Non-surgical Rhinoplasty

By Mr Ayad Harb / 16 May 2017

Mr Ayad Harb presents his protocol for non-surgical rhinoplasty using hyaluronic acid fillers injected at three key areas

Non-surgical rhinoplasty has remained within the domain of advanced aesthetic practitioners due to the perceived narrow margin for error and low potential risks.1 The procedure is not intended to replace a surgical procedure, much like a thread lift or liquid facelift is not intended as an equal alternative to a surgical facelift. 

However, the non-surgical rhinoplasty can correct minor deformities such as saddle nose, prominent humps and issues with proportions, and can be useful as an adjunct to a surgical procedure.

There are numerous described techniques that can achieve excellent results in experienced hands.2,3 However, one must always be mindful of the limitations and contraindications of these techniques as well as the potential risks and pitfalls. 

Mullen and Hunter, in their two-part article published in the Aesthetics journal, gave an excellent overview of the non-surgical rhinoplasty and the nasal anatomy relevant to the procedure and its inherent risks.4

This article will describe my protocol, the trademarked 3-point Rhino, a rationalised and standardised three-point method for performing a non-surgical rhinoplasty using hyaluronic acid (HA) fillers. This technique name has been trademarked, meaning that I have found this procedure to be safe, reliable and effective whilst also reducing the risks of swelling, scarring and inconsistent results.

The 3-point Rhino

The 3-point Rhino offers a rationalised approach of systematically addressing the most common anatomical traits in patients presenting for rhinoplasty – low radix, dorsal hump, and inadequate tip projection.5 Other less common complaints can be treated as required, but I have found that for the majority of patients the above concerns are more common. 

Through my experience and technique refinement, it has been possible to rationalise and simplify the non-surgical rhinoplasty into a fundamental three-point method, which is suitable for the majority of nose patients. To date, the 3-point Rhino has been employed in 148 patients with consistent, reliable and satisfactory results.

Figure 1: The three anatomical points and injection areas market on the patient

Non-surgical rhinoplasty is beneficial for both the patient and the practitioner. From the patient’s perspective, this is a 15-minute, office-based procedure, which is generally painless and carries minimal risk. 

The patient is usually pleased to hear that no anesthetic is required, the procedure should leave no scars and the result is immediate with no downtime. There is also a subset of patients who cannot have surgery for medical or personal reasons; in these instances non-surgical rhinoplasty can be an excellent way of achieving the nasal correction that they desire. 

Furthermore, the procedure can be used on patients who are considering a surgical rhinoplasty and wish to see how a ‘new nose’ might look, before embarking on potentially risky and costly surgery.

From a practitioner’s perspective, this is a relatively easy three-step corrective procedure that enables the practitioner to rationalise their assessment and subsequent treatment of the nose deformity. This obviates the need for excessive injections and serial refinements, as can be the case with other non-systematic or ‘inject-as-you-go’ techniques, which can lead to inaccuracies and swelling, as well as lengthy procedures and added discomfort to the patient.

 The 3-point Rhino method offers a reliable template for treating the most common nose complaints, by addressing the critical anatomical sites, with consistently satisfactory results. This rationalised 3-point Rhino method would be a good template for novice nasal injectors to follow and can later be adapted to treat more complex cases of nasal deformity.

Technique

Following appropriate consultation and consent, the patient is prepared in the treatment suite. The three anatomical points and injection areas are marked (Figure 1) at the radix, either side of the dorsal hump and the tip. Topical anaesthesia creams may be used; however, be aware that there is a slightly higher incidence of swelling, irritation and bleeding at the site, which could obscure the subtle contours needing treatment.6

To avoid the need for additional anaesthetic pre-injections, which can distort and mask the fine nasal discrepancies, a HA with integral lidocaine is selected. The ideal filler should be a viscous, cross-linked hyaluronic acid that offers increased longevity and volumising capability.

The injection is performed in the least traumatic way possible with the minimum number of penetrations – ideally only three. As the 3-point technique refers to the three critical anatomical points on the nose that are addressed with this procedure, not the number of injections made, occasionally it may be necessary to re-inject at the same site if the correction is insufficient.

In non-surgical rhinoplasty, as with surgical techniques, the principle should be to inflict the least amount of damage to the soft tissues, thereby reducing pain, swelling and scarring. The preference therefore is to use a needle, directly injecting at discrete points (Figures 2, 3 & 4). 

An inert HA filler, which triggers minimum tissue reaction and has a low swelling profile should be used. Non-HA collagen stimulators or other bioactive semi-permanent fillers that could provoke increased collagen formation or scarring should be avoided in the nose.7 For this technique in particular, I always perform with a needle for direct injection at the critical points; there are other instances when cannula is necessary such as correction of a deviation. Overzealous cannula techniques should be avoided to reduce the amount of repetitive burrowing under the skin and minimise the amount of trauma and potential scarring to the soft tissues of the nasal dorsum. 

