Rhinoplasty is a technically demanding surgery, and even in the best of hands, post-operative healing and ultimate aesthetic outcome can be unpredictable. In addition to the risk of general anesthesia, and the post-operative convalescence, rhinoplasty may lead to adverse cosmetic sequelae of polly break deformity, over the reduction of bony or cartilaginous dorsum, inverted V deformity, alar retraction, supratip depression and bossae. Patients may also have functional complaint secondary to iatrogenic nasal valve disruption. Even in patient with initial satisfactory outcome, slight asymmetries, depressions and contour irregularities may present several years after surgery. Despite these risks, cosmetic rhinoplasty is increasingly popular.
Discreet volumetric changes in the frontal-nasal angle, nasal dorsum and nasolabial angle lead to significant differences in our perception of the nasal aesthetic. These areas can be injected hyaluronic acid (Restylane) to improve the nasal profile and correct asymmetries.
The nose is composed of skin, subcutaneous tissue, nasal mucosa, cartilage and bone. The upper third is composed of the nasal bones, the middle third is composed of the nasal septum and the upper lateral cartilages, and the lower third encompasses the lower lateral cartilages and the caudal aspect of the cartilaginous septum. The midline septal cartilages provide underlying support to the lower two thirds of the nose. While this is the basic anatomic framework, variations and asymmetry are present in many individuals.
The nasal bones vary in thickness and width from the nasofrontal suture line cephalically to the end of the nasal bones caudally. They are thick and widest at the nasal suture, narrow ate nasofrontal angle before they widen, and become thinner approximately 9mm to 12mm below the nasofrontal angle. These anatomic variations in thickness and width are important to remember when HA injections are planned.
The thickness of the soft tissue and skin of the nose also varies at different anatomic points. The skin and soft tissue covering the nasal skeleton is thickest in the supratip region, while it is thinnest at the bony cartilaginous junction at the nasal dorsum. These variations in skin and soft tissue thickness affect the final nasal contour and profile after nasal augmentation.
Standardized pre-treatment frontal, lateral and 45 ̊ -view photographs are taken. The patient should be in semi-recumbent position and local anesthetic such as lidocaine may be applied to entry point of the nasal tip.
An appropriate cannula is first selected to administer the filler. In this study we used 27G 5cm blunt cannula. The smallest cannula that the product will flow smoothly through is preferable because a thin cannula minimizes patient discomfort and maximizes the result.
Prior to injection, the filler is mixed using a Baxa sterile connector locked to Luer lock, mixing the 1.3cc of Restylane with 0.1cc of lidocaine without epinephrine to reduce pain. Hyaluronic acid (Restylane) is injected in the subcutaneous plane just superficial to perichondrium or periosteum following aspiration to prevent inadvertent arterial embolization. Radix and upper nasal third injections should be medially placed to avoid the dorsal and lateral nasal arteries. Pre-injection palpitation may aid identification, and aspiration before injection is mandatory. The cannula is kept in the midline to avoid the nasal vessels that runs lateral to the midline. The cannula may be placed in two directions, first directed from the tip of the nose towards glabella to treat the dorsum, rhinion and nasion as well as glabellar furrows. Second, the needle is withdrawn and redirected towards the columella to lift the tip if desired.
Linear threading, serial droplet deposition and/or fanning techniques are used depending on the area and volume requiring correction. Serial droplet deposition involves precisely injecting only a very small volume of material with each insertion of the needle. Serial droplet deposition is the most useful technique in the nose for accurate to the deep dermis is avoided to prevent local ischaemia and extrusion of the implant.
Hyaluronic acid (Restylane) is injected in the midline in a retrograde linear fashion after aspiration while two fingers hold sides of the nasal bones to avoid lateral migration of the filler.
The nasolabial angle filling enables lifting of the tip of the nose. For women, this angle must 100 ̊or 110 ̊ to produce a delicate appearance of the nose. Care should be taken not to widen the columellar base too much by putting the thumb and index finger in a position and applying gentle pressure during injection. Immediately following injection, digital pressure is applied and the implant molded into position. Finally, an ice pack is applied to minimize post-operative bruising and edema. Patients are informed that they may experience some swelling, tenderness and redness for one to two days, but specific aftercare instructions are necessary.
