Abstract
This study was intended to assess the utility of hyaluronic acid dermal fillers in patients who do not wish surgery in addition to the patients with minor post-surgery asymmetries. This was a prospective study which included post-surgery patients for minor nasal asymmetries, patients unwilling for surgery and those waiting for revision surgery. It is of great use in candidates who do not wish surgery but had the desire for different nasal appearance especially for important life events like marriage etc. This study included 20 patients with follow up period of 18months. The results were compared on Nasal Imperfection Scale and Rhinoplasty Outcome Evaluation along with pre and post injection photographs. Nasal Imperfection Scale difference of 5 and Rhinoplasty Outcome Evaluation Scale differential of 50 is considered to be significant, which was observed in all individual cases. The growing need of medical rhinoplasty by the patient as well as surgeons has led to the introduction of fillers. Hyaluronic acid fillers are safe, easy and effective dermal fillers for patients undergoing all the expected indications of medical rhinoplasty. There is also growing number of candidates who wish for a ‘nose job’ for desired changes without coming under surgeon’s scalpel. Our clinical experience with 20 patients has been described with satisfactory results.
Keywords: Medical rhinoplasty, Non-surgical rhinoplasty, Dermal fillers, Hyaluronic acid fillers
Introduction
The popularity of non-surgical rhinoplasty, whether performed for primary nasal augmentation or post-operative revision is due to advancements in the field of various soft tissue fillers. Medical rhinoplasty is subtle but still requires proper planning of nose in relation to its environment—that is, its relationship with the face, lips, chin and neck [1, 2]. The original “non-surgical rhinoplasty” is thought to have been developed in the early 1900s by doctors in both New York City and Vienna who attempted to use paraffin wax to fill in the depression in the dorsum that characterized the saddle nose deformity. Although the initial results were promising, patients eventually developed delayed complications such as infections and granulomas. Han et al. in 2006 were first to introduce the concept of injectable filler rhinoplasty [3].
Attention is focussed on Hyaluronic Acid based fillers because of its ease of administration and moulding, as well as its safety profile. Hyaluronic Acid based fillers has been used as dermal aesthetic product for the correction of nasolabial folds, facial zygomatic fill and lip augmentation procedures successfully and the ongoing surveillance studies do indicate its efficacy and safety. Hyaluronic acid is a naturally occurring component of human connective tissue. It is non-immunogenic, unlike collagen. It has been found to be nontoxic, non-irritable, non-antigenic and biocompatible both in vivo and in vitro testing. Cross linking is used to make it more stable and longer lasting [4]. Hyaluronic Acid based Dermal Fillers are best used in Revision Rhinoplasty (post surgery defects) for precisely smoothening irregularities/asymmetries of what is often considered the most difficult procedure in cosmetic surgery. This procedure is necessary for approximately 5 to 12% of those who undergo Rhinoplasty. It is also gaining popularity in candidates who wish to have a different nasal appearance. This is a very useful tool for people who do not want surgical procedure on them and filler could change their appearance especially for important life events as marriage and other important social events. They are known to stay for as long as eighteen months or longer [5].
Hyaluronic Acid based fillers can refine the shape of almost any part of the nose, including the tip, the bridge and the sides of the nostrils. Precision injections—using a fraction of a millilitre of gel—can restore symmetry, conceal irregularities in the underlying nasal anatomy and make the nose appeal fuller, smoother and better proportioned while retaining the patient’s unique look. The procedure involves the injection of hyaluronic acid filler into areas around the nose which work to change the overall shape or result in a straighter nose.
The main indications are correction of asymmetries and contour irregularities and for correction of nasal angles both in the postoperative rhinoplasty patients as well as primary medical rhinoplasty candidates. Redaelli [1] used Hyaluronic Acid at nasofrontal angle, radix and tip.
