Nonsurgical Rhinoplasty Using Injectable Fillers: A Safety Review of 2488 Procedures

Nonsurgical Rhinoplasty after Rhinoplasty: A Systematic Review of the Technique, Results, and Complications

Introduction: Surgical rhinoplasty is a complex procedure with a high revision rate. Nonsurgical rhinoplasty (NSR) could avoid secondary rhinoplasty allowing the correction of postsurgical defects. A systematic review has been performed among adult patients who had previously undergone surgical rhinoplasty and now presenting for NSR with filler, demonstrated most common indications, fillers, and complications in this technique. Materials and Methods: A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) system guidelines. Primary outcomes included indications for NSR in patients with prior rhinoplasty and complication rate. Secondary outcomes included filler material and degree of patient satisfaction. Results: Twenty articles met the inclusion criteria, obtaining 2,048 patients analyzed in the review. Hyaluronic acid was the most used filler, found in 67% of patients. Indications were highly variable, considering deformities of the middle third of the nose the most remarkable. A high degree of satisfaction was found in the analyzed studies and the rate of major complications was low. Discussion and Conclusions: NSR in patients with prior rhinoplasty is a useful option for correcting a range from subtle aesthetic defects to severe nasal deformities. However, this technique is not exempt from complications, since an increased risk of skin necrosis has been observed.

Resolution of Vascular Compromise From Liquid Rhinoplasty Using Hirudo medicinalis Therapy

Hyaluronic acid (HA) fillers are a relatively safe and effective means of cosmetic treatment for the face; however, as the numbers of both patients and injectors continue to rise, reports of adverse events (AEs) and ischemia are increasing. Although visual complications and stroke are the most-feared AEs, skin and underlying tissue necrosis is far more common and can be catastrophic. HA can be dissolved with hyaluronidase, but this does not always resolve ischemia. In some instances, including the case presented here, conventional interventions are inadequate to reverse the progression of ischemia and restore blood flow. In this case study, HA injection of the nasal sidewall resulted in ischemia and impending necrosis of the nasal tip. Following failure of standard-of-care measures to reverse the progression of ischemia and restore blood flow, Hirudo medicinalis therapy was successfully used as an adjuvant treatment. To our knowledge, this is the first report of H. medicinalis therapy for treatment of ischemia and necrosis from aesthetic filler injection. Based on experience here, this approach should be considered for patients who are out of therapeutic options, or as a helpful adjunct to speed resolution of vascular occlusion. In addition, the success of H. medicinalis therapy, which acts locally on the microvasculature, may inform our understanding of the mechanism of vascular occlusion with fillers.

Level of Evidence 5 Therapeutic

The Use of Cross-Linked Hyaluronic Acid in Non-surgical Rhinoplasty Using Italian Technique

INTRODUCTION

Projection and upper rotation to the tip is fundamental in the nasal rejuvenation, as a matter of fact the tip is the most important and has strongly effects on the improve appearance and quality of life. The aim of the present study was to evaluate reshaping the tip of the nose by cross-linked hyaluronic acid using Italian technique.

METHODS

In a period between November 2019 and 2023, a total of one hundred and forty healthy, 95 females and 45 man patients, were performed with a mean age 44±5 (age range: 31-52 years old) affected by tip of congenital (22) or ageing nose hypotonia (118), and reduced volume that need of an elevation of the nose tip. The anatomic markers have been considered for the anthropometric measurements after the filler rhinoplasty. Two infiltrations were performed, one in the infiltration into the antero-caudal access over the columella produce upward rotation of the tip of the nose and second infiltration into the antero-superior access produce the projection of the tip of the nose. Medical device used in the study was Neofound STRUCT LIDO (LOVE COSMEDICAL srls-Via Toniolo 9, 57022 Castagneto Carducci, ITALY) containing sodium hyaluronate/hyaluronic acid high molecular weight (1.500

