The Perils of Non-surgical Rhinoplasty : A Safer Approach Needed? -A Comparison between PDO nose thr
Nasal augmentation and enhancement is one of the most popular aesthetic treatments in the world, especially in Asia. Amongst patients in the 18 to 30 year old age group, the shape of the nose is the top priority for facial enhancement(1). This concern is consistent with the opinions of physicians when asked about the area of the face they would enhance in this age group.
Compared to the Caucasian nose, the Asian nose has a lower and broader dorsum, shorter nasal bones, bulbous and poorly projected tip, as well as thicker skin. Consequently the commonest requests for enhancement of the nose involve correction of the nose bridge, tip enhancement or correction of a dorsal hump(2).
Fillers have been used for nasal augmentation for many years. Even though considerable experience in non-surgical rhinoplasty with fillers has been accumulated over the years, the nose remains a highly challenging part of the face to inject. Accidental intravascular injection of filler remains a much feared complication of nasal filler injections, even in the most experienced hands. Branches of the ophthalmic and facial artery supply the external nose, while the dorsal nasal and lateral nasal arteries supply the dorsum of the nose. While blindness is the single most feared complication when injecting the nose, vascular complications such as skin necrosis are highly undesirable and causes significant grief to both patient and physician.
A review published by the American Society of Dermatological Surgery in 2015 revealed that more than 25% of the reported cases of blindness caused by fillers were done in the nasal area(3). Whilst superficial vascular occlusion can sometimes be reversed with hyaluronidase and disasters averted, the outcome for visual loss as a result of retinal vessel occlusion by fillers remains extremely poor.
Aesthetic outcomes for nose fillers also vary. In the Asian nose bridge where the skin of the nose bridge is thicker and tighter, migration and lateral spread of the filler is not an uncommon result, causing significant distress to the patient. This can of course be reduced by using "harder" fillers such as calcium hydroxyapatite fillers, but these fillers will not be reversible with hyaluronidase should accidental intravascular injection occur. Overzealous correction of the Asian nose, obliterating the naso-frontal angle, also gives a unnatural appearance.
Given that there are various potential pitfalls associated with filler injections for nasal augmentation, surely the question is whether we have a good alternative for non-surgical rhinoplasty.
An emerging technique getting increasingly popular in Asia is the Hiko nose lift. In Korean, "Hiko" literally means "high nose". This is a modification of the PDO (polydioxanone) threadlift that is highly popular in East Asia. Absorbable PDO threads mounted on blunt cannulas are inserted into the nose to achieve elevation of the nasal bridge and dorsum, as well as elevation of the tip of the nose. The threads are placed in the supra-periosteal / perichondrial plane, exactly where we would place a filler, or a surgical implant.
The theoretical advantages of this technique are impressive; First, the threads basically function as an implant, but they are inserted in a minimally invasive way. Unlike fillers, the threads do not migrate laterally or inferiorly, giving a long lasting aesthetic outcome. There is little risk of overcorrection as the material does not absorb water ; what you see is what you get. Lastly, and most importantly, this technique carries virtually no risk of vascular occlusion and blindness.
The technique is, of course, in no way perfect. As with every implant it carries with it a risk of infection, which can be minimised by using a strict sterile technique. Some bruising and swelling can occur after the insertion of the threads, which should be reduced by cold compression of the area immediately after the procedure. Correction of a dorsal hump of the nose is challenging with the Hiko technique as the cannulas used to insert the threads are difficult to navigate over a hump. This may still require the use of fillers or even a surgical rhinoplasty. In patients who desire a very high nasal bridge, it may require a small supplementation of filler to achieve the desired endpoint.
In my personal practice, I have found this technique to be extremely gratifying for both patients and myself. It is a quick procedure that takes only about 15 minutes to perform, and it produces natural looking results in my patients, most of whom have told me that they would never do a filler to the nose again. Even in the odd case that i need to supplement the patient with a dermal filler, I would only need a very minute amount (0.1 to 0.2cc) to achieve the patient's expectations. This reduces the risk of vascular accidents greatly.
The medical ethos of "Primum non nocere", or "first do no harm" has never been more true than in the field of aesthetic patients. As physicians we are morally obliged to continually seek safer treatments for our patients. Given the potentially catastrophic consequences of dermal filler injections to the nose, the Hiko nose lift is certainly a exciting new development in the realm of non-surgical enhancement of the nose, and is a good skill set to have as an alternative to dermal filler injections.
About the Author:
Dr Chiam Chiak Teng, is the Resident Physician for Face, Body & Skin Aesthetics Medical Centre set in the bustling Orchard Road in Singapore. He is an external scientific advisor of International Fellowship in Advanced Aesthetic Science (IFAAS). A strong believer in multimodal treatments, he is known for using multiple treatments such as injectables, energy devices and thread lifts to achieve facial harmony for his patients. Dr Chiam is also a familiar voice on the air waves in Singapore, hosting a regular segment on the Gold 905 radio station giving aesthetic advice to the public.
*1. Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty.
Liew S, Wu WT, Chan HH, Ho WW, Kim HJ, Goodman GJ, Peng PH, Rogers JD
Aesthetic Plast Surg. 2016 Apr;40(2):193-201
*2. Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers.
Rho NK, Chang YY, Chao YY, Furuyama N, Huang PY, Kerscher M, Kim HJ, Park JY, Peng HL, Rummaneethorn P, Rzany B, Sundaram H, Wong CH, Yang Y, Prasetyo AD.
Plast Reconstr Surg. 2015 Nov;136(5):940-56.
*3. Avoiding and Treating Blindness From Fillers: A Review of the World Literature.
Beleznay K, Carruthers JD, Humphrey S, Jones D.
Dermatol Surg. 2015 Oct;41(10):1097-117