Nonsurgical Rhinoplasty or Medical Rhinoplasty
Unlike many other facial plastic surgery procedures, there are few non-surgical alternatives to rhinoplasty surgery. The only way to make permanent nose shape changes is to alter the underlying bone and cartilage framework. Such alterations ultimately get reflected on the outside as the nasal skin adapts. The search for a less invasive way to change the shape of one’s nose has only more recently been possible through the use of injectable fillers. Their use in the nose has been labeled as an injectable rhinoplasty or a non-surgical rhinoplasty. Using injectable fillers for certain nasal shape problems or to correct secondary rhinoplasty deformities has its merits. It is quick to do, has a low cost and avoids any type of recovery associated with a more invasive rhinoplasty.
While such injectable rhinoplasties are certainly appealing, how well do they work, who is a good candidate for it and what are the potential risks? Not to be confused with a surgical rhinoplasty, patient selection is crucial when using an injectable technique. Surgical rhinoplasty can change almost every component of the nose, injectable fillers can change very few. Thus injectable fillers can not do what a closed or open rhinoplasty can do, it simply is not a substitute for surgery. Non surgical rhinoplasty must complement and not compete with surgical rhinoplasty.
Indication of Non Surgical Rhinoplasty
- Raise and better define an underdeveloped nasal dorsum.
- Raise and better define a ptotic tip.
- Camouflage a dorsal bump.
- Correct asymmetry of the tip or dorsum by subtly augmenting the weaker side.
- Correct post-rhinoplasty contour defects. Most commonly, these present as saddle nose deformity or other type of dorsal cartilage collapse, polly beak deformity, dorsal asymmetry due to asymmetric scarring, asymmetry of the tip due to postsurgical scarring or cartilage over-resection and alar foreshortening.
A patient’s chief complaint about his or her nose needs to be addressed. The level of nasal deformity as it relates to the magnitude of the patient’s concerns should be critically assessed, as well. Past medical history should be reviewed, with an emphasis on drug use, allergies, history of cold sores, presence of autoimmune disorders, history of facial herpes virus, previous facial operations (specifically rhinoplasties or dermal filller treatments), Due to minor bleeding during injections, patients should not be on any blood thinners including warfarin, NSAIDs, vitamin E (including multivitamin form), certain herbs, and excessive alcohol intake. One recommendation is to cease ingesting anything that can thin the blood for 10 days prior to the procedure.
Patients should be informed of the risks and benefits of the procedure in order for them to have realistic expectations toward a satisfactory outcome. They should be informed that the results are not permanent, and may require further revision before acquiring the desired appearance. Moreover, non-surgical rhinoplasty with fillers does not exclude patients from surgical rhinoplasty in the future. Patients with one or more of the following conditions may also be excluded from the procedure: acute or chronic nasal infection, existing keloid scars, history of systemic collagen diseases, severe bleeding disorders, nasal respiratory impairment, and unrealistic expectations.An essential part of the informed consent is the discussion of a surgical rhinoplasty as a permanent alternative to a non-surgical rhinoplasty. It is very important for patients to know that both options, the surgical and non-surgical ones, are viable options if that is the case. Various reasons may sway the patient to have a nonsurgical rhinoplasty such as cost, lower risk, desire for a minimal change, time of recovery, and fear of surgery.
Prior to any medical or surgical correction of the nose, even before proposing possible corrections to the patients, it is important to study the nose. This allows us to decide if and what to propose to the patient. The nasal analysis is a detailed procedure which involves multiple measurements and angles, multiple softwares are available for complete analysis and beyond the scope of this article. The points which are pertinent to non surgical rhinoplasty are discussed here.
First step to analysis is a set of good photograps which include Frontal,Right oblique,Left oblique,Profile( lateral) and Basal views.
- Alar base width 2. Alar crease junction 3. Alar groove 4. Alar rim 5. Columella 6. Columellar base 7. Columella out line 8. Footplates of the medial crura 9. Glabella 10. Nasal base line 11. Nasal dorsum outline 12. Nasal lobule 13. Nasal lobule outline 14. Nasal radix outline 15. Nasal “unbroken” line 16. Nasion 17. Nostril sill 18. Rhinion (clinically this is evaluated with direct palpation of the dorsum) 19. Soft triangle or facet 20. Subnasale 21. Supratip area or supratip break point in clinical cases where a clear step over the nasal tip is present 22. Nasal tip 23. Tip defining points
- Trichon : mid point of forehead where forehead meets vertex or hairline.
