Professor Alwyn D’Souza discusses his techniques for performing non-surgical rhinoplasties using dermal fillers and the anatomical knowledge required
The term rhinoplasty refers to a procedure that changes the shape, size or proportion of the nose.1 The goal of the procedure is to alter the appearance of the nose (cosmetic rhinoplasty), to improve breathing (functional rhinoplasty) or both.1 These procedures often involve modifying the nasal septum, in which case the procedure is referred to as a septo-rhinoplasty.1 Examples of commonly altered features of the nose include removing the hump, reshaping the tip and changing the length and/or width.
The aim of this article is to provide practical pointers for safe practice of non-surgical rhinoplasty (NSR) using dermal fillers to practitioners who may not have received formal training in naso-plastic surgery.
Rhinoplasty can be broadly divided into surgical and non-surgical types. Surgical rhinoplasty is usually performed under general anaesthesia.1 Two approaches (closed or open) are used to expose the nasal skeleton.1 In closed rhinoplasty, cuts are made inside the nostrils, whereas open rhinoplasty entails making the cuts on the midline partition of the nose (the columella), which are joined to the cuts inside the nose.1 Both approaches also allow exposure of the nasal septum to straighten it, achieving an improvement in breathing. The surgeon may use various materials during surgical rhinoplasties, such as cartilage, bone, implants and various types of lining as required.1
To achieve an optimal result, surgeons adopt two main approaches. Most commonly, the nose is deconstructed and reconstructed to a variable degree, commonly termed structural rhinoplasty. On the other hand, I focus on preservation rhinoplasty techniques. In this method, cartilage, bone and the skin envelope is preserved as much as possible, thus maintaining pre-existing anatomy. In my clinical experience, this leads to a quicker recovery, while achieving the required natural aesthetic outcome.2 This is my primary reason for using this technique. Advanced technologies such as ultrasonic piezoelectric devices are used for this purpose, hence the commonly used term ultrasonic rhinoplasty. These devices allow for accurate sculpting and cutting of nasal bones (nasal bone osteotomy), which is an important part of rhinoplasty surgery.
NSR uses non-invasive methods such as threads, botulinum toxin or dermal fillers to change the shape and appearance of the nose. With fillers, the procedures are often referred to as ‘filler’ or ‘liquid’ rhinoplasty.3 Filler rhinoplasty has gained popularity over the last decade with increasing use of fillers by aesthetic practitioners to reshape the nose. Though a variety of fillers may be used, I recommend using hyaluronic acid (HA) fillers as they can be dissolved using hyaluronidase. In addition, botulinum toxins may also be used (rhino-myomodulation) to modulate muscle action on the nose, thus reducing some unwanted effects such as excessive drooping of the tip or widening of the nasal base when smiling.3 The combination of fillers and toxins often provides a superior result.3,4 Non-surgical methods have gained popularity among patients due to their limited downtime, low costs and reported safety and efficacy in achieving the desired results.4
Filler rhinoplasty is suitable for patients with certain cosmetic deficits such as a low radix, small hump, shallow nasal bridge, low/droopy tip or any minor asymmetries or irregularities.5 This method is also appealing to patients who are not medically fit to undergo surgical rhinoplasty, or those who want to avoid the risks, costs and downtime associated with surgery.5 Patients with a large dorsal hump, severely crooked nose, significant tip issues or substantial contour irregularities and breathing issues should be offered surgical rhinoplasty instead.5
Other contraindications for filler rhinoplasty include patients with pre-existing vision problems, a history of autoimmune diseases, bleeding disorders, allergies to filler components, previous NSR using silicone or unknown injection material, previous filler-related complications and patients with suspected or known body dysmorphic disorder (BDD) which has not been appropriately addressed.5
An in-depth knowledge of the anatomy/landmarks is essential when performing a safe and effective filler rhinoplasty.5 This includes familiarity with the layers of the nose encountered during injection (Figure 1).5 From superficial to deep the layers are: the skin (epidermis and dermis), superficial fat, superficial musculoaponeurotic system (SMAS), deep fat, perichondrium over the cartilage and periosteum over the bone, nasal cartilage and nasal bones.6
Although rare, as blindness and skin necrosis are potential major complications, detailed knowledge of nasal vasculature is essential (Figure 2). To date, there is no documented evidence of an intervention resulting in complete vision rescue after central retinal artery occlusion with HA.6 Encountered during this procedure are the blood vessels which are branches of the ophthalmic artery (from internal carotid system) and the facial artery (from external carotid system).5 The ophthalmic artery gives rise to the dorsal nasal artery and external nasal artery, which supply the upper part of the nose.5 On the other hand, the facial artery gives rise to the superior labial and angular artery to supply the lower part of the nose.5 These communicate with each other in a variable fashion and are superficially located, leaving the deep plane relatively avascular.5
The NSR practice began with surgeons using fillers to correct minor irregularities in the nose following surgery.6 Practitioners gradually used the technique for other types of defects such as deep radix (mentioned later), and extended the use for the nasal tip and base. A landmark book published in 2010 outlined the procedure in detail, with other publications cited.7
All patients should have standard photographs taken as part of the consultation process, and nasal function should be assessed. It’s my preference to apply topical anaesthetic to the entire nose and surrounding areas 30 minutes prior, even though most fillers have lidocaine incorporated in them. This lidocaine does take a few minutes to work, and using the topical application ameliorates immediate pain while lidocaine takes effect. In my opinion, regional nerve blocks (infraorbital, supratrochlear and external nasal) are also effective as this achieves almost complete anaesthesia of the nose. It is also useful to mark the key nasal landmarks and any contour irregularities or areas of concern at the beginning of the procedure.5
Clinicians performing this procedure should always follow a safe injection practice when placing fillers into the nose.5 This includes injecting into the avascular deep plane (sub-SMAS) directly above the perichondrium or periosteum, in order to avoid blood vessels.5 It is also crucial to stay in the midline where possible, and aspirating helps to assess for intravascular placement of the needle prior to injection.5 Inject slowly with small aliquots of filler to make incremental enhancements, minimising the number of injection sites (Figure 3).5
Individual injectors may adopt their own techniques for injecting. The following is my recommendation to ensure the patient is fully aware of what to expect and the outcome.