Figure 2: Left image. The first injection point at the radix. This elevates the lift-off point of the nose, giving it more aesthetic balance and blends in an hour-glass curve with the medial eyebrows.

Figure 3: Middle image. The second injection point at the dorsum. This helps to mask any prominent dorsal hump or depression.

Figure 4: Right image. The third injection point at the tip of the nose. This aims to enhance the light reflection points at the tip and give the appearance of greater lift. 

One should be mindful to minimise interference with the normal nasal anatomy in order to ensure that swelling and recovery time are reduced and that the result is natural. Factors that may contribute to excessive tissue oedema and bruising, thereby making the fine tuning of the procedure more difficult and less predictable, are the use of multiple injection points and repetitive refinement, crude injection technique and injection of low quality HA fillers.8,9 

Figure 5: Before and after non-surgical rhinoplasty using the 3-point Rhino technique

It is also imperative to reduce scarring, by minimising the amount of local tissue trauma, particularly in patients who may, in future, wish to consider surgical rhinoplasty as the disrupted tissue planes and additional scarring may make the operation more challenging.10 Among other similar techniques, the 3-point Rhino overcomes these barriers and simplifies the technique to just three critical points of injection, which yield aesthetically pleasing results for the majority of patients.



Injection point 1 is the radix

The HA filler is injected at the radix and bony dorsum and massaged into a fan shape, narrowing caudally towards the dorsal hump. The purpose of this point is to raise the level of the radix to the upper lash line for a better proportioned nose and reduce the appearance of a curved bottom-heavy nose. The fan shape also helps to accentuate the gentle hourglass curvature from the brow into the nose. A slightly more caudal injection at this point can be used if there is a very prominent dorsal hump that would require smoothing.

Injection point 2 is the dorsum

HA filler is injected as a small bolus immediately cephalad and caudal to the dorsal hump prominence. The HA bolus is massaged cautiously to reduce the prominence of the dorsal hump and smooth any contour irregularities on the nasal dorsum, leading gently into the lower third of the nose.

Injection point 3 is the tip

Finally, a small volume of HA is injected at the two light reflection points of the tip. This volume is highly variable, typically 0.05-0.1ml, and depends on the shape of the tip and the response of the soft tissues to the filler injection. These injections help to raise the tip slightly giving a very mild supratip break, which is more aesthetically pleasing than a perfectly straight profile, particularly in female patients.11 

The ideal patient

Figure 6: Before and after non-surgical rhinoplasty using the 3-point Rhino technique

The 3-point Rhino is extremely versatile and can be used to treat a wide array of patients. The ideal patient should have realistic expectations of the results that can be achieved following a non-surgical procedure. 

A typical nose with a gentle dorsal convexity or hump, low radix and deficient tip projection is the ideal candidate for treatment with non-surgical correction techniques such as the described 3-point Rhino method. It is important to make the patient understand that by adding volume to what they might already perceive as their ‘big nose’, it will naturally become bigger, though this will not be obvious. 

The improved balance and proportion, and the straightened profile and lifted tip, are much more noticeable and will make the nose more attractive and in harmony with the rest of the face. 

What results to expect

Figure 7: Before and after non-surgical rhinoplasty using the 3-point Rhino technique

The results from this technique are extremely reliable and repeatable if the patients are selected appropriately, the rules of minimal interference with the normal anatomy are respected and small volumes of a good quality HA filler are used. The typical volume required is 0.6-1.0ml. 

The result longevity depends on the type of filler that is used and other patient-related factors, such as physical activity and metabolic rate.12 One would expect the results of the 3-point Rhino and other non-surgical rhinoplasty techniques, using an appropriate HA filler, to last nine to 12 months.


Side effects and complications

As with any procedure, there are potential side effects and complications. These include compromised circulation if the filler is not injected sympathetically or if the skin is placed under excessive tension; abnormal nasal contours and boluses of large volumes of filler can be visible or palpable if extensive changes are attempted in a patient who would have been better treated with a rhinoplasty.1,2 

Generally, visibility and palpability of filler can be improved with gentle massage or with hyaluronidase injections if necessary. The fact that you can treat complications with hyaluronidase is another reason for choosing a reversible HA filler over non-HA alternatives.

The risk of blindness following non-surgical rhinoplasty, despite its exceptional rarity, remains an important material risk to the patient and should always be included in the consent process.13,14 

This risk is minimised by deep injection onto bone, minimum number of injections, slow injection technique and an intimate knowledge of the local anatomy. Other general risks of injection include bleeding, bruising, pain and infection. These can be minimised by employing sterile injection technique, maintaining a sound knowledge of the facial and nasal vascular anatomy and applying firm pressure to bleeding points to reduce the risk of bruising.13,14

Contraindications

The usual contraindications to any dermal filler also apply to non-surgical rhinoplasty, including acute or chronic skin disease, pregnancy, breastfeeding, allergies or intolerances to dermal filler materials.2,3 Caution should be exercised in patients who have had previous nasal surgery or trauma as the normal arterial anatomy can be altered and the viability of the skin may be more sensitive to tension.15,16

Difficulties can arise in certain noses. Patients who have very large noses or prominent dorsal humps that clearly require surgery should be advised accordingly. Previous surgery and trauma, thin skin and high-demand patients with unrealistic expectations are all potential pitfalls for the uninitiated practitioner.

