The dermal medical rhinoplasty: From blindness to safety.

The non-surgical rhinoplasty is presented as safe by majority of authors, with very rare risk of vision loss and skin necrosis. Publications explain that by injecting with cannulas against the bone and cartilage, complications are really reduced, compared with the use of needles. The description of a deep fat plane below the nasal subcutaneous muscular aponeurotic system (smas) could explain the safety of it's injections. Thanks to a good knowledge of the surgical anatomy of the nose and that if you know how to manage the complications, it's a reliable and safe procedure. On the other hand, an update on blindness from filler published in Aesthetic Surg J in 2024 report 48 cases in 3 years from 2015 and 365 new cases in the following 3 years from 2019. This dramatic increase in the number of cases of vision loss prove our current safety procedures are flawed. A publication by the Department of Plastic and Reconstructive Surgery Shanghai Ninth People's Hospital shows that 90% of cases of extensive necrosis and loss of vision following hyaluronic acid injections occur when cannulas are used. This can be explained by the fact that the nasal smas in which the vessels are located is attached to bone and cartilage. Consequently the universal advice to inject against bone and cartilage may be not the best way to avoid too frequent acute vascular obstruction. We propose another technique, the dermal medical rhinoplasty (D.M. R.). The skin must be pinched and disjoined from the smas. The injection must be very superficial, in the upper dermis or lower dermis to be sure of not creating a vascular obstruction. Upper dermis injections used the interpores technique to help create for instance lines of light thanks to sharp elevation of the tip of a 34 G needle, beveled angle turned upward and visible through the skin. The effect of the volume injected is instantly visible. Lower dermis injections used the vacuum technique to help creating volume on a precise spot above the smas, in the dead space created by a sharp elevation of the tip of a 27 G needle, beveled angle turned downward and then injecting the required volume The effect is instantly visible and under control. One advantage of the superficial nature of these injections is the precise modelling of the shape of the nose, with less volume of filler than after a deep injection. With 206 cases in 2 years of D. M. R. using these 2 techniques, there have been no complications of vascular obstruction or skin necrosis. This nonsurgical rhinoplasty is a really safe and effective alternative or complement to traditional augmentation rhinoplasty.