Non-surgical Rhinoplasty Part 2

Non-surgical rhinoplasty (NSR) is a procedure that is attractive to many patients who are not prepared for the downtime or risk of complications associated with surgical interventions, or who do not need a surgical reduction rhinoplasty.^1,2 NSR involves the reshaping of a nose using soft tissue augmenters such as hyaluronic acid (HA) and can provide a very natural result.¹

This article will draw upon the anatomical considerations discussed in our previous article, will explore the techniques for NSR and provide tips on how to perform a successful treatment. The possible complications and risks will also be explored, as well as how to best manage and avoid these.

Techniques for NSR

Some nose deformities are relatively simple to treat in NSR, others should be left to more experienced practitioners, or may require a surgical solution.

Low risk regions Low risk areas are relatively easy to treat and get good results, with a low chance of complications. Low risk areas include:³

• Mild dorsal hump
  
• Saddle deformity
  
• Short nose and flat nose
  

High risk regions High risk areas such as the nasal tip and glabella have the highest rate of skin necrosis, and should only be performed by experienced practitioners. High risk areas include:³

• Nasal tip
  
• Alar recess
  
• Glabella
  
• Micronose (requires larger volumes)
  

Nose treatment techniques

The use of both cannula and needles in NSR are both commonplace. For the techniques below we advocate the use of a cannula where possible, as the outcome of a significant intravascular injection of HA is so dire. Athough, we acknowledge it can be a more uncomfortable and difficult procedure than with a needle, while some finessing is still sometimes required with a needle.

1. Correcting the nasal dorsum- cantilever nose lift

By creating an entry point (after a small bleb of 2% lignocaine) at the nasal tip, you can access past the sellion for dorsal augmentation and posteriorly to the nasal spine in the case of tip elevation with a 22G, 50mm blunt cannula.

For the dorsum, depth should be at the deep subcutaneous layer in the supra-periosteal plane and the cannula should be inserted all the way up the dorsum past the sellion to the nasion. It is important to pinch the dorsum of the nose to check the positioning of the tip of the cannula and later to help mould the product and avoid lateral spread. A slow retrograde technique (injecting product as the cannula is withdrawn) will help the product stay in the correct plane.

If the dorsum needs to be widened, do not try to add larger volumes in the single tunnel formed by the cannula. Instead, retract the cannula and form a new tunnel lateral and inferior to the first, repeat for the contralateral side.

The sellion, the deepest point of the nasal root, is usually found to be a little bit higher in the Caucasian face than compared to other ethnicities.⁴ Injection of the dorsum can move this point by as much as 5mm to be closer in line with the medial brow.

By assessing the rhinion, a decision should be made as to whether product should only be injected to this point. If required, in the case of a small dorsal hump appearance, it can be improved by injecting product both at the cephalic and caudal part of the hump.

Augmenting the medial brow to the dorsum completes the treatment, using a 30G needle and carefully aspirating before injecting in a retrograde manner and contouring the glabella in balance with the upper nasal dorsum. By injecting from the medial brow to the radix it is possible to create a smooth arch whilst softening any pre-existing glabellar frown line. 

2. Correcting the nasal tip region

A bifid tip can be corrected by injecting product into the interdomal area, which can also be injected and filled to widen a narrow nasal lobule. To raise the nasal tip, it is vital not to inject into the tip itself. There is no solid foundation to lay the filler on, so no lasting change is achieved and it can lead to potential vascular compromise of the skin envelope. Cadaveric studies have shown a midline longitudinal columellar artery in 31.1% of dissections that would be at risk by injection at this point.^11,12

Instead, inject between the footplates of the lower lateral cartilages and the anterior nasal spine at the base of the columella (0.5-1.0ml may be needed). A hard thick fibrous tip that does not move when the nasolabial junction is pinched will be difficult to elevate. These patients will require a surgical procedure to reposition the nasal tip. Injecting up to 0.5ml into the columella can provide support for the tip of the nose, and if the tip droop is minor, it may be enough to provide the correction on its own.¹³

3. Correcting columella recession

From the nasal tip, place the cannula posteriorly down the columella in the midline and inject slowly in a retrograde manner with multiple tunnels if required, up to a maximum of 0.5ml. The desirable nasolabial angle ideal is 110-120 degrees (as discussed in Part 1 of this article, there are different ranges and it varies for men and women), however in many patients, this is often less than 90 degrees. To correct this, using a 30G needle, enter the skin to the nasal spine. This is normally done in conjunction with correction of the columella using a slow bolus of product. When treating both areas up to a total of 1ml of product can be used.

