From the Pages of Prime: Clinical Pearls for Optimizing Safety in Nonsurgical Rhinoplasty

Injection of dermal fillers is a relatively safe procedure, but adverse events (AEs), including serious ones like vascular compromise and ischemic complications, do occur. While filler complications can occur anywhere on the face, the nose is the most dangerous area of the face to inject filler with AEs that can be devastating.

Considering the global surge in demand for nonsurgical rhinoplasty (NSR) it is more important than ever that NSR injectors have a detailed understanding of nasal anatomy, a nuanced appreciation of nasal aesthetics, and a thorough knowledge of best practices in prevention, recognition and treatment of AEs. Adoption of and diligent adherence to the UISP described in this manuscript are key to prevention.

Injection safety in the nose hinges primarily on preventing and managing ischemic complications. Although bruising, erythema, tenderness and swelling may occur, these are transient and treatable with over-the-counter medication and vascular lasers. In addition, moderately serious AEs like granuloma and delayed onset of nodule formation that occur with filler injection in other areas of the face have not been reported after using FDA-approved fillers in the nose.¹

Overall, the principles that govern safe injection in the face can be applied to NSR; however, meticulous following of those principles is of paramount importance with nasal injections. There are numerous reviews and reports of filler- related blindness and tissue necrosis, which firmly illustrate this point.²

Vascular complications occur when the tip of the needle or canula is inside an artery and a large amount of filler material is injected under high pressure, obstructing critical blood supply to the skin or the eye. The only exception to this rule is in the tip of the nose or the alar area, where ischemia can occur because too much filler compresses the small vessels in a tight space, causing a compartment syndrome-like effect. Therefore, preventing complications hinges on preventing the confluence of these factors.

Is there a way to make sure that the tip of the needle or cannula is not inside an artery?

Unfortunately, the short answer to that question is – no. Until ‘smart’ needles that provide some signal upon passage into a blood vessel are widely available, we will be inherently injecting blind.

While aspiration is a widespread practice, there is no definitive evidence showing effectiveness in preventing complications. In fact, there is a growing consensus among expert injectors that aspiration is not only unreliable, but actually decreases safety.^3,4 It is unreliable because the test is only assessing the exact spot where the tip of the needle is located during aspiration, not necessarily where the product is injected. This maneuver assumes that the injector’s hand has remained perfectly still through the performance of aspiration and subsequent injection. If the tip of the needle moves, even by a millimeter, the test is rendered useless. As demonstrated by a recent ultrasound study, it is physically impossible to aspirate a viscous gel, like those used for facial filling, without moving the tip of the needle several millimeters during the procedure.^4,5

Considering the size of the vessels to be avoided, this distance is clearly far too large to ensure safety during product placement. Of note, some have argued that aspiration without motion is possible if the needle is resting on bone. This may be true for a brief suction time, but it is very unlikely true for the extended times suggested by the aspiration literature as necessary for a reliable test, especially when using the highly viscous fillers needed for good NSR outcomes.⁶ False negative findings with aspiration are common enough^7,8 to suggest the practice itself creates a false sense of security for injectors, which could lead to the placement of large amounts of filler under high pressure inside a patient’s artery. Until technology provides a way to detect arterial puncture, one must inject assuming that their needle or cannula is always inside a vessel.

If we cannot know whether a needle is in a vessel, what can be done to ensure safe injection?

Though there are no randomized clinical trials on the subject, there are evidence-supported practices that can reduce risk. First, one must do everything possible to limit the volume of filler deposited in any one injection point. Because one must assume that the needle tip is always in a dangerous place, injecting a large bolus of filler is an unsafe practice under any circumstance. Admittedly this position contrasts with many of the recommendations and techniques popular today and it is not uncommon to read claims that bolus injections on periosteum or perichondrium are ‘safe’. The literature on anatomic variability, however, provides clear evidence that doing so is unwise.

Given the absence of any true ‘safe plane’ for injection, it is best to take appropriate precautions. The sections below describe the UISP set of protocols developed by Dr. Rivkin. These principles should be applied in combination with adequate training and knowledge of anatomy.

Universal Injection Safety Precautions:

• Continuous retrograde motion as filler is moving through the needle. Constant motion limits the amount of filler deposited in any one place to a very small amount. This practice is more reliable than aspiration because, even if the needle is inside a vessel, it will exit the vessel before enough material has been deposited to cause an AE. If the injection is placed as a vertical column, this practice also improves tissue lift because expanding multiple tissue planes leads to more efficient and precise projection.
• Slow, low-pressure injections give the injector time to react if early signs of ischemia present. This type of injection also will not overcome systolic blood pressure, which is required for a filler to move retrograde through an artery.
• Injectors should use the smallest gauge needle possible. A small needle gauge encourages small injection volumes and enhances patient comfort.
• Cannulas should be 25G or larger. Sizes smaller than 25G can pierce vessels, but this must be balanced against the fact that larger cannulas can compromise precision, which is especially important in the nose.
• Diligent cleansing of the skin with alcohol, chlorhexidine or hypochlorous acid is important because fillers can remain under the skin for several years. We want to prevent the formation of an environment likely to harbor chronic infections.

