Dr Simon Berrisford details case studies on the use of PDO threads and HA filler in non-surgical nose reshaping.
The popularity of nose reshaping in the UK is apparent; the British Association of Aesthetic Plastic Surgeons (BAAPS) annual report into trends in 2017 indicated an increase of 2% in surgical rhinoplasty.1 However the trend towards ‘soft surgery’ or minimally-invasive treatments continues, and in my own clinic I see patients requesting non-surgical nose reshaping almost every day.
For minimally-invasive non-surgical purposes the nose can be divided into two parts, the visible external and the hidden internal. It is the visible external part that we are concerned with in aesthetic medical practice. This is the protruding part whose shape is determined mainly by the ethmoid bone and the cartilaginous nasal septum.2
It is important to recognise the nose as a ‘mobile organ’ whose musculature is involved in function such as dilation of the nostrils by the dilator naris muscles and in communicative facial expression by the procerus, the alar nasalis and the levator labii superioris alaeque nasi and others. The point of this is to understand that changes to the shape of the nose must be considered not only in the resting neutral expression but also in normal expression.
The types of presentations to aesthetic clinics include those who would like parts of the nose increased in size, those who need parts decreased in size, and those who require only positional change. It is important to clarify these requirements early on as patients often do not understand that adding HA filler materials or polydioxanone (PDO) threads to the nose will make the overall size larger, not smaller. Generally, those who require reductions in size of a segment of the nose should be referred to a plastic surgeon specialising in rhinoplasty. The precise width, angle and tip shape of the nose can become something of an obsession for some patients who may focus upon this and present with a history of multiple previous procedures, each followed by dissatisfaction, with a complaint that one can barely discern but the patient insists is dreadful. In my clinic, each new patient is given an iPad on arrival in order to fill in their personal details and their medical history, view the relevant consent form for their proposed procedure and then complete the Body Dysmorphic Disorder Questionnaire (BDDQ). This test has been validated and can be quickly administered to select those most at risk of having the condition.3,4 Our in-house psychologist is then available for assessment and referral if the patient agrees.
Nasal reshaping dates back to New York at the turn of the 19th century when liquid paraffin was used to correct the common ‘saddle nose deformity’, but proved to be harmful.5,6 More modern materials appeared in the 1960s, such as silicone and bovine collagen, and were more successful. It was in Asia and in particular South Korea, where the appetite for making the nose look more Western has driven the development of techniques to achieve minimally-invasive rhinoplasty7 – sometimes dubbed by certain clinics, especially in the US, the ‘lunchtime nose job’ or ‘liquid rhinoplasty’.
The next step was the Hiko nose thread-lift developed in Seoul 15 years ago.8 Hiko means ‘high nose’. The procedure, which uses polydioxanone (PDO) threads, can achieve a higher and straighter nasal bridge, a sharper definition of nasal profile and a more defined nose tip. This procedure has advantages over dermal filler procedures as the PDO threads cannot migrate out of position and widen the nose unnecessarily.8 Also, the main risks of dermal filler injections into the nose include occlusion or compression of blood vessels leading to visual change or loss9 and skin necrosis. These risks are minimised by the thread lift procedure as, by their nature, the threads cannot be injected into vessels and do not move out of their original position.
For patients attending their initial assessment, it is important to differentiate between those who have contraindications amenable to dermal fillers and/or PDO thread insertion, and those who will require open surgery. As an example, a patient attending my clinic recently was a Philippino female who considered herself to have two problems with her nose. Firstly, she had a deep glabella and radix which affected her profile significantly, and secondly, she had a very broad lower third which she wanted to be narrowed into the Western shape. In this case, it was possible to correct the first issue with dermal fillers injected into the glabellar region to make it project further and straighten the profile of the dorsum of the nose. However, it was not possible to narrow the lower third with threads, or any other non-surgical procedure so the patient was advised accordingly. The options for patients considering nasal remodelling include surgery, hyaluronic acid fillers, calcium hydroxyapatite fillers, PDO threads, PDO cogs, which are barbed threads, and hybrid procedures utilising more than one of these options. It is important to understand what your limitations are and discuss this openly with the patient.
The first patient described is a 40-year-old female whose nose was deviated to her left after being hit in a disturbance at a party several years ago, probably breaking her nose and most certainly shattering her confidence. As she did not seek medical assistance at the time, the nose remained permanently deviated but she was unable to face open surgery, which was the most suitable procedure for her.
Instead, it was agreed that we might attempt to shift the soft tissues of the nose to the right to improve her visage when viewed from the front, without attempting to alter the underlying structure. The patient preferred the idea of threads, and I decided on using PDO cogs as they can ‘pull’, whilst filler can only ‘push’. I would select cogs when trying to correct a deviation rather than a defect. Lidocaine was injected into the glabella region and three barbed absorbable PDO cogs were inserted and guided downwards toward the tip of the nose. Two were placed laterally, so as to allow the soft tissue to be pulled to the side, and the third centrally to allow the tip to be raised and reduce the hump on the dorsum of the nose. The cogs selected were 100mm 19g PDO as this is the widest gauge, giving best grip for a good pull. The type used in this case was the Honey Derma 3D cogs. These were chosen because, in my experience, they anchor strongly to the tissues after being placed in the supra-periosteal and then supra-chondral planes. With the patient able to watch, which can be helpful as they can indicate when they are happy with the correction, tension was applied to the anchored cogs and the nose pulled back towards the centre. A significant improvement was achieved, despite the obvious post-operative swelling. The light reflex on the after picture can be seen to be linear in comparison to the pre-op picture which is decidedly curved. After the swelling had subsided at the six-week check the result was even more effective.
The second patient was a 32-year-old female who had undergone open surgery previously and remained dissatisfied with the appearance of her nose. She still felt that the profile showed a central hump with a depression above and below. The patient also felt that the tip dipped down too far and she would like it raised. Both issues were minor but she was disappointed that they still existed after her surgery three years ago. On examination, the soft tissues of the nose were quite mobile over the underlying bony and cartilaginous structures. By sliding the tissues a few millimetres cranially, it was possible to disguise both the bony hump and to raise the tip. The patient did not want to have dermal filler injected as this may bulk out the nose, which she wanted to remain slim. PDO threads were discussed as an alternative. This patient was treated with the Hiko method, with lidocaine to the nasal tip and two different sized threads. The dorsum was treated with 29g 38mm mono threads of the Honey Derma type, and the columella treated with 30g 25mm mono threads. The result was the minimum needed for the patient to be happy with the outcome whilst not increasing the size of the nose noticeably. I believe this would not have been achievable with dermal filler.
Nose reshaping should be considered an advanced procedure in view of the risks associated with it. The anatomy of the nasal organ is complex and variable, and the vessels travel onto vital and delicate structures, such as the eye. Also, the skin of the middle third of the nose is the thinnest and most strongly adherent to the sub structures with the least ability to stretch to accommodate dermal filler, PDO threads and surgical instruments. Products put into this area can cause pressure increase and subsequent compression of vessels, as well as the more obvious danger of intra-arterial injection of product. This can lead to blindness and skin necrosis, which are unlikely to be recoverable. The best treatment to attempt should this happen is injection of significant amounts of hyaluronidase into the area and ideally into the affected blood vessel.10
The minimally-invasive nose reshaping procedure is becoming rapidly more popular, but should not be considered a natural extension of one’s repertoire just because one already uses a certain treatment. The complications can be disastrous and a thorough understanding of nasal anatomy is needed. I believe PDO threads appear to offer an effective alternative without the risk of intra-vascular injection for treating the nose.
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