I see the patient at least one week before the procedure. Standard photos are taken. Normal saline is injected using 1ml lock syringe with a 30 gauge needle to the areas to be corrected, immediately followed by standard photos again. Patient is also asked to appraise the results of this. I give a copy of photos to the patient. Patient is informed that saline will resorb, and the nose will return to pre-injection aesthetics within a few hours. I call this the ‘saline test’. After ensuring the patient is happy with the saline test result, the patient is asked to return a week later to inject the filler.
I use both hands when injecting – one for injecting and the other for stabilising and moulding to achieve the desired result. Personally, I believe it is also good practice to compress the dorsal nasal and superior portion of the angular arteries while injecting.
I start injections from the radix and work down to the base as required. Side walls are addressed last. This ensures a standard pattern of injection with adequate attention to all areas of the nose. Skin colour is monitored closely, and the patient is asked to report any visual symptoms or discomfort immediately. This ensures any vascular compromise is noted and remedial action may be instituted, thus minimising/avoiding serious complications such as skin necrosis and blindness. Typically, vascular compromise starts with blanching of nasal skin in and around the area of injection, and over a period of three to five minutes, blueish discolouration is noted. They may also complain of altered vision if ophthalmic circulation is affected.8 Adequate attention should be paid to overall facial aesthetics to ensure facial harmony.
To achieve safe and effective results, the radix needle should be used in a perpendicular fashion, injecting on bone, while watching for glabellar blanching (as a sign to stop the injection).9 Tenting the skin upwards to mitigate vascular occlusion, placing a finger above the radix to prevent superior filler migration and immediate massaging and moulding to ensure a smooth contour are additional techniques to optimise practice.5
For tip augmentation, injection should be in the deep plane on the cartilage at a carefully selected location that corresponds to the desired tip defining point, avoiding blanching or injecting directly between the domes to prevent splaying and widening of the tip.5 For nasal base injections, neuromodulation can be used one week prior to the procedure and fillers should be placed in the deep plane with care taken to avoid the columellar blood vessels. Extra caution is required when performing this procedure in patients who had previous rhinoplasties because the vascular pattern changes considerably post-surgery, making them more prone to complications.5
The patient is monitored for at least 15 minutes after injection and given clear instructions to report back should there be any unwanted effects such as visual symptoms, changes in skin colour (redness/blueish tinge in particular), increasing pain or discomfort.
Patients should be counselled regarding the potential complications associated with filler rhinoplasty.5 These include early complications like asymmetry and surface irregularities, hypersensitivity reaction with pain, swelling, itching, infections with abscess formation, cellulitis or Tyndall effect (blue hue underneath the skin due to fillers being injected too superficially).5 The severe complication of vascular occlusion, which can cause tissue ischaemia and even blindness or stroke secondary to retrograde embolism of the fillers, are fortunately rare, but patients should be aware that they can occur.5 Delayed onset complications include scarring, foreign body granuloma and build-up of biofilms with infection and cartilage necrosis.5
It is important to identify risk factors and undertaking a thorough assessment before performing the procedure to ensure it is safe for patients to undergo filler rhinoplasty. Patients may require antibiotics if there are signs of infection, or corticosteroids for hypersensitivity reaction or granuloma formation. Immediate expert help should be sought in cases of impending skin necrosis and blindness.5 Close follow-up is essential to monitor for any possible complications after a NSR. Patients should also receive clear instructions on symptoms and signs to look for and be advised to avoid excessive nose manipulation in the first 24-48 hours.
Filler rhinoplasty has gradually evolved over the years with excellent aesthetic outcomes when performed well. Careful patient selection, adequate counselling, meticulous technique and follow-up are essential pillars that should be followed by every filler rhinoplasty practitioner, and we owe this to our patients. It is my view that filler rhinoplasty should be performed by those who have a thorough understanding of surgical rhinoplasty. This is likely to ensure that any complications are minimised, and if they arise, are dealt with immediately and effectively.
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