- Glabella (soft tissue glabella). The most prominent anterior point in the midsagittal plane of the forehead between brows.
- Nasion : is the intersection of the frontal bone and two nasal bones of the human skull. Its manifestation on the visible surface of the face is a distinctly depressed area directly between the eyes, just superior to the bridge of the nose.
- Rhinon The most caudal point of the intranasal suture.
- Subnasale The point at which the columella merges with the upper lip in the midsagittal plane.
- Stomion: is the midline point at the junction of the upper and lower lip vermillion.
- Menton:is the most inferior midline point on the inferior border of the chin.
- Alar base plane (ABP), is a plane running through the alar base and utilized as a division between the midface and the lower face.
- Tip The apex of the lobule.
- Tip defining points. The most projecting area on each side of the tip, which produces an external light reflex.
- Supratip area. The area just superior to the nasal tip at the inferior aspect of the nasal dorsum.
Finding the ideal nose length for the face
- Measure the midfacial height (MFH) and the lower facial height (LFH). LFH should be equal to or 3 mm greater than the MFH
- Measure the chin vertical (Stomion-Menton).
- Calculate and draw the ideal nasal length (RT i) utilizing two different procedures: RTi=0.67 × MFH or RTi=SM.
- Calculate nasal length Nasion-tip.
Ideal Nasal projection
- Measuring Nasal Height Nasal height is measured at the nasion (N), rhinion (R), and tip defining point (T) (pronasalae). The reference of origin for the nasion begins at the anterior corneal plane, while the vertical alar plane is referenced when measuring rhinion height and tip projection.
- Ideal height of the nasion is between 9 mm-14 mm.Ideal dorsal height at the rhinion is between 18mm-22mm, while nasal tip projection is between 28mm-32 mm.
The ideal nasal projection is calculated from the ideal nasal length by multiplying by .67. It is measured from alar crease to nasal tip.
- Measure distance between superior eyelid crease and nasion and corneal plane and nasion.
- Ideal nasion at superior eyelid crease and 9-14 mm from corneal plane. Glabella to nasion 4-6 mm.
Change in postion of radix can change the apparent length of nose drastically.
Nasal Unbroken Line
The line joining the medial edge of eyebrow the radix dorsum and nasal tip should form a smooth unbroken line.
The procedures in aesthetic medicine are particularly indicated when these angles are reduced, in particular, when the frontal angle is less than 120º and the nasolabial angle is less than 90º. In the minimal-invasive surgical procedures, the nasofacial angle is also important, which is normally around 35º, and the nasomental angle is around 125º. These two angles allow us to evaluate the projection of the nasal tip with precision.
The examination of the nasal tip during movements is also very important, especially when the patient smiles or during a speech. This is carried out particularly during the first visit, when the patient comes into our offce and begins to tell us his or her needs. At these moments, during the smiles and natural movements, it is possible to see the rotation of the tip. Due to depressor septi overactivity.
Anesthesia and Prophylaxis
The most common types of anesthesia to injection sites include: lidocaine with epinephrine, topical lidocaine with tetrcaine for 30 min, anesthetic gel, or topical anesthesia with BLT applied for 15–30 min prior to injection . Applying a ice pack to the nose decreases sensation and provides good analgesia. A judicious combination of the above may also be used with care not to compromise the blood supply to the nasal tip.
Anesthesia may also be used as a means of loosening tissue and cartilagetilage prior to filler injection. For this, a 25-gauge or 27-gauge needle may be used to create a space from distal puncture site
Prophylactic antibiotics are not used for non-surgical rhinoplasty, but there is anecdotal evidence supporting prophylactic use use of Arnica montana, bromelain, and 1% vitamin K1 (phytonadione) cream to reduce bruising.
Doses vary depending on individual patient characteristics, but suggested maximum doses include: 1.5 mL at the fronto-nasal angle, 0.5 mL at the dorsum, 0.5 mL at the tip, and 1.5 mL at the nasolabial angle; as maximum doses to each specific area . We recommend limiting the initial total injection to 1.5 mL to avoid tension on the overlying skin as well as overcorrection. It is better to under-correct deformities, as they can be filled in or touched up during a follow-up visit in 2 weeks to 3 months.
