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PST 015: Five Minute Nose Job — Read the Transcript

June 24, 2018

Listen to the full audio here

Welcome to Plastic Surgery Talk with Doctor Stephen Mulholland, brought to you by SpaMedica in Toronto, Canada, where we have another podcast episode on the five minute nose job.

What is the five minute nose job? I get asked that very frequently. It is the same as an injectable rhinoplasty, your injectable nose job. It’s the use of soft tissue fillers, different types of fillers, to achieve an improvement in the shape and structure of the nose to improve nasal facial balance and harmony.

How long can you expect your five minute nose job or injector rhinoplasty to last?

Well, that depends on the type of soft tissue filler that’s deployed. If we have two broad categories of fillers that we use in five minute nose jobs.

There’s group A fillers, which are the simple sugar gels, hyaluronic acid gels, like Juvederm, Restylane , Teoxane , Esthélis. These sugar gels break down over time and, in general, you can anticipate the improvement in your five minute nose job to last about one year when you use products that Juvederm, Voluma, Restylane, Perlane, those types of products.

There’s also another class of soft tissue fillers or dermal fillers that are call the particulate biostimulants. A very fancy word for “They stimulate the body to make its own collagen.” And these fillers are, the effects of the fillers, that make the body’s own collagen will last for three to five years or more.

And those include things like Articol, also called Bellafill, Radiesse or Sculptra. Radiesse are little particles of calcium hydroxylapatite. Articol, Artefill, Bellafill are little particles of polymethylmethacrylate. And Sculptra are little injectable particles of polylactic acid. And each one of these little particles when injected stimulates a host response in the soft tissue of your nose to make collagen. And of course, then, it’s the collagen that lasts over several years and not the product itself.

So, the five minute nose job. We use soft tissue fillers to create contort and shape, to improve the appearance of your nose. We can use products, like Juvederm, Restylane, that last up to a year, or products that last longer than a year, may last many years, ’cause they stimulate your own collagen.

So, what kinds of problems can we address, fix and improve with the five minute nose job?

Well, I divide them into clinical appearance issues. five minute nose job does great for a bridge bump. If you have bridge bump, a little bump on the bridge of your nose, a hump, which is a very common anatomic variant, that can be fixed very nicely with a five minute nose job. We use a little bit of filler above the bump and below the bump and we raise the bridge till the bridge looks smoother.

Next most common problem fixed with the five minute nose job is a bridge scoop, the opposite of a bump. You actually have a ski jump or under-projected bridge. That can be ’cause you’re born with a weak bridge, it can be ’cause you had a rhinoplasty that overdid it, took the bump down, or trauma. So bridge scoops are beautifully fixed with the five minute nose job.

The next improvement can be achieve is a bulbous tip, a button nose, where we use the soft tissue filler to create more definition to the tip.

The other variant that can be improved nicely with a five minute nose job is a plunging tip. Patients who smile and their tip go, “Bing, bing,” and kinda dip down like those birds that dip into the water. And these plunging tips are improved by soft tissue fillers in elevating the tip itself. And that can be a nice phenotype or a rhinoplasty appearance that can be improved with injections.

The next is what’s call the retracted columella, or the partition between the nostrils that doesn’t project low enough, can be improved with soft tissue fillers in the five minute nose job.

Crooked noses, noses that go off to the side, are beautifully enhanced with an injection rhinoplasty. Sometimes, nostrils that flare can be improved by injecting at the base of the nose. That restricts the amount of excursion the nostrils are allowed. And that can be improved with the five minute nose job.

All these variants don’t usually occur unto themselves. Often, you’ll have a bridge bump and a plunging tip, or a bulbous nose and a weak bridge, or you have a retracted columella. All these usually come in groups. And by being accessed by a physician who’s got a lot of experience in both rhinoplasty or injection rhinoplasty, I think you can arrive at the right injection pattern treatment for you.

I often get asked by patients, “If I do a five minute nose job, am I gonna be able to come back one day and do a surgical rhinoplasty if I want?” And the answer is “Yes, probably, depending on the filler. And sometimes, not advisably, if you use a long term filler.”

So let’s analyze that answer. Well, if you’re fixing a bridge bump or a bridge scoop or a bulbous tip or a plunging tip or retracted columella or a crooked nose with a five minute nose job and I use Juvederm and Voluma. In one year it’s gonna be gone. The soft tissue is healthy and pliable. Yes, absolutely, then you can do a surgical rhinoplasty.

There are patients like that. They will see me, we talk about the options, they opt for a quick fix. The five minute nose job allows them to live for about a year with a difference nasal facial balance and proportion, looking at the selfies and the photos and asses, “Do I really like my nose straighter? Do I like my tip more defined?” And once they have a comfortable level with that, they can then, as the product wears off, switch to the five minute nose job to the rhinoplasty.

Sometimes they wanna convert to the surgery before the product is gone. Or sometimes the product … Like Voluma sometimes last 18 moths or 2 years. I can see the patient back, your positioning, and inject a little enzyme, which is an antidote to the HA gel sugar filler, and the Juvederm and the Restylane washes away. And three to four weeks later, you can do your rhinoplasty.

