Non-Surgical Rhinoplasty (Part 2)
As with the many features that define an attractive face, the nose undoubtedly plays a crucial role.
As with the many features that define an attractive face, the nose undoubtedly plays a crucial role. Indeed, it will often be one of the first point to be scrutinized when looking at an individual’s face. This has placed a huge burden on the aesthetic field to manufacture techniques that are able to improve the appearance of the nose. Just in 2017, rhinoplasty procedures for both females and males were the 10th and 6th most common surgical procedures in the United States, respectively. In addition to that, the largest proportion of the patients are between 19 to 34 years old, which indicate that the demand is usually highest amongst younger patients.
Traditionally speaking, rhinoplasty is a challenging surgical operation that is used to change the functional performance and aesthetic appearance of the nose through the manipulation of bone, cartilage, and soft tissues. The success rate for rhinoplasty rests mostly on the surgical expertise of the performing practitioner. Even a few millimeters in difference can bring about drastic changes in appearance. It is absolutely essential then that the surgeon has experiences with rhinoplasty and its techniques, a thorough grasp of nasal anatomy, and the soft skills required to control a patient’s expectations. In the aesthetic sense, however, there are two ways to approach the nose: reconstruct the nose to enable its proper functioning and an aesthetically-pleasing result or modify only the aesthetic proportions of the nose to better suit the patient’s cosmetic needs.
Given the complexity of surgical rhinoplasty, many patients and medical professionals have focused on rhinoplasty procedures that are efficient, safe, and have minimal adverse effects. One of these procedures involves the use of dermal filler injections, which has many of the qualities from above. Dermal fillers remain a popular choice, as they can be used in place of grafts and can eliminate the potential risks associated with surgical procedures. As a matter of fact, dermal filler procedures have accounted for over 72% of all nonsurgical procedures done in the United States in 2017. The results from dermal fillers are fast, reliable, and consistent. The risks involved are usually technique-related, and the practitioner must be experienced and have considerable knowledge in respect to facial vascular anatomy.
Characteristics of the nose
There are a few points that constitute the reasons patients first seek consultation for rhinoplasty. These defects or imperfections can be viewed in a few different planes, and they are usually best viewed and compared in a side-to-side manner via six standard pre-procedure rhinoplasty photos that provide the required baseline and framework to analyze the nose. These are the frontal, right and left oblique, right and left lateral, and basal views.
Through the examination of these views, you will be able to ascertain the technical information you need for the appropriate aesthetic corrections. The frontal view is composed of three equal horizontally-divided parts. The most superior third has the nasal bones; this should be symmetrical and have 75% of the intercanthal distance. The second third is made of the upper lateral cartilages and the dorsal septal cartilage. At this area, there is a line present that connects the glabella to the ipsilateral tip-defining point called the brow-tip aesthetic line. This line must be curvilinear, symmetrical, and smooth. Any deformities that were a result of trauma or surgery can disrupt this fragile line. The lower third is the nasal tip, which can be classified as bulbous, narrow, bifid, boxy, or amorphous. An elegant nasal tip is diamond-shaped with two tip-defining points that can be shown via the light reflex they reflect. These points should be within 1cm of each other. The nostril rims are paid the least attention, but they should be in the shape of a “gull-in-flight” with the columella.
On the lateral view, you will have a more accurate view of the profile of the nose and the ala-tip complex. The length of the ala and tip should be about equal, and there must be at least 2 to 4mm of columella present below the level of the nostril rim. The nasal tip profile should have a “double break,” meaning that the ideal shape will form through the appearance of a tip-defining point and a subtle angulation at the junction of the tip lobule with the columella. Some patients also prefer a supratip break that is between the nasal tip and the nasal dorsum.
The basal view offers an accurate assessment of the nasal base width and nasal tip symmetry. From this view, the nose should form an equilateral triangle. In other words, the width of the columella and the width of the lobule must be at a 2:1 ratio. The tip should be about one-third of the total height, while the nostrils should make up the last two-thirds.
Patients consider nonsurgical rhinoplasty when they run out of options. There are typically two kind of patients: ones with severe deformities that are readily apparent but may not have any surgical treatment done before, and the other type are patients that have undergone a prior surgical rhinoplasty but were unable to achieve the desired result. The latter compose the bulk of the patients that seek minor correction. For example, patients with noses that deviate slightly to the right or left or have a high dorsal hump would want a uniform, straight nose with the width of the nose proportional to the chin, the appropriate intercanthal distance, and the light reflections at the tip of the nose.
