Special Feature: Preventing Complications in the Nasal Area

By Allie Anderson / 06 Jul 2021

Journalist Allie Anderson speaks to aesthetic trainers Miss Priyanka Chadha, Mr Dalvi Humzah and Mr Ash Labib to explore how to safely administer dermal filler to the nose and avoid complications

Most of us have spent more time than ever at home in the last 16 months, due to the COVID-19 pandemic. Working remotely has seen millions relying on video conferencing platforms to communicate with colleagues, forcing many to scrutinise the way they look on screen.

In the article, ‘A Pandemic of Dysmorphia: Zooming into the Perception of our Appearance’, the authors outline that Zoom displays an unedited version of oneself in motion; a self-depiction very few people are used to seeing on a daily basis. This may have drastic effects on body dissatisfaction and influence a desire to seek cosmetic procedures.”1 The article, published in last November’s Facial Plastic Surgery and Aesthetic Medicine, highlighted that the nose is a feature of one’s appearance that holds up particularly poorly to harsh self-analysis. In fact, an image taken 12 inches away from the face increases a person’s perception of their nose size by 30%, compared with one from five feet.2 Similarly, the shorter focal length of a webcam tends to broaden the nose, as well as making the face appear rounder and the eyes wider set.3

At the same time, the link between social media and body dissatisfaction is increasingly evident – and again, the nose is the focus. On TikTok, for example, the hashtag #nonsurgicalnosejob has attracted around 16.4 million views.4 This is reflected in the demand for non-surgical rhinoplasty, which, according to one clinic, rose by 29% between 2019 and 20205 – in contrast to the surgical equivalent, which steadily declined in popularity during the decade leading to 2020.6

Dubbed the ‘liquid nose job’, it is easy to see why dermal fillers in the nasal region are so widely sought after. They offer a quicker and comparatively more affordable alternative to surgical rhinoplasty, and require less downtime. However, they are certainly not without risk – some of which can be catastrophic – so aesthetic practitioners must be skilled masters in the practice of non-surgical rhinoplasty to prevent complications from occurring.

Complications from fillers in the nasal area

According to Mr Ash Labib, ENT surgeon and founder of AL Medical Academy, minor problems are not especially uncommon. “The complications which arise from nose fillers vary from tiny areas of bruising, slight swelling and erythema to, rarely, something more serious occurring like a vascular occlusion, leading to necrosis,” he states.

Swelling and erythema, reported in up to half of patients undergoing a non-surgical rhinoplasty,7 tend to be mild and self-limiting. Vascular complications are rare,7,8 but a recent case highlighted the potential severity of necrosis if an occlusion is not identified and addressed quickly.9 However, proximity of the treatment area to the eyes means nose fillers carry a small risk of eye-related complications, including ophthalmoplegia, ptosis and even vision loss,10 as all of the practitioners interviewed attested.

“The vascular anastomotic network around the nasal region and, indeed, the glabella region, is incredibly complex and intricate,” explains plastic surgery registrar Miss Priyanka Chadha, founder of Acquisition Aesthetics. “There are a variety of vessels which, if injected directly or through retrograde embolisation, can lead to an occlusion that can, in turn, lead to skin necrosis or even blindness,” she says.

The 2015 paper Avoiding and Treating Blindness from Fillers: A Review of the World Literature, identified 98 reported cases of vision changes, of which 25.5% were from treatments in the nasal region – the second highest-risk area behind the glabella (38.8%).11 While almost half (47.9%) of complications were caused by autologous fat; almost a quarter (23.5%) were caused by hyaluronic acid fillers. Pain and immediate vision loss were the most common symptoms, and the authors reported that most cases of vision loss did not recover.

In a 2019 update to their review,10 the authors reported that 48 new cases of vision complications caused by fillers had occurred between January 2015 and September 2018. The nasal region was the highest-risk site, accounting for more than half (56.3%) of cases, with treatment to the glabella region causing 27.1% of complications. Hyaluronic acid fillers were responsible for the overwhelming majority (81.3%) of problems, with 10 cases recovering vision completely and eight reporting partial recovery of vision.

