**20. Redness on the nasal skin**

When the silicone has entered into the skin, it can cause granuloma due to chronic inflammation. Although the granuloma has been removed, the remaining inflammation, e.g., redness on skin, still exists. One of them is redness due to neovascularization such as telangiectasia due to silicone block in the skin.

Nasal redness and telangiectasia can be reduced using laser treatment. To utilize laser for treatment, we need basic knowledge about the use of laser.

There are three characteristic properties of laser light: monochromatic light. The light contains only a single wavelength, which is determined by the magnitude of released energy. The light has coherent characteristic, and the photon moves regularly as it has the same wavefront to one another.

The light is highly directional. A laser light has a very tight beam that is dense, strong, and concentrated. The three abovementioned characteristics can be achieved since there is a process of stimulated emission.

A light is part of the spectrum of electromagnetic radiation with an energy known as photon, while the molecule that absorbs the light is called chromophore. The energy is transferred from photon entering into chromophore in the skin. After the energy is absorbed, the light can initiate photochemical reaction, heat up the tissue to the state of coagulation or evaporation, and can destroy or detonate tissue structure through extremely rapid localized heating.

Laser is an instrument that produces light beam with certain wavelength or color that is very parallel and coherent. The light wavelength is absorbed maximally by the component of the treated skin. When the absorption characteristics of the target tissue accurately meet the most ideal wavelength, it will develop maximum specificity of laser to tissue interaction.

The mechanism of action of laser is consistent with specific chromophore with certain wavelength. There are three major chromophores in the body, which are hemoglobin, pigment, and water. For redness and telangiectasia cases, we use laser, which mostly works on hemoglobin. The wavelength of laser must be adjusted to the existing problem. Laser light enters the target area on the skin, and subsequently the light is absorbed by specific blood vessel in the skin causing damage on the target blood vessel that contains hemoglobin without injuring the surrounding tissue. We need basic knowledge to perform safer use of laser [28, 29].

In addition to chromophore, we also need to know about thermal relaxation time (TRT). TRT is the time it takes for a target substance to cool half the temperature needed for heating the target without increasing the temperature of surrounding tissue. In order to perform safe procedure, the fluence of a laser pulse must be high enough to heat the target, and the pulse duration must be shorter than the TRT of the target. Each target has its own TRT. For blood vessel, which has TRT up to microseconds, we need long pulse duration; therefore, we should use the longpulse Nd:Yag laser instead of the QS Nd:Yag laser, which only has pulse duration of nanoseconds. QS Nd:Yag is usually used for tattoo removal.

Laser works based on the selective photothermolysis principle. In this case, it can be used for hemoglobin to treat redness due to the silicone injection. Some lasers that can also be used are vascular laser such as pulse dye laser (PDL) or long-pulse Nd:Yag [30, 31].

**15**

**Figure 11.**

*telangiectasia are reduced (b).*

heal in 2–3 months.

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

other vascular disorders at the dose of 6–8 J/cm2

according to Fitzpatrick classification [30].

A previous study shows that pulse dye laser (PDL) with a wavelength of 595 nm

every 8 weeks. To prevent side

can be used for vascular disorder such as angioma, port-wine stain, rosacea, or

effect, cooling is always performed before laser procedure; some instruments have already had a cryo cooler. The side effects of post-PDL laser treatment are bruising, crust, post-inflammatory hyperpigmentation, particularly for skin types 3–6

Long-pulse Nd:Yag laser with a wavelength of 1064 nm is also good for treatment of vascular disorder. For deeper vascular disorders and those abnormalities in patients with dark skin types such as the Fitzpatrick skin types 3–6, the instrument will give greater advantages because the 1064 nm wavelength is usually used for pigment chromophore. In contrast, the instrument also has lower safety limit as poor cooling process can often burn the skin. Side effects of long-pulse Nd:Yag laser are bullae, crust, post-inflammatory hyperpigmenta-tion, and scar [31, 32]. In utilizing the long-pulse Nd:Yag laser, we need to set the pulse duration. In silicone-induced disorders, there will be redness on the skin, and one of them is telangiectasia that requires higher dose but lower pulse duration (**Figure 11**).

In erythematous skin cases, the long-pulse Nd:Yag laser with a wavelength of 1064 nm, at dose of approximately 100 J, spot size of 4, and pulse duration of 10 ms, can be used. For telangiectasia, the power is approximately of 180 J, a spot size of 2, and pulse duration of 5 ms. Sufficient cooling before and after laser procedure should be done, either by using ice pack, air cooling, cryo, or other methods. The laser treatment should be started at a low dose, and the dose is increased gradually for each visit until a change can be observed. The target does not diminish instantly;

For a necrotic skin, skin excision on the nasal dorsum is usually done, which is followed by curettage of the surrounding area. We usually clean up the necrotic area and performed wound care, open wound healing enhanced with topical medication that can induce granulation, laser diode, PRP, or others. In general, the wound will

the color does not always change rapidly; sometimes it only becomes paler.