RESULTS

The effect on the upward rotation of the tip nose was evaluated using Global Aesthetic Improvement Scale and morphometric evaluation. All the subjects showed at least 2-3 grade improvement in GAIS score after HA filler injection. The analysis of patient satisfaction after the last follow-up visits clearly demonstrated good results. A significant morphometric difference was detected comparing the T0 and T90 (p<0,0001), while no difference was present comparing T90 and T180 means (p=0.11). The outcome of the present clinical study gives greater projection and upper rotation to the tip with great gratification of the patients and the surgeon. An augmentation of the tip nose with hyaluronic acid filler produces a rejuvenation of the nose area resulted in a more youthful appearance. No adverse event was observed. In 35 patients, additional HA infiltration had to be performed after 2 weeks.

CONCLUSION

In conclusion, the Italian technique descripted in the present paper is safe, simply, and efficacious for rejuvenation of the nose, with elevated levels of patient satisfaction.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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Key Words

• Aesthetic
• Filler
• Hyaluronic acid
• Non-surgical rhinoplasty
• Nose reshaping
• Rhinofiller
• Rhinoplasty

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Affiliation(s)

Antonio Scarano Department of Innovative Technologies in Medicine and Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100, Chieti, Italy.
Andrea Sbarbati Department of Neurosciences, School of Medicine, Biomedicine and Movement Sciences, Anatomy and Histology Section, University of Verona, Verona, Italy
Domenico Amuso Department of Innovative Technologies in Medicine and Dentistry, University of Chieti-Pescara, Chieti, Italy
Roberto Amore Department of Innovative Technologies in Medicine and Dentistry, University of Chieti-Pescara, Chieti, Italy
Segio Rexhep Tari Department of Innovative Technologies in Medicine and Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100, Chieti, Italy
Iris Alla Department of Innovative Technologies in Medicine and Dentistry, University of Chieti-Pescara, Via Dei Vestini 31, 66100, Chieti, Italy

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Nonsurgical Rhinoplasty: Diamond Injection Technique for Nasal Tip Contouring

Background: A more pleasing nasal tip appearance is becoming the most frequent reason for nonsurgical aesthetic rhinoplasty procedures. Objective: To present the "Diamond Injection Technique," an innovative 4-point hyaluronic acid (HA) filler injection procedure for nasal tip refinement and to assess its aesthetic outcomes and efficacy. Methods: Data were collected from a prospective single-center cohort of patients undergoing nonsurgical rhinoplasty with injectable fillers. Anthropometric measurements, the 5-point Global Aesthetic Improvement Scale (GAIS), and a patient-reported questionnaire were used to evaluate the aesthetic outcomes and treatment efficacy before treatment and 6 months later. Results: The study included 107 patients; 82 were women. The median age was 35 (18-47) years. The mean volume of HA filler injected was 0.12 mL (range: 0.05-0.2). At 6 months, the GAIS-calculated outcome was excellent in 90.65% of patients, with a high degree of patient satisfaction and objectively pleasant changes in anthropometric measurements. Conclusions: The "Diamond Injection Technique" proves to be a safe, comprehensive, and effective procedure for refining the nasal tip to a pleasing diamond shape, satisfying a high percentage of patients.

Nonsurgical rhinoplasty using the hyaluronic acid filler VYC-25L: Safety and patient satisfaction in a retrospective analysis of 492 patients

BACKGROUND

Aesthetic treatment of the nose with hyaluronic acid (HA) fillers is increasingly popular but carries a small risk of major complications. Large patient cohorts are required to better understand this risk.

AIMS

To evaluate safety and patient satisfaction in a large series of nonsurgical rhinoplasty treatments with the HA filler, VYC-25L, in "real world" clinical practice.

