Continuing Education Activity

The nonsurgical rhinoplasty technique using injectable filler material serves to mainly correct the shape and overall appearance of the nose. This activity reviews the evaluation and management of patients undergoing nonsurgical rhinoplasty and explains the role of the interprofessional team in improving care for patients who undergo this procedure.

Objectives:

• Identify the anatomical structures, indications, and contraindications of the nonsurgical rhinoplasty.
• Describe the equipment, personnel, preparation, and technique regarding the nonsurgical rhinoplasty.
• Review the appropriate evaluation of the potential complications and clinical significance of the nonsurgical rhinoplasty.
• Summarize interprofessional team strategies for improving care coordination and communication to advance the nonsurgical rhinoplasty procedure and improve outcomes.

Introduction

Given the advent of various injectable fillers along with their reported safety and efficacy, nonsurgical rhinoplasty has recently gained popularity for patients looking to alter the shape and/or appearance of the nose without incurring the risk, cost, and downtime typically associated with surgical rhinoplasty.[1]

Despite these potential advantages, nonsurgical rhinoplasty remains a technically challenging procedure with significant associated risks (e.g., vascular occlusion). It thus should only be performed by those clinicians who possess a sound understanding of the relevant anatomy and safe injection techniques.[2]

Herein, we outline the principles of a successful non-surgical rhinoplasty using injectable fillers with an emphasis on properly evaluating patients and executing a thorough, anatomic-based procedural plan.

Anatomy and Physiology

First and foremost, a sound comprehension of the relevant anatomy is vital to performing a safe and successful non-surgical rhinoplasty using filler.

Below are the layers of the nose encountered during nonsurgical rhinoplasty (listed from superficial to deep):

1. Skin – thickest at the tip and radix, and thinnest at the rhinion; NOTE: skin in Asian and African American patients tends to be thicker and oilier, thus making for a more difficult injection (i.e., less pronounced effects and more post-procedural edema)
2. Superficial fat – a space where major vessels lie
3. Superficial musculoaponeurotic system (SMAS) – a thin fibromuscular layer where major vessels may lie
4. Deep fat – this is a relatively avascular plane ideal for injecting filler; NOTE: small perforators of the arteries mentioned above may lie in this sub-SMAS plane; thus, the filler should be injected slowly and in small amounts while consistently aspirating before every injection.
5. Perichondrium and periosteum – a thin fibrous layer over cartilage and bone, respectively
6. Nasal cartilages and nasal bones

The vasculature of the nose encountered during nonsurgical rhinoplasty arises from both the internal and external carotid system via the ophthalmic and facial artery, respectively. While various branching patterns (particularly with the facial artery) and anastomoses exist between the two systems, the following categorization provides a basic description of the relatively constant vasculature encountered during nonsurgical rhinoplasty[3]:

• Ophthalmic artery (internal carotid system)—gives rise to the dorsal nasal artery and external nasal artery (via the anterior ethmoid artery) to supply the upper portion of the nose
• Facial artery (external carotid system)—gives rise to the superior labial and angular arteries which branch to include the columellar artery and the lateral nasal artery, respectively, to supply the lower portion of the nos

NOTE: For a useful and simplified schema of the superficial nasal blood supply, the reader is referred to the cadaveric study performed by Saban et al.[4]

Emphasis is on injecting into the avascular deep fat or sub-SMAS plane to avoid vascular occlusion and its devastating sequelae, namely skin necrosis, and blindness.[5]

Equally important to adhering to safe injection planes is comprehending pertinent rhinoplasty terms and definitions, several of which are characterized below[6]:

• Anatomic dome – the anteriormost projected portion of the lower lateral cartilages between the medial and lateral crus
• Columella – the column in between the nostrils at the base of the nose
• Dorsum – the anterior nasal surface between the tip and the radix
• Infratip lobule – the part of the tip between the tip-defining points and the columellar-lobule junction
• Lower lateral cartilage (LLC) – the paired caudal nasal cartilages consisting of the medial, intermediate, and lateral crura
• Nasion – the skin depression at the junction of the nose with the forehead (should protrude roughly 11 to 14 mm from the upper eyelid with its deepest portion at a level between the lashes and supratarsal crease)
• Nasolabial angle – the angle that exists resulting from a line drawn through the most anterior to the most posterior point of the nostril intersecting the vertical facial plane on the lateral view. Ideal angles vary, though they have been defined as 90 to 115 degrees, with a more acute angle preferred for males.
• Radix – the junction that exists between the frontal bone and the nasal bones
• Rhinion – the point located at the bony-cartilaginous junction over the dorsum of the nose
• Soft triangle – the thin skin fold between the anterior portion of the nostril and the caudal border of the dome between the medial and lateral crura
• Subnasale – the junction of the columella and the lip
• Supratip area – the area just cephalad to the nasal tip at the caudal portion of the nasal dorsum
• Tip – the most anterior aspect of the nasal lobule
• Tip defining points – the most projecting area on each side of the tip that produces an external light reflection
• Tip projection – the distance from the most projected portion of the tip to the most posterior point of the nasal–cheek junction; in general, the tip projection should be roughly 55% to 60% of the length of the nose
• Tip rotation – the movement of the tip cephalad or caudad pivoted at the alar base on the profile view
• Upper lateral cartilages – the paired cephalad nasal cartilages spanning laterally from the anterior septum and composing the lateral walls of the middle third of the nose