Now, if you go the other route and if you use something like Radiesse, Sculptra, Articol, that leads to very thick collagenous fibers. It should last many years. Sometimes, there’s too much adherent tissue to lift the nasal skin up and do a successful rhinoplasty. So be very cautious when you use soft tissue fillers that have a permanent nature to them, like Radiesse, Sculptra, Articol. They’re good for long term to permanent corrections of small defects like a nasal bridge bump, but it may render your nose unable to convert from the injectable to the surgical rhinoplasty.

Are there different filler options for your five minute nose job?

I get that question a lot. And absolutely, you can select the filler for the longevity, the result you want to achieve. And so, you can divide into two groups of filler options. The soft tissue sugar gels, the most commonly injector fillers on the planet, including Juvederm, Restylane, products like  Esthélis and Teoxane.

These are soft tissue sugar gels that will last about a year. And they can be used to correct the bridge, the tip, a crooked nose, a plunging tip, retracted columellas, safe in the knowledge that over one year, sometimes a little longer ’cause the nose doesn’t move a lot.

Without a lot of movement the products like fillers tend to stay longer. And in animated body parts and face parts like lips and smile lines that move a lot, the product breaks down faster. The nose doesn’t have a lot of movement, so it’s very common to get 12, 14, 16 months out of the filler.

And so, those are good products ’cause you get a long term result but they go away. They’re also good products ’cause you can do a rhinoplasty after soft tissue filler rhinoplasty or injection rhinoplasty done with the sugar gels.

The other product category or group are the particulate biostimulants. These are products that when injected stimulate the body’s own collagen. They last for years. They form a much stickier fibrotic substrate, so it’s very hard to do a rhinoplasty after. So you wanna be cautious to ensure you never wanna do a rhinoplasty after your injection treatment with products like Articol, Radiesse or Sculptra.

Articol is polymethylmethacrylate beads that stimulate the production or collagen. It also goes under the name Bellafill or Artefill. Radiesse is calcium hydroxylapatite, also stimulates collagen production. And Sculptra is polylactic acid. All these little particles from these three products, Sculptra, Radiesse, Articol, stimulate your own collagen. They give a nice long term result, but you can’t easily go back and do a surgical rhinoplasty after those products.

In some international markets, you can actually find liquid medical silicone. And that’s a soft gel that lasts forever. It’s just … It’s illegal to use silicone in Canada or the United States on medical problems like an injection rhinoplasty. In some areas in the world, you can inject liquid silicone in small amounts in the nasal bridge and that will last again many, many, many years.

So lots of product options. You have to go to a certified physician to find out which product works best for your five minute nose job.

Is there an age restriction on getting this five minute nose job procedure?

In actuality, no. There’s no age restriction other than common sense. So, if you’re a voting adult and you’ve thought about the risks and benefits, you wanna do a five minute nose job or injection rhinoplasty. Yeah, of course you can do that ’cause you’ve been mature enough to analyze the risks, the benefits and the outcomes.

However, if you have a bridge bump or bridge scoop or crooked nose and you’re 14, 15 or 16, your nose hasn’t finish growing. So you’re not a candidate for surgical rhinoplasty. Yes, you could do a five minute nose job. However, now, we’re doing a cosmetic treatment on a teenager. And teenagers are hard enough to come to terms with maturity and a self-image and a healthy, confident perception of yourself without adding cosmetic treatment. So, I’d be very cautious, for those very reasons, on injecting a teenager. There’s not anatomic or physical reason why you couldn’t. And if they have a traumatic defect or a really hereditary abnormality that’s quite unattractive, a five minute nose job in your middle teen years might be just the thing to give you the confidence until your nose has finished growing and you do a rhinoplasty when you’re a little more mature.

So, it’s not that I don’t inject an adolescent. I make sure I’m with the parents, that the parental-adolescent decision making process is founded on practicality and on a plan that includes a temporary treatment, like the five minute nose job, and maybe transitioning to skeletal and emotional maturity to rhinoplasty at 18 or 19.

When would I advice a nonsurgical five minute nose job over surgical rhinoplasty?

There’re time when it becomes the indicative treatment of choice. And usually, the best result is always gonna be a nose job. I kinda recommend that as the treatment of choice for anyone with a nasal facial unbalance that they don’t like.

However, if they are completely resistant to the concept of surgery. They’re afraid, they’re medically unwell. If they’re expectations exceed what a rhinoplasty could do, if they’re unaccepting of recovery and the concept of risk, then perhaps I would suggest to them that the proper indication for them is gonna be a five minute nose job.

So people with unrealistic expectations, with a fear of surgery, with an inability to appreciate expectations that are realistic are far better off to treat them with a five minute nose job.

