The Surgeon Nose Best

Rhinoplasties remain consistently one of the most sought after cosmetic procedures. Mariel Chow sniffs out the ins and outs of nose jobs.

Dr. Jagjeet Singh - April 10, 12:00 AM

Based on 2016 statistics by the International Society of Aesthetic Plastic Surgery, rhinoplasties made up 7.6 percent of total cosmetic procedures performed worldwide. Rhinoplasties have consistently remained in the top five list of most popular cosmetic surgeries in Asia. This however has led to men and women resorting to dangerous procedures at supposedly ‘better’ prices, carried out by non-qualified practitioners who perform procedures in dingy back rooms and hotels. 
Our nation is no stranger to the rot that has been plaguing the aesthetic medical industry. Based on first-hand accounts, plastic surgeon Dr. Jagjeet Singh even tells the story of a patient who underwent nasal thread augmentations with a beautician. Despite threads poking out of her nose, the beautician assured the patient that it was part of the process. Following a two-week period, infection ensued, leading to a massive build up of pus. 
Dr. Jagjeet had to control the infection and perform revisional surgery with dermal fat grafts to minimise scarring. This story is one of many disasters, which have kickstarted an awareness campaign against non-registered personnel performing illegal beauty treatments. While this epidemic permeates all facets of aesthetic surgery, we will focus on the nose by speaking to Consultant Plastic and Reconstructive Surgeons, Dr. Jagjeet Singh and Dr. Ruslan Johan as they explain procedural forms, talk about why treatments with unqualified personnel remain popular, and reveal how this leads to morbid consequences. 
Why are nose dorsum augmentations one of the most popular procedures in the Asian market?
Dr. Ruslan: Asians are somehow blessed with noses that are considered “not beautiful” by international standards. I believe with the current intermingling of cultures, the Asian perception of beauty has become more skewed to Western aesthetics, particularly Nordic facial characteristics. 
Dr. Jagjeet: Anthropologically, oriental noses have been classified as Platyrrhine in nature. These appearances include a low dorsum with thicker skin and weaker cartilage support. All these put together result in a low and broad-based dorsum with very little 3-Dimensional projection. Hence, many aesthetic procedures tailored towards the oriental population are to make the face more 3-dimensional in appearance, giving it more projection. This is why dorsal augmentations are more common among Orientals while nasal reductions are commoner in Caucasians. 
Why do dorsal augmentation complications happen?
Dr. Ruslan: Not every face can pull off a Western nose, there are limitations. Many patients come in with photographs of their desired nose, birthing unrealistic expectations. Patients must understand that whatever cake you bake depends on the ingredients. If you currently have a very flat nose with a low bridge and flared nostrils, I can’t promise Gisele Bundchen results as your original features won’t allow it. Plastic surgeons can do our best to enhance your unique features, but never will we promise model-like outcomes. In addition, bodies and dermal types are unique and at times, aren’t capable of accepting too much augmentation. If the impractical is desired, patients who demand for high tips may end up with dermal breaches, as hard structures have propensities of pushing through skin. This problem can also happen to patients who want long implants too. 
Doctors who offer augmentations should possess the knowledge and experience in order to prescribe the best possible treatment. Unfortunately, because patients commonly develop unrealistic expectations, or prefer the best at the cheapest price, they may wind up in the hands of unqualified practitioners and non-medical personnel. Unqualified practitioners or beauticians don’t understand the importance of aseptic techniques. Anytime there’s a breach in the skin, there’s potential for bacterial entry. When these unscrupulous non-registered personnel perform procedures in improper environments like hotels or clinics, they may be fulfilling desires but risking a patient’s life. That’s the price you pay when one takes medical procedures too lightly. 
 
81410840_l.jpg 2.73 MB
Why are non-specialists or beauticians offering nose dorsum augmentations or surgeries despite the illegalities?
Dr. Ruslan: I think money is the issue. If I were an unlicensed practitioner offering treatments or surgeries cheaply, patients would flood in. Similarly, however, some of these non-medical personnel also offer treatments at exorbitant prices, duping patients into believing expensive means good quality. According to news from the grapevine, beauticians are travelling to China for two weeks to learn how to perform surgery or injections. Upon their return, these beauticians believe they’re skilled or have capabilities of executing invasive procedures. I can’t stress this enough, doctors who perform surgery need the knowledge, skill and experience to handle any adverse situation because the scalpel can kill. There are patients who don’t mind taking risks because of cheaper prices but is money saved worth lives?
Many unqualified practitioners perform nose surgeries and injections because they believe it’s easy. Some even watch YouTube videos and suppose they’ve acquired enough skills to cut or inject. While I don’t deny simplicities, such procedures are only easy as long as surgeons are well versed in related complications. Do you think beauticians or GPs would have the knowledge to handle adverse occurrences? Probably not. 
Dr. Jagjeet: There’s a very high demand for these procedures. The aesthetic and cosmetic surgery industry is advancing fast because of consumer demand. Like Dr. Ruslan said, everyone wants the best outcomes for the cheapest price and fastest recovery. In Malaysia, there are still trends for patients agreeing to medical treatment and surgeries at beauty centres. Some even assume beauty centres are the only place that offer services. It’s also a problem when beauty centres don’t inform patients of the availabilities of treatments by doctors and surgeons in proper medical centres. The public needs to be aware about these practices, and should decide for themselves if they want someone who goes house-to-house injecting silicone. In addition, they should decide if going to hotel rooms for surgery or injections is a smart decision. Ask yourself, is it safe? In my point of view, it’s not. 
In line with Dr. Ruslan's lamentations, beauticians aren’t familiar with complications. They don’t know the details of anatomy and how to maintain sterility and aseptic techniques. A procedure may seem simple until a complication is encountered. Only then do these non-medical personnel realise how risky procedures are. By then however, it’s already too late, and patients are the ones who suffer most. 
 
A patient who had an implant inserted in a different country extrusion occurred.
What are the commonest forms of dorsal augmentations and its complications?
Dr. Ruslan:  The simplest form of nose augmentation would be slight elevation of the dorsum with dermal fillers. Filler injections pose some problems. Firstly, hyaluronic acid (HA) fillers aren’t permanent. It may look great for a month or two before it slowly dissipates or requires a top-up. Moreover, filler gels may flow downward with gravity, where patients end up with bulbous bridges or tips. 
Unlike HA fillers which dissipate over time, many non-registered practitioners also advocate illegal silicone fillers which cannot dissolve. If complications arise, it’s worth noting that such materials are difficult to remove despite surgical intervention. Furthermore, even if I were to remove as much filler as possible and replace silicone with an implant, results end up unaesthetic, with added risks of infection. Lastly, and although rare and unspeakable, poor injection of both HA and silicone fillers can travel along facial arteries all the way to corners of the eye and retina, causing immediate blindness. 
 
Threads that were removed because of infection
Dr. Jagjeet: The commonest non-surgical augmentation would be HA acid filler. Among non-medical practitioners, all sorts of material have been used, with the most common being silicone. Some of the commonest filler side effects are bruising, headache and redness. Infections are possible, and are usually treated with antibiotics. The worst complication would be blood supply compromise to the nose. This happens if fillers press on blood vessels supplying the nose. While such a problem remains rare, this is where hyaluronidase plays a role. With reversible elements, HA fillers can be dissolved to certain extents and at times, reverse the compromised blood supply. Nonetheless, compromises to blood supply can be reduced by drawing the cannulas and needles back to check if blood vessels were hit. 
All filler materials used by doctors and surgeons have received Ministry of Health (MOH) approvals, certifying their safety. When it comes to non-medical personnel, this step doesn’t happen. As such – and because no credible supplier would go through the trouble of getting approval with aims of selling to beauticians – most products offered at spas aren’t registered and therefore aren’t certified as safe. Based on personal experiences, I’ve seen patients injected with commercial grade silicone and charged no more than RM500 per session. Besides being permanent, people who inject such substances don’t understand the irreversible dangers. 
Other common nasal augmentations are beautifications with silicone implants and costal cartilage. As of late, we are also seeing thread-lifting trends where anywhere between five to 25 threads are inserted into the nose. 
What are the commonest complications related to nose threads?
Dr. Ruslan: Threads to even the face are losing popularity in America due to ineffectiveness. In truth, because threads didn’t deliver on promised results, patients ended up suing suppliers. As companies couldn’t afford massive litigation, threads were introduced to countries like Malaysia. In my opinion, threads will only have abilities of suspending skin if both ends are anchored by hard tissues. With threadlifts, only one end is anchored to concrete structures. In my opinion, this won’t result in enduring outcomes. Furthermore, unlike Western noses, Oriental noses often feature flared nostrils, which face forward. When threads are inserted, flaring may become exaggerated, resulting in worse results. 
Dr. Jagjeet: Thread complications are divided into three known problems. First there’s extrusion, where some of the threads stick out of the insertion point – usually the tip of the nose. When this happens, threads must be removed immediately to avoid infection. There can be redness and swelling immediately after the procedure but if side effects persist, infection must be considered. Mild infections may respond to antibiotics. Severe infections call for total thread removal. Finally, there are contour irregularities and scarring. The dorsum’s skin is thin and sometimes inserted threads can be seen or felt. When threads are absorbable, the body will dissolve them through an enzymatic process. The resultant effect may be dermal tightening along the nose which alters its shape. 
 
