Using dermal fillers as an alternative to a surgical rhinoplasty is safe and efficacious, according to a retrospective review.
In an analysis of 5,000 cases of patients who underwent a nonsurgical rhinoplasty, 96% said they were satisfied with their initial results, reported Ayad Harb, FRCSPlast, and Colin Brewster, MRes, MRCS, both of Queen Elizabeth Hospital in Birmingham, England.
Writing in Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons, they said that with only minor complications occurring in less than 1% of patients, the procedure was also deemed relatively low risk.
“We find this treatment an excellent alternative to surgical rhinoplasty in those patients who do not want, cannot have, or do not need surgery,” commented Harb — who personally performed all 5,000 treatments — in a statement. “This study demonstrates high efficacy and safety, and relatively low complication rates in the hands of an experienced clinician.”
In an accompanying video, the journal’s editor-in-chief, Rod J. Rohrich, MD, explained: “This treatment known as nonsurgical rhinoplasty has been used throughout the past decade, but the safety and efficacy has not been extensively studied.”
Rohrich, who was not involved with the study, praised Harb and Brewster for conducting “the largest study of nonsurgical rhinoplasty to date.”
All the procedures in the study were performed using hyaluronic acid gel fillers – Teoxane’s Teosyal Ultra Deep 25 mg/mL integral lidocaine, which was FDA approved in 2017, or Perfectha Subskin 20 mg/mL, which is not available in the U.S.
Harb and Brewster noted that these particular fillers were chosen due to “their high viscosity, longevity, and reversibility.”
Women represented over 4,700 of the cases, at an average age of 27. The most common indication for the procedure was the presence of a dorsal jump (44% of patients), followed by a correction of a prior surgery (20%), dropping nasal tip (15%), lack of definition (9%), frontal asymmetry (7%), and a bulbous tip (6%).
Harb underscored that the key to getting a good result is the technique of the board-certified plastic surgeon performing the treatment.
The patient’s nose should first be assessed at three points: radix, dorsum, and the tip. Then the surgeon should perform a pinch test to assess the laxity of the skin, as laxity is required for the injection; if there isn’t enough laxity to the patients’ nasal skin, the risk of complications greatly increase, in particular for incorrect filler placement and vascular injury, he explained.
As for the actual injections, in which 0.3-mL Becton Dickinson syringes with integral 30-gauge needles were utilized, most procedures lasted an average of only 12 minutes (range 5-25 minutes).
The authors noted that although 0.5-mL, 30-gauge needles were originally used, they were later swapped out for the 0.3-mL option “as it enabled an even lower injection pressure and offered more accuracy of injection.”
Harb also explained that topical anesthesia is often used with dermal fillers, although clinicians should note that about 10% of patients may have related skin irritation, erythema, or edema. Most hyaluronic acid fillers on the market today also contain lidocaine with the preparation.
When placing the filler, injectors should aim to maintain the midline of the nose, perpendicularly injecting deep into the periosteum or perichondrium at a low pressure, starting at the radix, the authors said. Using a “micro-droplet technique,” each injection site should deposit a maximum of 0.1 mL at a time, and the injector should massage the gel into place after each injection.
As the injections continue down through the midline, deposits at the tip can be much smaller — as little at 0.02 mL per site. The average volume of hyaluronic acid needed per each procedure was about 0.72 mL, ranging from 0.30 to 2.40 mL, the authors said. “[D]eep, central, slow, and at low pressure and low volume” is the basic technique to follow for this procedure.
Immediately after the procedure, patients reported an average pain level of 2 on a scale of 1 to 10. Approximately 11% of patients experienced bleeding during the procedure, and only 2% had immediate bruising.
Other adverse events were generally uncommon. Fewer than 0.5% of patients experienced arterial occlusion, most of which occurred at the nasal tip. Three patients had skin necrosis — two cases occurring at the nasal tip and one on the bridge. All three of these cases resolved quickly and fully with medical intervention.
Only two patients had a localized skin infection, which resolved with oral antibiotics, Harb and Brewster said. A few patients elected to have the filler dissolved in order to opt for a surgical rhinoplasty.
Within 24 hours of the procedure, 36% and 29% of patients experienced erythema and swelling, respectively. After 5 days, this increased to about 54% and 43% of patients, respectively, but this resolved in the majority of patients within 2 weeks, and in almost all the patients after 2 weeks, the authors reported.
On average hyaluronic acid fillers last 6 to 12 months — mostly dependent on the type of filler used — and about one-third of patients returned at 12 months seeking retreatment.
“However, some patients experienced improvements that lasted up to 2 years — and that’s been my experience, as well — from 1 to 2 years,” Rohrich said.
“Practitioners who undertake non-surgical rhinoplasty must have a comprehensive understanding of nasal anatomy and aesthetics,” Harb recommended. “It is also vital to maintain an acute ability to recognize immediate complications and a readiness to treat. This study demonstrates low complication rates, with an infection and skin necrosis rate of 0.04% and 0.06%, respectively.”
Harb and Brewster reported no disclosures.