Journal of Cosmetic and Laser Therapy

ISSN: 1476-4172 (Print) 1476-4180 (Online) Journal homepage: http://www.tandfonline.com/loi/ijcl20

Non-surgical rhinoplasty using filler, Botox, and

thread remodeling: Retro analysis of 332 cases

Yasser Helmy

To cite this article: Yasser Helmy (2018): Non-surgical rhinoplasty using filler, Botox, and
thread remodeling: Retro analysis of 332 cases, Journal of Cosmetic and Laser Therapy, DOI:
10.1080/14764172.2017.1418509

To link to this article: https://doi.org/10.1080/14764172.2017.1418509

Published online: 15 Mar 2018.

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JOURNAL OF COSMETIC AND LASER THERAPY
https://doi.org/10.1080/14764172.2017.1418509

Non-surgical rhinoplasty using filler, Botox, and thread remodeling: Retro analysis of
332 cases
Yasser Helmy
Plastic Surgery, Al-Azhar University, Cairo, Egypt

ABSTRACT ARTICLE HISTORY

Background: Non-surgical nasal job has been practiced and published with doubtful concerns about Received 24 April 2017
efficiency and safety among physicians and aesthetic surgeons. Aim: of the work to share our experi- Accepted 8 December 2017
ences in non-surgical rhinoplasty using filler, Botox, and thread with presentation of aesthetic and KEYWORDS
complication outcome. Patient and methods: Retrospective analysis of the aesthetic and complication Non surgical; Nose;
outcomes and techniques for non-surgical remodeling rhinoplasty using fillers, Botox, and PDO absorb- Remodeling; Deformities;
able threads in 332 cases. Results: Non-surgical nasal remodeling provides temporary correction of small Corrections
nasal deformities with achieved satisfactory aesthetic outcome and very low incidence of complications.
Conclusion: Non-surgical nasal remodeling with injection precautions could work efficiently and safely
in outpatient clinic with good temporary results up to 6 months.

Introduction nose either by filler, Botox, or threads was used solely. Of

332 cases, 182 underwent filler correction by hyaluronic
The term non-surgical rhinoplasty, as we know nowadays,
acid (HA) using 27-gauge needles, in 163 cases and by
is referred as practiced idea about a century ago when
injecting Ca hydroxyapatite (Ca HA), in 19 cases, using
Rebert Gersuny and James Leonard used liquid wax
23-gauge needle. Also, 111 cases underwent Botox injec-
made from paraffin to correct saddle nose (1). Decades
tion for the nose and 39 cases underwent nose narrowing
later, microdroplet silicon injections on multiple sessions
and dorsal correction by polydioxanone threads. Twenty-
was practiced by Robert Kotler and Jack startz. The high
nine cases were done at Al-Azhar university hospitals and
rate of granuloma and ulcers were made less popularity of
the remaining were done at private practice in period
the idea (1,2). Alexander (2002) used FDA-approved fillers
from June 2012 till October 2016.
for nose job injection and published many papers on the
Filler and Botox were injected in the nose, Brands used
non-surgical nose job (3,4). The era of polyacrylamide
in the study are Made by Allergan, FDA approved,
injection also attracted some physicians to inject it in the
BOTOX 100 units, and Juvederm ultra3, contains non-
nose (3). Nasal blood supply is highly considered when
animal HA with the addition of 0.3% lidocaine. Nasal
any injecting procedure in the nose (5). Nasal units,
job was a part of the other facial rejuvenation procedure
angles, facial aesthetic proportion with the nose, and all
in most of the cases. Only 293 cases were injected by filler
facial units are making harmony in human facial look (6).
or Botox in the nose, and 35 cases were asking only for
When physicians correct any observed nasal deformities,
nose job. Thirty-nine cases underwent facial thread lifting,
the facial attractiveness could be more apparent with
while nine cases underwent thread rhinoplasty.
improvement of self-image satisfaction.
Injections were carried out at outpatient clinic, after
In this study, we will present our experiences including
full aseptic precautions, using withdrawal technique before
the aesthetic and complication outcomes and techniques
injection. Injection were practiced in tangential direction,
for non-surgical remodeling rhinoplasty using fillers,
with dermal touching maneuver, when injecting the dor-
Botox, and PDO absorbable threads in 332 cases.
sum, frontonasal angles and base of alae, while in perpen-
dicular maneuver to inject the base of the columella
(Figure 1(a, b)), or superior to inferior technique in tip-
Material and methods
domal areas, and oblique injection in all other areas.
Retrospective analysis of hundreds of our patients’ records Filler was injected to correct primary or postoperative
who were submitted for routine cosmetic rejuvenations by deformities in different sites according to each case pre-
Filler, Botox, and thread lifting, in Egypt, Saudi Arabia, sentation. Sites of injection were varying at one site or
Qatar, and UE, which showed that 332 cases underwent more of the following; frontonasal angle, naso-facial angle,
nose job remodeling. Each technique for correction of the dorsum of the nose, supra-tip area, infra-tip lobule, domal