Hyaluronic Acid Derivatives
Hyaluronic acid (HA) is a naturally occurring component of human connective tissue. The chemical structure is
identical across species and this minimizes the likelihood of immunogenicity. Cross-linking and other techniques have been used to render HA more stable, producing its superior longevity.
Voluma is more cross-linked than other HA fillers and has a higher percentage of low molecular weight hyaluronic acid, making it exceptionally smooth, viscous, and cohesive. Increased cross-linking makes the filler more resistant to enzymatic degradation. Under study conditions, duration of effect was up to 2 years.
Juvederm and Restylane are relatively soft materials. They can only provide moderate augmentation of the dorsum, they cannot lift a drooping tip very much and they are poor at sculpting defining points of the tip and the sidewall of the nose.
Calcium hydroxylapatite filler (CaHA – Radiesse, MERZ Aesthetics Inc., San Mateo, CA)
Radiesse is a biodegradable filler consisting of 30% synthetic CaHA microspheres (diameter of 25-45μm) suspended in a 70% aqueous carboxymethylcellulose gel carrier. The soluble carrier gel evenly distributes the Radiesse CaHA microspheres providing 1:1 correction and gradually dissipates leaving the microspheres at the injection site where they induce neocollagenesis by fibroblast activation.
The advantages of CaHA are its relative persistence of effect average of 9–10 months and its high density. This last quality allowes to effectively sculpt noses to patient satisfaction. It is possible to significantly elevate a droopy tip without excessive rounding. In fact, CaHA makes it possible to precisely create aesthetically pleasing tip defining points in patients with rounded and poorly defined tips.
Artefill is a third-generation methyl methacrylate filler in a collagen carrier that was FDA approved in 2006 for nasolabial fold correction. The filler is 20% methyl methacrylate and 80% bovine collagen. It is permanent and must not be used in first sitting. Many patient convinced with the results of temporary fillers do request a permanent fix and Artifill may be used in those cases.
Silicone is a synthetic, inert substance composed of polymerized dimethylsiloxane. It is available in varying degrees of viscosity, ranging from water thin to solid blocks or sheets. Liquid silicone is typically injected into the subdermis to provide permanent soft tissue augmentation.
TECHNIQUE and TIPS
When using soft tissue fillers in the nose, patient selection is paramount. Good candidates for injectables are resistant to surgery, have thick skin, and have deformities that do not involve the nasal tip or alae.
An appropriate needle is first selected to administer the filler. The smallest needle that the product will flow smoothly through is preferable because a thin needle minimizes patient discomfort and maximizes precision. The advantage of HA agents and silicone is that they will flow through a 30-gauge needle. CaHA is more easily delivered through a 27-gauge needle. Discomfort is rather mild and topical anesthetic (23% tetracaine and 7% lidocaine) is adequate. We reconstitute HA and CaHA by mixing 1 mL of filler material with 0.3 mL of 1% lidocaine with epinephrine (1:100,000). The reconstitution decreases the viscosity of the products, making them easier to inject precisely. In addition, it reduces discomfort during injection and seems to result in decreased posttreatment edema and ecchymoses.
Needles or Microcannulas
Dermal fillers may be injected using either a hypodermic needle or blunt-tip microcannula. CaHA is generally injected with a 30mm-long 27 gauge or 19mm-long 28 gauge inner diameter needle or a 25 or 27 gauge variable length microcannula. Needles have the advantage of extreme precision of movement, the possibility of deep intradermal injection, and a requirement for smaller injection volumes. Disadvantages of needles include pain, bruising, and nerve/vessel laceration. Cannulas cause less trauma, pain, and bruising and allow a large area to be treated at the chosen injection depth. Some authors advocate blunt tipped cannulas for all filler injection as a way to reduce complications and discomfort . I think this is not a good idea in the nose. The weakness of cannulas is precision. It is much easier to know the exact location of a needle tip than the tip of a cannula that bends easily as it is advanced through the tissue.
The virgin nose treated with large amounts of HA (greater than 0.5 mL) may be placed at risk for vascular compro-
mise, particularly if injected with a larger particle or more robust HA such as Perlane (Medicis Aesthetics, Scottsdale, AZ) or Juvéderm Ultra Plus (Allergan, Irvine,CA.) The larger particle size of these HA products can apply pressure onto nasal vasculature, leading to the possibility of vascular compromise. In addition, the hydrophilic properties of HA may expand the skin soft tissue beyond the product’s original deposited borders, resulting in a distorting augmentation. Juvéderm is noted to be more hydrophilic than Restylane (Medicis Aesthetics, Scottsdale, AZ) and therefore more likely to expand the nasal tissues.Therefore, Restylane (and not Juvéderm) has been a favored choice.
