The Nonsurgical Rhinoplasty: A Retrospective Review of 5000 Treatments

Sir: We read with great interest the article by Harb and Brewster reporting a large retrospective study of 5000 nonsurgical rhinoplasties.1 The use of dermal fillers has greatly evolved over the last decade, including ever more indications for use. The physical properties of hyaluronic acid, its ease of use, and the existence of a reversal agent have made it the first-line choice of treatment. As reported in the study, the use of hyaluronic acid in the nose is a viable alternative to surgical rhinoplasty by camouflaging a dorsal hump or correcting imperfections related to a previous rhinoplasty. Vascular necrosis remains the main concern of practitioners providing nonsurgical rhinoplasty. Needle injections are deemed to be safer when performed medially. However, anatomic studies have demonstrated high variability in arterial distribution in the nasal region.2 Thus, even highly trained practitioners cannot predict the location of vessels precisely, especially in patients who have had previous nasal surgical procedures. In their article, Harb and Brewster report 24 cases of arterial occlusion and three cases of skin necrosis. Although rare, these complications can be devastating to the patient. Intravascular injection can potentially lead to more serious complications, such as blindness.3 The use of 22-gauge to 25-gauge cannulas (blunt, dome-shaped tip with side delivery) should be considered as a potentially safe solution to minimize vascular injuries and provide similar results. From a single entry point in the nasal tip with a 25-gauge or 22-gauge sharp needle, a 7-cm cannula can safely reach all medial and lateral nasal regions (Fig. 1) (glabella, nasal dorsum, lateral walls, nasal tip, columella, and anterior nasal spine).4 Decreasing the number of entry points also decreases the potential vascular and infection risk.Fig. 1.: Nonsurgical rhinoplasty using a 25-gauge cannula with a single entry point (red dot). Doses of hyaluronic acid: 1, 0.3 cc; 2, 0.4 cc; 3, 0.1 cc (each side).Have the authors considered using cannulas instead? PATIENT CONSENT The patient provided written consent for use of her images. DISCLOSURE The authors have no financial interests or conflict of interest to report. No funding was received for this work. Thomas Radulesco, M.D., Ph.D., M.S.Aix Marseille UniversityAssistance Publique des Hôpitaux de MarseilleInstitut Universitaire des Systèmes Thermiques IndustrielsDepartment of Otorhinolaryngology and Head and Neck SurgeryLa Conception University HospitalMarseille, France Leigh J. Sowerby, M.D., Ph.D.Department of Otolaryngology–Head and Neck SurgeryWestern UniversityLondon, Ontario, Canada Claire Hopkins, M.D., Ph.D.King's CollegeLondon, United Kingdom Justin Michel, M.D., Ph.D., M.S.Aix Marseille UniversityAssistance Publique des Hôpitaux de MarseilleInstitut Universitaire des Systèmes Thermiques IndustrielsDepartment of Otorhinolaryngology and Head and Neck SurgeryLa Conception University HospitalMarseille, France