What Can I do for Indentation on Nose After Kenalog Injection?

Question

Four days ago I had a kenalog injection around the tip of my nose -- I had rhinoplasty 3 months ago. Now I've developed an indentation. I've lost confidence in my surgeon after experiencing one problem after another. (I also have eyelid retraction from bleph that hasn't resolved and a horrible columella scar). Can indentation heal on its own? Will it get worse and can it be fixed via revision? He wants to inject saline. Please help.

Richard H. Tholen, MD, FACS · Answer

I am one of the plastic surgeons who advocate [judicious, careful, precise, and gradually-increasing strength] steroid injections for excessive subcutaneous scar tissue after rhinoplasty (or other scar-causing operations or injuries). Your example is why the part in bold is the important part. When excessive scar tissue forms, there are only 3 options:

	
		Live with it. The scar may soften and fade over time, but too much scar remains too much scar .
	
		Re-operate (Hope it goes better the second time. Unfortunately, often it does not. Unpredictable. More surgery and recovery. Costly.)
	
		Steroid injection to shrink and flatten the scar bulk and excess. Requires precise injection, starting with very low doses and strengths, waiting 6-8 weeks, then gradually increasing dose and strength until the precise beneficial effects are seen. Also requires patience. Inexpensive.


	Steroid injections work by breaking bonds between collagen bundles that excessive scar is made up of. Since the exact amount and concentration of steroid necessary to produce the exact desired effect is totally unpredictable, simply shooting in a strong steroid is not in keeping with the plan I outlined in step 3 above.

	Your steroid dose was (obviously, now that the effect is seen) too much or the concentration (strength) too potent. Your options are now limited to waiting to see if your body remodels the thinned tissue and improves the "dent" a bit. This is probably wishful thinking, but perhaps your body has not yet finished its excessive scar formation at 3 months post-op. If it has, the dent will probably remain much as you see it now.

	Saline is very temporary and will only serve to get you out of your surgeon's office. Within an hour or two (perhaps a bit more if the needle stick induced a tiny bruise and swelling), the dent will return. Fillers (such as HA or hydroxyapatite) are temporary, but will serve as a temporary "fix." Only your own tissue (as a graft beneath the skin surface) will serve to remodel and improve contour here on a long-term basis.

	It sounds as if you need damage control. Seek another ABPS-certified plastic surgeon and get another opinion, only if to serve as a second opinion. Lack of trust makes every problem worse, and every proposed "solution" suspect. You need to restore that. Answers exist; you must simply seek them out, and be prepared to pay for them. Most reputable surgeons will try to keep the financial impact of helping you to a minimum. We too have been there! Best wishes!

David Shafer, MD, FACS · Answer

If you have an indentation on your nose or face, you may consider injection of dermal fillers such as Juvederm or Restylane.  However, if you post pictures, we may be able to give you more specific advice.  

	 

	Good Luck.

Toby Mayer, MD · Answer

Nasal dent after rhinoplasty steroid injection can be treated with your own tissue put in thru a tiny incision inside the nose. You should wait at least 2-3 months before doing this to see if the dent subsides.

Philip S. Schoenfeld, MD, FACS · Answer

The use of steroids post rhinoplasty surgery is quite common.  It is extremely important to use a lower concentration of steroid such as Kenalog 10, and a conservative amount of the steroid to avoid potential complications to the nose related to the steroid injection.  I am not certain that the indentation will resolve over time.  If the indentation in your nose is very obvious, there is no harm in injecting a dermal filler to the nose in order to fill in the indentation.  If your nose continues to settle, simply add more filler.  After a year, and when the filler has been resorbed, you may elect to have a more permanent solution such as a cartilagenous, fat,  or fascial graft placed to camouflage the indentation of your nose.

Eric M. Joseph, MD · Answer

You probably had a steroid injection to your tip to treat an area of fullness. If this has left an indentation, this may be treated with an Injectable Filler in many cases. Without a photo or examination, it's impossible to advise you regarding your condition. We have had teriffic success filling indentations related to steroid injections: typically from injecting facial scars or acne.

If your surgeon is not experienced in using fillers for nasal indentations, you may want to find one who is. Our experience and preference is to use Silikon-1000, an off-label filler for permanent results.

I hope this helps.

Dr. Joseph

Michael L. Schwartz, MD · Answer

I'm sorry to hear of all the problems you are having. At this time it seems best to wait another couple of months. At that time you can reassess the dent and the scar. Fillers may be helpful or a graft if you need to have the scar revised. Best of luck.

Andre Panossian, MD · Answer

One of the risks of steroid injections to the nose is that you can get contour depressions where there was a fullness previously. The way that steroids work is to thin out and soften all tissues that it comes into contact with. This can include fat, scar, cartilage and even skin. In the worst case scenario, you can sometimes develop an ulceration of the skin due to excessive thinning of the tissues. Your contour depression or divot is likely the result of this process. Typically, an injectable filler can solve the problem. However, this is usually a temporary solution, and who wants to get an injection in the nose every 6 months? The alternatives are to have fat injection to fill the space or to surgically fill the space with a cartilage graft. The disadvantage of fat injection is unpredictability in the final result, including some residual lumpiness. But saline injection will absolutely do nothing to improve the problem.  My suggestion would be get a different board certified plastic surgeon to take a look. Also, you will need to wait 6-9 months for the post surgical swelling to subside before committing to another surgery.

Michel Siegel, MD · Answer

Steroid injections have a 4-6 wk lasting effect, so the dent may or may not get deeper. From your description it sounds like waiting may be your best option at this point. Once the steroid has taken full effect, again 4-6 wks, a plan can be made. At that point cartilage can be used, or perhaps a filler. Saline in my opinion will not acomplish anything.

	Best of luck,

David A. Bray, Sr., MD · Answer

You have hit on the major problem with steroid injections> They are uncontrollable. I think you need to allow more time and then perhaps a filler would be best

Peter E. Johnson, MD · Answer

Seems we hear more about steroid injections in the nose after rhinoplasty, though the dark side is dents and skin blemishes from the steroids. We think the steroids are best avoided. For the present, it is possible for some recovery in your dent as the steroid wears off.
	Best of luck, peterejohnsonmd.com

What Can I do for Indentation on Nose After Kenalog Injection?

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