METHODS

This was a retrospective analysis of consecutive adult patients undergoing nonsurgical rhinoplasty with VYC-25L by a single injector between January 2020 and July 2022. All patients received initial treatment (typically ~0.3-0.5 mL of filler) and touch-up at 4-6 weeks (~0.1-0.3 mL). Safety data were collected throughout a mean follow-up of 11.1 months. Patient satisfaction was assessed using the FACE-Q Satisfaction with Nose and Satisfaction with Outcome questionnaires.

RESULTS

A total of 492 patients were included (984 treatment sessions including touch-ups). Of these, 467 (94.9%) were female and the mean age was 30.0 years. All treatments were associated with early transient edema; other adverse events included bruising (n = 123; 25%), residual asymmetry (n = 18; 3.7%), and suspected localized vascular occlusion (n = 3; 0.6%). The latter cases were easily resolved with hyaluronidase injection plus oral steroid and aspirin. No patients experienced infection, necrosis, blindness, lumps, granuloma, or delayed-onset nodules. Mean Rasch-transformed FACE-Q scores were 90.2% for Satisfaction with Nose and 99.2% for Satisfaction with Outcome.

CONCLUSIONS

In a large cohort of patients treated in routine practice based on a systematic approach, nonsurgical rhinoplasty with VYC-25L was safe and effective.

Non-surgical rhinoplasty using polydioxanone threads

OBJECTIVE

To demonstrate the effects of PDO threads non-surgical rhinoplasty on patients' quality of life (using FACE-Q Scale) and first impression assessments.

METHODS

This is a prospective cohort study of 10 adult patients who sought non surgical rhinoplasty to improve tip rotation or reduce the appearance of a dorsal hump. All patients fulfilled the study's enrollment criteria. Prior to treatment, patients completed pre-treatment FACE-Q surveys and pre-treatment photos were obtained. Each patient was treated with the appropriate size and number of PDO threads necessary to achieve optimal correction result (OCR). Two weeks after treatment, the patient completed posttreatment FACE-Q surveys and posttreatment photos were obtained and analyzed. First impression surveys were created using pre- and posttreatment photos, and the survey was completed by 146 blinded evaluators.

RESULTS

There was statistically significant improvement in the FACE-Q scores for social function (p = 0.02), psychological function (p = 0.0009) and satisfaction with nose (p = 0.0001). There was significant reduction in scores for appearance related psychosocial distress (p = 0.03). For the first impression surveys, there was a statistically significant improvement (p = 0.029) in the attractiveness scale posttreatment. Although not statistically significant, there was reduction of the dorsal hump (p = 0.15) and increase in the nasolabial angle (p = 0.48) and Goode's ratio (p = 0.16). There were no major adverse events or complications.

CONCLUSION

This study shows that the PDO threads alone can be used safely to achieve minor nasal changes especially in tip rotation and appearance of dorsal hump, to improve patients' quality of life, and perceived attractiveness of treated patients.

An Innovative Approach for Nasal Reshaping using Hyaluronic Acid Intradermal Injections

Background

Nasal reshaping using hyaluronic acid (HA) filler has become a widespread technique and injections are usually performed in deep layers. As an alternative, we propose an innovative approach where HA is injected into the dermis, the so called MesoRhinoFiller.

Aims and Objectives

The aim of this study was to describe our injection technique using a smooth, cohesive, and slightly viscous HA filler injected in the dermis.

Materials and Methods

A retrospective review of the author's clinical experience from March 2017 to March 2020 was presented. A total of 280 consecutive patients were treated with HA injections to improve their nasal appearance. The mean volume was 0.5 cc HA filler/treatment.

Results

An average increase of 4.9 ± 3.4° was obtained for the nasofrontal angle, and of 7.0 ± 4.5° for the columella labial angle. Asymmetries in the nasal profile and alar rim were also corrected. All the patients were satisfied with the results and no complications occurred.

Conclusion

Injecting HA fillers in the dermal plane is a versatile approach that provides very satisfactory results. This technique allows one to better correct aesthetical, post-traumatic, and post-surgical defects compared with the usual injection rhinoplasty procedures where the filler is injected deep onto the bone/cartilage in the midline of the nose.