4. Spreader grafts

There have also been descriptions of NSR for functional problems as well as cosmetic. The most notable is the use of injectable fillers to try to widen the nasal valve, this in turn improves the passage of air. This is classically a surgical procedure carried out by harvesting cartilage grafts and inserting them to lift the upper lateral cartilages off the septum and therefore widen the nasal airway. This has been described with both HA and hydroxyapatite. While these injections will only be temporary, at the least, this allows a patient to assess the potential functional improvement that could be achieved with a surgical procedure.⁵

NSR key considerations⁶

• If you are injecting in high-risk regions like this it is essential to have hyaluronidase on hand and to know the correct dilution factors.
  
• A hard, thick fibrous tip that does not move when the nasolabial junction is pinched will be difficult to elevate non-surgically and a surgical solution should be sought.
  
• Patients who have had any implants placed during surgery should not have anything more than tiny amounts of HA, 0.1- 0.2ml in total to feather irregularities.
  
• A compromised, altered blood supply coupled with arteries that may be fixed by scar tissue greatly increase the risks of causing skin and cartilage necrosis. Therefore extra caution should be taken and an understanding that the tissue may not be as pliable and more difficult to inject filler into. 
  

Complications of NSR

The greatest concern when treating the nose is intra-arterial injection of product. The literature has well documented cases of brain infarction, skin necrosis and blindness from injecting fat, fillers and volumisers.⁷ The mechanism for blindness is well considered and appears to be an embolic event. Injection into an artery causes retrograde flow proximal to the central retina’s branching point. The filler is then carried forward with the blood flow, causing an obstruction. Clinically, patients may present with a sudden blind spot or visual field deficit; this may match a filling defect in the retina, so avoidance is critical when injecting in this area. The ophthalmic artery terminates in two small branches, the superior trochlear artery and the dorsal nasal artery.8 It is very important to note that the proximal blood supply has short and direct connections to the internal carotid and retinal arteries. Product injected into these can cause blindness and brain infarction.⁸ The distal blood supply at the tip and alar can also be affected by embolisation, leading to ischaemic events from prolonged erythema to skin necrosis.

The desirable nasolabial angle ideal is 110-120 degrees, however in many patients, this is often less than 90 degrees

Signs of inter-arterial injection:

Pain: escalating pain may be a sign of increasing ischaemia

Blanching of the skin: avoid using adrenaline when injecting the nose so any sudden blanching can be easily recognised

Livdeo phase: blotchy red or blue mottled skin patches may be a sign of tissue ischaemia

Capillary refill: normal capilllary refill is one to two seconds after thumb depression and a slow refill is a sign of vascular compromise, which can lead to ischaemia and ultimately cell and tissue death.

After the initial ischaemic event from the filler injection, the healing phase will occur firstly with demarcation of the healthy and necrotic tissue. After a period, this necrotic tissue sloughs off and healing occurs with new skin and scar tissue formation.

Management⁹ 

Due to the nature of products used today most complications can be reversed with the use of hyaluronidase if HA is used. There are differing hyaluronidase units required that will depend on the type of product being used. Injecting product into the arterial supply can have devastating consequences. In the case of a vascular event, injecting hyaluronidase both into the surrounding tissue, but ideally the vessel, is the best hope for reperfusion. Examination of the pattern of ischaemic change will determine which branches have been affected. Nitropaste, hot compresses, hyperbaric oxygen and GTN, a nitrate dilator used for angina, have all been suggested to treat these events, but as often discussed in various round table events with many practitioners, the key factor is to inject hyaluronidase in significant volumes as soon as possible. Knowledge of the relevant anatomy and a good technique can help to avoid complications.

Other complications

• Lumps and nodules: can occur if too much product is injected, the product is injected too quickly or if the product is injected too superficially. Correct with excision and drainage of product or hyaluronidase.
  
• Tyndall effect: blue discolouration of the skin caused by too much product placed too superficially. This can be removed by injection of hyaluronidase.
  
• Infection: proper skin disinfectant agents should be used and a good technique with minimal incision sites. Broad-spectrum antibiotics such as ofloxacin10 can help to deal with more persistent infections such as those proposed by the biofilm theory.
  
• Delayed hypersensitivity: all sites of injected HA become hard several months after treatment. Various treatments including long-course antibiotics, steroids and removal of all traces of HA have been suggested.
  

Conclusion

For practitioners wanting to achieve good NSR results, they must be suitably trained and have knowledge in the appropriate anatomy of the nose. They should also conduct a thorough consultation with the patient prior to treatment. Avoidance of complications is reduced by good technique (aspirating before injection and use of cannula where possible) and awareness of the blood supply to the nose.

This article is the second of two on non-surgical rhinoplasty by Mr Geoffrey Mullan and Mr Ben Hunter. Their previous article was published in the December 2016 issue of Aesthetics, and detailed the relevant anatomy to consider for non-surgical rhinoplasty. To read this article, click here.