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Cosmetic: Original Articles

The Nonsurgical Rhinoplasty: A Retrospective Review of 5000 Treatments

Harb, Ayad F.R.C.S.Plast.; Brewster, Colin T. M.Res., M.R.C.S.

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Plastic and Reconstructive Surgery: March 2020 - Volume 145 - Issue 3 - p 661-667
doi: 10.1097/PRS.0000000000006554
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Abstract

Rhinoplasty is a challenging surgical procedure requiring expertise and experience to minimize the complication rate. It can also prove to be an expensive treatment for the patient, with the possibility of protracted recovery time. Short-term postoperative edema and ecchymosis may prolong recovery, and adverse outcomes such as iatrogenic deformity are not uncommon even as a delayed presentation after a seemingly normal recovery. Furthermore, functional deficit may result from midvault collapse and nasal valve disruption.1

The use of dermal fillers has become an integral part of nonsurgical facial cosmetic practice since the turn of the century, with a wider range of increasingly safe products available, including those with supplementary local anesthetic.2 Patients are particularly drawn to these procedures, as they provide instant results, are associated with minimal recovery time, and come at a lower cost. Several authors have broadly described techniques to improve the cosmetic appearance of the nose using either hyaluronic acid or calcium hydroxylapatite because of their safety, duration of effect, high viscosity, and elasticity.

Nonsurgical injectable-filler rhinoplasty has continued to increase in popularity since its conceptualization in 2006, with social media playing a large part in its evolution.3 Although this procedure is not intended to replace surgical rhinoplasty, it has proven beneficial in discrete cases of inadequate tip projection, dorsal hump, and low radix.4 Nonsurgical rhinoplasty has also been used to improve functionality of the nose by splinting the nasal valves.5 Many have described using dermal fillers to correct deformities in the nose; however, few have assessed follow-up results, with the most notable study to date retrospectively analyzing outcomes in 295 patients.6

The safety and efficacy of nonsurgical rhinoplasty has been contentious, as more evidence is sought to justify its place in nasal cosmetics procedures. Some have reported disastrous complications, leading to assumptions that nonsurgical rhinoplasty is inherently unsafe.7

This study reports the experience and results of a single clinician (A.H.) using his previously described nonsurgical rhinoplasty technique.8 To date, this is the largest case series reporting outcomes in nonsurgical rhinoplasty.

PATIENTS AND METHODS

This study retrospectively reviews a case series between March of 2016 and January of 2019 by a single plastic surgeon (A.H.) specializing in nonsurgical rhinoplasty. The previously described technique is a nonsurgical procedure for nose correction using hyaluronic acid dermal fillers injected percutaneously with a fine-caliber needle, in microdroplets, after assessment of three critical aesthetic areas of the nose: the radix, bridge, and tip.4,8

Cross-linked hyaluronic acid gels [Teosyal Ultradeep 25 mg/ml integral lidocaine (Teoxane Laboratories, Geneva, Switzerland); Perfectha Subskin 20 mg/ml (Sinclair Pharma, London, United Kingdom)] were used for injection because of their high viscosity, longevity, and reversibility. No topical or additional anaesthesia was used.

Inclusion criteria included any patient older than 18 years who presented with intentions to improve the cosmetic appearance of their nose. Patients with previous open rhinoplasty or injectable rhinoplasty were also included. Exclusion criteria included any patient deemed unsuitable because of clinical contraindications (e.g., autoimmune diseases, pregnancy, breastfeeding, or known allergies); those patients with concerns that were deemed unattainable with nonsurgical treatments (e.g., severe asymmetry, deformities of the alar complexes); and those patients with severe scarring following surgery, in whom the risks of skin complications were deemed to be too high.