An Experimental Model Exhibiting Anterograde and Retrograde Vascular Occlusion of Facial Fillers to Avoid Vision Loss

Background

Facial filler injection techniques that help decrease the risk of vascular occlusion are an important growing area of study. This study demonstrates a model of injecting fillers into a simulated bifurcated arterial system, using different sized needle gauges at a constant injection pressure.

Methods

Three facial fillers were injected into a bifurcated intravenous tubing with continuous irrigation at a constant pressure to simulate a vascular system. Videography was used to observe for retrograde flow through the simulated supratrochlear artery to the bifurcation point, where the filler was redirected by anterograde flow into the branch representing the ophthalmic artery.

Results

Filler injection with retrograde flow to the bifurcation occurred with all the 27G needle trials. In comparison, the 30G needle trials were only able to reach the bifurcation point in three of the nine trials. The average time to the bifurcation point with subsequent ophthalmic artery anterograde flow with the 27G and 30G needles were 8.44 (95% confidence interval ±2.06) and 33.33 (95% confidence interval ±16.56) seconds, respectively.

Conclusions

Larger 27G needles consistently reached retrograde flow and the bifurcation point faster than 30G needles. This study suggests thinner needles may be less likely to cause retrograde occlusion.

Displacement of Hyaluronic Acid Dermal Filler Mimicking a Cutaneous Tumor: A Case Report

There has been considerable growth in the number of cosmetic injectable procedures in recent years. Consequently, physicians in general are seeing a greater number of patients who have previously had cosmetic implants. These patients often fail to mention or do not admit to having had previous cosmetic procedures, conditions that should be noted in their medical histories. In this article, the authors report a rare case of hyaluronic acid filler displacement resulting from injection in the nasal radix region that had been administered 10 months prior, which the patient failed to mention. The filler migration mimicked facial tumors, entangling an otherwise easy case and it was only recognized with the use of dermatological ultrasound. This serves as a warning and a reminder to include complications from cosmetic procedures in diagnostic hypotheses. Physicians need to be vigilant, question their patients' medical histories, and be familiar with diagnostic imaging options. The presence of dermal fillers should always be considered in cutaneous tumor lesions, since they can last for months to years, or be present in locations distant from the site of application.

Postoperative Fillers Reduce Revision Rates in Rhinoplasty

Background

Rhinoplasty is a complex procedure with revision rates of up to 17%. Even minor imperfections after surgery can be significant.

Objectives

This review aims to investigate the use of hyaluronic acid (HA) fillers postaesthetic rhinoplasty and assess the rhinoplasty practice of the senior author.

Methods

From the senior author's practice, case records were obtained for patients who underwent surgery followed by nonsurgical rhinoplasty between 2015 and 2022. Data were retrospectively obtained and analyzed. The variables measured included the number of patients treated with fillers postoperatively, volume and type of filler used, locations of injection, and frequency of injections and complications.

Results

Eight hundred patients underwent rhinoplasty between March 2015 and March 2022, and 10.6% (n = 85) of these underwent nonsurgical rhinoplasty using the HA filler for postoperative imperfections. The Juvederm 2 filler (Allergan, Irvine, CA) was mainly used with a mean volume of 0.2 mL. A total of 11.8% (n = 10) of patients had fillers for a second time and 3.5% (n = 3) required a third filler. The majority of patients had fillers in the rhinon area (82.3%; n = 70), and no complications were reported, with patient satisfaction levels being good.

Conclusions

Often, there is hesitancy to use fillers after surgery due to the assumption that fillers will be required in the long term and complication rates can be high for postrhinoplasty nose fillers. From our series, we conclude that after surgery, fillers last for a greater time period than those used purely for primary augmentation. Hence, the authors recommend rhinoplasty surgeons to consider HA filler use for patients troubled by postsurgery surface irregularities.

