The alternative nose job  11 May 2015  Non-Invasive Rhinoplasty (NIR) is a viable method of correcting nasal imperfections, writes Dr Lionel Jedeikin. Rhinoplasty is the most challenging of all cosmetic surgery procedures. The nose, being the central focus of the face, is obviously very important from an aesthetic point of view. Any defect, asymmetry or anatomical abnormality of the nose can be improved or corrected by meticulous, well-planned surgical intervention. This is known as rhinoplasty and is often performed simultaneously with corrective surgery of any breathing problems, known as septoplasty. The combination is therefore referred to as septo-rhinoplasty. When considering any correction of nasal imperfections, both the patient and the surgeon need to consider various parameters that will determine whether the surgical approach or the use of non-invasive (NIR) materials would improve the aesthetics of the nose. Factors to be considered include the degree of correction required, the cost of surgery, surgical downtime (recovery period), the general health of patient (is the patient an anaesthetic risk?) and, will the solution be long-term or will continued treatments be required? Once all of the above factors have been well considered by both surgeon and patient, a decision is made as to which line of treatment will be undertaken. It must be understood that, in certain situations, NIR may not be a possible alternative at all. What exactly is NIR? NIR employs the use of injectables to facilitate the improvement in nasal aesthetics. These injectables are characteristically the hyaluronic acid fillers known as Restylane/Perlane, Juvederm and Teosyl. (There are approximately 40 filler products currently on the market.) All of these are prepared in varied viscosities and the ‘thicker and more viscous’ the injectable, the longer it will last. Another aspect of nasal aesthetics is the appearance of the nasal skin; the most common request is the removal of small spider-like veins known as telangiectasia. This is quite easily done using the IPL laser or a vascular laser. It is not painful and healing is rapid. Indications for NIR As mentioned earlier, certain factors need be taken into account to determine whether an invasive or non-invasive path is taken. Basically there are two categories – Primary and Secondary. The Primary category of patient typically presents with minimal aesthetic defects, which would not necessitate a surgical intervention. Injectables can correct small ‘dents’, improve nasal tip projection and correct slight asymmetries. In the Secondary category, the patient has undergone a primary surgical rhinoplasty with less than satisfactory results, requiring revisionary treatment. Secondary can also include patients who have sustained a trauma to the nose, leaving them with small, unacceptable aesthetic defects which would respond favourably to injectables. If these are minor, then fillers can be used, If not, further secondary rhinoplasty needs to be considered. How is NIR performed? The most important consideration is the doctor/surgeon as the results of NIR are totally operator-dependent. As such, the surgeon must be able to determine exactly where and what the defect is. It’s imperative that this be done with the patient in front of a mirror, whilst the surgeon clearly marks the areas with a surgical marker. This will ensure that both surgeon and patient are on the same page. Good clinical photographs must be taken before and after the injection and the procedure must be done under sterile conditions. Local anaesthetic blocks should be given or EMLA anaesthetic cream applied at least 30 minutes prior to injection. Oral or intravenous sedation can be used depending on the patient’s pain threshold and anxiety levels. Application of ice packs to the injected area is recommended for 24 hours post-injection. The normal post-injection sequelae must be explained to the patient, and massage techniques can be suggested to obviate small lumps and bumps. Botulinum Toxin in NIR Botulinum Toxin, such as Botox and Dysport, is a very powerful tool to modulate facial aesthetics. There are several muscles around the nose which are responsible for nasal movements, most of which have specific functions. There is one muscle in particular which pulls the tip of the nose down, particularly while smiling. This muscle is known as the Depressor Septi Muscle and there is one on either side at the lower point of the nose tip. Very small amounts of Botulinum Toxin injected into this area will relax the muscle and prevent it from pulling the nose tip down. Extreme care should be taken to inject the toxin accurately into the specific anatomical location to prevent irregularities in the smile or problems with patient speech. It should, therefore, be performed by a doctor or rhinoplasty specialist who understands this anatomical region. Advantages and Disadvantages Advantages of NIR • Quick procedure • Limited downtime • Immediate results Disadvantages of NIR: • Short-lived • Costly (9-monthly filler injections required and 3-4-monthly botulinum injections required) • Pain • Bruising • Aesthetic dissatisfaction (NIR is operator-dependent) From the above information, it can be ascertained that there is definitely a place for NIR. As I specialise in rhinoplasty, I suggest that all patients ensure that whoever they consult with in respect to NIR has a very good understanding of facial aesthetics, as well as facial anatomy. As simple as filler injections/Botulinum Toxin may seem to be, there are disadvantages which must be explained in full to all patients. Before and after photographs should be provided, as well as the option of contacting previous patients. For further information regarding NIR, please contact The Association of Plastic Surgeons South Africa (APRSSA) or the author. Dr Lionel Jedeikin is a plastic and reconstructive surgeon based in Cape Town. Email him on lioneljed58@gmail.com