Approaches to Non-Surgical Rhinoplasty

Non-surgical rhinoplasty (or simply NSR) is ideal for patients who do not want to experience the complications and downtime associated with conventional surgical procedures. It is also used when a surgical procedure is not needed. Reshaping the nose with a soft tissue augmenter e.g. hyaluronic acid, NSR is able to deliver dramatic yet natural looking results.

In this article, we will discuss about the techniques to perform non-surgical rhinoplasty treatments. We will also discuss about the anatomical considerations of a NSR, while exploring its potential risks and complications (and the best ways to manage and prevent these). Plus, this article will provide tips on how to achieve successful treatment outcomes.

Key considerations of a non-surgical rhinoplasty

• It may be difficult to non-surgically elevate a hard and thick fibrous tip that cannot move when pinching the nasolabial junction. Consider a surgical solution instead.
• When performing injections in high-risk areas, it is important to have hyaluronidase injectables handy. In addition, it is important to be familiar with the dilution factors.
• An altered, compromised blood supply (coupled with arteries fixed by scar tissues) significantly increase the risk of cartilage and skin necrosis. Therefore, doctors should be extra cautious while injecting dermal filler into tissues. Keep in mind that tissues may be more difficult to inject as they tend to be less pliable.
• For patients who have previously had implant placements, it is not recommended to use more than 0.1 to 0.2ml of hyaluronic acid in total.

Complications of non-surgical rhinoplasty

One of the greatest concerns associated with non-surgical rhinoplasty is injection of fillers into a blood vessel. Injecting into an artery can cause retrograde flow proximal to the branching point of the central retina. Carried forward with the blood flow, the filler will eventually cause an obstruction. Clinically the filling defect in the retina may manifest as a visual field deficit or a sudden blind spot. During a non-surgical rhinoplasty, it is important to avoid any accidental injection into the artery. The ophthalmic artery is known to terminate in two small branches, which are the dorsal nasal artery and the superior trochlear artery. Be aware that there are short and direct connections from the proximal blood supply to the retinal arteries and internal carotid. Injecting product into these areas may cause brain infarction and blindness. Additionally, embolization may affect the distal blood supply at the alar and tip, subsequently causing ischemic events such as skin necrosis and prolonged erythema.

Other complications associated with NSR

• Tyndall effect – This is characterized by the blue skin discoloration (which results from excessive amount of product placed too superficially). As with most complications, this can be reversed using hyaluronidase injection.
• Lumps and nodules – These can occur when the product is injected too superficially, too quickly or when too much product is injected. Correction can be done through drainage of product or excision. Hyaluronidase can also be used for treating lumps and nodules.
• Delayed hypersensitivity – A few months after treatment, the injection sites can become hard. For complete removal of hyaluronic acid, it is recommended to use treatments such as steroids and long-course antibiotics.
• Infection – In order to reduce the risk of infection, practitioners should use appropriate skin disinfectants while minimizing incision sites with good techniques. Persistent infections (such as those related to a biofilm) can be treated using broad-spectrum antibiotics such as ofloxacin.

Managing complications associated with non-surgical rhinoplasty

Due to the nature of hyaluronic acid products, most complications are reversible using hyaluronidase. The units of hyaluronidase needed will vary depending on the type of the product. Accidental injection into the artery can lead to catastrophic consequences. If there is a vascular event, hyaluronidase should be injected into the surrounding tissues or ideally, the vessels for reperfusion. In order to determine which branches are affected, practitioners should examine the pattern of ischemic change. Some of the possible treatment options include GTN, hyperbaric oxygen, hot compresses, Nitropaste, and nitrate dilator (which is commonly used for the treatment of angina).

Techniques for non-surgical rhinoplasty

While certain nasal deformities can be easily treated with a non-surgical rhinoplasty, others may be more technically challenging and should be performed by experienced practitioners. Severe cases of nasal deformities may need a surgical intervention.
In general, low risk areas are associated with a lower of complications. It is relatively easy to treat these areas and obtain satisfactory results. Examples of low risk areas include flat nose, short nose, saddle deformity and mild dorsal hump.
High-risk regions, on the other hand, are associated with a higher risk of skin necrosis. These regions should only be treated by more experienced practitioners. Some of the common high-risk regions are micronose, glabella, alar recess and nasal tip.

While the use of needles is common in non-surgical rhinoplasty, it is generally advisable to use a cannula whenever possible. Granted, cannula can cause more discomfort and is difficult to use. However, needles are associated with a higher risk of complications. For example, an inadvertent injection into a blood vessel can have catastrophic consequences.

A. Cantilever nose lift: correcting the nasal dorsum

After applying an appropriate amount of 2% lidocaine, create an entry point at the nasal tip using a 50mm, 22G blunt cannula. This allows assess through the sellion for dorsal augmentation (or posteriorly to the nasal spine for tip elevation).

