5/14/2020
LIVE WITH ROD J. ROHRICH , M. D. March 12‐13, 2021
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Staying Safe with Nasal Fillers During Covid - Role in Rhinoplasty (Preliminary)
Rod J. Rohrich, M.D., F.A.C.S.
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Staying Safe with Nasal Fillers During Covid - Role in Rhinoplasty (Preliminary)
Rod J. Rohrich, M.D., F.A.C.S.
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DISCLOSURES ● Book Royalties - Thieme Publishers
● Instrument Royalties - MICRINS
● Research/Expert Consultant - MTF/Allergan
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Fillers in Rhinoplasty Top 5 Cosmetic Medicine Procedures 5 Year Trend -Quick Facts
●Botulinum Toxin Type A ●Hyaluronic Acid Dermal Fillers ●Chemical Peels ●Laser Hair Removal ●Microdermabasion 8
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Fillers in Rhinoplasty Five Nasal Filler Indications
● Want to “Wear their Rhinoplasty”
● Cannot Afford Rhinoplasty
● “Bridge” to their Secondary/Tertiary Rhinoplasty
● Do Not Desire Nasal Surgery !
● Should not have any more Nasal Surgery!
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Fillers in Rhinoplasty
Dorsal Nasal Artery
Angular Artery Nasal Region Lateral Nasal Artery
Facial Artery
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Fillers in Rhinoplasty Danger Zones: Nose ● Vasculature superficial to SMAS
● Subdermal vascular system most prominent at tip
● Anastomoses with dorsal nasal and ophthalmic systems – embolic routes!
Rohrich, R.J., J.P. Gunter, and R.M. Friedman, Nasal tip blood supply: an anatomic study validating the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg, 1995.
Toriumi, D.M., et al., Vascular anatomy of the nose and the external rhinoplasty approach. Arch Otolaryngol Head Neck Surg, 1996. 122(1): p. 24-34. 8
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Fillers in Rhinoplasty Preventing and Treating Serious Filler Complications
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Fillers in Rhinoplasty PREVENTING FILLER COMPLICATIONS
● Inject Slow Low Pressure / Small Increments ● Inject Antegrade / Retrograde high risk areas using serial puncture ● Blunt or Small Bore Needle in high risk areas ● Know your Anatomy well
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Fillers in Rhinoplasty
Embolization Routes from the Nose!
Park, S.W., et al., Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. Am J Ophthalmol, 2012. 154(4): p. 653-662 e1.
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Fillers in Rhinoplasty
Blindness Caused by Cosmetic Filler Injection: A Review of Cause and Therapy
Carruthers, Jean D. A.; Fagien, Steve; Rohrich, Rod J.; Weinkle, Susan; Carruthers, Alastair Plastic and Reconstructive Surgery. 134(6):1197- 1201, December 2014. doi: 10.1097/PRS.0000000000000754
Fig. 1. Vascular anatomy of the periocular region. (Copyright Jean D. Carruthers, M.D., 2014.)
Copyright © 2015 Plastic and Reconstructive Surgery. Published by Lippincott Williams & Wilkins. 12
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Fillers in Rhinoplasty Managing Tissue Necrosis
● 6 days postinjection ● Hyaluronidase 10U/0.1 ml HA ● Injections 10-15 minute intervals ● Nitropaste TID ● PO aspirin ● Hyperbaric oxygen ● Close follow-up
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Fillers in Rhinoplasty
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Fillers in Rhinoplasty Managing Tissue Necrosis
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Fillers in Rhinoplasty NASAL FILLER COMPLICATION TREATMENT
● Flood area - Hyaluronidase (250- 300 U) repeat q 15 min until pink ● Aspirin 325mg ● ? Hyperbaric Oxygen - 3 to 5 days ● Keep area moist with TID Bactroban ● Monitor / see patient daily until healed
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Nasal FillerFillers Complicationin Rhinoplasty
Kurkjian, T.J., J. Ahmad, and R.J. Rohrich, Soft-tissue fillers in rhinoplasty. Plast Reconstr Surg, 2014. 133(2): p. 121e-6e. 17
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Fillers in Rhinoplasty NASAL FILLER -CONCLUSIONS
● 5 Specific Nasal Filler Indications ● Use Deep Incremental amounts- Hyaluronic Acid Fillers ● Stay in the Midline –Know Nasal Anatomy ● KEY ROLE OF INJECTOR! ● How to Manage/Prevent Complications- Role of Hyaluronidase
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Fillers in Rhinoplasty Staying Safe with Nasal Fillers During Covid - Role in Rhinoplasty (Preliminary)
Rod J. Rohrich, M.D., F.A.C.S.
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Fillers in Rhinoplasty Covid Minimum Standards- Nasal Fillers
● Screening ● Temperature ● N95 Masks ● Face Shields vs Protected Eye wear ● PPE ● Gloves
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Fillers in Rhinoplasty WASH YOUR HANDS!
Panel A: NO HAND WASHING Imprint of a health care worker's ungloved hand was obtained for culture after the worker had performed an abdominal examination of a patient. The pink colonies represent MRSA grown in culture from this handprint.
Panel B: AFTER USING CLEANSING ALCOHOL FOAM Another hand imprint was obtained after hand disinfection. The culture was negative for MRSA.