CONTACT Yasser Helmy Ali, MD dryasserhelmy@gmail.com, dryasserhelmy@azhar.edu.eg Plastic Surgery, Assistant Professor of Plastic Surgery, Faculty of
Medicine, Al-azhar Univerity.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ijcl.
© 2018 Taylor & Francis Group, LLC
2 Y. HELMY

Figure 1. Technique of filler injection. B: at base of the columella. C: at nasal dorsum, touching the deep dermis. C: sites of Botox injection: at the depressor septi nasi
muscle to elevate nasal tip, to the dilator naris at mid lateral alae when there is flaring in the alae and of course to the bunny lines when it is existing.

Table 1. Helmy’s score for subjective patient satisfaction

areas, over lateral crura, inter-crural; between medial cur-
ura, and/or at base of the columella.
Amount of hylouronic acid filler is ranged from 1 to 2 mL,
and the amount of calcium hydroxylapetite was in average
2.1 mL. Filler injection was being injected tangential when
augmenting the dorsum and it was being touching the dermis
anyway. I used Ca HA filler, only in case of saddle nose and it
was deep on the dorsal nasal bone.
Botox was injected at the depressor septi nasi muscle, constric-
tor nasai muscle at the base of lateral crura to make tip definition
and up word tip rotation. Botox was injected sometimes to the
dilator naris at mid lateral alae, in case, there is flaring in the alae
and of course to the bunny lines when it is existing (Figure 1(c)).
Dose of Botox was 2–4 units/each injection site.
Threads were inserted in the dorsum of the nose using
absorbable, polydioxanone (PDO) 6–10 monofilament screws
to augment saddle nose (Figures 2(a)), while 4D barbed
opposing two threads at the base of the nose, to narrow the
base (Figure 2(b)). 4D barbed opposing two threads were
inserted transversly at the inter-domal areas, to define the
tip, and at fronto nasal angle to correct it (Figure 2(c)).
Each barbed thread is packed separately, inside blunt cannula,
each 10 monofilaments are packed together, and all are ster-
ilized by EO gas, Korean made.
Facial aesthetic angles, frontonasal, nasolabial, nasofacial nasal,
and dorsum heights were measured. Pre-and post-nasal job remo-
deling photo documentation in frontal, lateral, and basal views
were documented. Al-Azhar Ethical committee approved the
applied for non-surgical nasal job.
Score Description
0 Dissatisfied
1 Less satisfied
2 Moderate satisfied
3 Highly satisfied
4 Fully satisfied
study and informed consent was taken from patients before any
procedure for the procedure and photography. Subjective assess-
ment of patient satisfaction by my innovated score (Helmy’s
satisfaction score). Score was designed by questionnaire from 0
to 4: 0––dissatisfied, 1––minimal satisfaction, 2––moderate satis-
faction, 3––high satisfaction, and 4––full satisfaction (Table 1).
Results
Patients’ follow-up showed accepted temporary nasal deformity
correction and near normal nasal aesthetic angles, up to 6 months
and camouflaging of the dorsal hump and nasal length. Patient
satisfactions score showed patient highly to fully satisfied when
using the filler, but moderately to highly satisfied when I used
Botox or threads, for non-surgical nasal job. The frontonasal angle,
nasolibial angle, nasofacial angles are markedly improved to be
near normal measurements. Saddle-nose deformity, supra tip
depression, inratip lobule depression, alar irregularities, domal
definition, clomellar lengthening, were corrected by fillers
(Figures 3–5). Tip definition, rotation, alar flaring improvement

Figure 2. A: threads were inserted in the dorsum of the nose using absorbable, polydioxanone (PDO) 6–10 monofilament screws to augment the saddle nose. Sites
of threads insertion. B: at the dorsum and base of the nose. C: at inter-domal space and at the fronto-nasal angle.
 JOURNAL OF COSMETIC AND LASER THERAPY 3

Figure 3. A: pre-HA injection to the nasal dorsum and frontonasal angles. B: post-filler injection.

