Ultherapy Shrinks Nasal Skin after Rhinoplasty following Failure of Conservative Measures (2013)

Sir:FigureIt can take months—and sometimes years—for nasal-tip edema to resolve after rhinoplasty, which can be challenging for patients and surgeons. Although various conventional modalities have been used to counteract edema, they are not successful for all skin types or in all situations. With the advent of the Ultherapy Ulthera System (Ulthera, Inc., Mesa, Ariz.), the capability now exists to safely and reliably manipulate the contour of the skin to permit the skin to conform optimally to the underlying cartilaginous framework. Thus, the cartilage and skin can work in tandem to create a more ideal nasal-tip configuration. During the past 18 months, the author has used Ultherapy to control edema and shape the nasal skin after rhinoplasty in 21 patients (19 women and two men, aged 22 to 66 years). Participants were required to have nasal skin types that typically are not amenable to conforming to underlying anatomical structures and thus would preclude an optimal result. The patients had previously undergone conservative attempts to reduce postoperative edema, which were not successful. All patients had been informed that Ultherapy is not a “proven” or U.S. Food and Drug Administration–approved modality for enhancing or expediting the results of rhinoplasty, but that it is U.S. Food and Drug Administration approved for facial skin tightening and brow elevation. Ultherapy creates microthermal injury in the dermis and subdermis at depths of 1.5, 3, and 4.5 mm. Healing of these lesions, at the consistently spaced locations, leads to skin contraction, remodeling of scar tissue (revisional rhinoplasty), and, when desired, a degree of thermally induced subcutaneous fat loss. The average number of treatments per patient was 2.1. The average time between rhinoplasty and the initial Ultherapy treatment was 3.22 years. Four nasal-tip skin types are anatomically limiting with respect to achieving optimal postrhinoplasty aesthetic results: large skin sleeve, thick skin sleeve, scarred skin sleeve, and C-shaped curvature. However, Ultherapy proved successful for three of these skin types (Figs. 1 through 3.) All patients were pleased with their result, as measured by a posttreatment survey, and there were no treatment-related adverse effects. Follow-up is ongoing to assess the durability of results, and a full clinical report is planned.Fig. 1: Large skin sleeve. (Left) Preoperative view of a 19-year-old model with a large skin sleeve who underwent open rhinoplasty with suture techniques on March 3, 2000. (Center) A pre-Ultherapy photograph, taken 11.5 years postoperatively, shows only subtle improvement. In addition to elastic taping (performed routinely for at least 3 weeks), this patient received four steroid injections over 19 months postoperatively. Ultherapy was performed on November 22, 2011 (11.5 years postoperatively). (Right) A post-Ultherapy photograph, taken 3 months after treatment, shows substantial reduction of edema and improvement in contour.Fig. 2: Thick skin sleeve. (Left) Preoperative image of an 18-year-old woman who underwent secondary open rhinoplasty on August 4, 2008. The surgery included a “golf tee” graft for tip projection, definition, and control of a very thick skin sleeve. (Center) A pre-Ultherapy photograph, taken 3 years postoperatively, shows significant improvement but poor definition, and waxing and waning tip edema caused by poor skin contraction. Postoperatively, she received four steroid injections and two conventional external ultrasound treatments over 17 months. Ultherapy was performed twice between July 29, 2011, and January 4, 2012 (3 years postoperatively). (Right) A post-Ultherapy photograph, taken 4 months after treatment, shows marked improvement in definition.Fig. 3: Scarred skin sleeve from multiple rhinoplasties. (Left) Preoperative view of a 31-year-old woman who underwent open tertiary rhinoplasty including alar baton and crushed tip grafts on December 17, 2008. (Center) A pre-Ultherapy photograph, taken 18 months postoperatively, shows improved contour but poor definition. In addition to elastic taping, this patient received three steroid injections over 6 months, two radiofrequency treatments, and seven conventional external ultrasound treatments. Ultherapy was performed three times between November 14, 2011, and January 30, 2012 (3 years postoperatively). (Right) A postprocedure photograph, taken 4 months after the final Ultherapy treatment, shows substantial improvement in definition.In the author's experience, Ultherapy has been particularly useful for patients who would typically be considered poor candidates for rhinoplasty because of the quality or quantity of their skin. The success achieved in the present series has led the author to use Ultherapy routinely in his practice to reduce tip edema following rhinoplasty. Ultherapy's mechanism of action appears to be absolute shrinkage of the skin sleeve,1–3 renewal of the cutaneous structure including enhanced elasticity,4 and the ability to remodel scar tissue. Ultherapy also has been used successfully to reduce the size of silicone-injected lips nonsurgically. A proposed mechanism of action is remodeling of the silicone bead capsule.5 In postrhinoplasty patients, Ultherapy appears to “shrink wrap” the skin over the underlying cartilaginous framework. With this modality, rhinoplastic surgeons are able to control another anatomical element—the skin—to allow optimal sculpting of the central feature of the human face. Andrew N. Kornstein, M.D. Museum Mile Surgery Center, 1050 Fifth Avenue, New York, N.Y. 10028, [email protected] DISCLOSURE The author has no financial interest to declare in relation to the content of this article. No funding was received for the preparation of this article. PATIENT CONSENT Patients provided written consent for the use of their images.