UISP Specific to NSR:

• Ice the skin of the nose prior to injection. This will shrink the vessels and decrease the risk of perforation. One exception is patients who have had rhinoplasty in the past, as their dermal blood supply is already compromised. For these patients, icing may increase the risk of ischemia.
• Use 0.3 cc or 0.5 cc insulin syringes backloaded with filler. These syringes come with smaller needles (28G to 31G) and permit the precise deposition of tiny (0.01 cc to 0.03 cc) amounts of product. Insulin syringes improve safety by limiting the amount of product injected per spot. The outcome is improved because of an increase in precision. They also improve patient comfort. Aspiration is not possible with these syringes due to needle size and syringe construction.

Additional suggestions to improve safety for nasal injections include:

• Place most injections at the midline, as the major vessels of the nose mainly run on the lateral aspects. However, there are vessels in the midline, and anatomic variability dictates that some people will have a dorsal nasal artery which runs down the middle of the dorsum. Careful adherence to the UISP rules is necessary, even in the midline. Advanced NSR injectors will regularly inject outside of the midline, because correction of many asymmetries and cases of cartilage collapse, require filling of the nasal sidewall.
• Pinch-compress the dorsal nasal and supratrochlear vessels during radix injection to prevent inadvertent cannulation.

The goal of UISP and the other effective safety precautions is not to prevent our needle or cannula from entering a vessel. We enter vessels all the time when we inject filler, as is obvious from the frequency with which we cause bruising. The goal is to make sure that, no matter where the tip is, we never inject enough filler to cause an ischemic AE.

References:

1. Wang JV, et.al. Utility of preinjection aspiration for hyaluronic fillers: a novel in vivo human evaluation. J Cutan Med Surg. 2020; 24(4): 367- 371.
2. Beleznay K et.al. Update on avoiding and treating blindness from fillers: a recent review of the world literature. Aesthet Surg J. 2019; 39(6): 662- 674.
3. Rivkin AZ. Aspiration: I don’t do it and neither should you. J Cosmet Dermatol. 2021 Apr;20(4):1042- 1043
4. Goodman GJ et.al. Aspiration Before Tissue Filler-An Exercise in Futility and Unsafe Practice. Aesthet Surg J. 2022 Jan 1;42(1):89-101.
5. Lin F, et.al. Movement of the Syringe During Filler Aspiration: An Ultrasound Study. Aesthet Surg J. 2022 Sep 14;42(10):1109-1116.
6. Kapoor KM et al. Factors influencing pre-injection aspiration for hyaluronic acid fillers: a systematic literature review and meta-analysis. Dermatol Ther. 2020;e14360.
7. Torbeck RL et.al. In Vitro Evaluation of Preinjection Aspiration for Hyaluronic Fillers as a Safety Checkpoint. Dermatol Surg. 2019 Jul;45(7):954-958.
8. Van Loghem JA et.al. Sensitivity of aspiration as a safety test before injection of soft tissue fillers. J Cosmet Dermatol. 2018 Feb;17(1):39-46.
9. Murray G, et.al. Guideline for the Management of Hyaluronic Acid Filler-induced Vascular Occlusion. J Clin Aesthet Dermatol. 2021 May;14(5):E61-E69. Epub 2021 May 1.
10. Jones, D et.al. Preventing and Treating Adverse Events of Injectable Fillers: Evidence-Based Recommendations From the American Society for Dermatologic Surgery Multidisciplinary Task Force. Dermatologic Surgery 47(2):p 214-226, February 2021.
11. Rommel F et.al. Evaluating Retinal and Choroidal Perfusion Changes After Ocular Massage of Healthy Eyes Using Optical Coherence Tomography Angiography. Medicina (Kaunas). 2020 Nov 26;56(12):645.

Fang WT et.al. Descriptive Analysis of 213 Positive Blood Aspiration Cases When Injecting Facial Soft Tissue Fillers, Aesth Surg J, Vol 41, Issue 5, May 2021; 616–624

Rivkin A. Nonsurgical Rhinoplasty Using Injectable Fillers: A Safety Review of 2488 Procedures. Facial Plast Surg Aesthet Med. 2021 Jan-Feb;23(1):6-11.

Rivkin A. PMMA-collagen Gel in Nonsurgical Rhinoplasty Defects: A Methodological Overview and 15-year Experience. Plast Reconstr Surg Glob Open. 2022 Aug 19;10(8):e4477