Figure 4. A: pre-HA injection to the nasal dorsum and base of the columella. B: post-filler injection.

and bunny lines elimination are highly achieved by Botox (Figures
6 and 7). Thread got a measurable improvement in nasal saddling,
tip narrowing and reduction of the nasal base (Figures 8 and 9).
Recorded complication was infection in one case only, injected by
HA at the supra-tip depression and fortunately. This case was
completely healed by local MEBO ointment with oral broad-
spectrum antibiotic (Figure 10). No any other complications
were recorded in our analysis.
Discussion
The concept of nasal remodeling is not brand-new thinking. It was
tried more than a century ago by many physicians before evolving
of modern surgical rhinoplasty techniques (7,8). As time goes with
multidisciplinary subspecialties overlapping, non-surgical nasal
remodeling has found a place again. Many reasons make the
physician and even aesthetic surgeon sometimes could consider
non-surgical rhinoplasty. Big sector of aesthetic clients is not
agreeing to submit for surgery and general anesthesia either due
to psychological or physical factors (9). Second consideration for
non-surgical rhinoplasty is postoperative minute deformities (10),
or pre-operative temporary corrective plan to enable surgeon to
judge if his planned surgery could meet patient’s expectation
or not.
The name of non-surgical rhinoplasty is sometimes doubt-
ful (10) for plastic surgeons and some are preferring to define
it as non-surgical nasal remodeling (11), although many pub-
lications are under the title of non-surgical rhinoplasty (12).
4 Y. HELMY

Figure 5. A: 26-years-old female patient presented with crooked nose and noticed irregularities. B: post-filler injection front view.

Figure 6. A: 30-years-old female patient presented with nasal humb and dropped tip. B: post-filler correction.

Of course, use of fillers, Botox, or thread cannot achieve
précised correction in big nasal deformities (10), as it is not
an alternative for surgery. In this study, if there is any sig-
nificant nasal deformity, in rotation, projection, saddling, tip
width, septum, or bone, it has been corrected by surgery and
this totally agrees with Pontius et al. (13).
In this study, more than 300 cases were submitted to
correction of minor nasal deformities by non-surgical nasal
remodeling as an outpatient service and this is almost a
universal agreement as the procedure is carried out in at
outpatient clinics and this is come with Hirsch et al. (14)
publication. This study presents a large number of patients
who underwent non-surgical nasal remodeling, and has
included not only filling remodeling but also using of Botox
and thread for non-surgical nasal reshaping in contrary to
Schuster in 2015 when he studied 63 cases injected with filler
only (15).
In this study, fillers were used in most cases about 55% of
the cases, while Botox is used in 33.4% and threads’ nasal
remodeling was used in 11.7% of cases. Most fillers used in
this study were HA in 89.5% of cases, while Ca HA correction
to the nasal dorsum was confined only to 19 cases, resembling
about 10.5% of cases.
This could be attributed to the easiest technique of hyaluronic
filler injection when compared with Ca HA and the wide varieties
of its application, in nasal tip, supratip, infratip, columella, side
walls, nasolabial groove, frontonasal angles, and it could be
injected easily anywhere in the nose either touching dermis,
 JOURNAL OF COSMETIC AND LASER THERAPY 5

Figure 7. A: 40-years-old female patient presented with postoperative supra-tip depression. B: post-filler correction.

Figure 8. A: 25-years-old female patient presented with saddle-nose and tip-down rotation. B: post-filler correction front view. C: pre-filler correction basal view. D:
post-filler correction basal view, with improved dorsum, base width and tip rotation.
6 Y. HELMY

Figure 9. A: 24-years-old female patient presented with nasal humb and depressed tip. B: post-nasal dorsum filling by HA and Botox injection to rotate the tip upword.