When treating the dorsum, make sure that the depth is in the supraperiosteal plane at the subcutaneous layer. Ideally, insert the cannula into the nasion, past the sellion. Check the position of the cannula tip by pinching the dorsum of the nose. This also helps to avoid lateral spread and mold the product. In order to keep the product in the correct plane, it is recommended to use a slow retrograde technique by administering the product while withdrawing the cannula.
If widening of the dorsum is needed, retract the cannula to form a new tunnel inferior and lateral to the first (repeat this step for the contralateral side). Practitioners are advised against adding large volumes in the single tunnel created by the cannula.
The sellion is the deepest point of the nasal root. It is typically positioned higher in a Caucasian face in comparison to other ethnic groups. Through injection into the dorsum, it is possible to move this point by up to 5mm closer to the medial brow.

The decision on whether to inject into the sellion should be made based on careful assessment of the rhinion. If there is a small dorsal hump, the product should be injected onto both the caudal and cephalic parts of the hump to improve its appearance.

To complete the treatment, augment the medial brow to the dorsum with a 30G needle. Aspire carefully before performing a retrograde injection and contour the glabella in balance with the nasal dorsum (specifically, the upper nasal dorsum). To soften any existing glabellar frown lines and create a smooth arch, inject to the radix from the medial brow. To treat a flattened nasal bridge (radix), use a cannula to administer about 0.75ml of hyaluronic acid with the tunneling technique. Create an entry point at the tip of the region, then building up and widening the radix in this region.

B. The correction of the nasal tip area

The injection of product into the interdomal region may help to correct a bifid tip. Alternatively, the product can be administered to the interdomal area to fill and widen a narrow nasal lobule. When raising the tip of the nasal, it is important to avoid injection into the tip itself, which could result in vascular compromise of the skin envelope. Furthermore, this is not likely to achieve long lasting results due to the lack of solid foundation for the filler to lay on. Based on the findings of cadaveric studies, injection at this point could damage the midline longitudinal columellar artery in up to 31.1% of dissections.

Therefore, it is safer to inject between the anterior nasal spine at the columella base and the footplates of the lower lateral cartilages. In most cases, 0.5 to 1ml of product is required. It is difficult to elevate a thick, hard fibrous tip that doesn’t move when pinching the nasolabial junction. For these patients, a surgical procedure may be required for repositioning the nasal tip. Injection of approximately 0.5ml of product into the columella will provide support for the nasal tip. This may be sufficient for correction if the tip droop is minor. For patients with an under developed dorsum and a low radix, use 0.9ml of hyaluronic acid to create more tip projection and rotation. Treat the base of columella to improve the nasolabial angle and to lift tip. Dorsal augmentation can also be performed for a more refined tip.

C. The correction of the columella recession

To correct the columella recession, place the cannula from the nasal tip down to the midline of the columella posteriorly. Then inject 0.5ml of product gradually using the retrograde technique. If needed, practitioners may use multiple tunnels. Generally, the ideal nasolabial angle ranges from 110 to 120°. Keep in mind that the range differs for male and female patients. Most patients seeking a non-surgical rhinoplasty tend to have a nasolabial angle of lower than 90°. For correction, use a 30G needle to inject into nasal spine through the skin. This procedure is usually performed in combination with columella correction with a slow bolus of hyaluronic acid. For the treatment of both areas, practitioners may use up to 1ml of product. For instance, patients with a dorsal hump can be treated with 0.55ml of product. Perform dorsal augmentation in the supra-tip area and at the radix to disguise the dorsal hump. This gives a supra-tip break with slight kick-up of the nasal tip.

D. Spreader grafts

Non-surgical rhinoplasty can be used for both cosmetic and functional purposes. Most notably, injectable fillers can be used to improve the air passage by widening the valve of the nose. Conventionally, the widening of nasal airway can only be achieved through a surgery (in which cartilage grafts are harvested and inserted to lift the upper lateral cartilages off the septum). Products such as hydroxyapatite and hyaluronic acid are commonly used for this purpose. Granted, the results of these injectables are not permanent. However, they allow the assessment of the potential functional improvements that could be obtained via a surgery.

Conclusion

In order to obtain optimal non-surgical rhinoplasty results, it is important that doctors receive suitable training. More importantly, they should be familiar with the anatomy of the nose. Prior to treatment, doctors should perform a thorough patient consultation. As with most interventions, the key to a successful non-surgical rhinoplasty is appropriate management of patient expectations. Patients should be made aware of the limitations of the treatment and have an attainable, realistic treatment goal. In order to prevent complications, high risk areas should be left to more experienced practitioners (or treated surgically). Good techniques (such as using cannula whenever possible and performing aspiration before injection) may also help to reduce the risk of complications.