By a thread

PDO threads should be considered as an effective alternative to non-surgical nose augmentation with dermal filler, says Dr Huw Jones

As we well know, the popularity of non-invasive medical aesthetic treatments is on the up and up. The central features of each third of the face are the key focal points when conversing with one another, so it is understandable that these areas are the most frequently treated with nonsurgical and surgical procedures.

Rhinoplasty literally means “nose moulding” or “nose forming”. This can be either surgical or non-surgical and will address congenital, traumatic causes or aesthetic issues. While surgical rhinoplasty has been the primary form of treatment, non-surgical management has become an appropriate alternative treatment route, especially where the requisite change in appearance is relatively minor. The surgical approach will always remain the gold standard for more complicated presentations, but the potential side effects – including prolonged swelling, altered sense of smell, numbness, nerve injury and altered breathing – make non-surgical approaches very attractive as long as they are effective.

HAD YOUR FILL

Non-surgical rhinoplasty using dermal filler has become a very popular injectable procedure. It is used to lift the nose tip, add height to the bridge and correct minor “crookedness”, while experienced injectors can also use this method to sculpt the appearance of the nose. Dermal fillers are, however, associated with several potential side effects – bruising, swelling, infection, skin discolouration, migration and nodule formation – and some of these are potentially serious. Migration of product can result in overhanging of the columella or widening of the bridge of the nose, giving an appearance like that of the characters from the movie Avatar. 

More serious complications relate to potential vascular occlusion and include skin necrosis and even blindness. The risk of these more serious complications is increased if the patient has had previous trauma or surgery to the nose, both of which can result in altered local vascular supply. Though popular and very effective, this procedure should not be seen as a simple or quick fix, as the practitioner should be aware of and able to manage potentially serious complications. 

ANOTHER OPTION

A more recent non-surgical approach to non-invasive nose augmentation involves the use of PDO (polydioxanone) threads. These cog or barbed threads are made from a high tensile, biodegradable complex carbohydrate polymer. They can be accompanied by simple mono threads for dermal rejuvenation or small amounts of dermal filler to achieve optimal outcomes. I tend to use filler, if required, at a follow-up appointment.

PDO threads can help to lift the nose tip, address minor contour issues, and reduce nasal width to give a slimmer appearance and achieve better definition. Potential side effects include swelling, discomfort, bruising and infection. There is little risk of migration or nodule formation when PDO threads are correctly inserted. More importantly, there is no risk of the vascular complications associated with dermal fillers. As such, PDO threads are now my first choice for non-surgical nose treatments, especially where there has been previous surgery or trauma.

Polydioxanone threads, unlike HA dermal fillers, do not absorb water and therefore do not require time to set. Effectively, what you see is what you get, and this is a great opportunity to show your patients the true outcome of the treatment straight off the bat. There is no risk of over-correction and the need to correct irregularities is minimal.

The threads are placed in or just under the skin and stimulate the production of collagen, elastin, and hyaluronic acid. They also stimulate the development of new blood vessels and improve lymphatic drainage, paving the way for better skin quality. Results show immediately and will continue to improve for six to eight months, at which point they will dissolve and be absorbed by the body, ultimately lasting up to 24 months. In a non-surgical rhinoplasty PDO thread treatment there will be a degree of permanent improvement.

HOW IT’S DONE

I have performed approximately 100 PDO thread nose procedures and there has been not one complaint of intra or postprocedural excessive pain – the process is quick and well tolerated by the patient. I use Intraline Nose PDO Threads, which are barbed, loaded in 19G cannulas and come in 38mm and 50mm lengths. The cannula is L-type silicone-coated for ease of insertion, with an ultra-thin wall. I tend to use one or two of the shorter threads vertically in the columella and two to six of the 50mm threads along the bridge of the nose. These threads effectively work as an implant, producing a lift while maintaining a slender nose bridge. I have not used postprocedure tape to reduce swelling but will consider this.

TECHNIQUE

1. Cleanse the skin thoroughly 

2. Inject small volume of plain lidocaine 1% or 2% into tip of nose 

3. Puncture the skin in the subnasale so that this is not visible after treatment

4. Insert the 50mm cannulas along the bridge of the nose to the glabella reaching the selion at a depth that the thread is not visible

5. Withdraw the cannula with slight pressure on cannula tip to prevent the thread being withdrawn

6. Insert the shorter threads vertically downwards, while holding the nose tip in an elevated position, to reach the spine of the maxilla

7. Post-treatment icing and arnica application will help to reduce swelling and bruising and the use of compression tape has been advocated.

If my pre-treatment assessment suggests additional skin rejuvenation is required, I insert a few short 29G/ 30G mono threads intradermally at this point. Should I feel a small amount of filler will enhance the result, especially with a nasal hump, I will arrange a follow-up appointment when any swelling or bruising has subsided to reduce potential complications.

I believe that PDO threads offer a safe, highly effective and easily-administered development in the non-surgical rhinoplasty management of a frequently presenting cosmetic concern. While PDO threads can be considered the number one option for many non-surgical rhinoplasties, dermal fillers will be better for dorsal hump issues. Over-filling with filler can result in a very straight and high nasal bridge, often referred to as the “Greek nose”.

Assessment of the presenting concerns, as always, is of primary importance. Management, including of patients’ expectations, may result in surgical referral or treatment with PDO threads, dermal filler or a combination of the two nonsurgical procedures.