Non-surgical rhinoplasty complication: red nose tip could be pressure necrosis
Non-surgical rhinoplasty procedures which seek to improve the appearance of the nose using dermal filler injections – from disguising a dorsal hump to elevating the nasal tip – have become more and more popular in recent years.
However, this treatment is regarded as an advanced technique, and many experienced aesthetic clinicians have a healthy fear of performing such treatments which can result in significant complications, including blindness and septal injuries. But there is a little-known danger that if your patient presents with a red nose in the days after a nose tip lift, you may have caused another type of vascular injury which can result in pressure necrosis and must be rapidly treated.
In this blog, Dr Tim Pearce explores this uncommon complication, explains the science behind the presentation, how to spot patients who should not be treated in the first place due to their increased risk of compromise, as well as how to diagnose this complication and treat it promptly.
Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better practitioner, then step one is to register for the free webinars by Dr Tim.
Why does my patient have a red nose after a non-surgical nose job?
This complication is specific to injections delivered to the tip of the nose. Unlike other presentations of vascular injuries, this nasal compromise presents with redness and pain but there is often no evident concern when performing a capillary refill test (CRT), so you may be lured into a false sense of security thinking that you are not dealing with a vascular occlusion or compromise.
But do not be foiled, this could be a pressure injury which is equally concerning.
Dr Tim notes that this presentation in the confined space of the nasal tip is comparable to stage one pressure ulcer formation. In the tip of the nose the minimal vasculature means that there are only capillaries, and these tiny vessels are much more sensitive to pressure injury.
Looking at the science of blood pressure within the vascular system in the body, the normal systolic blood pressure is around 120 mmHg (over 80 mmHg diastolic), as you move into the arterials and eventually into the capillaries the blood pressure drops, to a point where the systolic is less than 20 mmHg in the capillaries. Therefore, there is a much-reduced blood pressure in the capillaries of the nose compared to other facial arteries, and it will take much less pressure to occlude those vessels by compression. Similarly, the confined space or lack of room within the nose and the nasal tip can impact on the pressure differences present in the area when injecting. All these factors can lead to the formation of a pressure sore and ultimately superficial or more complex necrosis if not recognised and treated early enough.
Buy a limited edition facial anatomy poster for your clinic as a helpful reminder of the vasculature of the face.
How to spot a nose tip complication
Persistent redness in the lower third of the nose following a non-surgical rhinoplasty procedure, particularly those involving injections into the nasal tip – such as the on-trend Tinkerbell nose lift – is almost certainly a sign of this type of pressure injury.
A more diffuse boundary to the injury presentation is also noted with significant redness around the area where there is the most product placement, fading laterally from that point outwards. This type of pressure injury is localised to the tip of the nose. It does not follow the path of major vessels, as typically seen with intravascular occlusion which may track upwards in the face, along the line of a vessel.
Once identified, the recognised treatment is dissolving of the dermal filler using hyaluronidase (Hyalase®) – ideally you will have used a temporary hyaluronic acid-based product which can be reversed using this enzyme. Download Dr Tim’s hyaluronidase consent form template, which will help you explain the risks of its use to your patient
What are the risk factors for injecting fillers into the nose?
We have already discussed the lack of space within the nose, particularly in the lower third where the skin is taught and there is limited room for product placement. Therefore, it stands to reason that high volume injections of dermal filler products into this area to achieve an aesthetic result will increase the risk of nasal complications such as pressure injuries.
Dr Tim notes that any quantity over 0.5ml could be increasing the potential risk of causing a complication. He advises that you consider how much mobility is present in the individual nose that you are injecting, as this will determine if increased product placement only increases pressure rather than achieving the lift or enhancement you are seeking.
The use of high G-Prime products, in larger quantities, also increases the risk due to the nature of the products which tend to be firmer, hold their shape and thus can naturally apply more pressure upon surrounding tissue. Such products are however perfect for providing a nasal tip lift, and Dr Tim himself favours the use of products like Juvéderm Voluma, but they must be used in a less-is-more approach based upon the available space in the tip of the nose. He recommends that aesthetic clinicians who are embarking upon performing regular non-surgical rhinoplasty treatments get into the habit of feeling patients’ noses prior to injecting to increase their understanding of the variety of anatomy when it comes to noses – types, shapes, and mobility, depending on age, gender, and ethnicity.
It is vital to always maintain a good eye on the capillary refill as you inject the nose, it is likely to be delayed in the early stages of a problem in the nasal tip until compensation starts, so can give an early indication of a problem including a pressure injury.
Those who train in liquid rhinoplasty are taught to regularly check using the capillary refill test (CRT) after every single injection of product throughout the procedure. This aims to reinforce what normal capillary refill looks like in the area, so in the event of a problem, identification becomes much easier. In the later stages of treatment, and certainly post treatment, CRT will no longer be a good guide to a potential nasal tip compromise and the predominant presentation will be redness and pain. Similarly, pain in the nose with good CRT can indicate the presence of septal injuries, check out this video on severe nose complications for more insight.
When it comes to the patient themselves, there is potentially an increased risk of nasal tip complications in individuals with a medical history of hypertension or high blood pressure. Similarly, those with a history of multiple surgical rhinoplasty or nasal trauma can present with skin adhesion and scarring which further compromises the available space for dermal filler placement, you would do well to consider refusing to treat such individuals due to the risk of causing a pressure complication.
Patients should always be advised to report prolonged redness of the nasal tip and especially any pain in the days post procedure. You really want to see these cases as soon as possible.
Aesthetics Mastery Show
RED NOSE TIP COMPLICATION. Pressure necrosis after non-surgical rhinoplasty
This blog follows our recent Aesthetics Mastery Show, in which Dr Tim Pearce discusses the 8 different mechanisms by which vascular injury after dermal filler can cause necrosis.
You will find more information about dermal filler nose job complications in our previous blog Spotting septum necrosis, severe non-surgical rhinoplasty complication.
For further learning and access to exclusive support groups, you may consider our Dermal Filler Complications Mastery eLearning course by Dr Tim Pearce. This course includes modules on:
- Impending Necrosis
- Nerve Injury
- Salivary Gland Injury
- Inflammatory Lesions
- Non-Inflammatory Lesions
Are you still anxious about delivering cosmetic injectables safely?
If you want to learn more about mastering medical aesthetic treatments and complications or conquering the anxiety of where to place your needle, then register for the next Dr Tim webinar.
Dr Tim Pearce eLearning
Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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