**14. Preoperative planning**

The management of silicone-induced granuloma depends on the affected area; however, basically a doctor will first make a design planning. Next, the doctor will perform procedures according to the design or images and following the plan that has been discussed with the patient.

Depending on the occurring complication, we evaluate whether we need to remove the excessive skin from the nasal columella or should only perform curettage and subsequently install a nasal implant.

Mark the area that will be excised and the protruding granuloma on the dorsal of the nose; therefore, during the surgery we emphasize on the location where the curettage will take place. If we plan to place a solid nasal implant, then we need to make a midline to ensure the implant stays straight when the swelling occurs due to anesthetic drugs.

Depending on the problem, when the nasal dorsum has become wider along with inflammation and the damaged skin, an elliptical vertical excision can be performed on it (**Figure 5**).

**Figure 5.** *Elliptical excision of granuloma on the nasal skin.*

**Figure 6.** *Design of excision procedure to remove the excessive skin at columella area.*

During silicone injection, it is common to have a wider and descending skin at the area of nasal columella due to migration of silicone injection, which always run downward from the nose; therefore, a skin excision can be performed at lateral and dorsal areas of the nasal columella (**Figure 6**).

### **15. Technique**

After we have planned the management to overcome nasal problems, we subsequently transfer the plan into preoperative design images and subsequently perform an incision or excision following the plan.

#### **16. Design of nasal implant**

In some cases that require implants, the nasal implant is first carved before an excision is performed. Solid implant that has been commonly used is the L-shaped solid implant; however, other kinds of solid implant can also be used.

In making an implant, there are some guidelines on facial esthetics and architectural balance that should be considered.

The face can be divided into three zones with identical width. The first includes a horizontal line from the hairline to the eyebrow; the second horizontal line is from the eyebrow to the nasal base and menton; and the third horizontal line is the line from the nasal base to the end border of the chin.

The association between the lips and chin should be evaluated. The chin projection is determined by a vertical line drawn from a point of one and a half ideal length of the nose to the part of vermillion of the upper lip. The lower lip cannot be more than 2 mm posterior to this line. The position of chin varies extremely depending on sex. In women, the position is slightly posterior to the lower lips, while in men the position of the chin is in-line (**Figure 7**) [20, 21].

The implant is carved or made prior to anesthetic procedure following the guidelines of architectural balance and problems of nasal silicone granuloma as well as the patient's preferences. For nasal silicone granuloma cases, L-shaped nasal solid implant is used, and part of the nasal bridge is shaved so that it becomes slender since patients with granuloma due to silicone injection usually have wider nose and they want the nose become slender (**Figure 3**).

The height or the length of the implant is the midline border between the eye and eyebrow up to the nose. The crus of the implant must be measured following

**11**

*Management of Nasal Silicone Granuloma DOI: http://dx.doi.org/10.5772/intechopen.87188*

*Guidelines on measuring facial beauty and architectural balance.*

*L-shaped solid silicone implant. The edge is shaved so it becomes slender.*

**Figure 7.**

**Figure 8.**

the base of columella to the nose. Usually, the crus is made straight so that it can elevate the descending skin caused by silicone injection (**Figures 8** and **9**).

Incision is always made on a hidden area and follows the contour of Langer's line. The excision is made following preoperative design image, which is an elliptical excision on the nasal dorsum (**Figure 5**); the procedure is generally performed when the condition is very severe with inflammation and the skin is wrinkled and extremely wider. The risks of the procedure are the formation of thin vertical scar line on the nasal dorsum and dog-ear phenomenon at the end of excision. An accurate calculation before surgery is essential. It is suggested that the skin removal should not be too wide to prevent dog-ear phenomenon or we can place a nasal implant so that it seems firm and creates a better look. Excision can also be made on the area adjacent to excision cut in order to reduce granuloma around the lateral nose. The skin superior to the granuloma must be thick enough to maintain vascularization and a viable skin. Many patients do not want any lengthy scar along their nose; therefore, the management of nasal silicone granuloma only includes curettage, placement of implant, and excision of the excessive skin at columella area.

After the patient received anesthetics using lidocaine or xylocaine without adrenalin, we perform a skin excision at the columella area and remove the excessive skin on the lateral and dorsal columella; afterwards, we perfom undermining procedure inferior to the granuloma using a curved clamp starting from the nasal dorsum area to the nasal bridge near the glabella and lateral of nose depending on the occurring problem. Next, curettage is performed to remove the granuloma. The skin superior

*Cosmetic Surgery*

**15. Technique**

**Figure 6.**

During silicone injection, it is common to have a wider and descending skin at the area of nasal columella due to migration of silicone injection, which always run downward from the nose; therefore, a skin excision can be performed at lateral and

After we have planned the management to overcome nasal problems, we subsequently transfer the plan into preoperative design images and subsequently perform

In some cases that require implants, the nasal implant is first carved before an excision is performed. Solid implant that has been commonly used is the L-shaped

In making an implant, there are some guidelines on facial esthetics and architec-