Augmentation of a deep radix will soften the fronto-nasal angle and may camouflage a prominent rhinion and dorsal cartilaginous hump. Medial linear subcutaneous threading of the bony and cartilaginous dorsum will narrow a broad nose, and lengthen a shortened nose. Saddle nose deformity and/or upper lateral collapse may be disguised with injection superficial to perichondrium. Functional internal valves collapse may be addressed with an endonasal ‘spreader’ injection followed by molding to the desired aesthetic result. For patients desiring the appearance of a narrow nose, the height of the nasal bridge is augmented to create the illusion of a thinner and longer nasal rhinion.
Nasal tip ptosis can be addressed with single puncture injection into the collumellar base to open the nasolabial angle. This angle may be opened further with injection of two units of Botox into the depressor septi muscle.
Restylane is favored for non-surgical rhinoplasty because of its chemical structure and its biological behavior. Restylane is made of hyaluronic acid, which has similar chemical characteristics of human bones. The results can last for one year or more. Due to Restylane’s chemical structure, it provides more tissue support, which makes it the optimal product to use in non-surgical rhinoplasty. In patients with the appropriate skin thickness, the injection can significantly elevate the bridge and refine the nasal tip to create a more aesthetically pleasing appearance.
It is a misconceived notion that this type of injection is like any other type of injection and can be performed equally well by all physicians. It is imperative that the physician performing the injection has significant experience in injection technique to optimize the result for the patient.
Complications of surgical rhinoplasty may also be treated with hyaluronic acid (Restylane). Collumellar and alar retraction may be corrected. These are often complicated by scarring, and the absence of a bony plate to stabilize the implant. However, prior infiltration of local aesthetic can help stretch the scarred tissue before injection of filler. Minor prominences may also be addressed.
In our experience we can summarize the major advantages of this unifocal non-surgical technique as follows:
1. Patient is fully awake. No risks of general anesthesia.
2. Instant result
3. More precise procedure than surgical rhinoplasty, more detailed adjustments to nasal contour
4. The patient is in complete control of the procedure’s result.
5. Less post-operative pain
6. Does not cause bleeds or persistent swelling.
7. The procedure is temporary and reversible
8. Less expensive
Adverse Effects and Complications
In our experience with 20 cases of non-surgical rhinoplasty using hyaluronic acid (Restylane), few side effects were reported. Two cases of bruising and one case required touch up secondary to unsatisfactory outcome. There were no reported major complications including infection, ischaemic necrosis from arterial embolism and pressure necrosis from over injection of nasal tip and osteophyte from periosteal injection. These risks were reduced, with effective nasal analysis, meticulous injection technique, and a good understanding of nasal cartilaginous and vascular anatomy. Intravascular filler injection can lead to arterial embolization and subsequent skin necrosis or retinopathy. Visual impairment following middle facial third filler exclude retinal embolism. Prompt anticoagulation and hyaluronidase injection may be a useful adjunct should complications arise.
Zambudio G, Ruiz Jl, Guirao MJ, Sánchez JM, Girón O, Gutiérrez MA. Ostoplastia por vía anterior para el tratameinto de las orejas promientes. Una técnica mínimamente invasiva. Cir Pediartr. 2007;20:119-21.
Aguilar R, Soto C, Barrena S, Diaz M, López JC, Ros Z, et al. Estudio de la evolución de 238 otoplastias mediante encuesta de satisfacción. Cir Pediatr. 2008;21:104-6.
Mustarde JC. The correction of prominent eras using simple mattress sutures. Br J Plast Surg. 1963;16: 170-6.
Furnas DW. Correction of prominent eras by concha-mastoid sutures. Plast Reconstr Surg. 1968;42:189-93.
Stenstrom SJ. A natural technique for correction of congenitally prominent ears. Plast Reconstr Surg. 1963;32:509-18. 22.
Stenstrom SJ, Heftnes J. The Stenstorm otoplasty. Clin Plas. Surg. 1978;5:465-70.
Dimitri E. Panfilov, Aesthetic Surgery of the facial Mosaic. 2007;67:559-69.
Mustardé, JC: The correction of Prominent Ears Using Simple Mattress Sutures: A Ten Year Survey. Plast Reconstr Surg. 39:382-386, 1967.
Furnas, DW: Correction of Prominent Ears by Conchal Mastoid Sutures. Plast Reconstr Surg. 24:189-193, 1968.
Stenstorm, SJ: A “natural” technique for correction of congenitally prominent ears. Plast Reconst. Surg 32:509-518, 1963.
Fritsch, MH: Incisionless Otoplasty. Laryngoscope. 105:Supple 70:1-11, 1995. (Early technique before cartilage scoring added)