Indentation at the alar base: should I fill it with an Implant (prosthesis) or injection?

Which option you choose depends on your goals. If you have a distinct indentation and want to maintain the shape long-term, surgery with an Implant (prosthesis) is the starting point. If you want to try something small first or prefer to leave room to reverse it later, hyaluronic acid injection is the starting point. However, there is no research yet that directly compares only the alar base (the area around the base of the small nose). The evidence for each is based on research in nearby areas, such as surgery to raise the nasal bridge (dorsal augmentation).[1]The comparison points are "shape durability," "infection and exposure (material protruding through the skin)," "vascular risk," and "reversibility." Narrowing down to these four points makes it easier to organize the differences.

What are the strengths and weaknesses of Implant (prosthesis) (artificial material)?

The strength is that it maintains the decided shape for a long time. In reports of silicone use over 30 years, when a pocket (space for placing the material) that fits the material precisely is created, such as beneath the periosteum (under the bone membrane), it is said that displacement and movement can be reduced and stability achieved[2]The weakness is the risk of infection and exposure (where the material protrudes from the skin) due to insertion of a foreign object. This risk is common to artificial materials in general and is also organized in meta-analyses that summarize many studies[1]With skilled technique and experience, risks can be reduced, but cannot be eliminated to zero.

What is different about methods using your own tissue (cartilage and bone)?

With methods using your own tissue (autologous tissue), the textbook describes a technique where finely minced cartilage is transferred to this area at approximately 1.5cc per side[3]In people with cleft palate, guidelines recognize that bone transfer surgery can improve depression at the base of the nostrils and asymmetry of the alar base[4]Compared to synthetic materials, some reports indicate that complications from the initial surgery are actually fewer with synthetic materials. On the other hand, it has been pointed out that revision surgery to correct infection or exposure is more difficult with synthetic materials[5]For those who prefer not to use foreign materials or those who have undergone revision surgery in the past, your own tissue becomes an option to consider.

How safe is hyaluronic acid injection?

Let's start by looking at the numbers. A systematic review that collected and examined many studies on hyaluronic acid injection into the nose found that minor complications such as bruising and swelling occurred in about 13 out of 100 people (13.34%). On the other hand, serious complications such as skin necrosis (death of skin tissue) or vision impairment were reported in about 3 out of 1,000 people (0.3%)[6]. Although serious complications are rare, if the agent enters a blood vessel, it can lead to eye complications including blindness. This point has been systematically examined in analyses that compiled multiple studies[7], and the area around the nose is naturally a location with many blood vessels where caution is needed. It is premature to think that "non-invasive means safe." Even if serious complications are rare, they do occur—proceed with the understanding that you should confirm whether the provider has extensive injection experience and what contingency measures are in place in case of emergency.

How do they compare in terms of "can it be corrected later"?

Hyaluronic acid is a material that the body absorbs, so repeated injections are the prerequisite to maintain the shape. In contrast, Implant (prosthesis) and transplants of one's own tissue are methods that create shape in a single surgery. However, particularly with artificial materials, it is noted that correction becomes difficult after infection or exposure occurs[5]. "Will you make the effort to return repeatedly for injections," or "will you accept the burden of a single surgery and the risk of a foreign material." When you think about it this way, what you prioritize becomes clear.

So how do you choose? Four points to confirm at your consultation

First, discern whether the cause of the depression is the shape of bone or soft tissue such as skin or fat. Second, the reasoning behind the recommended material, which layer to place it in, and the design of how to create the pocket (space for the material)[2]. Third, preparedness for vascular risk if you choose injection[6][7]. Fourth, the correction plan if things don't go well, such as infection, exposure, or dissatisfaction with the result[5]. Each method has its own weaknesses. The practical approach is to have your depression's cause examined at your consultation, then hear the answers to these four points and compare them to make your decision.