The face can be divided into three zones with identical width. The first includes a horizontal line from the hairline to the eyebrow; the second horizontal line is from the eyebrow to the nasal base and menton; and the third horizontal line is the line

The association between the lips and chin should be evaluated. The chin projec-

tion is determined by a vertical line drawn from a point of one and a half ideal length of the nose to the part of vermillion of the upper lip. The lower lip cannot be more than 2 mm posterior to this line. The position of chin varies extremely depending on sex. In women, the position is slightly posterior to the lower lips,

The implant is carved or made prior to anesthetic procedure following the guidelines of architectural balance and problems of nasal silicone granuloma as well as the patient's preferences. For nasal silicone granuloma cases, L-shaped nasal solid implant is used, and part of the nasal bridge is shaved so that it becomes slender since patients with granuloma due to silicone injection usually have wider nose and

The height or the length of the implant is the midline border between the eye and eyebrow up to the nose. The crus of the implant must be measured following

solid implant; however, other kinds of solid implant can also be used.

while in men the position of the chin is in-line (**Figure 7**) [20, 21].

dorsal areas of the nasal columella (**Figure 6**).

*Design of excision procedure to remove the excessive skin at columella area.*

an incision or excision following the plan.

tural balance that should be considered.

from the nasal base to the end border of the chin.

they want the nose become slender (**Figure 3**).

**16. Design of nasal implant**

**10**

**Figure 7.** *Guidelines on measuring facial beauty and architectural balance.*

#### **Figure 8.** *L-shaped solid silicone implant. The edge is shaved so it becomes slender.*

the base of columella to the nose. Usually, the crus is made straight so that it can elevate the descending skin caused by silicone injection (**Figures 8** and **9**).

Incision is always made on a hidden area and follows the contour of Langer's line. The excision is made following preoperative design image, which is an elliptical excision on the nasal dorsum (**Figure 5**); the procedure is generally performed when the condition is very severe with inflammation and the skin is wrinkled and extremely wider. The risks of the procedure are the formation of thin vertical scar line on the nasal dorsum and dog-ear phenomenon at the end of excision. An accurate calculation before surgery is essential. It is suggested that the skin removal should not be too wide to prevent dog-ear phenomenon or we can place a nasal implant so that it seems firm and creates a better look. Excision can also be made on the area adjacent to excision cut in order to reduce granuloma around the lateral nose. The skin superior to the granuloma must be thick enough to maintain vascularization and a viable skin. Many patients do not want any lengthy scar along their nose; therefore, the management of nasal silicone granuloma only includes curettage, placement of implant, and excision of the excessive skin at columella area.

After the patient received anesthetics using lidocaine or xylocaine without adrenalin, we perform a skin excision at the columella area and remove the excessive skin on the lateral and dorsal columella; afterwards, we perfom undermining procedure inferior to the granuloma using a curved clamp starting from the nasal dorsum area to the nasal bridge near the glabella and lateral of nose depending on the occurring problem. Next, curettage is performed to remove the granuloma. The skin superior

#### **Figure 9.**

*Patients with silicone injection usually have wider columella area since liquid silicone will migrate downward due to gravity. Therefore, we have to remove the excessive skin of the lateral and the dorsal columella and place the implant to create a straight nose.*

to it must be thick enough and well-vascularized. In cases with remaining granuloma with thick fibrosis and those with difficulty in curettage, other modalities should be performed after surgical recovery period such as steroid injection.

To create a good-shaped nose, we remove the excessive skin at the columella area, and at the nasal bridge, we can place an implant so that the skin is firmer and the shape is cosmetically better. Nasal silicone implant is placed under the nasal skin at the curettage area, which has been previously occupied by silicone granuloma.

We can perform curettage to remove silicone and granuloma. In order to create a better superior nasal tip so that the nose seems straighter, we have two choices. The first choice is that we can place the implant under the skin, and at the area, the curettage is performed; or we can put sutures at the lateral area of superior tip of the nose from lateral columella with opposite direction as presented in the following video.

## **17. Postoperative management**


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*Management of Nasal Silicone Granuloma DOI: http://dx.doi.org/10.5772/intechopen.87188*

follow-up visit.

*shaping a straighter nose (b).*

**Figure 10.**

9.Avoid any trauma for 2 weeks.

10.Remove the stitches on day 10–14.

8.If there is a seroma, we can remove it by suctioning using syringe during the

*Patients with silicone injection usually have wider columella area (a). After the excessive skin of the lateral and the dorsal columella are removed and the implant is placed, the columella area will be more slender, thus* 

11.Have a normal diet, but avoid foods that cause excess lip movement such as apples and corn on the cob for 2 weeks after surgery (**Figure 10**).