The practitioner should recognise these issues and should never be afraid of refusing to treat a patient. The 3-point Rhino template is not suitable for treating severely deviated noses, septal problems, functional nose complaints and other unilateral asymmetries, which should be treated with meticulous assessment and bespoke injection techniques or surgery.

Conclusion

The 3-point Rhino is a procedure that offers a simplified and rationalised method of addressing the most common anatomical traits in patients presenting for rhinoplasty – low radix, dorsal hump, and inadequate tip projection. This method has demonstrated consistency and reliability for producing aesthetically pleasing results, whilst avoiding undue trauma to the natural anatomy and reducing the risks of swelling and scarring. 

References
  1. McKeown DJ, ‘The risk of blindness following ‘non-surgical rhinoplasty’,Journal of Plastic, Reconstructive & Aesthetic Surgery, 2013, 66. <https://www.ncbi.nlm.nih.gov/pubmed/23631867>
  2. Beer KR, ‘Nasal reconstruction using 20 mg/ml cross-linked hyaluronic acid’, Journal of Drugs in Dermatology, 2006, 5, pp.465-6. <https://www.ncbi.nlm.nih.gov/labs/articles/16703786/>
  3. Alexander Rivkin & Kontis TC, ‘The history of injectable facial fillers’, Facial Plastic Surgery, 2009, 25, pp.67–72. <https://www.ncbi.nlm.nih.gov/pubmed/19415573>
  4. Mullen, G & Hunter B, ‘Non-surgical Rhinoplasty’, Aesthetics, 2016, pp.34-36. <https:// aestheticsjournal.com/feature/non-surgical-rhinoplasty>
  5. Constantian MB, ‘Rhinoplasty: craft and magic, St Louis: Quality Medical’, CRC Press; 1 Har/DVD edition (22 July 2009)
  6. Product Information, Emla Cream (lidocaine-prilocaine), Astra-Zeneca Pharmaceuticals, Wayne, PA.
  7. Van Loghem J & AlexandrovnaY et al., ‘Calcium Hydroxylapatite: Over a Decade of Clinical Experience’, Journal of Clinical Aesthetic Dermatology, 2015, 8, pp.38-49. <https://www.ncbi.nlm. nih.gov/pubmed/25610523>
  8. Philippe Lafaille & Benedetto A, ‘Fillers: Contraindications, Side Effects and Precautions’ Journal of Cutaneous Aesthetic Surgery, 2010, 3, pp.16-19. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2890129/>
  9. Zielke H & Wobler L et al., ‘Risk Profiles of Different Injectable Fillers: Results from the Injectable Filler Safety Study (IFS Study)’, Dermatologic Surgery, 2008, 34, pp.326–335. < https://www.ncbi. nlm.nih.gov/pubmed/18177399 >
  10. Guyuron B & Kinney B, ‘Aesthetic Plastic Surgery Video Atlas’, Elversier, 2011, pp.170-172.
  11. McArdle A & Young R et al., ‘Preferences for the white female nasal supratip break’ Annals of Plastic Surgery, 2012, 68, pp.366-8. <https://www.ncbi.nlm.nih.gov/pubmed/22421480>
  12. De Boulle K & Glogau R et al, ‘A Review of the Metabolism of 1,4-Butanediol Diglycidyl Ether– Crosslinked Hyaluronic Acid Dermal Fillers’, Dermatolic Surgery, 2013, 39, pp.1758-1766. <https:// www.ncbi.nlm.nih.gov/pubmed/23941624>
  13. Nandasoma U, ‘A question of consent’, MDU Journal, 2015. <https://mdujournal.themdu.com/issue-archive/issue-1/a-question-of-consent>
  14. GMC, Consent guidance: Part 2: Making decisions about investigations and treatment’, 2017, pp.28-36. < http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_part2_making_ decisions_about_investigations_and_treatment.asp >
  15. FURTHER READING:
  16. Constantian MB, Rhinoplasty: craft and magic, St Louis: Quality Medical, CRC Press; 1 Har/DVD edition (2009).
  17. Rohrich R, Adams P, Dallas Rhinoplasty: Nasal Surgery by The Masters, CRC Press; 3 edition (2014), 

Comments

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  • Mrs Gill Naylor 10 Aug 2018 / 11:08 AM

    Excellent information allows a good review of my practice