You must be able to select the appropriate patients for rhinoplasty procedures that use dermal fillers. If rhinoplasty with dermal fillers cannot provide a patient with a good result, they should be put on the surgery list instead. Assess the nose carefully and examine the deformity to ensure that it is not severe enough to discredit filler use. Noes that are chosen to be corrected via fillers should ideally only have a structural defect with no signs of functional deficit. Furthermore, through this aesthetic correction, it must not concurrently impede the functionality of the nose, such as breathing. Patients that generally will have positive results are those with a mild dorsal hump, a mildly-deviated nose, a high nasal tip with a flat radix, and/or slight asymmetry from previous rhinoplasty. Patients with a more severe dorsal hump, deviated nose, upturned nose, and/or bulbous nose are not expected to have positive results from the use of dermal fillers as a standalone treatment plan. Take special precaution in treating patients that have had a history of paraffin or liquid silicone injections, as skin irregularities and vascular compromise are much more likely. An experienced practitioner will have the forethought to be extremely careful treating patients with history of surgical manipulation; as a precautionary measure, some practitioners advocate using a minute amount of dermal filler to observe the rise of the skin as the filler starts volumizing the area. Although it is important to scrutinize every patient, the majority will have mild deformities that can be corrected with fillers.
Hyaluronic acid (HA) dermal fillers are known for their safety profile, and this alone has made many practitioners opt for the application of HA fillers in the nasal region. The risk for complications in this area is too great to consider more permanent options without compromising patient safety. In addition, the thin layer of skin at the dorsum of the nose will subtly change when injected with dermal fillers that can affect the overall appearance of the nose along with other facial features. Practitioners should always have hyaluronidase injections on hand when they encounter problems with HA fillers. Hyaluronidase are enzymes that target hyaluronic acid dermal fillers to dissolve them. They are used in cases of complications such as inadvertent intravascular injection that may lead to vascular compromise in the region. Due to the differences between HA filler products, Juvederm Volume is the product of choice, as it has been demonstrated to have excellent lifting capacity and a longer duration of action than most HA fillers. An alternative would be Juvederm Ultra due to its resilience to contouring forces, which makes it suitable to correct indentations with the least amount of filler material. In addition, HA fillers are broken down faster and easier in dynamic regions of the body, such as the nasal area, lips, and eyes. Passive areas of the body can see the effects of HA fillers last up to 12 months.
Restylane Lyft has also been used by practitioners in the nasal region, as it has both high G’ and lifting properties. Using low G’ fillers will result in the nose falling flat and deviating from the corrected position. Restylane Lyft is more suitable for treatment of dorsal humps. Another product called Restylane Refyne may be more suitable for smaller deformities, as it has strong product integration. The Belotero product line also can be considered, as it can provide significant structural integrity to help volumize the nose. In finer soft tissue defects, Belotero Balance can be used instead to ensure that the dermal filler material does not erode through cartilage to cause a more significant defect.
Apply topical anesthesia to reduce patient discomfort and use a cannula so that the injection sites sustain less trauma. For dorsal hump treatment, the main aim is to bring the depression points to align with the hump so that the nose transitions smoothly into a linear and harmonious structure. Mild nasal humps are easily correctable via the retrograde injection technique. Start at the nasion down to the depression just above the hump and continue with a concurrent tip rotation with the cannula to target the nasofrontal and nasofacial angles. Next, place the filler in the saddle created between the elevated nasal tip and the rhinion to straighten the nose. Some practitioners prefer using a 32G needle to prick the skin and then proceed with a 38mm long 25G cannula. Although you may find the dorsal hump easy to correct, remain vigilant to ensure natural results are achieved. Injecting above the dorsum hump may bring the radix forward, and if overdone, it may appear too artificial. Use the cannula at the tip of the nose and slide the septal cartilage over the hump. Remember to inject slowly so that you can see the skin lift from the dermal filler material. About 0.5ml is required for most patients. Using a needle provides greater precision, and you can better predict how much correction you need. The injection must be done gently and precisely so as to not cause excessive damage to the surrounding tissues. The injection procedure generally takes about 15 minutes.
The most common side effects are transient and mild and include bruising, headaches, swelling, erythema, and infection. Most of the time, they are self-limiting and resolve within a few days. The most serious adverse effect is vascular compromise. Vascular compromise can be caused by inadvertent intravascular injections or vascular compression due to filler deposition into a limited space. It has a higher incidence in patients with a history of rhinoplasty, as their vascular circulation has been compromised. Vascular complications are dreaded because they can cause skin necrosis and even blindness. Mild cases have been reported as causing only multiple mottled erythematous patches over the vascular supply area—which includes the nose, glabellar area, and forehead—for about 1 to 4 weeks.
