Aptos unveil a minimally invasive approach for nose reshaping
Plastic surgeons are facing increasing pressure from patients to simplify their procedures, such as minimising scars or reducing the operation time and recovery period. In some areas of aesthetic surgery, we have non-invasive alternatives such as botulinum toxin injections, commercially available soft tissue fillers, or thread lifting to lift the ptotic tissue. Interestingly, aesthetic nasal surgery is one of the fields in which the minimally invasive options are few. However, some patients asking for nasal surgery do not necessarily need a standard aesthetic rhinoplasty procedure1.
In some cases, only a nasal tip lift is enough to achieve satisfactory nasal harmony and aesthetics. Herein, we describe a simple, office-based procedure that can be performed under local anaesthesia in a matter of minutes with virtually no downtime and can also be combined with any other minimally invasive procedure. Our technique allows the surgeon to rotate the nasal tip over the hump, only through a small access puncture made on the central nasal tip2,3.
Patients and methods
The author (NC) successfully performed a minimally invasive rhinoplasty with the Aptos thread lifting technique in 28 carefully selected patients. Between October 2016 and March 2018, with an eight-to-twelve months follow-up. Patient ages ranged from 21 to 50 years. All of the patients elected not to undergo any aesthetic nasal surgery but were requesting a slight improvement in their nasal shape.
APTOS Excellence Visage
We used the Aptos Excellence Method — absorbable threads P(LA/CL) (poly-L-lactic acid 75% + caprolactone 25%) with multidirectional barbs for lifting and armouring. The threads have a special barb arrangement. Each subsequent barb is located in the opposite direction from the previous one, which allows stronger hypodermic fixation and supports grouping the tissues on every micro-section of the thread. To insert the threads, we used a round tip hollow blunt cannula very safe and does not damage soft tissues. It has been more than 21 years since the first APTOS thread and method were introduced to the aesthetic world. It was first developed in 1996 by plastic surgeon Dr Marlen Sulamanidze4.
In the pack you will find P(LA/CL) threads with barbs USP 2/0, EP3, 190mm–10pcs; round tip hollow blunt cannula 20G x 150mm; straight 10pcs (Figure 1–2).
The external nose has a pyramidal shape. The nasal root is located superiorly, and an apex of the nose ends inferiorly in a rounded ‘tip’. Spanning between the base and apex is the dorsum of the nose. Located immediately inferiorly to the apex are the nares; piriform openings into the vestibule of the nasal cavity. The nares are bounded medially by the nasal septum, and laterally by the lateral cartilaginous wings of the nose. The skeleton of the external nose has both bony and cartilaginous components. The bony component is located superiorly and is formed by the frontal bone, nasal bones, and maxillae. The cartilaginous component, which is located inferiorly, is formed of the one septal cartilage, two lateral cartilages, two alar cartilages also some smaller alar cartilages are present. The overlong skin extends into the vestibule of the nose. While the skin over the bony part of the nose is thin, on the cartilaginous portion it is thicker and contains sebaceous glands5 (Figure 3–4).
Before the procedure, the midline and the most prominent spot of the nasal domes were marked, and the nasal dorsum and caudal septum and columella were infiltrated with local anaesthetic — adrenalin solution. An 18-gauge needle was inserted through the nose tip to create the entry point (centre of domes tip defining point) (Figure 5).
First Step: with the Aptos Excellence Visage, the columella angle needs to be enlarged by moving the columella through the entry point and placing the thread into the nasal septal cartilage. The cannula will not be removed at all during the procedure. Forward and backward manoeuvring will place the entire 190 mm multidirectional thread into the columella (Figure 6).
econd Step: with the Aptos Excellence Visage, it is necessary to move along the nasal dorsum from the entrance point and to put the thread over the nasal periosteum and proceed to the glabella to lift the nasal bridge. The cannula will not be removed at all during the procedure. Forward and backward manoeuvring will place the entire 190 mm multidirectional thread into the nasal dorsum (Figure 7).
Intraoperatively, the magnitude of change and the exact effect can be determined by observing the rotation of the tip as the thread is tightened. This is a crucial point at which the amount of tip rotation and projection should be evaluated. A slight overcorrection is suggested in all cases. The nose was taped for 3 to 4 days postoperatively at night, and each patient was instructed to apply the same tape for three weeks3,6,7.
The results were satisfactory in all but 8 of the 28 cases based on patient satisfaction surveys.
Three patients did not find the result satisfactory, and the procedure was repeated after 6 months. Five patients found the results inadequate, and those patients underwent traditional rhinoplasty afterwards. The nose tip lift of Aptos thread lifting methods was also extraordinarily effective in secondary rhinoplasty patients. After an initial loss of the overcorrected projection and rotation, the results were durable throughout follow-up. The operation duration was under 30 minutes in all of the cases. Our most extended follow-up was 12 months, during which we observed that the outcome appeared after the third month and did not undergo any change afterwards3. We have not seen any complications related to the absorbable thread, such as palpability or visibility through the skin (FigureS 8-10).
The rapid production of scar tissue in the interface of the skin acts as a biological glue that maintains the new tip position over time. According to our experience, it takes a minimum of three to four weeks to achieve strong subcutaneous fibrosis. The Aptos Excellence Visage absorbable thread, if detached earlier than this period, might be reversible, which may be seen as an advantage of this procedure by the patients. As a continuation of this study, it might be beneficial to measure the nasal length and the nasolabial angle pre- and postoperatively at different times, so that we can have data by which to judge the necessary overcorrection precisely.
The nose tip lift described herein is one of very few minimally invasive alternatives for aesthetic nasal tip surgery. For selected patients, our method can be used as a simple, office-based procedure that can be performed under local anaesthesia without any significant morbidity, a very high patient satisfaction, and a recovery period of only 2 to 3 days. The absorbable thread serves as an internal splint, and the permanent result is attributable to tissue fibrosis. The reversibility of the result, at least for a short period, is also appealing to patients who are uncertain about the outcome of nasal surgery.