*Illustration of a patient's skin due to complication of silicone injection on the nasal skin; there is an erythematous skin, and among them, there is a telangiectasia (a). After Nd:Yag laser, the reddish skin and* 

**21. Pitfalls and the management**

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

*Cosmetic Surgery*

**20. Redness on the nasal skin**

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

When the silicone has entered into the skin, it can cause granuloma due to chronic inflammation. Although the granuloma has been removed, the remaining inflammation, e.g., redness on skin, still exists. One of them is redness due to

Nasal redness and telangiectasia can be reduced using laser treatment. To utilize

There are three characteristic properties of laser light: monochromatic light. The light contains only a single wavelength, which is determined by the magnitude of released energy. The light has coherent characteristic, and the photon moves

The light is highly directional. A laser light has a very tight beam that is dense,

A light is part of the spectrum of electromagnetic radiation with an energy known as photon, while the molecule that absorbs the light is called chromophore. The energy is transferred from photon entering into chromophore in the skin. After the energy is absorbed, the light can initiate photochemical reaction, heat up the tissue to the state of coagulation or evaporation, and can destroy or detonate tissue

Laser is an instrument that produces light beam with certain wavelength or color that is very parallel and coherent. The light wavelength is absorbed maximally by the component of the treated skin. When the absorption characteristics of the target tissue accurately meet the most ideal wavelength, it will develop maximum

The mechanism of action of laser is consistent with specific chromophore with certain wavelength. There are three major chromophores in the body, which are hemoglobin, pigment, and water. For redness and telangiectasia cases, we use laser, which mostly works on hemoglobin. The wavelength of laser must be adjusted to the existing problem. Laser light enters the target area on the skin, and subsequently the light is absorbed by specific blood vessel in the skin causing damage on the target blood vessel that contains hemoglobin without injuring the surrounding

In addition to chromophore, we also need to know about thermal relaxation time (TRT). TRT is the time it takes for a target substance to cool half the temperature needed for heating the target without increasing the temperature of surrounding tissue. In order to perform safe procedure, the fluence of a laser pulse must be high enough to heat the target, and the pulse duration must be shorter than the TRT of the target. Each target has its own TRT. For blood vessel, which has TRT up to microseconds, we need long pulse duration; therefore, we should use the longpulse Nd:Yag laser instead of the QS Nd:Yag laser, which only has pulse duration of

Laser works based on the selective photothermolysis principle. In this case, it can be used for hemoglobin to treat redness due to the silicone injection. Some lasers that can also be used are vascular laser such as pulse dye laser (PDL) or long-pulse

tissue. We need basic knowledge to perform safer use of laser [28, 29].

nanoseconds. QS Nd:Yag is usually used for tattoo removal.

strong, and concentrated. The three abovementioned characteristics can be

neovascularization such as telangiectasia due to silicone block in the skin.

laser for treatment, we need basic knowledge about the use of laser.

regularly as it has the same wavefront to one another.

achieved since there is a process of stimulated emission.

structure through extremely rapid localized heating.

specificity of laser to tissue interaction.

two times a week has offered relatively satisfying results [27].

**14**

Nd:Yag [30, 31].

A previous study shows that pulse dye laser (PDL) with a wavelength of 595 nm can be used for vascular disorder such as angioma, port-wine stain, rosacea, or other vascular disorders at the dose of 6–8 J/cm2 every 8 weeks. To prevent side effect, cooling is always performed before laser procedure; some instruments have already had a cryo cooler. The side effects of post-PDL laser treatment are bruising, crust, post-inflammatory hyperpigmentation, particularly for skin types 3–6 according to Fitzpatrick classification [30].

Long-pulse Nd:Yag laser with a wavelength of 1064 nm is also good for treatment of vascular disorder. For deeper vascular disorders and those abnormalities in patients with dark skin types such as the Fitzpatrick skin types 3–6, the instrument will give greater advantages because the 1064 nm wavelength is usually used for pigment chromophore. In contrast, the instrument also has lower safety limit as poor cooling process can often burn the skin. Side effects of long-pulse Nd:Yag laser are bullae, crust, post-inflammatory hyperpigmenta-tion, and scar [31, 32].

In utilizing the long-pulse Nd:Yag laser, we need to set the pulse duration. In silicone-induced disorders, there will be redness on the skin, and one of them is telangiectasia that requires higher dose but lower pulse duration (**Figure 11**).

#### **Figure 11.**

*Illustration of a patient's skin due to complication of silicone injection on the nasal skin; there is an erythematous skin, and among them, there is a telangiectasia (a). After Nd:Yag laser, the reddish skin and telangiectasia are reduced (b).*

In erythematous skin cases, the long-pulse Nd:Yag laser with a wavelength of 1064 nm, at dose of approximately 100 J, spot size of 4, and pulse duration of 10 ms, can be used. For telangiectasia, the power is approximately of 180 J, a spot size of 2, and pulse duration of 5 ms. Sufficient cooling before and after laser procedure should be done, either by using ice pack, air cooling, cryo, or other methods. The laser treatment should be started at a low dose, and the dose is increased gradually for each visit until a change can be observed. The target does not diminish instantly; the color does not always change rapidly; sometimes it only becomes paler.

### **21. Pitfalls and the management**

For a necrotic skin, skin excision on the nasal dorsum is usually done, which is followed by curettage of the surrounding area. We usually clean up the necrotic area and performed wound care, open wound healing enhanced with topical medication that can induce granulation, laser diode, PRP, or others. In general, the wound will heal in 2–3 months.

Excessive granuloma or extensive fibrotic area occurs due to a hard necrotic skin, which creates difficulty in curettage. We can repeat the curettage procedure after a few months, which is followed by steroid injection. For less good-looking nose, excision procedure of the remaining skin can be repeated.

The skin can be burnt due to laser treatment for removing redness or telangiectasia for nasal area. Sufficient cooling before and after laser procedure should be done immediately. Sometime a strong topical steroid such as clobetasol propionate can be applied directly onto the skin after the laser procedure.