For a more comprehensive review of nasal anatomy, the reader can read the references cited for further study.[7][8][9][10]

Upon obtaining a thorough understanding of the relevant anatomy, only then can a comprehensive nasal analysis be performed. Such analysis should include not only classically recognized facial/nasal angles and proportions (some of which are detailed above) but also acknowledge cultural and/or ethnic preferences.[11][12][13][14][15] Ultimately, however, the patient's personal aesthetic and desired outcome takes precedence over classical definitions of attractiveness when deciding how to reshape the nose.

Indications

Non-surgical rhinoplasty is indicated for the correction of mild cosmetic deficits of the nose in patients either not medically able to undergo surgery or those patients looking to avoid the cost, downtime, and risks associated with traditional surgical rhinoplasty. From a logical standpoint, patients who benefit from nonsurgical rhinoplasty are similar to those patients who would benefit from specific cartilage grafts placed during surgical rhinoplasty (e.g., shield grafts, tip grafts, radix grafts, onlay grafts, rim grafts). With that in mind, non-surgical rhinoplasty using fillers may be useful in addressing the following[16][17][18]: 

• Low and/or deep radix
• Dorsal convexity (i.e., hump)
• Dorsal concavity or shallow dorsum (e.g., patients of African or Asian descent)
• Upper and middle third contour irregularities or asymmetries (e.g., crooked nose)
• Decreased tip projection
• Decreased tip refinement
• Decreased tip rotation
• Alar rim irregularities
• Alar base deficiency
• Minor asymmetries or irregularities after primary rhinoplasty

Of note, some propose that strategically placed filler may provide functional improvements as well (i.e., filler simulates spreader, butterfly, or batten grafts), though this remains controversial. [19]

NOTE: The patient should understand that while non-surgical rhinoplasty has its appeal, there exists an equally safe, reliable, yet permanent alternative in a properly executed surgical rhinoplasty. Thus, all patients seeking non-surgical rhinoplasty should receive an offer for surgical rhinoplasty as well.

Contraindications

Those who perform non-surgical rhinoplasty must be able to determine which patients would be better served by surgical rhinoplasty. In general, results from non-surgical rhinoplasty are typically limited in patients with a large hump, severe deviation, excessive tip rotation issues, or significant tip contour irregularities. Additionally, the surgeon should instead offer surgical correction to patients interested in undergoing a hump reduction, who have a superiorly positioned nasion.  Also, patients should recognize that “nasal reduction” cannot be performed with filler. However, specific techniques (e.g., dorsal augmentation and tip projection) may give the illusion of a thinner or narrower nose. Likewise, realistic expectations require emphasis throughout the consultation process.

Contraindications to fillers, in general, include patients with a history of autoimmune disease, bleeding disorders, and hypersensitivity to one of the filler components (e.g., lidocaine). Patients with signs of inflammation or infection near the injection site, or who are pregnant, or breastfeeding should avoid receiving injectable fillers as well. NOTE: patients with a history of frequent herpes simplex virus outbreaks (e.g., several a year) should receive prophylactic antivirals.

Non-surgical rhinoplasty should be avoided in patients who have had previous non-surgical rhinoplasty with either silicone or with an unknown injection material.

Patients with suspected or known body dysmorphic disorder (BDD) should receive a referral to psychiatry before considering non-surgical rhinoplasty because they tend to have poor satisfaction following such procedures and show a higher rate of aggression and litigation toward those performing them. The prevalence of BDD may be prevalent in up to 43% of patients who present for a cosmetic rhinoplasty consultation.[20]

Relative contraindications to undergoing non-surgical rhinoplasty with fillers would include patients actively taking anticoagulants, antiplatelet agents, and non-steroidal anti-inflammatory drugs for increased risk of bleeding and bruising. Similarly, patients taking herbal medications and supplements such as chondroitin, ephedra, echinacea, glucosamine, ginkgo biloba, goldenseal, milk thistle, ginseng, kava, and garlic should withhold these supplements for several days before and after treatment to minimize complications (e.g., bleeding and bruising). Additionally, caution is necessary for patients with a history of nasal implants or previous rhinoplasty for fear of increased complications, including infection and tissue ischemia. For this reason, some authors propose waiting up until 12 months after a rhinoplasty to perform injections.[21]