Figure 10. A: 42-years-old female patient presented with deep fronto-nasal angle and slightly depressed tip. B: post-fronto-nasal angle filling by HA and Botox
injection to rotate the tip upword.

which preferred by me, or on cartilage when indicated to correct
cartilaginous deformity.
Ca HA is less soft and it work good, when injected deeply over
the bone and used to augment the dorsum and could last for about
3 years in contrary to 6 months’ duration of HA. This study
resultsas regard longevity, and possible degradation of HA by
hyaluronidase injection is coming with Smith’s study (16) accord-
ing to type of filler injected.
Many complications could be happened while non-surgical
remodeling including; Botox over dosage, infection, ischemic
necrosis from arterial embolism, pressure necrosis from over
injection of nasal tip, osteophyte from periosteal injection and
blindness (17).
The most catastrophic complication reported in injection
rhinoplasty by fillers is blindness (15,17,18) but it is reported
also in other facial filling by fat (18) or HA, and it could be
extremely avoided by proper precautions during injection
specially syringe aspiration, withdrawal injection, and avoid-
ance of high-pressure bolus injection.
In this study, there are no any above-mentioned com-
plications, unless one case was complicated by infection,
after supra-tip area has been injected by HA but have been
spontaneously healed with topical ointment but oral
Antibiotic.
The incidence of infection in our analysis was about 0.3%,
while incidence in Schuster’s study was 5.2%, as two cases were
complicated by moderate redness and inflammation in one case
and rejection in the other case. Schuter’s (15) complicated cases
occurred after injection of Ca HA over the cartilage in both cases,
and reported about 10.7% in his group treated by Ca HA.
 JOURNAL OF COSMETIC AND LASER THERAPY 7

Figure 11. 43-years-old female patient presented with deep fronto-nasal angle and dropped nasal tip. B: post-Botox injection to bunny lines and to depressor
muscles of the nose, tip is rotated the tip up.

Figure 12. A: 23-years-old female patient presented with saddle nose and wide-bulb nose. B: 3 months post corrections by threads, post-mono-filament eight
threads at the dorsum and post cross 4D two barbed threads for the base of the nose

However, in this study there is no any report of Ca HA injection
over the cartilage or any report of its complication.
This could be attributed to reactive inflammation of Ca
HA in Schuter’s (15) study, and he concluded that it is
recommended to use HA in all cases without any more injec-
tion of Ca HA. In this study, Ca HA is confined only to
injection over the bone, and all other sites were injected by
HA, which is smoothly absorbed after 6th month and could
by reversed by hyaluronidase injection.
According to my practice experience, I think withdra-
wal aspiration, before injection is a must, and it could be
the safest step before injection, to avoid intravascular

Figure 13. A: 36-years-old male patient presented with postoperative deep fronto-nasal angle and ill-defined tip. B: Immediate post-4D nasal correction by threads;
one thread was inserted at the fronto-nasal area and two barbed threads were inserted transversely in the tip of the nose, to get good definition of the nasal tip.
8 Y. HELMY
Figure 14. Infection complication, post-HA injection at the nasal tip, this case was healed by epithelial creeping after topical MEBO ointment and oral antibiotics for 5
days.
embolus, and subsequent blindness. Injection techniques
for fillers are differing among physicians, but the most
important consideration is to avoid intravascular
injection.
In this study, nasal blood supply and injection precautions
were considered strictly to avoid intravascular bolus, as most
authors are concurring about (5,15)
Antiseptic technique with proper sterilization, meticulous
handling, and withdrawal precautions during any injection, all
should be considered. Immediate reperfusion management by
ophthalmologist should be started, if blindness (17) is diag-
nosed, using all tools as dissolving hyaluronidase injection,
corticosteroids, diuretics, oxygen, nitropaste topical applica-
tion, hyperbaric oxygen, carbogen, and lysis therapy
(15,19,20). Training of surgeons and dermatologists who are
interesting in such cosmetic, minimally invasive procedures
(21), is requiring share of such experience.
Conclusion
Proper precautions during injection rhinoplasty specially syr-
inge aspiration, withdrawal technique, and avoidance of high-
pressure bolus injection are absolutely indicated. Non-surgical
nasal remodeling could work efficiently and safely in out-
patient clinic with good temporary results up to 6 months.
Conflict of interest
The author declares no any conflict of interest or financial fund for this
study.
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