Photo credits to Plastic & reconstructive Surgeon, Dr Jagjeet Singh
To date, there’s some evidence to support facial lifting threads. Conversely, I can’t find any evidence for the nose. It’s a technique developed in Korea which has sparked a lot of interest. I have discussed this with some colleagues (plastic surgeons) in Seoul and even they don’t seem to support the use of threads. The Malaysian Society of Plastic and Reconstructive Surgeons similarly agrees that threads aren’t the ideal option for dorsal augmentation. 
What are implant and costal cartilage augmentations’ commonest complications?
Dr. Ruslan: We have to be wary of infection. Once infection hits, problems will rear its ugly head after a week. Patients may find the onset of fevers and continual swelling and redness of the targeted area. Infections can be conservatively treated with antibiotics, but it must be noted that once infection takes form, it never ends. Even though minute, bacterial seedlings can bloom into something severe. Should infections not settle, surgeons have no choice but to remove the implant and revisit chances for revisional surgery after six months. 
Dr. Jagjeet: The best way to avoid complications is to ensure patients get the right implant. Not only are detailed assessments crucial, surgeons must also be familiar with implant forms and the many approaches to surgical insertion. Implant based surgery means foreign material implantation that’s performed in clean, safe environments or gazetted surgical facilities like hospitals with fully equipped operating rooms. Sterility is imperative and it’s the public’s responsibility to choose the right surgeon and surgical environment. The MOH imposes high standers on surgical facilities and the reason for this is patient safety. I still find it puzzling that there are individuals who agree to operations in beauty centres and hotel rooms. 
The commonest cartilage augmentation complication is resorption. Cartilage may thin over time and this can change the original size and shape of the implant. Nonetheless, it’s a very good technique provided that patients agree to additional surgery and scars to chest walls where cartilage is harvested. For me, I usually reserve this approach for revisional cases, but there are other surgeons who prefer costal cartilage augmentation for all cases. It’s a matter of opinion and patient preference. 
How can patients avoid untoward instances?
Dr. Ruslan: Choose a surgeon that’s trained in his or her particular field. Unlike beauticians or non-registered personnel who learn skills through two-week training stints in China, plastic surgeons undergo a period of apprenticeship. During this time, we do nothing more than stand next to a superior surgeon for months, assisting. Then, there comes a day where an apprentice is given the honour of performing the surgery. When patients undergo procedures with qualified professionals, they’re given the opportunity to be cut open by someone who’s been exposed to many patients with ranging characteristics. When individuals opt to have treatment with the untrained, they are placed in the hands of someone who may only understand singular methods to a variable treatment. This leads to unmet expectations and increased complications which necessitate revisional surgery and more money spent. In order to guarantee safe outcomes, I recommend checking on your doctor’s credentials, ensuring he or she has been approved by the Malaysian Medical Council. 
Dr. Jagjeet: It’s very difficult to predict when complications happen. Of course, all surgeons want zero complication rates but that’s not humanly possible. The most important thing to recognise is whether your surgeon understands how to treat or reverse specific complications. This is where knowledge and training play a crucial role in patient safety. Individuals can mitigate adverse possibilities if they choose a qualified healthcare professional who practices at accredited centres. All treatments discussed are medical procedures that must adhere to strict sterility and infection control. Beauty centres and people’s houses are not places where procedures should be done, as such environments risk lives. 

 

Find a Doctor

Dermatologists
Dr Lim Shueh Wei
Verified
Other
Dr.Kuljit Singh
Verified
Aesthetic Physician
Dr Lenzo Ling Ing Heong
Verified
Aesthetic Physician
Lau Kian Hong
Verified