Donskey C and Eckstein B. N Engl J Med 2009;360:e3
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Fillers in Rhinoplasty SKIN PREP
● ALCOHOL
● CHLORHEXIDINE
● HYPOCHLOROUS ACID -HOCL
● BETADINE SOLUTION
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Fillers in Rhinoplasty SKIN PREP- mode of action
● ALCOHOL- 60-80% denatures cells
● CHLORHEXIDINE- cell disruption
● HYPOCHOLOUS ACID- inhibits mast cell degranulation
● BETADINE SOLUTION – Inhibits cellular reception/attachment – viral >bacterial
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Fillers in Rhinoplasty POVIDONE-IODINE =BETADINE
Povidone-iodine Povidone-iodine (iodine with the water-soluble polymer polyvinylpyrrolidone, PVP-I) Discovered in 1955 at the Industrial Toxicology Laboratories in Philadelphia
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Fillers in Rhinoplasty CHLORHEXIDINE
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Fillers in Rhinoplasty THE AVALANCHE TRIAL
Conclusion
The AVALANCHE trial
no clinically relevant or statistically significant difference between alcohol vs chlorhexidine for skin antisepsis for the prevention of surgical site infection
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Fillers in Rhinoplasty
The Science of Stabilizing Hypochlorous Microcyn™ (HOCl) Technology acid (HOCl)
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Fillers in Rhinoplasty “5” Actions of Hypochlorous Acid
Eradicates microorganisms - bacteria (including MRSA, VRE), viruses, fungus and spores
Reduces Inflammation- inhibition of mast cell degranulation . Reduce Itch and pain Increases Oxygenation to improve healing Break Down Biofilm
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Fillers in Rhinoplasty HOCl Action: Eradicates Micro-Organisms
● HOCl reacts with surface proteins, interfering with function of affected proteins. ● Transmembrane proteins transport nutrients; enzyme activity
● HOCl reacts with lipids in membrane, destabilizing cellular integrity leading to lysis.
● HOCl and reaction products penetrate cell wall and cell membrane, interfering with intracellular processes.
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HOCl Action : Anti-Inflammatory
Inhibition of Mast Cell Degranulation
Microcyn inhibits Mast Cell Degranulation It does not eliminate it – but reduces it Resulting in less inflammation and less redness
Medina et. al., 2006
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Fillers in Rhinoplasty Anti-Inflammatory Properties: Inhibition of Mast Cell Degranulation
Super-oxidized water prevents allergen- and calcium-induced mast cell degranulation for up to 8 hours after a single exposure
- Antigen + Antigen
Medina et. al., 2006
Medina-Tamayo, et.al., Nat’l Inst. of Rehab., Mexico City, 2005
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Fillers in Rhinoplasty CHLOROUS ACID- VIRUCIDAL
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Fillers in Rhinoplasty ANTIVIRAL VS ANTIBACTERIAL SKIN PREP OVERALL Chlorhexidine > Betadine Solution- Antibacterial
Chlorhexidine = Alcohol -Antibacterial
Hypochlorous Acid – Antibacterial/Antiviral
Betadine - Antiviral >> Anti- Bacterial only
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Fillers in Rhinoplasty BETADINE IS A BETTER ANTIVIRAL AGENT
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Fillers in Rhinoplasty
Betadine® Solution (povidone-iodine10%)
Antiseptic Non-Sterile Solution
A topical aqueous solution of 10% povidone-iodine
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Fillers in Rhinoplasty POVIDONE-IODINE AND CORONA VIRUS
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Fillers in Rhinoplasty
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Fillers in Rhinoplasty
NO SCIENTIFIC DATA
CHLORHEXIDINE ORAL RINSE (PERIDEX)
ANTIBACTERIAL >> ANTIVIRAL
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Fillers in Rhinoplasty
EVOLVING SCIENTIFIC DATA
TRANEXAMIC ACID SOLUTION/TABLETS
EXCELLENT ANTIVIRAL
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Fillers in Rhinoplasty PRE OP BETADINE /MOUTHWASH GARGLE
• BETADINE- 4:1 MOUTH GARGLE
• 15 SECOND MOUTH GARGLE
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Fillers in Rhinoplasty
4 : 1 Betadine /Alcohol Free Mouthwash Gargle
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Fillers in Rhinoplasty 4 : 1 Betadine / Mouthwash Gargle
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Fillers in Rhinoplasty
Betadine® Solution Swabsticks (povidone-iodine solution USP, 10%)
Antiseptic Non-Sterile Solution
Available in packages of 1 or 3 Swabsticks
Convenient, flexible rayon-tipped Swabsticks impregnated with 10% povidone-iodine solution
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Fillers in Rhinoplasty SKIN PREP
NASAL MUCOSA/NOSTRILS
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Fillers in Rhinoplasty SKIN PREP
NASAL MUCOSA/NOSTRILS
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Fillers in Rhinoplasty 4 CARDINAL PRINCIPLES- POST COVID NASAL FILLER SAFETY
ALWAYS STAY DEEP
STAY MIDLINE
CLOSE NOSTRILS
AVOID TOUCHING NASAL MUCOSA
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Fillers in Rhinoplasty NASAL FILLERS POST COVID SUMMARY
● BE SAFE ● ALL COVID PRECAUTIONS ● COVID NEGATIVE ● FULL PPE/ N95/ FACE MASKS ● SKIN PREP= CLORHEXIDINE ● NARES/NOSTRIL PREP= BETADINE SWABS
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Fillers in Rhinoplasty NASAL FILLERS POST COVID
● BE SAFE ● ALL COVID PRECAUTIONS ● COVID NEGATIVE ● FULL PPE/ N95/ FACE MASKS ● SKIN PREP= CLORHEXIDINE ● NARES/NOSTRIL PREP= BETADINE SWABS ● AVOID NASAL MUCOSA CONTACT IF POSSIBLE
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Fillers in Rhinoplasty NASAL FILLERS POST COVID
● FURTHER CLINICAL RESEARCH
● ROLE OF BETADINE NEEDS TO BE DELINEATED WITH PROSPECTIVE TRIALS
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Fillers in Rhinoplasty
Thank you
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