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Talent & Techniques: A practical approach to non-surgical rhinoplasty

Talent & Techniques: A practical approach to non-surgical rhinoplasty

Surgical rhinoplasty is one of the most popular aesthetic procedures worldwide. However, until recently, patients who wanted to avoid surgery – and the associated risks, recovery and expense – have never had a viable, non-invasive alternative that could accomplish similar cosmetic goals.

Capitalizing on the advent of long-lasting injectable fillers, non-surgical rhinoplasty (NSR) can correct mild or moderate cosmetic nasal irregularities.

I perform this procedure to achieve the following cosmetic goals:

  • Raise and better define an underdeveloped nasal dorsum.
  • Raise and better define a ptotic tip.
  • Camouflage a dorsal bump. The dorsum is leveled by injecting filler above and below the bump.
  • Correct asymmetry of the tip or dorsum by subtly augmenting the weaker side.
  • Correct post-rhinoplasty contour defects. Most commonly, these present as saddle nose deformity or other types of dorsal cartilage collapse, poly beak deformity, dorsal asymmetry due to asymmetric scarring, asymmetry of the tip due to post-surgical scarring or cartilage over-resection and alar foreshortening.

Appropriate candidates

Not all patients are candidates for the NSR procedure. Some are better served by a surgical approach. Most of these can be grouped together as patients who need a reduction of their nose. They include:

  • Patients with a large nose who want a reduction.
  • Patients with a tip that is large and round who desire a smaller, sculpted tip. This is especially so with patients who have thick tip skin.
  • Patients with a severely twisted nose.
  • Patients with wide ala who want narrowing of their nasal base.
  • Patients with an overly projected nose who want de-projection.
  • Patients with a hanging columnella.

My technique

NSR should be performed with the patient sitting straight up, as close to 90 degrees as is comfortable, leaning their head against a head rest to minimize movement. Injecting the patient in this position allows the practitioner to constantly re-assess the aesthetic effect of the nasal injections on the appearance of the entire nose and the patient’s face as it is viewed by others.

After taking standardized photographs, I use a compounded triple anesthetic cream for 15 to 20 minutes prior to the procedure. Following removal of the cream, the patient ices the area to be injected. During the injection procedure, the patient can self-administer nitrous oxide if that is an option, and an assistant can tap a shoulder or leg as a distraction.

Currently, hyaluronic acid (HA) is the most popular filler material for aesthetic injections due to its natural look and feel and its reversibility with hyaluronidase. The ability to dissolve HA is a critical safety feature for non-surgical rhinoplasty, especially for injectors who are not yet proficient in the technique. An HA with high viscosity and a high elastic modulus will lift tissue well and hold its shape, both essential for a successful NSR. A filler with these qualities, as well as low hydrophilicity and a long duration of action would be the preferred choice for NSR.

Voluma and Lyft are currently the FDA-approved fillers that best satisfy these criteria. Lyft has the highest G’ and would be the ideal choice, but it lasts only eight to ten months. Voluma lasts for one to one and a half years in the nose and provides enough G’ to accomplish the goals of NSR.

Conversely, while some practitioners recommend Juvéderm as a good filler for use in the nose, it is a soft, hydrophilic filler with a short duration of effect. Due to its limited ability to lift tissue, along with the risk of post-procedure edema causing compression ischemia in a fragile area like the tip, I do not endorse this product for the NSR procedure.

Restylane, also frequently used for this procedure, is less hydrophilic than Juvéderm, and it has better elasticity, but with a six-month duration of effect, it is not ideal.

For maximum patient comfort and safety, HA filler can be transferred into a 0.3 cc, 31G diabetic syringe in a sterile manner by carefully removing the plunger, placing 0.2 cc of filler into the syringe and replacing the uncontaminated plunger. 21G, 1.5” needles work well for transfer. The rheology of the small syringe permits all FDA-approved HA fillers (including Voluma) to flow through the 31G needle at reasonable injection pressures.

I perform injections, for the most part, as tiny boluses or as short linear threads at the level of the periosteum or perichondrium, placing small amounts of filler as I withdraw the needle. I will place filler into the area of the radix, dorsum, sidewall, tip, columnella and ala as needed to correct each individual irregularity. I will then massage and mold the filler to blend into the desired contour. The volume effect of most fillers decreases by about 25% within the first couple of weeks, so a touch-up visit is recommended for about four weeks after the initial procedure.

Experience matters

When performed carefully, NSR is a safe and simple procedure that makes patients extremely happy. However, this is a procedure with more risk than many other facial injections. It should only be performed by experienced injectors who understand fillers well and are very familiar with the anatomy of the face.

The injector must know how to recognize adverse events like ischemia and intravascular embolism of filler as they happen, and be comfortable with treating these types of adverse events.