Non-surgical rhinoplasty can immediately improve many conditions of the nose, including:
Improving the bridge
Correcting asymmetry
Enhancing the tip of the nose-tip ptosis, supra tip saddle, tip projection
Columellar and alar retractions or scarring
Smoothing nasal humps or depressions
Minor post rhinoplasty asymmetries or irregularities
The main use of injectable fillers in the nose is to camouflage the profile (dorsal) hump by either filling below and/or above the hump or to augment a flat nose. For patients with a hump, filling around the hump will give the illusion that the nose and hump is smaller. In patients with ethnic noses, it can be a great tool to help define their nasal bridge. Non-surgical rhinoplasty is also beneficial for smoothing out nasal imperfections like dents and for fixing minor symmetry issues. If a patient has had too much of their nasal dorsum taken down during a previous surgical rhinoplasty, a liquid rhinoplasty can correct this problem.
Advantages of the procedure:
It is reversible
No down time
As a trial for patients apprehensive to undergo surgery but desire a change in appearance.
Solution for people who already had surgery (minor defects)
Patient refusing surgery
Patient waiting for revision surgery
Safety of Dermal Fillers
A complete medical history is always necessary and should cover allergic or hypersensitivity reactions to any substance, including anesthetics. Dermal fillers are contraindicated during pregnancy and breastfeeding and are not recommended in immunocompromised individuals, patients with autoimmune diseases or receiving certain drugs, such as interferon [6].
While generally considered a safer alternative to a nose job, non-surgical rhinoplasty does have risks. The dermal filler used in this type of cosmetic procedure can cause some irritation.
Longevity of Hyaluronic acid based fillers is reported to last 6 to 18 months [1, 5].
Materials and Methods
We evaluated twenty patients who underwent Non surgical rhinoplasty where Hyaluronic Acid based fillers were injected depending on the corrective procedure required by the individual patient. All patients provided written informed consent for treatment. Because the study was a retrospective review of patient’s treatment, no Ethics Committee approval was needed; however, the principles of the Declaration of Helsinki were followed.
The following tests were applied to evaluate patients from the baseline to the end of the treatment. The procedure is designed to restore the desired facial symmetry and to make the nasal contour more appealing.
Besides taking photographs of the patients, before the user experience and after the user experience the following evaluation scales were used for the subjective improvement.
Nose Imperfection Scale
Rated by the patient on an 8-point scale.
1—perfect feature; 2—almost perfect; 3—minimal imperfection; 4—mild imperfection; 5—mild to moderate imperfection; 6—moderate imperfection; 7—moderate to marked imperfection; 8—very marked imperfection.
After correction at least 5 point difference should be observed to establish a satisfactory score.
The ROE (Rhinoplasty Outcomes Evaluation) is used in order to estimate rhinoplasty results. It is made up of six questions, two for each factor considered key in patient satisfaction (physical, emotional and social). The Questionnaire helps to better quantify this subjective assessment. Each question has five answer options, graded from zero to four. Therefore, the questionnaire score may vary between zero and 24. From the baseline of dissatisfaction the patient should mention the highest degree of satisfaction and the differential should be 50 to illustrate good satisfaction as perceived by the patient.
Technique
Written informed consent taken from all the patients. Patient is well counselled prior to the procedure about their individual expectations and realistic outcomes. Patient is positioned reclined on a chair or couch. Prior to the procedure, prilociane or EMLA 5% cream (25mg lidocaine + 25mg prilocaine) is applied locally for topic anaesthesia. Epinephrine is avoided so that any form of blanching during injection of filler can be noticed, which indicates vascular compromise. The material used in all our patients was Hyaluronic acid (HA). The needle entry point is positioned cranial to the concavity, the skin is elevated pinched between the index finger and thumb, and the needle inserted deep up to the nasal bone, in the subperioesteal layer or in the sub-SMAS layer, staying close to the midline to avoid lateral vascular structures. For dorsal augmentation/injection, we prefer injecting in 2 planes, above and below the subperiosteal plane. After aspiration, the needle is gently withdrawn and injection is performed caudocranially in a retrograde manner, in fine multiple linear threads fanned over the desired area, while massaging and manipulating the filler into the defect with the fingers after each injection.
