Dr Yusra Al-Mukhtar explains non-surgical rhinoplasty

The non surgical rhinoplasty is suitable for both male and female patients, and is an alternative to surgical rhinoplasty to correct minor deformities such as dorsal hump deformities, saddle nose, and poorly projected or downward drooping tips. It can be a suitable treatment for those patients who do not wish to go under the knife, and for those with low radix, where elevating the nasofrontal angle and nasolabial angle will result in an aesthetically pleasing curvature.

Limitations and risks

Over-projection of the radix is undesirable and can be counterproductive, resulting in a more disproportionate and enlarged appearance, and so those patients who present with a high radix are not suitable for this procedure. Those patients with significant lateral cartilage deformities may also be best suited to a surgical procedure, as significant deviations requiring product placement lateral to the nose would put the patient at high risk of causing an occlusion and potential embolism of filler into the angular artery, and subsequently central retinal artery.

The ideal patient will understand that the procedure will result in improvement largely in profile, straightening the appearance of a hump, elevating a downward droop, and should be engaged with the fact that they may need repeat treatments every one to two years depending on the filler product used. Patients’ expectations must be managed and those that have particularly large noses, very deep dorsal humps, a high radix, difficulty breathing or thick tissue type at the nasal tip may be best treated surgically and should be counselled accordingly.

Patients who have had previous surgical rhinoplasty pose greater risk of arterial complications due to the altered anatomy, and these cases must be approached with care and only performed by experienced advanced injectors. Further to this, I believe it is appropriate and unethical to treat patients that have body dysmorphia. Those that have unrealistic expectations may be difficult to manage pre and post-operatively, and treatment in such cases may be best avoided.

Patients must be appropriately counselled about the risks involved with the procedure. The vasculature of the nose in particular deems it a high risk area to inject, as the angular artery that sits on the lateral aspect of the nose communicates directly with the retinal artery. There are approximately 150 reported cases of blindness to date, and of those 33% arise from injections to the nose. The experienced injector must always remain conscious of this fact, communicate this with the patient, and employ safe injecting techniques to reduce the risk of an occlusion.

Product selection

The non-surgical rhinoplasty involves changing the skeletal structure of the nose. As such, I opt for a hyaluronic acid dermal filler for safety and ease of reversal, with approximately 25mg/ml of hyaluronic acid giving it volumising capacity with a high G-prime and cross-linked to provide longevity. The dermal filler of choice should have a high safety profile and a low risk profile. In my experience, a product that contains local anaesthetic makes treatment more tolerable in these otherwise sensitive areas.

Preparation and protocol

An aseptic technique should be used, cleansing the nose with 20% chlorhexidine or Clinisept+ to disinfect the area. I believe practitioners should always aspirate to check if the needle is in a blood vessel prior to injecting as a safety measure, and also to ensure that injections are deep to the bone or supraperichondrium (cartilage). I also advise injecting slowly and in small increments, always keeping an eye on the skin to check for any blanching which would indicate a vascular occlusion. Any signs of an occlusion must be treated promptly by dissolving the filler with hyaluronidase. It is important that patients are advised that if they experience any changes in skin colour, note ulceration or blistering of the skin, or experience
white spots, which could indicate an impending necrosis, they must return for urgent treatment.

Dr Yusra Al-Mukhtar BDS (Hons) BSc (Hons) MFDS RCS Ed Mjdf RCS Eng is medical director of Dr Yusra Clinic in London and Liverpool. She is a dental surgeon and a medical aesthetic clinician with several years’ experience in head and neck surgery and skin cancer surgery.

References

1. ME Tardy, S Dayan, D Hecht, ‘Preoperative rhinoplasty’, Otlaryngol Clin North Am, (2002), pp.1-27.

2. Non-surgical minimally invasive rhinoplasty: tips and tricks from the perspective of a dermatologist Ali Sahan1 , Funda Tamer2 Acta Dermatovenerologica 2017;26:101-103

3. J Cutan Aesthet Surg. 2010 Jan-Apr; 3(1): 16–19. Fillers: Contraindications, Side Effects and Precautions Philippe Lafaille and Anthony Benedetto

4. Mohammed H.Abduljabbar, Mohammad A.Basendwh, Journal of Dermatology & Dermatologic Surgery, July 2016, Complications of hyaluronic acid fillers and their managements

5. Swift, A, Remington K, Clinics in Plastic Surgery, July 2011, Volume 38, BeautiPHIcation™: A Global Approach to Facial Beauty

6. Stephen S. Park, Clin Exp Otorhinolaryngol. 2011 Jun; 4(2): 55–66. Fundamental Principles in Aesthetic Rhinoplasty