HA formulation has medium viscosity and deep dermal placement is typically recommended. We have found
the dermal placement of HA to be undesirable because it can result in persistent blue lines(Tyndall effect) and the formation of telangiectasia. Alternatively, persistence is unaffected and correction is as good, if not better, when HA is placed subdermally. Subdermal placement is especially critical when administering fillers to the nose. In most cases, sub-SMAS placement is even more ideal.
Correction of Bridge of nose
Correction of depressed bridge of nose or radix. Analyse the profile picture and calculate the ideal radix projection and desired nasofrontal angle.During initial consultation or before filler injection a trial procedure with saline or local anesthetic injection helps assess the volume required and also allows the patient to see the expected results. Always under correct when using HA filler. The ideal filler would be CaHa or Radiesse due to higher density and better placement characteristics. The needle is advanced perpendicular to the skin and injection into deep subcutaneous in case of HA and supra periosteal in case of CaHA fillers. A maximum of 1.5 ml in injected. Following injection the area is moulded with finger and steristrips or splint may be applied to prevent displacement.
Correction of dorsal nasal hump
In profile view the location of hump and also the projection is calculated. Small humps are corrected by injecting fillers above and below the hump to correct the nasal line. its important to stay mid-line during injection. If the hump is large and injecting filler may change the location of radix which is already ideal or may increase the length of nose beyond the ideal such cases must be subjected to surgical hump reduction.
Correction of nasal tip
Correction of nasal tip with fillers must usually be avoided as the tip dynamics are complicated. When HA fillers are used it must be placed in subcutaneous plane and CaHA in supra perichondrial plane. Use low volume 0.3-0.5 ml only and subsequently build up in further sittings.Be careful to study well whether two paired points of correction are indicated, as in wider noses, especially in men, or only one central point as often happens in women. The derotated tip or small nasolabial angle can be improved with injection to columellar base or just above anterior nasal spine. The collumellar show can be increased by injection in subcutaneous plane 0.1 ml filler between the medial plates of LLC.
Correction of post rhinoplasty deformities
The postrhinoplasty patient with a minor dorsal defect is the ideal candidate for filler augmentation. However, the operated nose is intuitively at greater risk for vascular compromise because rhinoplasty surgery will likely have altered the native vasculature of the nose. Placement of the product laterally near the lateral nasal artery blood supply or at the base of the nose near the columellar artery entry may place the nose at particular risk for vascular compromise. Hydrophilic and expansive properties of HA make it a troublesome choice for placement in the soft tissues of the postrhinoplasty nasal tip, which may already have a tenuous blood supply secondary to scarring. This theoretical risk may be greater for Juvéderm than for Restylane because of Juvéderm’s increased hydrophilic properties. These cases Radisse is the preferred filler.
Complications of Fillers and avoiding it
Early side effects include erythema, edema, and bruising; they are in fact a normal physiological reaction to
the injection of a foreign substance and can often be mitigated by cooling the injected area. Pain is reduced by
slow injection and administration of local anesthetics in small volumes. Bruises are said to be reduced by using
arnica, aloe vera, or vitamin K creams. Allergies may occur within hours in cases where the patient has been
sensitized before. Lumps and bumps occur when an unsuitable fller is injected superfcially or in the wrong
location. These may occur immediately or develop from clumping of the substance due to muscle activity.
Vascular compromise becomes evident within a day in case of arterial occlusion due to inadvertent intravascular
injection or compression by the filler volume. Blanching of skin during injection is a sign of compromised vascularity and injection must be stopped immediately. Tissue necrosis is a serious complication usually at nasal tip , ala and columella. Thin skin and skin with telenjectiasis are to be avoided for injections. Rare complication of intraareterial embolization and blindness and stroke are major complications and any head ache immediately following injections must be promptly evaluated.