Product selection

Selecting the appropriate products for the procedure and, in particular, the exact area in which the nose is being augmented is an important factor in mitigating the risk of complications, the three practitioners say. Generally, hyaluronic acid is preferred for high-risk areas like the nose, because in cases of misinjection, vascular occlusions or other complications, hyaluronidase can be administered to rapidly break down the hyaluronic acid.8,12

Consultant plastic, reconstructive and aesthetic surgeon, Mr Dalvi Humzah, founder of Dalvi Humzah Aesthetic Training, says the product he chooses varies depending on which of the three main nasal regions he is treating. He comments, “The upper part of the nose is made up of nasal bone, so you need a product that can replicate that firmness and doesn’t spread. Many people will wear glasses or sunglasses, so the product needs to withstand those pressures, not move around and last a relatively long time.” For that reason, he recommends a high-viscous filler that also has a high G-prime. He explains, “For this, the products are all ‘off-label use’ and I use either Belotero Intense or Radiesse. I would use Radiesse in a specific area where it has a bony defect or to lift the drooping tip.”

For the lower part of the nose, Mr Humzah says, a filler that mimics the suppleness of that region is required. “You don’t want the nose to look and feel very stiff and not move, so the chosen filler needs to be slightly flexible to allow movement of the nose,” he says, adding, “The third part of the nose people are concerned about is the columella. Again, you need a product that can withstand pressure and provide support, so that product should have a high G-prime and low viscosity. I use Belotero Volume as an ‘off-label’ indication.”

Miss Chadha points out the importance of conducting a thorough assessment of the patient and their individual needs in deciding which product to use. “It always depends on the patient, their overlying skin tissue envelope and their underlying structure, which must be examined by looking, feeling and touching the nose,” she says. Practitioners should do this while the patient changes their facial expression – smiling, for example – to enable dynamic, as well as, static assessment of the nose in relation to the other facial features, she advises. “This will help to ascertain how to proceed with treating the nose and connecting muscles. Generally speaking, when treating the nose, I choose fillers with a high G-prime and thus, a high lifting capacity, typically either Teosyal Ultra Deep or Restylane Lyft,” Miss Chadha explains. Mr Labib, conversely, chooses Juvéderm Voluma.

Techniques and placement of dermal filler

As well as identifying the best products for each patient, the appropriate placement of the filler is essential. Mr Labib describes what he terms a ‘no-go area’ or ‘danger zone’, where one should avoid injecting completely. He states, “That is the quadrant on the lateral wall of the nose, between the medial canthus and the infraorbital frame. If you inject in the midline of the nose, which is less vascular and less anastomotic, and you stay deep to the bone and cartilage, that is the safest place to inject.” A systematic review of non-surgical rhinoplasty techniques, outcomes and complications reported that although multiple studies documented injections into the nasal sidewall without complication, it is generally advisable to limit injections to the midline of the nose to avoid the dorsal nasal arteries on either side.8

Debate surrounding the comparative merits and drawbacks of needles versus cannulas is ongoing. For Mr Labib, a needle is the preferable tool of choice. “I believe that, in my hands, a needle is safer because it’s more precise allows you to go down to the right plane (bone and cartilage) and it also enables you to use less product,” he says, adding, “I must have trained more than 2,000 people globally in this technique and I always teach them to use a needle with precision and safety.” Miss Chadha states that how and by whom a practitioner is trained often determines whether they lean towards needles or cannulas in their own practice, but that ultimately, it is guided by personal preference. She comments, “The area is challenging due to the anastomosis and the proximity to important vessels around the eyes, and thus, the cannula is often considered to be safer.” However, like Mr Labib, she argues that the precision and definition required are best achieved with a needle. “If you are trained in performing the procedure with a needle you can often move to using cannulas with confidence, whereas the other way around can be more challenging; people may be more nervous to move from cannula to needle,” she adds.

Figure 1: Patient before and after non-surgical rhinoplasty using 0.65ml of Belotero Volume. Patient treated by Mr Dalvi Humzah

According to Mr Humzah, both cannulas and needles can be used safely depending on the area of the nose being augmented. When using a needle, he says, it is important to consider the angle at which you place it into the nose. “If you come in at an angle rather than at 90 degrees to the bone, you tend to be in a safer position because you can slide the needle into the deep space underneath the vessels,” he says, thereby minimising the risk of piercing a blood vessel and causing bleeding. This is straightforward when performing the procedure on the top part of the nose, Mr Humzah adds, because of the way the layers of tissue are arranged. “You have skin, then fat, then muscle, and a space on top of the bone. If you penetrate underneath the muscle, you can slide the needle at an angle along the bone and deposit the product,” he says. The nose tip, however, is more vascular and the arrangement of vessels less uniform, he highlights. “With a needle in the tip area, it’s very easy to inject into a vessel, so you need to exercise caution,” Mr Humzah adds.