Technique

The technique described by the first author (A.H.) begins with methodical assessment of three critical aesthetic points on the nose: the radix, dorsum, and tip. Adequacy of projection, symmetry, and definition are noted, and the quality of the skin is tested. To achieve any enhancement at a given point, adequate laxity of the skin is required. This can be assessed by a pinch test, whereby the assessor’s ability to pinch skin away from the underlying bone/cartilaginous skeleton would present a potential target for injection of an implant. In cases of tightness of the skin envelope, where no skin pinch is possible, the correct plane of injection is likely to prove challenging to access, exposing the injector to the likely increased risks of incorrect placement, vascular injury, or injection under higher pressure. In these circumstances, treatment is avoided and the patient is counseled about the likely risks.

The injection technique involves the use of 0.3-ml Becton Dickinson (Franklin Lakes, N.J.) syringes with integral 30-gauge needles. The product is decanted into these syringes using an aseptic technique. The use of these needles enables the injector to administer a highly viscose product through a fine-caliber needle, under a low-pressure injection. Furthermore, it enables a high-precision injection of small aliquots, and the 30-gauge needle is relatively comfortable for the patient. The injections follow some basic principles, to ensure safety and lower risks of intravascular injection. These principles are to maintain the midline of the nose, injecting deep at the level of periosteum or perichondrium. It is imperative to inject at low pressure, and that also means a slow and low-volume injection. At all times, the injection level is rechecked, as the highly cohesive product can have a tendency to push the injecting needle more superficially and expose the injector to inadvertent superficial injection. The injections are carried out in a systematic method, beginning at the radix and moving caudally with multiple deposits of no more than 0.1 ml per injection. Frequently, and especially nearer the tip, deposits of filler can be as small as 0.02 ml per site. With each injection point, the gel implant is massaged into place and can be maneuvered more laterally should lateral volume be required. The injections continue in the midline until the tip is reached. The tip is injected perpendicular to the skin, and the product is deposited onto the anterior surface of the alar cartilage, where possible, to improve projection and definition, and to create a supratip break, which can be very desirable, especially in achieving a more feminine appearance.8

This technique evolved slightly over the course of this treatment period. Initially, the preferred needle was a 0.5-ml 30-gauge needle, as this was the smallest available; however, this was changed to a 0.3-ml 30-gauge needle, as it enabled an even lower injection pressure and offered more accuracy of injection.

Postprocedural progress at 2 weeks was assessed by telephone consultation, and all patients were given direct contact numbers in case of emergency or concern. All patients were offered follow-up at 4 to 6 weeks following the procedure. Measured outcomes include adverse events and complications and requirement for top-up treatments.

Photographs were taken immediately before and after the procedure. All images have been taken (following written consent) on a Sony alpha-5000 ILCE 5000 camera (Sony Corp., Tokyo, Japan), with a 16- to 50-mm lens and are stored securely.

RESULTS

Between March of 2016 and January of 2019, 5000 patients underwent nonsurgical rhinoplasty, performed by the first author (A.H.), using the described technique. The mean patient age was 27 years (range, 18 to 78 years). The largest age group was aged 25 to 34 years, totalling 52 percent of the cohort. There were 4702 women and 298 men.

The most common indication for treatment was dorsal hump (44 percent). Postsurgical correction was second most common (20 percent), with all indications summarized in Table 1.

Table 1. - Indication for Nonsurgical Rhinoplasty
Indication Percentage of Patients
Dorsal hump 43.6
Postsurgical correction 20.0
Drooping nasal tip 14.7
Lack of definition 8.7
Frontal asymmetry 7.0
Bulbous tip 6.0

Treatment time was relatively short, with a mean of 12 minutes (range, 5 to 25 minutes). The mean volume required for each procedure was 0.72 ml (range, 0.30 to 2.40 ml). The average pain score reported by patients immediately after treatment was 2 of 10. Clinical photographs obtained before and immediately after treatment are shown in Figures 1 and 2. Figure 2 also demonstrates a third image obtained 2 years after treatment, with no further intervention performed.

Fig. 1.
Fig. 1.:
Before and immediately after treatment. Injection to the radix reduces the appearance of the dorsal hump. Tip injection raises this tip to give a mild supratip break.
Fig. 2.
Fig. 2.:
Before treatment, immediately after treatment, and 24 months after treatment. Injection to the radix reduces the appearance of the dorsal hump. Tip injection volumizes the supratip and reduces the drooping appearance. The third image demonstrates the longevity and stability of treatment in this patient after 2 years. No further treatment was administered.

Adverse Events

The commonest intraoperative complication was bleeding, which was defined as that beyond the amount that would occur after standard needle puncture and needing a pause in treatment and application of pressure, and was encountered in 559 patients (11.1 percent). Immediate bruising occurred in 100 patients (2 percent).

Arterial occlusion was immediately apparent in 24 patients (0.48 percent), manifesting with painless blanching or mottling of the skin, at the time of treatment, typically in an irregular distribution at or distant from the site of injection. In these cases, treatment was suspended and management of impending ischemia prioritized. Of these 24 cases of vascular compromise, the nasal tip injection (16 patients) was the commonest site, the bridge was second with six, and the radix was third with two. Fourteen patients displayed spontaneous return to adequate perfusion with vigorous massage of the skin and application of warm compresses. Ten patients were treated with immediate hyaluronidase infiltration and made a full recovery thereafter, with no necrotic sequelae. Hyaluronidase dosage was 1500 IU in 1 ml of saline, injected at the site of injection and the areas where skin changes were seen. No patients required a repeated hyaluronidase treatment. All patients with suspected or confirmed vascular occlusion were followed up within 2 hours in the clinic to check on early recovery and then followed up over the following 48 hours by telephone consultation and photographs were checked.

Postprocedural complications were assessed after 2 weeks. Erythema and swelling were reported as the most common complications and improved with time, as summarized in Table 2. One patient experienced prolonged swelling at the tip 3 months following her treatment. This was treated with a single injection of triamcinolone to reduce localized edema. Four patients described self-resolving headache between 2 and 28 days after treatment. Six patients requested reversal of the treatment after deciding to proceed with surgical rhinoplasty. Two patients developed localized skin infection, which was treated with oral antibiotics.

Table 2. - Erythema and Swelling Reported at Time Intervals
Within 24 Hr (%) Within 5 Days (%) Within 2 Wk (%) After 2 Wk (%)
Erythema 35.6 53.5 10.9 1
Swelling 28.7 42.6 25.7 3
*
Percentage of 5000 patients.

Three patients suffered skin necrosis, two of which were at the nasal tip and one at the nasal bridge. The first was a case of postsurgical correction and had displayed no immediate signs of ischemia. However, at 3-month follow-up, the patient described having suffered a 1-cm area of patchy superficial skin necrosis at the nasal tip. The patient had managed this conservatively and his skin had fully healed with only residual erythema seen at the review appointment. The second case had mild blanching of the nasal tip during injection but no arborization pattern or mottling of the skin to suggest intravascular injection. The decision at the time was to manage this conservatively, as it appeared like there was no overt sign of vascular insufficiency. Two days after the procedure, however, the patient reported worsening pain and discoloration of the nasal tip while on vacation abroad. Photographs taken showed a gray discoloration of the nasal tip and superficial sloughing of the skin around the tip and nasal ala. Clinical advice was given and the patient was promptly treated with hyaluronidase and oral antibiotics locally. Close follow-up was maintained with the patient, and her skin made a rapid recovery. It appeared that the injury was limited and superficial. The infection was treated and the skin was healed, although it was slightly erythematous, after 10 days. The final case displayed what appeared as a localized area of bruising at the radix during injection. Subsequently, a small area (<1 cm) of fixed staining developed that was managed conservatively and healed after 2 weeks, with no residual scarring.

Follow-Up and Repeated Treatment

All patients were offered a routine follow-up appointment after 6 weeks, and if any further treatment was required, it was performed at that time at no charge to the patient. Patients were allowed to return earlier or later than 6 weeks if there was any cause for concern. Approximately 6 percent of patients opted to return at 2 weeks; however, only 0.8 percent (n = 40) required retreatment at that stage. The remainder were counseled and reassured. At 6 weeks, we saw a return rate of 22 percent, with 15 percent of patients requiring a top-up treatment. This was offered free of charge to the patients.

The advised duration of treatment was 9 to 12 months. Approximately 32 percent of patients returned at 12 months, most of whom were treated, with another 5 percent returning at 18 months, all of whom were treated. This was regarded as a new treatment. Follow-up and repeated treatment are summarized in Table 3.

Table 3. - Follow-Up and Repeated Treatments at Time Intervals
Within 2 Wk (%) 2–6 Wk (%) 6 Wk–6 Mo (%) 6–12 Mo (%) 12– 8 Mo (%)
Follow-up attendance 6 22 3 32 5
Repeated treatment 0.8 15 2 30 5
*
Percentage of 5000 patients.

Although we did not record objective aesthetic outcomes as part of this review, we have learned certain lessons about the behavior of the nose after treatment and the longevity of the result. The immediate result of treatment can often appear slightly exaggerated, giving an overcorrected appearance, particularly at the radix. This can be accounted for by the viscosity of the gel implant and the immediate skin reaction to treatment. This appearance typically reduces and appears more natural and proportionate within the first hours. Subsequent to this, edema can overtake the result and the early and sometimes very satisfying sharp contour of the nose is lost temporarily. Our advice is that edema will mostly resolve within 1 week; however, this can take up to 6 weeks, in some patients, especially where larger volume corrections are required. At the 6-week review, the patient is offered a touch-up procedure. It is relatively common (15 percent) for patients to experience a significant decline in their result after resolution of the edema. We hypothesize that this is mainly attributable to initial underfilling or from pressure of the tightly expanded skin on the soft gel implant. Although these crosslinked hyaluronic acid products are designed to last 12 months, it is common to find that clinical results, though gradually declining over time, will typically extend beyond this period. At the 12-month review time point, it is usual to find that the shape of the nose has not completely returned to its pretreatment shape, but rather has retained a softer contour. At this stage, it is possible to repeat the treatment. We prefer not to repeat the treatment before this stage, to avoid the risks of product accumulation and expansion of the skin on the nose.

DISCUSSION

This is the largest nonsurgical rhinoplasty study to date, reporting a single surgeon’s experience, outcomes, and complications. It shows high efficacy and safety and relatively low complication rates in the hands of an experienced clinician. This study reports few complications, with an infection and skin necrosis rate of 0.04 percent and 0.06 percent, respectively. The latest significant case series described results in 295 patients, reporting six (2 percent) patients with cellulitis, two (0.67 percent) with skin necrosis, and two (0.67 percent) with visible irregularities.6

Complications in nonsurgical rhinoplasty can be broadly categorized into patient-, clinician-, or product-related factors. Careful patient selection, based on appropriate expectations; honest and ethical discernment between those cases that are suitable for nonsurgical treatment and those that are better suited for conservative or surgical treatment; clinical contraindications; and psychological assessment should minimize the risks caused by patient-related factors. Clinician factors such as injection technique, an intimate knowledge of the local anatomy, experience in diagnosing imminent complications, and skill in managing these complications are arguably the greatest determinants of success and rates of complications. Product-related factors, including viscosity, level of crosslinking, integral anesthesia, and reversibility will also play a part in the final outcome.

When injecting hyaluronic acid in the nose, we follow the basic principles outlined by the first author (A.H.), which are that the injection should be deep, central, slow, and at low pressure and low volume. The clinician should be mindful that injections should be made into the tissue plane between the superficial musculoaponeurotic system and perichondrium or periosteum. Injecting too deep may disrupt the normal nasal anatomy and in turn complicate further procedure, in particular, future open surgical rhinoplasty. An injection too superficial (e.g., intradermal or subdermal) risks palpability, vascular occlusion, or skin necrosis.7,9 Furthermore, in patients who have previously undergone surgical rhinoplasty, there is often disruption to the columellar blood supply, which can increase the risk of vascular insufficiency and skin necrosis. This underscores the requirement for practitioners who undertake nonsurgical rhinoplasty to have a comprehensive understanding of nasal anatomy and nasal cosmetics. Formal training and clinical experience are vital to ensure effective and safe treatment.