Equipment

Filler Selection

The two main fillers used for non-surgical rhinoplasty are hyaluronic acid (HA) and calcium hydroxyapatite (CaHa), with HA being the more widely used. While several product variations exist for both HA and CaHa, choosing the correct filler depends on a variety of characteristics, three of which will be highlighted here, including the filler’s reversibility, duration, and stiffness. For a complete discussion of the types of filler available for injectable rhinoplasty, the reader can read the review article by Friedman and Wang.[22]

Without a doubt, the safest fillers to use are those that are not only biodegradable but also reversible, such as HA fillers, which can easily and rapidly dissolve with hyaluronidase. Not only does this reversibility provide some level of increased safety given the potential for vascular occlusion events, but also reversible products can be dissolved if overfilling or misplaced injections occur.

The duration of the filler should also be a consideration when choosing a product. In general, HA fillers last for 6 to 12 months, while CaHa fillers last up to 12 to 18 months (with potentially longer duration after repeated treatments due to collagen synthesis). Nevertheless, it remains important to counsel patients that repeated injections will be required to maintain the effects of the non-surgical rhinoplasty, regardless of filler type.

Another filler characteristic to be considered includes the elastic coefficient, or G-prime, which represents a measure of the filler’s ability to resist flow (i.e., stiffness). Fillers with a high elasticity or G-prime, such as CaHa, are more resistant to deformation (i.e., remain more stable over time), tend to provide a more robust “filling” effect, and require less product to achieve a comparable result. On the downside, high G-prime fillers cause increased post-procedural edema and pain and may feel less “natural” than lower G-prime options, such as HA.

Permanent fillers (e.g., silicone and polymethylmethacrylate) are best avoided due to the risk of granulomas, uncorrectable irregularities, and irreversible complications (e.g., vascular injury).

In general, the ideal filler for non-surgical rhinoplasty would be one that is reversible, easy to inject, and provides long-lasting support to the nose. Additionally, many surgeons advocate for non-inflammatory fillers that cause minimal native tissue distortion and thus are easily removed during surgical rhinoplasty. For these reasons, approximately 80% of non-surgical rhinoplasty is performed with HA. Nevertheless, some authors still endorse CaHa as the filler of choice due to its longer duration, improved moldability, and increased stiffness.[1]

Cannula Versus Needle Injection Techniques

Theoretically speaking, using a small blunt cannula (e.g., 27-gauge) to perform non-surgical rhinoplasty may decrease the risk of vascular occlusion; nevertheless, reports of tissue ischemia and blindness have been reported even with canula use. A technical advantage to using the cannula may be apparent when injecting large flat areas (e.g., for dorsal augmentation), which can help decrease local tissue trauma and increase efficiency by minimizing the number of injection points. Meticulous needle injection technique using a small caliber needle (e.g., 30-gauge), however, ensures pinpoint precision and accuracy.

NOTE: Regardless of the technique used (cannula versus needle), emphasis must be placed on proper injection techniques including injecting into an avascular sub-SMAS plane, routinely aspirating to assess for intravascular needle/cannula placement, injecting slowly, and placing small aliquots of filler (no more than 0.1 mL) at each site.[17]

Routine Materials

Typical materials include disinfectant wipes (e.g., alcohol or chlorhexidine), topical anesthetic, a marking pen, gauze (for hemostasis), and a lubricant (for nasal molding).

Emergency Kit

Every clinician performing nonsurgical rhinoplasty with fillers should have a readily available emergency kit for vascular occlusion events containing: 2% nitroglycerin paste, sublingual nitroglycerin 0.6 mg, aspirin 325 mg, warm compresses, hyaluronidase, topical timolol 0.5%, systemic corticosteroids, and/or mannitol, and/or acetazolamide 500 mg.[23][24][23]

Personnel

An assistant is useful to help prepare the desired filler, disinfect the skin, and apply the topical anesthetic. An assistant may also be helpful to record the location and amount of product used and to provide distraction techniques (e.g., vibration, massage) to minimize patient discomfort during injections.

Preparation

A history and examination are obtained with a focus on detecting any contraindications to non-surgical rhinoplasty, as listed previously (SEE CONTRAINDICATIONS).

Preoperative photography using standard rhinoplasty views should be taken both before and 1 to 2 weeks after the procedure. Digital imaging software should be considered, as this helps to improve patient-clinician communication and provides a realistic expectation of the procedure results.[25]

The skin should undergo meticulously disinfecting using chlorhexidine gluconate wipes.

Topical anesthetic (e.g., lidocaine) is applied 30 minutes before the procedure.