In general, Mr Humzah says he prefers to use a needle if correcting or augmenting a small area along the dorsum, where a single-entry point is used to deposit a column of product. However, with a ‘total nose’ augmentation – requiring multiple entry points on the dorsum, the tip and other regions – a needle is less ideal, he says, explaining, “If I’m reshaping and contouring several areas with a cannula, I can slide along the different planes to lay my products. The nose is a painful area to treat, but a cannula sliding along the nasal bone is uncomfortable, but not painful for the patient.”

“Immediately stop treating as soon as you suspect any signs and symptoms of a problem, and make sure you have an in-date emergency kit ready”
Miss Priyanka Chadha

Neither needle nor cannula are completely without risk, and one is not universally better than the other, Mr Humzah says. Understanding the complex anatomy and physiology of the nose and facial structures is paramount, and as such, comprehensive training is essential. Moreover, all the practitioners interviewed concur that non-surgical rhinoplasty should only ever be carried out by highly skilled practitioners with a medically qualified background.

Using ultrasound to prevent and manage complications

There are emerging benefits to using ultrasound alongside non-surgical rhinoplasty to prevent, diagnose and treat complications. Ultrasound can help practitioners to:24

  • Identify the depth and precise location of blood vessels
  • Ascertain any variation in vascular anatomy
  • Identify the exact position of any obstruction
  • Trace the supply and flow of blood to and from the area
  • Better understand the patient’s unique three-dimensional anatomy
  • Recognise how tissues react with the filler upon movement

According to Mr Humzah, a lower-resolution, handheld device will often suffice in guiding the placement of dermal fillers before or during the treatment itself. He comments, “However, for treating complications you need a higher-resolution ultrasound head that you can dial up to a higher frequency, which allows you to look at the layers of skin at 2-3mm in depth.” These higher-frequency machines tend to be fixed, and are typically more expensive than handheld, low-frequency alternatives. But there are now some new, ultra-high-frequency handheld machines available that would be useful in these situations. “Ultrasound requires more specialist training to use and interpret what it’s telling you. But I believe there is a place for ultrasound in non-surgical rhinoplasty and complications management. It’s like following a roadmap while driving – it makes a lot of practical sense,” Mr Humzah says.

Managing complications

A clinicians’ training must incorporate not just the safe use of products and techniques, but also how to recognise and manage complications should they occur, the practitioners highlight. That way, poor outcomes can be prevented.

Miss Chadha suggests that aspirating before injecting the product can indicate whether you have inadvertently entered a blood vessel and thereby minimise the risk of vascular complications.13 She adds that observing, talking to, and listening to the patient while slowly and incrementally injecting small volumes of filler is crucial, as is watching for blanching of the skin which can indicate a vascular occlusion.14 “Immediately stop treating as soon as you suspect any signs and symptoms of a problem, and make sure you have an in-date emergency kit ready,” she adds, which she states should include hyaluronidase, which should be administered swiftly to dissolve hyaluronic acid, together with syringes, needles, gauze, saline and adrenaline in case of anaphylaxis. “Full, continued assessment should be carried out after treatment with hyaluronidase, to note if the patient has pain or discomfort, to test their capillary refill time appropriately, note any discoloration or further blanching, and take well-documented photos for medical records,” Miss Chadha says.

Figure 2: Patient before and after non-surgical rhinoplasty using Juvéderm Voluma. Patient treated by Mr Ash Labib

Evidence suggests that firmly massaging the area can eliminate any obstruction and encourage blood flow,15,16,17 while if an arterial embolus is suspected gently tapping on the area can help to dislodge it.18,19 However, if conservative measures like these are unsuccessful or the capillary refill time is greater than three seconds, Miss Chadha recommends reconstituting using the Aesthetics Complications Expert (ACE) Group World high-dose pulsed hyaluronidase protocol.14 If severe skin necrosis is a threat, hyperbaric oxygen therapy (HBOT) can be considered.20 It has been used post-treatment to encourage tissue healing following an occlusion,21,22 but local availability, cost, inconvenience and risks can preclude its use in worst case scenarios.23

Other problems which may occur post-treatment include infection and persistent pain, which, according to Mr Humzah, is often overlooked as a potential complication. “The nose has lots of nerves and if you inject close to those nerves, you can cause damage or neuropraxia,” he says. He explains that pain can be treated with appropriate analgesia and antibiotics prescribed for infection as needed. Most importantly – as all the interviewees highlighted – practitioners should have a clinical referral pathway in place, enabling them to act quickly, ensuring the patient has a smooth transition to emergency or specialist care if required. 

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