The vascular system of relevance in this procedure is the dorsal nasal artery, which is a branch of the ophthalmic artery and the lateral nasal artery. These arteries are at great risk of intravascular injection in the hands of an inexperienced injector. The filler material can migrate in the reverse direction to the ophthalmic artery, which explains how blindness may come about in certain patients. The retinal and the posterior ciliary artery are occluded, which leads to ischemia and ultimately cell death. To prevent such an occurrence, the routine use of cannulas are recommended instead of needles. Although it is common to perform the blood aspiration test prior to injection, the thin vessels of the nose tend to provide false-negative results where blood may not be pulled into the syringe even though the needle may have hit a blood vessel. In addition, the smoother progression and injection speed of a cannula can also help further risk reduction.
The onset of ischemic signs is a crucial period to know when to administer hyaluronidase. It is important for you to recognize signs such as blanching during injection and grayish discoloration as early as possible. If any of these occur, inject hyaluronidase subcutaneously into the ischemic site and area surrounding it immediately. Continue on with sublingual nitroglycerin and oral aspirin (100mg) intake. Steroids and antibiotics can be given to reduce the risk of inflammation and the formation of secondary infection(s). The other less-known side effect is temporary redness. It is caused by vascular dilation that comes about because of impaired circulation through vascular compression, which is in turn caused by the dermal filler. It can last for over a few months and can be resolved via hyaluronidase if HA fillers are used.
Knowledge is paramount
The characteristics of HA dermal fillers make them a unique choice among fillers. They have volume expansion capabilities and can be dissolved via hyaluronidase. Technically, any practitioner is allowed to perform nonsurgical rhinoplasty, but they must have extensive knowledge over the facial vascular anatomy, especially concerning the nose, and they must have sound theoretical and hands-on training. It is an advanced procedure, and you must be always prepared in the case of vascular compromise. Indeed, tissue necrosis can occur as fast as one or two days.
- Ase Kristine Rognmo Mikalsen, Ivar Folstad,corresponding author Nigel Gilles Yoccoz, and Bruno Laeng, ‘The spectacular human nose: an amplifier of individual quality?’, PeerJ, 2014. https://www. ncbi.nlm.nih.gov/pmc/articles/PMC3994647/
- BAAPS, ‘The Bust Boom Busts, 2017. https://baaps.org.uk/media/press_releases/29/the_bust_ boom_busts
- Louis S.Belinfante, ‘History of Rhinoplasty’, Oral and Maxillofacial Surgery Clinics of North America, 2012. http://www.sciencedirect.com/science/article/pii/S1042369911001737>
- Deo, S, ‘The History of Indian Rhinoplasty, Aesthetics, 2016. https://aestheticsjournal.com/feature/ the-history-of-indian-rhinoplasty>
- Y.Gao, J.Niddam, W.Noel, J.P.Meningaud, ‘Comparison of aesthetic facial criteria between Caucasian and East Asian female populations: An esthetic surgeon’s perspective’, Asian Journal of Surgery, 2016. <http://www.sciencedirect.com/science/article/pii/S1015958416301798>
- Stephen S. Park, Fundamental Principles in Aesthetic Rhinoplasty, Clin Exp Otorhinolaryngol, 2011 Jun; 4(2): 55–66. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3109328/>
- JeongHoon Suhk, JinSoo Park, & Anh H. Nguyen, ‘Nasal Analysis and Anatomy: Anthropometric Proportional Assessment in Asians—Aesthetic Balance from Forehead to Chin, Part I’, Semin Plast Surg, 2015 Nov; 29(4): 219–225. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4656173/>
- Jacob I. Beer, David A. Sieber, Jack F. Scheuer, & Timothy M. Greco, ‘Three-dimensional Facial Anatomy: Structure and Function as It Relates to Injectable Neuromodulators and Soft Tissue Fillers’, Plast Reconstr Surg Glob Open, 2016. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5172484/>
- Beleznay K, Carruthers J, Humphrey S, Jones D, ‘Avoiding and Treating Blindness From Fillers: A Review of the World Literature’, Dermatologic Surgery, 41 (2015), pp.1097-1117.
- Gronow, C, ‘News Special: The AIIVL Consensus Group’, Aesthetics, 2017, <https://aestheticsjournal. com/feature/news-special-the-aiivl-consensus-group>
- The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank STATISTICS. https://surgery.org/sites/default/files/ASAPS-Stats2017.pdf (accessed 6 July 2018).
- Ferril GR, Winkler AA. Rhinoplasty and Nasal Reconstruction. (ed). ENT Secrets, 4th ed. Elsevier; 2016. pp. 405-411.
- Seo KKI. Nose. (ed). Soft Tissue Augmentation: Procedures in Cosmetic Dermatology Series, 4th ed. Elsevier; 2018. pp. 123-133.