Some clinicians have recommended aspiration prior to injection of filler in order to avoid vascular embolism. This is a cumbersome practice with questionable benefits.Most fillers are thick gels. Building up enough negative pressure for aspiration of blood takes a lot of hand force and would only work for Voluma due to its smooth viscoelastic properties.Even in experienced hands, by the time one aspirates and then injects, the needle is no longer in the same place, rendering the test useless.Rather than aspirating, the following accepted best practice standards for injecting filler is a more reliable way of preventing complications :
- Needles should be as small as possible so that filler flow rate is low.
- Fillers should always be injected slowly and under low pressure, especially in the nasal area. The blindness complications in the literature occurred because a filler embolus was injected with enough force to overcome systolic blood pressure and travel up into the ophthalmic vasculature. Gentle injection technique should prevent this complication.
- The needle should be advanced through the skin slowly and filler should only be flowing when the needle is moving out of the skin. This way, even if the tip of the needle is inside the lumen of a vessel at some point, only a tiny amount of filler will enter the vessel, as the needle will be out in the next moment.
- Small volumes of filler should be introduced with each injection.
- Always ice prior to injection. Ice decreases pain and shrinks blood vessels, making them less likely to be punctured.
While not really a complication, vaso-vagal episodes can be disturbing to the novice injector. Diaphoresis, sudden pallor, a sensation of nausea are all warning signs of an impending episode. It is more likely to happen if the patient has not eaten much prior to their appointment. In the setting of cosmetic injections, patients become vaso-vagal primarily because they are holding their breath in anticipation of pain. The frequency of these episodes dropped dramatically once we began to routinely remind our patients to breathe. Distraction shoulder tapping also helps them tolerate the injections without excessive anxiety. If the patient does become vaso-vagal, our routine is to immediately place them in reverse Trendelenberg position, increasing blood flow to the brain.
Delayed reactions are those that occur 6 weeks after the filler injection. They are caused mainly due to bacterial
bioflms,although this view has been vehemently disputed. They may induce granulomas as well as the so-called cold abscesses. As bioflms are mostly bacterial in nature, they should not be treated with steroid injections.
Complication management starts with the preventative measures outlined above. If, however,the clinician suspects that an ischemic event is unfolding, there are immediate steps that he or she should be ready to take. First, injection should stop immediately. The area should be massaged vigorously in an effort to restore blood flow and Hyaluronidase should be injected into the area. A dose of 50–80 units should be sufficient. Even if a non-hyaluronic acid filler has been used, Hyaluronidase is useful because it dissolves some native hyaluronic acid and decreases interstitial pressure, easing blood flow. Topical 2% Nitroglycerin paste (Nitro-bid. Savage Labs, Melville NY) should be in the room and readily available to anyone performing this procedure. It is a great vasodilator that acts very quickly. In situations of potential ischemia, a small amount should be applied to the area in question and it should stay on for at least 15 min. The patient should take aspirin 325 mg immediately. If the skin becomes pink again and remains so after a period of observation of 15 min or so, send the patient home on aspirin every 4 h for a day, warm compresses, and periodic massage of the area. If the skin becomes dusky, reapply the Nitropaste for another 30 min and consider reinjecting the area with Hyaluronidase. If damage continues to unfold, the injector should consider hyperbaric oxygen therapy and referral to a plastic surgeon.
BOTOX FOR NOSE
The muscles involved in the rotation of the nasal tip towards the maxillary bone, are the depressor septi nasi and levator labii alaeque nasi. Their treatment with BOTOX is easy. The depressor septi nasi muscle can be injected along both its insertion above the columella and in the nasal spine .If there is hypertonia of the levator labii alaeque nasi muscle with a clear lift of the nasal sides and rotation of the tip downwards, these muscles are injected with botox. Its important that fillers and botox are not used in same sittting.
The sites of injection
- Two injections of 2.5 unit Botox in each levator labii alaeque nasi tangential to alar base.
- Injection of 5units Botox in two plane one half in subcutaneous at columellar base and half deep in contact with bone at anterior nasal spine.
To appreciate the result, it is necessary to wait for 7 to 15 days. We always perform a retouch session after 15 days, both to evaluate the results and for possibly enhancing it with another injection of a few units.It is important to be careful while treating the levator labii alaeque nasi muscle, since it is possible that the length of the upper lip can increase, getting ptosis. The risk is lower in youmg women with gummy smile, short lips (less than 1.5 cm)than in older people (over 60 years of age) with long lips. When the distance between the nasal spine and the apex of the Cupid’s arch is more than 1.8 cm, the treatment is strictly contraindicated.