Nonsurgical Rhinoplasty in Review

A liquid nose job, or nonsurgical rhinoplasty, has grown in demand over the years with the increasing availability and popularity of dermal fillers and injectables. As is the case with other injectable procedures, it provides less morbidity to the patient, requires less downtime after the procedure, and is also much less expensive.

A nonsurgical rhinoplasty can be performed with temporary or more permanent fillers for a long-term result. It is typically used to augment selective areas in a patient’s nose to achieve a desired result or function in certain patients. Though the nose is a small area that can appear to be hyper-vascular, a liquid nose job using fillers can be performed safely based on the properties, indications, and risks of the product used and on adequate patient selection.¹ A thorough analysis of the deformity and the involved anatomy and proper injection techniques are essential to achieve good outcomes and also to avoid treatment-related problems or complications.¹

Basic nonsurgical rhinoplasty techniques include augmentation of the dorsum of the nose and camouflaging of a nasal dorsal hump which can be treated fairly easily with fillers.² Advanced maneuvers also include increasing the rotation of the nasal tip, projecting the nasal tip, straightening the nose, lowering the alar rims, and potentially even improving the overall function of the nose.²

Recent studies have shown that most dermal fillers and injectables are met with overall success and high patient satisfaction, yet vascular compromise and its associated complications are the major problem of which physicians should be wary and vigilant.³ Fillers as well as other rhinoplasty options should be discussed openly with patients and considered on a case-by-case basis, and the performing physician should be comfortable and knowledgeable regarding different types of fillers, indications, and injection technique to prevent serious adverse events.³

Injectables and surface treatments for the nose could be used as a stand-alone treatment or also in conjunction with surgical rhinoplasties. Fillers such as autologous fat have various advantages and disadvantages in eliminating small degrees of asymmetry after a rhinoplasty.⁴ On rare occasions, cerebral ischemia and severe ocular occlusion from an occluded vessel can occur.⁵

Injection Tips

The best plane/area to inject is the deep fatty layer, just above the perichondrium and periosteum (cartilage and bone) within the nose.¹ To be on the safe side, less is typically more. It is better to inject small incremental boluses, constantly reassessing the area to avoid overfilling it and producing deformities, asymmetries, or irregularities within the injected tissue. The most feared and devastating complications are vascular occlusion, necrosis, or even blindness.⁵ Though uncommon, this makes the nose a challenging location to treat with dermal fillers.⁵ Thus, when injecting this area, it is best to be over-prepared. Have a vial of hyaluronidase handy to potentially dissolve the filler substance in the case of a vascular occlusion or tissue necrosis, to salvage as much tissue as you can with an immediate reversal of the procedure and treatment.⁵

Between the skin and bone of the nose there are approximately four layers, from superficial to deep. To prevent vascular occlusion or compromise, an injection into the deep fatty layer prevents embolization and tissue necrosis.⁵ Dermal fillers in the nose are usually injected in the following order: radix (sellion—below the glabella), rhinion (the junction where the bone and cartilage meet), nasal tip lobule, and supra tip lobule areas.¹ To minimize an asymmetric result the surgeon or injecting physician should always mark the midline of the nasal bridge and perform the procedure without deviating too much from this midline marking.¹

Injection technique is also important. Sometimes it is preferable to use 27-gauge microcannulas instead of needles and injections through multiple tunnels with small, intermittent boluses for safety and cosmesis.² A large bolus injection with a large quantity of product should be avoided, due to Tyndall effect (bluish discoloration of the overlying skin) and possible tissue necrosis due to compression of the vessels or vascular occlusion.⁵ Some studies have found that hyaluronic acid fillers work best to shape the nasal tip while calcium hydroxyapatite work best in the nasal dorsum.² Nonetheless, adhering to a well-studied technique and being well-versed at performing the procedure itself as well as the surrounding anatomy represents the best way to achieve optimal results and avoid major complications.

References:

1. Johnson ON 3rd, Kontis TC. Nonsurgical Rhinoplasty. Facial Plast Surg. 2016;32(5):500-506.
2. Moon HJ. Injection Rhinoplasty Using Filler. Facial Plast Surg Clin North Am. 2018;26(3):323-330.
3. Mehta U, Fridirici Z. Advanced Techniques in Nonsurgical Rhinoplasty. Facial Plast Surg Clin North Am. 2019;27(3):355-365.
4. Wang LL, Friedman O. Update on injectables in the nose. Curr Opin Otolaryngol Head Neck Surg. 2017;25(4):307-313.
5. Thomas WW, Bucky L, Friedman O. Injectables in the Nose: Facts and Controversies. Facial Plast Surg Clin North Am. 2016;24(3):379-389. doi:10.1016/j.fsc.2016.03.014