varicose lesion disappears instantly, leaving a wheal that is replaced later by crusts. A disposable Teflon-coated nickel or gold needle of 0.075 mm diameter is used (Fig. 17). This

**9. Radiofrequency thermocoagulation of nasal vascular lesions**

**•** Treatment with photosensitive drugs

gies with a safety margin for patients.

burns and hypopigmentation.

and the electrode configuration.

reduces chances of allergic reactions, and thermal diffusion.

**8. Definitive hair removal with laser or IPL**

**•** Phototype VI of Fitzpatrick

**Figure 18.** Before and after various auxiliary procedures for treatment of accident sequels.

**Figure 19.** Nasal ala reconstruction with auricular compound graft, complemented with dermabrasion and PMMA.

Thermocoagulation is a safe technique that selectively delivers energy to the vascular lesion, preserving the epidermis. This procedure can be done in every season, in any kind of skin, is not painful, and does not require posttreatment bandages. The only drawback is that in every site treated the patient will have for some days a crust, and for some patients this is socially unacceptable. Effectiveness is seen in the first session (Figs. 18 and 19).

### **Author details**

Guillermo Blugerman1\*, Diego Schavelzon1 , Gabriel Wexler2 and Roberto Schale1

\*Address all correspondence to: blugerman@centrosbys.com

1 Plastic Surgery Department of Centros ByS, Centros B&S de Excelencia en Cirugía Plástica, Argentina

2 Universidad Nacional del Nordeste, Argentina

Conflict of interest: none. Authorized consent was obtained from the patients included in the chapter.

#### **References**

**Figure 19.** Nasal ala reconstruction with auricular compound graft, complemented with dermabrasion and PMMA.

unacceptable. Effectiveness is seen in the first session (Figs. 18 and 19).

\*Address all correspondence to: blugerman@centrosbys.com

**Author details**

146 Miniinvasive Techniques in Rhinoplasty

Argentina

the chapter.

Guillermo Blugerman1\*, Diego Schavelzon1

2 Universidad Nacional del Nordeste, Argentina

Thermocoagulation is a safe technique that selectively delivers energy to the vascular lesion, preserving the epidermis. This procedure can be done in every season, in any kind of skin, is not painful, and does not require posttreatment bandages. The only drawback is that in every site treated the patient will have for some days a crust, and for some patients this is socially

, Gabriel Wexler2

1 Plastic Surgery Department of Centros ByS, Centros B&S de Excelencia en Cirugía Plástica,

Conflict of interest: none. Authorized consent was obtained from the patients included in

and Roberto Schale1