Pre and Post injection Photographic Analysis with a DSLR camera in good ambient light setting is done. Photographs taken in standard frontal, lateral and oblique views and basal view.
Recovery Time
There is very little to no down-time involved in the procedure. In fact, most patients return to their normal, daily activities right after their visit. There is no significant swelling, bruising or pain. However, sunglasses or heavy eyeglasses must be avoided for two weeks after the procedure.
Results and Analysis
The history of patient, filler used and the recordings were entered as per Tables1 and 2.
Table1.
Comparative patient NIFS and ROE scores before and after injection
| SN | Age/Sex | Indication | Dose (HA based filler) | NIFS | ROE | ||
|---|---|---|---|---|---|---|---|
| Pre | Post | Pre | Post | ||||
| 35/F | NF angle | 1ml | 7 | 2 | 20 | 83 | |
| 25/M | Hump | 1ml (0.5ml above and below) | 8 | 3 | 25 | 75 | |
| 22/M | Post SMR saddle | 2ml | 7 | 2 | 13 | 67 | |
| 21/M | Saddle | 2ml | 7 | 2 | 16 | 75 | |
| 18/F | Hump | 1ml above hump and 0.5ml at tip of nose | 7 | 2 | 16 | 75 | |
| 45/F | NL angle | 1ml | 7 | 2 | 22 | 85 | |
| 29/M | Hump | 1ml (0.5ml above and below) | 8 | 3 | 25 | 75 | |
| 20/M | Post Rhinoplasty irregularity | 2ml | 8 | 3 | 23 | 77 | |
| 31/M | Tip | 1.5ml | 7 | 2 | 16 | 75 | |
| 28/F | Hump | 1ml above hump and 0.5ml at tip of nose | 7 | 2 | 16 | 75 | |
| 34/F | NF angle | 1ml | 7 | 2 | 20 | 83 | |
| 28/M | saddle | 1ml (0.5ml either side) | 8 | 3 | 25 | 75 | |
| 27/M | hump | 2ml | 7 | 2 | 13 | 67 | |
| 31/M | Saddle | 2ml | 7 | 2 | 16 | 75 | |
| 19/F | Nasal Hump | 1ml above hump and 0.5ml at tip of nose | 7 | 2 | 16 | 75 | |
| 50/F | NL angle | 1ml | 7 | 2 | 22 | 85 | |
| 39/M | Hump | 1ml (0.5ml either side) | 8 | 3 | 25 | 75 | |
| 24/M | Post Rhinoplasty minor irregularities | 2ml | 8 | 3 | 23 | 77 | |
| 30/M | Saddle | 2ml | 7 | 2 | 16 | 75 | |
| 26/F | Hump | 1ml above hump and 0.5ml at tip of nose | 7 | 2 | 16 | 75 | |
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Table2.
Comparison of mean pre and post-operative ROE scale results
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Photographic evaluation was done before and after the injection of the filler (Figs.1, 2, 3, 4, 5).
Fig.1.
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Fig.2.
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Fig.3.
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Fig.4.
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Fig.5.
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The mean pre-procedure ROE score was 18 and post-procedure was 75. NIFS difference of 5 and ROE Scale differential of 50 is considered to be significant, which is seen in all individual cases.
Discussion
Medical rhinoplasty is a growing field of aesthetic medicine that every aesthetic doctor should have insights about. It is very safe and easy to perform in the outpatient setting. This technique is useful for many aesthetic problems of the nasal dorsum and tip. The technique can also be used to correct many postsurgical defects without going under the knife again. It also offers a less invasive, nonpermanent and affordable method of primary correction for patients who are not interested in surgical alternatives. However the surgeon should be well versed with the nasal anatomy and vasculature, and trained in the procedure. Surgeons should be aware of risk factors that are potentially associated with dissatisfaction and revision of the procedure. Fillers may be a good alternative for patients who require only small alterations to correct nasal depressions or deformities. Rejection of surgical methods, for a variety of reasons, may prompt the surgeon to consider filler rhinoplasty as an alternative.