Level of Evidence 5

PMMA-collagen Gel in Nonsurgical Rhinoplasty Defects: A Methodological Overview and 15-year Experience

Nonsurgical rhinoplasty (NSR) is an alternative to surgical rhinoplasty for patients who desire correction of mild-to-moderate aesthetic nasal defects but do not wish to undergo surgery due to concern about risks, recovery time, or cost. Although not a surrogate, NSR can be a more accessible and more precise modality for achieving aesthetic goals. Furthermore, for certain types of defects, the precision possible with filler injection versus surgery can make NSR the preferred procedure. In these instances, polymethylmethacrylate (PMMA)-collagen gel is a valuable tool for appropriate candidates due to its permanence and its favorable safety profile when injected appropriately.

An Italian Online Survey Regarding the Use of Hyaluronidase in Previously Hyaluronic Acid-Injected Noses Looking for Surgical Rhinoplasty

Background

Nonsurgical nasal reshaping (nSNR) with hyaluronic acid (HA) filler is a well-established procedure performed to ameliorate nasal appearance and is considered a valid alternative to surgical rhinoplasty in selected patients.

Objectives

The aim of our study is to evaluate the decision-making process and management of patients undergoing rhinoplasty, with previous HA filler injection, and evaluate if consensus could be achieved to recommend guidelines.

Methods

Between April and May 2021, an online survey was sent to 402 Italian surgeons of different specialties. The survey collected information regarding the types of treatment of patients who have previously undergone nSNR, who should undergo surgical rhinoplasty. For those surgeons using hyaluronidase, an additional information was collected.

Results

In a range of time of 2 months (April and May 2021), a total of 72 surgeons replied and completed the survey: out of the 402 questionnaires sent, the response rate was approximately 18%. The majority of respondents (61.5%) replied to inject hyaluronidase (HYAL) in patients who had to undergo a rhinoplasty but reported previous nSNR. Of the surgeons who use HYAL, 70% performed rhinoplasty after a waiting time of 3 to 4 weeks.

Conclusions

Either direct surgical approach or hyaluronidase injection first seems to be a viable options. The use of HYAL before surgery is the choice with the broadest consensus in our survey. However, a larger case-control study with long follow-ups is necessary to understand if in patient seeking surgical rhinoplasty who already received nSNR, the injection of hyaluronidase before surgery is mandatory, recommended, or not.

Vasculature of the Nasal Cartilage Region Related to Filler Injection

BACKGROUND

A filler injection in the nose can be essential but is also dangerous, especially in the nasal cartilage region. To safely and accurately perform a filler injection, surgeons must have detailed knowledge of nasal anatomy.

OBJECTIVES

Associated the vessel branches and the characteristics of different nasal regions to provide suggestions for more suitable injection sites.

METHODS

Fifty specimens underwent computed tomography (CT) after contrast infusion. Qualified specimens were selected for 3D CT reconstruction. Dissection was performed to confirm the accuracy of the CT data.

RESULTS

The branches of arteries with large diameters, the dorsal nasal artery (DNA) and the lateral nasal artery (LNA) were distributed within the superficial musculoaponeurotic system layer. The DNA was seen in only 58% of specimens. The artery crossed the midline over the upper lateral cartilage in 16% of specimens. The LNA was a constant branch that traversed the nasal tip. The LNA crossed the midline to the contralateral side in 18% of patients. We divided the nasal cartilage dorsum into two regions for easy handling: the supratip region (STR) and the nasal tip region (NTR). The branches distributed in the STR mostly originated from the DNA (81.6%, 40/49), while those in the NTR mostly originated from the LNA.

CONCLUSIONS

The vasculature of the nasal cartilage region observed in this study is similar to that observed in previous studies. However, we found that the STR was an advantageous area for filler injection. At the same time, we provided suggestions for more suitable injection methods.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .