Non-surgical rhinoplasty with dermal fillers

The nose is the centre point of the face, linking the most important components of facial expression: the eyes and the mouth. Emotions, feelings, intentions and even honesty are expressed by the eyes and the mouth.

So, it is no surprise that some authors have made a proposal to consider the face as an organ, with 18 functions categorised into four major roles: physiologic, aesthetic, expressive and identity (Siemionow, 2008).

The nose is the link between the aforementioned areas, it is at the central point of the face, so any imperfection in the nose will be easily noticed. This is the reason it is so important, and why any irregularity in the shape or size of the nose is a frequent concern (Coleman, 2006; Miller, 2019).

According to a survey conducted by the British Association of Aesthetic Plastic Surgeons (BAAPS), rhinoplasty is a common procedure, representing 10% of all cosmetic surgeries in the UK (BAAPS 2020). In Asia, rhinoplasty is the second most common surgical procedure, after blepharoplasty (Liew, 2016).

Some authors think that the outcome of a surgical rhinoplasty is not always as predictable as it would be desired, irrespective of the excellence of the technique and the experience of the surgeon (Matta, 2019; Miller, 2019), hence the need of a minor procedure to make subtle corrections when required, after a formal surgery. From this perspective, non-surgical rhinoplasty (NSR) would seem to be an adjuvant technique to surgery of the nose—a simple add-on treatment to improve the surgical outcome.

In the literature, it is also called liquid or injectable rhinoplasty and, in some cases, is also referred to as a nose job. NSR seems to be more adequate term.

Nonetheless, the injection of dermal fillers in the nose is the second most frequent cause for blindness, secondary to any treatment in the practice of aesthetic medicine (Sito, 2019), so this technique should not be considered as such a simple and straightforward treatment.

Anatomy

There are several important considerations regarding the anatomical characteristics of the nose, both from the aesthetic and safety point of view.

Aesthetic assessment

A careful evaluation of some anatomical measures must be followed before any procedure. Table 1 and Figures 1a–c show the values generally accepted for the most important angles of the nose, separated for men and women (Redaelli, 2016; Miller, 2019).

Figures 1a–c. Main angles of the nose

Safety of the procedure: vascular risk

Blood supply to the face comes from the external and internal carotid arteries. The internal carotid artery irrigates the nose, as well as the glabella, the forehead and around the eyes, and the rest of the face comes from the external carotid artery (Arx, 2017).

The nose receives blood from two main sources:

• The dorsal nasal artery, which originates from the ophthalmic artery (terminal branch)
• The lateral nasal artery, originating from the facial artery.

There is a rich net of vessels at the nose tip, alae and columella, originating directly or indirectly from the facial artery (Arx, 2017).

At the face, there are several anastomoses in both horizontal and vertical directions, creating a polygonal system where the blood flow can be directed in one way or another, depending on the specific needs at each moment (Alessandrini, 2015). In the nose, we find a vascular network where arteries are interconnected in two axes, longitudinal (intercarotid) and transversal (transfacial) (Alessandrini, 2015):

• The internal carotid artery connects with the external carotid artery and the facial artery connects with the ophthalmic artery
• The left carotid artery connects with the right carotid artery at several points, including at the nasion, the nasal dorsum and at the tip of the nose.

There are also a number of anatomical variations that have been studied by various authors:

• The facial artery is symmetrical in only 68% of patients (Niranjan, 1988)
• A longer course was identified in 10% of facial arteries (Niranjan, 1988)
• Loukas (2006) described five types of facial artery after studying 284 hemifaces from 142 cadavers
• According to Tansatit (2017), only 34% of patients will have both dorsal nasal arteries, while 28% will have a single dorsal nasal artery
• The main arteries at the dorsum of the nose run laterally, leaving the central part free. However, this is not a constant finding (Sahan, 2017)
• The dorsal nasal artery crosses the midline of the nose, so the midline of the nose is not completely safe (Lee, 2020; Tansatit, 2017)
• In patients with a single dorsal nasal artery, there is a greater risk of necrosis after intra-arterial injection, due to the absence of a compensating contralateral circulation and anastomoses (Tansatit, 2017).

» The ideal filler for non-surgical rhinoplasty should be reversible, non-hydrophilic, with a high elastic coefficient (G’) to resist deformation and provide a good lifting, as well as a high viscosity to prevent lateral diffusion «

So, the important concept to retain is the variability of the trace that arteries will follow, making it very difficult for the practitioner to be completely sure of the safety of the procedure.

Patient selection

The usual clinical criteria for selecting patients for dermal filler procedures should be followed (Table 2), with special attention being paid to the screening of body dysmorphic disorder. (Milotich, 2011; Tejero, 2012). It is also a good idea to read the instructions leaflet of the dermal filler being used to find out what the specific contraindications are from the manufacturer, because in case of a side effect or complication, that document will be the main guideline for the malpractice insurance, and it could put a limit to the cover.

Specifically, candidates for NSR will be patients not wishing to have surgery for any reason, with minor irregularities in the cartilage that could be corrected with a filler, for example, a low radix, saddle deformation of the dorsum or droopy nasal tip, but any large deformation or big protuberant bumps would need surgery (Miller, 2019).

If the correction is bound to require a great amount of filler, it should also be considered a contraindication, due to the risk of complications secondary to vascular compromise, displacement of the filler and irregular outcome (Liew, 2016).

Generally, if the practitioner is not reasonably sure to be able to improve the condition of the patient, refraining from treating would be the correct attitude, and in the specific indication of nose fillers, that is even more important. As later described, nose filler is a treatment with a great risk of complications, including blindness and brain infarct, so the practitioner must carefully assess the benefit versus the risks for the patient. At the end of this article, Figure 2 shows the importance of patient selection.

Figure 2. A case showing the importance of patient selection. In this case, a minor correction meant an enormous difference for the patient

Post-surgical rhinoplasty

After any nose surgery, there is a greater risk of suffering complications following NSR due to altered tissues and anatomy, and blood supply might be compromised already by the surgery, as some protective anastomoses could have been affected (Reza, 2018). Any graft in the area must be considered as a contraindication in most cases (Miller, 2019). In fact, a history of prior nose surgery is a contraindication for many authors (Liew, 2016; Reza, 2018; Ulas, 2019).

However, on the contrary, some authors consider dermal fillers to be a good option for correcting minor imperfections after surgical rhinoplasty. According to Sahan (2017), 5–15% of patients will follow a surgical revision after having rhinoplasty, and so he considers NSR to be a good option for those cases.

For safety reasons, following an elective surgery, any minor correction with fillers should be carried out by the same surgeon, as only the surgeon knows exactly what was done. Let us not forget that prior surgery changed the anatomy, and some vessels might have been affected, hence a limited or compromised vascularity might exist.

Products for non-surgical rhinoplasty

In the past, many products have been used for non-surgical rhinoplasty, from paraffin in the late 19th century by Dr Robert Gersuny, interrupted due to the appearance of paraffinomas, a type of foreign body granulomatous reaction (Matta, 2019; Leupe, 2016), to medical grade silicone by Robert Kotler and Jack Starz, but with frequent granulomatous reactions and ulcers. Collagen of bovine origin was introduced in 1981, and later it was calcium hydroxyapatite (CaHA) that proved to be a safer alternative. Finally, hyaluronic acid (HA) was used, and it soon became the most common filler for non-surgical rhinoplasty (Leupe, 2016), although injecting HA in the nose still is an off-label indication (Miller, 2019).

When comparing HA and CaHA, patient safety is the argument used to support the use of HA, because hyaluronidase can be used to dissolve it in the case of complications or unwanted results. On the other hand, durability supports the use of CaHA, as it will last for longer, making it the elective product for some authors (Humphrey, 2009).

Rheology

The ideal filler for NSR should be reversible, non-hydrophilic, with a high elastic coefficient (G’) to resist deformation and provide a good lifting, as well as a high viscosity to prevent lateral diffusion (Miller, 2019). Furthermore, the size of the particles of the filler might play a role, as the larger the particle size, the greater the risk of increasing the pressure onto the vessels (Humphrey, 2009).

Some authors consider that CaHA meets most of the above criteria, except that it is not reversible, and for them it is their best option.

Considering the risks of injecting dermal filler in the nose, HA seems a safe election, as it could be dissolved easily if needed.

Tips and techniques

Level of injection

It is imperative to have a strong knowledge of the anatomy of the region (Walker, 2018). At the dorsum of the nose, arteries are located at the level of superficial or deep fatty layers, so fillers could be injected safely at deeper levels, supraperiosteally, to minimise the risk of intra-arterial injection (Tansatit, 2017; Walker, 2018; Guvenz, 2019). The dorsal nasal artery is usually located laterally, so injecting centrally should usually be safe (Guvenz, 2019), but this is not a constant finding (Sahan, 2017). So, there is no safety rule in the nose.

There are a number of tips that minimise risks in this area: injecting very slowly, gently and in small aliquots, using smaller needles and never injecting in a previously surgical nose (Walker; 2018; Sito, 2019). Aspiration is compulsory, but it might also collapse small vessels (Guvenz, 2019).

Needle versus cannula

Generally, the use of a cannula seems to be a safer alternative in comparison with the needle.

However, the cannula should be greater than 25G, typically 22G (Sahan, 2017; Walker, 2018), because a 25G cannula might behave as a needle and it could get inside a vessel. The dorsal nasal artery has a diameter of 1–1.2 mm, so with a 25 G cannula with a 0.51 mm diameter, the artery could easily be perforated and injected into the vessel (Lee, 2020). Tansatit (2016) demonstrated that introducing the cannula in a perpendicular angle has a greater risk of perforation of the artery.

Protection of vessels

There are manoeuvres to separate the vessels from the injection level: the skin of the nasal dorsum is raised with the other hand's fingers to separate it from the deeper layers, and the cannula is introduced to reach the supraperiosteal level (Sahan, 2017; Matta, 2018; Ramos, 2018).

Some authors consider pressing the lateral walls of the nose at the dorsum with both fingers to collapse blood flow on the dorsal nasal arteries and prevent intravascular injection to be a good practice (Liew, 2016; Walker, 2018).

» Should a vascular complication occur, it must be treated as an absolute emergency, with an estimated timeframe of 1 hour for recovering the blood flow to the retina to prevent permanent damage and blindness «

Retrograde versus microdroplets

Injecting in small quantities is considered a safer practice (always less than 0.1 ml per bolus) (Walker, 2018; Sito, 2019).

Volume to inject

Some authors recommend not to inject volumes higher than 0.5 ml in the nose, as it could compromise the blood flow, leading to vascular events (Humphrey, 2009; Sito, 2019).

Complications and management

The main results of a recent metanalysis on vascular complications due to dermal fillers are shown in Table 3 (Sito, 2019).

Furthermore, Guvenz (2019) indicated a rate of 1% of patients having vascular complications. Table 4 shows the risks and types of complications (Leupe, 2016).

Some reaction to the filler, such as swelling, is usual at the beginning, and it will disappear in a few days. In some cases, the foreign body response will decline slowly along the following months.

Granuloma

Granuloma is an inflammatory reaction that can take place with any kind of dermal filler, but it is more frequent after permanent fillers. It usually becomes noticeable after 6 months from the injection. In most cases, there is a triggering episode of acute infection at any other place (for example, pharyngitis). It is unclear if the granuloma is a delayed hypersensitivity reaction or if it has a bacterial origin with the development of a biofilm (Leupe, 2016).

The treatment of a granuloma will depend on the causing agent. More conservative treatment will be given to biodegradable fillers (HA, CaHA) where hyaluronidase is the first option, followed by intralesional steroids (triamcenolona acetonide), and antibiotics can be used if a biofilm is suspected (new macrolides), but there is not a well-defined protocol. When permanent fillers were used, or if the evolution gets more complicated, surgical excision will be needed (Leupe, 2016).

Vascular compromise

The risk of suffering a vascular compromise following facial dermal fillers is 1%, and the nose is the second most frequently affected area.

Early recognition of signs and symptoms of vascular compromise or occlusion is vital for the outcome, and acute pain is usually the first symptom. The sudden, immediate appearance of an area with white colour or blanching is also common. Later on, other signs will be visible that show the limited oxygen supply to the tissues, such as livedo reticulatis or a bluish or dusky (grey) colour in the affected area (King, 2019).

The HELPIR technique is a very complete protocol for the treatment of vascular occlusion after dermal fillers, which has been described by Treacy (2020) as:

• H: hyperbaric oxygen
• E: epithelial stimulation
• L: low level (light) laser (633 nm)
• P: platelet rich plasma
• I: intense pulsed light
• R: resurfacing laser.

Candidates for non-surgical rhinoplasty are patients with minor irregularities in the cartilage that could be corrected with a filler

It should be applied in case of a superficial vascular compromise in the absence of signs or symptoms of impending blindness or central nervous damage, which would be the indication for taking the patient to the best possible hospital at a 1-hour distance.

Blindness

This is an exceedingly rare complication. In the UK, the first reported case was in 2012. Globally, the exact incidence remains to be determined, but at least 98 cases had been documented up to 2015 (Walker, 2018), though a more recent study by Chatrath (2019) has identified 190 cases published in journals from 2000–2018.

In the majority of cases, blindness will come from injections with dermal fillers in the glabella or the nose. According to Chatrath (2019), 90 cases representing 47% of the total were attributed to autologous fat injections. HA was responsible in 28% of cases (n=53), but interestingly, the cases of blindness from HA had a better outcome, with 6 cases of recovery of vision and 11 cases with improvement when treated with hyaluronidase.

The glabellar complex is the most frequent origin for blindness that is associated with dermal fillers injections, with nearly 35% of cases, and the injection in the nose is the second most frequent origin (24%). The nasolabial fold and forehead each account for around 13% of cases, and the temple and the cheek are each responsible for 5% of cases (Chatrath, 2019).

Four types of presentation for blindness have been described: with/without ophthalmoplegia and with/without ptosis (Walker, 2018).

The mechanism will always imply a higher pressure at the plunger of the syringe to create a retrograde flow towards the internal carotid artery, and later the blood pressure will move the embolus forward to the retina. The main symptom will be acute pain with vision loss, and other ocular symptoms that may be present (ptosis, strabismus, etc) (Walker, 2018). Furthermore, ranging from 23–39% of all cases of blindness, there will be an additional complication with neurological symptoms from the central nervous system, as aphasia or contralateral hemiparesis (Walker, 2018).

Treatment

To prevent irreversible damage at the retina, there is an interval of 60–90 minutes according to some authors (Walker, 2018; Chatrath, 2019), though others would reduce this time interval to just 20 minutes.

The treatment algorithm includes:

• Stopping the procedure, calling emergency services and getting the patient to the best hospital as soon as possible and up to 1 hour away, with an ophthalmologist to take over the case
• Hyaluronidase should be injected at the site of the injection and along the affected vessel, flooding all the tissues with the objective of reducing the embolus and intravascular pressure. Retrobulbar injections must be practised only by competent practitioners, because of the risk of creating additional complications. Hyaluronidase will not be effective after 4 hours from the onset (Walker, 2018; Chatrath, 2019). As impending blindness is an emergency, no allergy test would be needed in this case
• Massage the globe to dislodge the emboli by repeatedly applying mild pressure onto the eye two or three times per second, until arriving to the hospital. The pressure should indent the globe a few millimetres (Walker, 2018; Chatrath (2019)
• One or two drops of timolol 0.5% into the eye to reduce intraocular pressure
• 300 mg of aspirin or subcutaneous heparin to prevent blood clots, except if there are signs of cerebral infarction or symptoms of complications from the central nervous system (Walker, 2018).

Other measures at the hospital will include infusion of Mannitol 20%, acetazolamide 500 mg iv, intravenous prostaglandin E14 to increase blood flow to the retina or hyperbaric oxygen. See Table 5 for further information.

Conclusion

With the increase in popularity of non-surgical rhinoplasty, there is an increasing risk of its complications, the worst-case scenario being blindness, or even brain damage.

As the nose has a complex vascularity and frequent anatomical variations, it is difficult to create a safety rule for the technique. The key elements to prevent complications are an in-depth knowledge of the anatomy, expert and gentle hands for the technique, applying an adequate product and patient selection.

Previous surgical rhinoplasty increases the risk for the treatment with dermal fillers at the nose.

Should vascular occlusion take place, it must be treated as an absolute emergency, with an estimated timeframe of 1 hour for recovering the blood flow to the retina to prevent permanent damage and blindness.

As an alternative for a non-surgical rhinoplasty on the right patient, the use of polydioxanone (PDO) threads could be considered, as well as cogged threads made with resorbable products. Though further experience on those products is needed, the advantage seems to be the absence of serious vascular complications.

It would be desirable to carry out a prospective study on the outcome of non-surgical rhinoplasty with dermal fillers compared with absorbable threads, as it could clarify the alternative for the treatment in terms of efficacy and safety of the patients.

Key points

• Non-surgical rhinoplasty is the second most frequent cause for blindness from dermal fillers
• Previous surgery increases the risk of complications
• Anatomical variations are very frequent, so there is no safety rule
• Early recognition of signs from vascular occlusion is vital for a prompt response, and if the affected vessel includes those irrigating the retina, the patient needs to be treated urgently at a hospital by an expert ophthalmologist.

CPD reflective questions

• What size of cannula could be considered safe?
• What signs or symptoms would you find in a vascular occlusion?
• Do you agree in injecting a great amount of dermal filler as needed to correct big deformities at the nose?