The injectable agent should be selected with caution. Hyaluronic acid is chosen because of its reversibility in the event of vascular occlusion.10,11 Other benefits include premixed agents with local anaesthetic, thus avoiding the requirement for preprocedural local anesthetic, which can distort or mask subtle deformities that one is looking to correct. Topical anesthetic preparations can also be used; however, clinicians must be aware that up to one in 10 patients suffers skin irritation, erythema, or edema.12

Time to follow-up or top-up treatment following the primary procedure has been reported variably. Rivkin and Soliemanzadeh reported a 44 percent top-up rate in the first 2 months after the primary procedure. By 12 months, 90 percent of patients had returned for top-up treatment.6 In our practice, we recognize that undercorrection was the chief reason for early patient return to the clinic. This is primarily attributable to the variability in tissue swelling and subsequent resolution, which adds an element of unpredictability to the final result. We attempt to address this by offering a complimentary top-up treatment within the first 6 weeks of treatment. This helps to ensure that the standard of our results and the satisfaction of patients remain high. This case series observed a top-up rate of 15.8 percent within 6 weeks and 17.8 percent within 6 months of the initial procedure.

We find this treatment an excellent alternative to surgical rhinoplasty in those patients who either do not want, cannot have, or do not need surgery. Our experience in nonsurgical rhinoplasty has shown this to be a versatile procedure that can be used to tackle a range of aesthetic concerns such as a dorsal hump, drooping tip, septal deviation, and minor contour inconsistencies, that sometimes bear a considerable social and psychological morbidity for the patient. This is especially pertinent in those patients who have previously undergone surgical rhinoplasty and are left with subjectively or objectively unsatisfactory results. Postsurgical patients make up a fifth of our nonsurgical rhinoplasty practise. In these patients, we find that all factors discussed previously should be more acutely considered, including patient selection and counseling, injection technique, and complication identification and management. The most common indications for postrhinoplasty corrections are midline asymmetry of the nasal dorsum, overreduction or collapse of the nasal dorsum, and concerns about a boxy or asymmetric tip. The possibility of correcting these imperfections is often limited by the degree of scarring and the flexibility of the skin envelope.

Nonsurgical rhinoplasty can be a highly satisfying treatment for both patient and clinician. However, it does carry considerable risk, which must be explained to the patient. We try to ensure high patient satisfaction by the availability of a patient liaison, a flexible follow-up policy, and top-up treatments that effectively manage the commonest caused for concern. Another advantage of nonsurgical rhinoplasty was highlighted by six patients in this study, who were satisfied with their aesthetic result and used their experience to have their treatment reversed so they could proceed to surgical rhinoplasty. Only three patients in this cohort of 5000 reported overt dissatisfaction with results, despite the usual counselling and follow-up measures offered. It must be noted that there has been no formal patient-reported outcome measure, and this is based on verbal feedback at follow-up. Interestingly, having been offered reversal of their treatment and a return to their original nose shape, all three patients declined.

The authors acknowledge that this is an individual clinician’s results and may not give a true representation of this procedure’s outcomes and risk profile in widespread practice, given the diversity in background and experience of the practitioners offering this treatment in the United Kingdom and beyond. New regulations from the Cosmetic Practice Standards Authority regarding use of dermal fillers should encourage safer practice by qualified clinicians across the United Kingdom.13

CONCLUSIONS

This is the largest case series of nonsurgical rhinoplasty to date, with low complication rates and positive outcomes reported. Prospective, multicenter evidence is required to further assess its safety and efficacy, but these results reiterate previous evidence that this is a safe and effective procedure in the hands of an experienced clinician.

PATIENT CONSENT

Patient provided written consent for the use of patient’s images.

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12. Emla Cream (lidocaine prilocaine) product information. Wayne, Pa: Astra-Zeneca Pharmaceuticals. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2000/19941s11lbl.pdf. Accessed January 20, 2019.
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