The principle of therapy in managing patients with granuloma due to silicone injection is preventing the development of inflammation as it will cause extention of damage. Evacuation of silicone-induced granuloma should be performed since the liquid silicone in the tissue is persistent and will continuously induce immune response. Although the granuloma has been excised, the remaining silicone, which has migrated to all direction and has been absorbed in the skin, cannot be removed, and therefore, it may cause recurrent granuloma. The remaining inflammation, both

For granuloma or fibrosis that cannot be removed by surgical procedure, other modalities are required to treat the remaining fibrosis and inflammation that can

Some case reports suggest that to treat silicone-induced granuloma, intralesion injection can be used as well as topical treatment of pimecrolimus, which is applied two times daily for 3 months. Topical imiquimod can be used for 8 weeks as well as minoxillin, allopurinol, and oral prednisone at the dose of 30 mg/day [22, 23]. Results of those treatment have not been satisfying although intralesion injection of triamsinolone is more significant for treating the occurring inflammation [24].

Granuloma and remaining fibrosis may also be treated with subdermal injection of triamcinolone acetonide at a dose of 10 mg/ml or a combination of triamcinolone acetonide and 5-fluorouracil. Steroid injection can be performed at the earliest

The injection is performed once or twice weekly as many as five to seven times. The dose depends on the amount of remaining granuloma and fibrosis, and usually

**18. Adjunctive therapy to overcome other complications**

granuloma and fibrosis, requires further treatment.

**19. Fibrosis and remaining granuloma**

within 2 weeks after wound closure.

it is at dose of 0.2–0.4 cc per injection.

still be seen on the skin, i.e., skin redness and telangiectasia.

**Figure 10.**

*Cosmetic Surgery*

**Figure 9.**

*the implant to create a straight nose.*

to it must be thick enough and well-vascularized. In cases with remaining granuloma with thick fibrosis and those with difficulty in curettage, other modalities should be

*Patients with silicone injection usually have wider columella area since liquid silicone will migrate downward due to gravity. Therefore, we have to remove the excessive skin of the lateral and the dorsal columella and place* 

To create a good-shaped nose, we remove the excessive skin at the columella area, and at the nasal bridge, we can place an implant so that the skin is firmer and the shape is cosmetically better. Nasal silicone implant is placed under the nasal skin at the curettage area, which has been previously occupied by silicone granuloma. We can perform curettage to remove silicone and granuloma. In order to create a better superior nasal tip so that the nose seems straighter, we have two choices. The first choice is that we can place the implant under the skin, and at the area, the curettage is performed; or we can put sutures at the lateral area of superior tip of the nose from lateral columella with opposite direction as presented in the following video.

1.Use nasal splint or gauze for a week to prevent splint displacement.

5.Normal saline solution for the nose to overcome postsurgical nasal

6.To reduce swelling, apply cold compress to periorbital within the first

7.When sleeping, the patient should keep the head elevated approximately 45°.

performed after surgical recovery period such as steroid injection.

**17. Postoperative management**

congestion.

48 hours.

2.Prescribing antibiotics for 5–7 days.

3.Prescribing analgetics every 4–6 hours as necessary.

4.Prescribing anti-inflammatory drugs for 5–7 days.

**12**

*Patients with silicone injection usually have wider columella area (a). After the excessive skin of the lateral and the dorsal columella are removed and the implant is placed, the columella area will be more slender, thus shaping a straighter nose (b).*


## **18. Adjunctive therapy to overcome other complications**

The principle of therapy in managing patients with granuloma due to silicone injection is preventing the development of inflammation as it will cause extention of damage.

Evacuation of silicone-induced granuloma should be performed since the liquid silicone in the tissue is persistent and will continuously induce immune response. Although the granuloma has been excised, the remaining silicone, which has migrated to all direction and has been absorbed in the skin, cannot be removed, and therefore, it may cause recurrent granuloma. The remaining inflammation, both granuloma and fibrosis, requires further treatment.

For granuloma or fibrosis that cannot be removed by surgical procedure, other modalities are required to treat the remaining fibrosis and inflammation that can still be seen on the skin, i.e., skin redness and telangiectasia.

### **19. Fibrosis and remaining granuloma**

Some case reports suggest that to treat silicone-induced granuloma, intralesion injection can be used as well as topical treatment of pimecrolimus, which is applied two times daily for 3 months. Topical imiquimod can be used for 8 weeks as well as minoxillin, allopurinol, and oral prednisone at the dose of 30 mg/day [22, 23]. Results of those treatment have not been satisfying although intralesion injection of triamsinolone is more significant for treating the occurring inflammation [24].

Granuloma and remaining fibrosis may also be treated with subdermal injection of triamcinolone acetonide at a dose of 10 mg/ml or a combination of triamcinolone acetonide and 5-fluorouracil. Steroid injection can be performed at the earliest within 2 weeks after wound closure.

The injection is performed once or twice weekly as many as five to seven times. The dose depends on the amount of remaining granuloma and fibrosis, and usually it is at dose of 0.2–0.4 cc per injection.

Etanercept, which works on TNF-α receptor and Fc-IgG1 binding, has been reported providing good result for silicone granuloma [25–27]. The administration of this drug at the dose of 50 mg twice weekly or 25 mg of subcutaneous injection two times a week has offered relatively satisfying results [27].