For someone, let’s say that’s had a previous nose job that hasn’t gone so well and they’re in that early three or four or five months phase. Sometimes the irregularity from the nose job can be fixed and supported with a five minute nose job, and the injection rhinoplasty will sustain them for that one year it takes to settle before they can do the revision rhinoplasty. So as a bridging problem for a postsurgical contra-regularity until they’re ready for their revision, soft tissue fillers and the injection rhinoplasty is often the best option for them.

And so, often the five minute nose job is best suited for those patients that don’t want surgery, never gonna have surgery, afraid of having surgery, not good candidates for surgery, don’t have the recovery time allotted that’s required after a nose job, or they’re waiting for their enhancement surgery and just trying to improve their appearance while that waiting is occurring. Those are the best indications for ensuring patients are considering their five minute nose job over surgical rhinoplasty.

When patients frequently ask me, “What’s gonna happen to the filler after it’s injected in my nose?” So, what’s the disposition and break down pathway for these products?

As for the sugar gels, Juvederm, Restylane, Perlane, Emervel, Teoxane, Esthélis, the simple sugar gels. They’re broken down by the body’s natural pathways. So, they’re little sugar molecules held together by cross-linking. And over many, many months, a year or more, your body breaks down those sugar molecules into component parts. They’re broken down into water and carbon dioxide, and processed by your liver and your kidney. Very safe process.

For the more long term biostimulants like calcium hydroxylapatite, Articol, Artefill, Radiesse, the component polymers are broken down by other enzymes very slowly over 6, 12, 18 months. And as those artificial injectable molecules are broken down, they have been replaced by your own collagen. And then, the collagen is broken down very slowly over years by an enzyme called collagenase, which is present in your body and breaks down collagen.

And so, ultimately, all these products commonly available in Canada are eventually eliminated or replaced. They’re all safe. There’s no toxicity to your liver, your kidney or any other organ. And there’s very little risk of allergic or localized reaction to the products.

Are there any risks to the five minute nose job?

Well, like everything in medicine, there’s always a risk. They’re rare. The risk of a complication that’s serious is rare following injection rhinoplasty. But there’s one serious risk that is very rare that needs to be discussed with every patient. And that is the very rare risk of a vascular occlusion and necrosis, the death of nasal tip skin, or the injection to the nasal root, embolization of the injectable particulates to the back of the eye and blindness.

So localized vascular occlusion or embolism of these little particles to other areas of the face, particularly the retina, is the principal extremely rare risk but extremely catastrophic. So it can lead to necrosis of tissue and scar or localized blindness at the back of the retina.

How do we minimize these catastrophic, conjunctival complications?

Small volume injections, low pressure, don’t use sharp needles. I use microcannula in the nose, and the knowledge of where the vascular arcades, the largest vessels, are and avoiding them. So although the catastrophic complications that we talked about, blindness and necrosis, occur, they should be exceedingly rare but always addressed during the consultation with the patient.

Other complications that are less catastrophic that should be discuss with the patient include things like swelling. A little too much product ’cause there’s always a little hydrophilia, meaning these little gels acts as a sponge and they absorb your own interstitial fluid. And what looks like a bridge correction that’s nice, over a few weeks can be a little bit too much. And then we can use the enzyme, not to wash out the entire product, but as a small antidote to reduce the soft tissue fillers effect in certain areas. And so, an adjustment at one month is not an uncommon side effect of injection rhinoplasty. And sometimes the adjustment is not taking the product down but adding just a little bit more to get the desire result.

So, swelling, bruising, inadequate correction or over correction are all complications that either go away or can be adjusted.

So, what’s the relative cost of a five minute nose job injection rhinoplasty compared to, let’s say, a surgical rhinoplasty?

In general, the syringes and product that are used throughout the country in Canada and the United States are gonna be syringes of Juvederm and Voluma. That might cost you, depending on the practice, between six, seven, eight, or nine hundred dollars per syringe. In general, it takes one to two syringes to correct most five minute nose job injection rhinoplasty patients. And that means you’re look at approximately 15 hundred to 19 hundred dollars for the five minute nose job, to get one to one and a half years of improvement.

Now, if you compare that to a surgical rhinoplasty, which may range from 5,000, 8,000, 10,000, 12,000 dollars, is a fraction of the surgical price. But the moment you’ve done two or three injection rhinoplasty over three or four years, you’ve pretty much paid for almost a third to a half of our nose jobs. So, once you’ve done one injection rhinoplasty, unless you have a major reason why you don’t wanna do a surgical nose job, it makes more economic sense to try on your new nose with the injection rhinoplasty and move to the surgical rhinoplasty when that first year result wears off.

So, thank you for joining me at Plastic Surgery Talk. Doctor Stephen Mulholland, here in Toronto, Canada. And our podcast today was on the five minute nose job, also known as the injection rhinoplasty. If you found this entertaining, educational, pleas share this in all your social media channels. And I look forward to seeing you on our next podcast.

Dr. Stephen Mulholland, MD
Posted by Dr. Stephen Mulholland, MD
has been practicing plastic surgery for over 20 years. He is one of Canada’s most renowned and best plastic surgeons in Toronto with his wealth of experience, artistry, and humbleness towards his patients.

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