In the current user experience the Nose Imperfection rating scale from baseline average of 7.2 which corresponds to moderate to marked imperfection was corrected to 2.25 or Almost perfect feature in the patients. The relative patient satisfaction was high.
Under the Rhinoplasty Outcome Evaluation (ROE) Score the baseline average was 18 where the patients were not satisfied with their external appearance, this was raised 4 times where it was 75 indicating high satisfaction.
Technically, it is most important what depth to place a specific implant. If placed too superficially, can give a lumpy or nodular appearance with visible whitish papules. If placed too deep, can lead to masking of correction. Generally, it is better to err on placing the filler deeper. The downside of this deeper placement is that the augmentation effect may not be as apparent, though it may last longer given less mobility [7]. We prefer injection into the sub-SMAS or subperiosteal plane, the needle is advanced till contact is made with the nasal bone, staying near the midline. The angular artery and dorsal and lateral nasal arteries are laterally placed and thus staying close to midline ensures lesser chances of intravascular injection. Small volume injections injected slowly, without applying too much pressure, with retrograde threading fanned out over the area; while massaging and manipulating the filler into the defect with the fingers, after each injection. Aspiration before every injection is mandatory and it is safe to give compression of the angular artery while injecting [8]. HA is slightly under-injected as it absorbs water from the surrounding tissues and may swell up to 30%.
Post procedure mild pain, swelling or erythema is expected which usually subsides with NSAIDs and ice application.
Adverse Effects
Most practitioners agree that biodegradable fillers should be used in preference to permanent fillers for safety reasons, although some authors still favour permanent fillers. In our study we assessed safety of the procedure, as there are potential disastrous complications that can occur, such as amaurosis after injection of fillers, fat, or local anesthesia [9] probably due to accidental intra-arterial injection with subsequent occlusion of the central retinal artery or its branches [10–12], or skin necrosis from inadvertent injection into angular artery in the nasolabial fold or supratrochlear artery in the glabella, or any of its branches [13–16].
Therefore it is important not to exert excess force when injecting and attention should be paid to the needle size, as well as the viscosity and particle size of the filler [17].
This is a particular issue when comparing CaHA and HA fillers, as CaHA is harder to inject due to its higher viscosity, and therefore higher pressure has to be applied than with HA fillers.
In the unlikely event of microembolism and vision loss following HA treatment, injection of hyaluronidase should be the first-line treatment as it is an enzyme that hydrolyses HA and has been shown to degrade intravascular HA [18, 19]. There is no similar dissolving agent known for CaHA. Adjunct therapy with reperfusion of the occluded vessels with hyperbaric oxygen, topical application of Nitropaste which acts as a vasodilator [6, 20, 21]. Intravenous diuretics, corticosteroids and antibiotics, apart from carbogen and hyperbaric oxygen inhalation, lysis therapy is also given [22]. Because of the high number of complications associated with CaHA (10.7%), most authors prefer to use HA rather than CaHA for injection rhinoplasty, particularly because it has the potential for immediate degradation using hyaluronidase [10].
Conclusion
Our experience with Hyaluronic Acid based fillers was satisfying in terms of surgeon as well with the treated patients. The patient aesthetic satisfaction grade was high indicating no major perceivable pain with formulation and significant correction in terms of aesthetics making patients more comfortable to face the external environment. Due to its safety profile as compared to other filler agents, as well as the availability of Hyaluronidase to reverse its effects in the unlikely event of an adverse effect or an over-injection, it is the preferred material for use for injection rhinoplasty.
Funding
None.
Compliance with Ethical Standards
Conflict of interest
The authors declared that they have no conflict of interest.
Footnotes
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Contributor Information
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