A marking pen may be useful to identify key nasal landmarks, including the midline, nasion, rhinion, and tip-defining points. The clinician may also find it helpful to outline any contour irregularities (e.g., concavities) or other areas needing attention.

Technique or Treatment

Before detailing the technical nuances of non-surgical rhinoplasty, it is worth reiterating that the clinician should always follow safe injection techniques when placing filler in the nose. These include injecting into an avascular sub-SMAS plane (directly above the perichondrium or periosteum), staying midline when possible (also helps prevent asymmetries), aspirating to assess for intravascular needle/cannula placement, injecting slowly, placing small aliquots of filler at a time, and minimizing the number of injection sites. Lastly, the use of a blunt-tipped cannula may increase the safety of nonsurgical rhinoplasty by theoretically reducing the likelihood of intravascular injection.[26][17] TIP: using two hands (one for injecting, the other for stabilizing, pinching, and/or molding) can help achieve safe, reproducible results.

The approach to non-surgical rhinoplasty is relatively uncomplicated and relies on making incremental enhancements to the cartilage and bony framework of the nose. Nevertheless, multiple non-surgical rhinoplasty techniques exist with variations on what type of filler to use, the order of injection, the specific injection technique employed (e.g., droplet, threading, need for subcision), location of filler, and the amount of filler required.[5][1][26][27][22][18][21][19][28]

Regardless of the technique employed, reproducible, and satisfactory results are attainable if safe injection techniques and an anatomic-based treatment plan are executed. For those trained in surgical rhinoplasty, the graft-based technique (wherein the filler simulates the effects of a similarly positioned cartilage graft) represents the most intuitive approach.[21]

Herein, we list several areas that can be addressed with non-surgical rhinoplasty and describe key maneuvers required to produce safe and reliable results:

Radix/dorsal augmentation: First, the desired height of the radix and dorsum is determined, as well as the amount of supratip break (if any). The selected areas of the radix and/or dorsum are then filled with a 30-gauge needle using a series of droplets precisely placed in the midline with a 90-degree inclination. Alternatively, dorsal augmentation is achievable using a cannula introduced via the supratip and advanced in a sub-SMAS plane up to the height of the desired augmentation but not beyond the nasion. The cannula bevel should be faced down, and the filler injected in a retrograde fashion. In either approach (needle or cannula), the skin should be tented upwards to mitigate vascular occlusion. Some authors recommend placing a finger above the radix to prevent superior filler migration. Typically, 0.5 mL is an appropriate amount of filler for full dorsal augmentation. Immediate massage and molding will help to ensure smooth contour. NOTE: some authors advocate that dorsal augmentation with HA requires slight overcorrection to account for the immediate post-injection edema. If significant overcorrection occurs during the procedure, this can usually be addressed with molding and massage.

Dorsal convexity (hump) camouflage: The illusion of hump reduction is a relatively straightforward maneuver achieved by strategically augmenting the midline dorsum with a few precise needle injections placed cephalad and/or caudad to the existing dorsal convexity. An amount of 0.2 mL per injection site is typical. As with dorsal augmentation, radix height and supratip break must be determined before injecting.

Straightening the crooked nose: Just as surgically placed onlay grafts and/or asymmetric spreader grafts help to straighten a crooked nose, so too does carefully placed filler along the dorsum and nasal sidewall provide camouflage to contour irregularities of the mid to upper third of the nose. Of note, extra care should be taken when injecting laterally on the nose due to the vascular arcade (see ANATOMY above). In particular, direct injection in the region of the alar groove should be avoided to avoid intravascular injection of the lateral nasal artery. For this reason, some advocate adhering to midline injections while using massage and molding to lateralize the filler into the desired location.

Premaxillary deficiency: Besides presenting as an obvious alar base discrepancy, asymmetry of the premaxilla can promote tip asymmetry as well as alar-columellar discrepancies (e.g., ipsilateral ala retraction). Like the premaxillary graft in surgical rhinoplasty, filler can be placed under the alar base to correct this asymmetry. Importantly, the filler should be injected deeply on the maxilla from a medial position to avoid vascular complications. Injection with a cannula is our preferred technique of injection in this region.

Tip projection: Like the effects of various tip-projecting grafts in surgical rhinoplasty (e.g., tip graft, shield graft, caudal septal extension grafts, etc.), so too can filler be used to augment tip projection. Safe tip injection techniques include placing very small aliquots of filler in a location that will correspond to the desired tip defining point. Depending on the clinician’s experience, an infratip or supratip approach are both options. Regardless of the method used, filler should be injected at the depth of the perichondrium. Injection directly between the domes should be avoided to prevent splaying of the domes, which can result in inadvertent tip widening. If the infratip lobule warrants augmentation as well, and further injection can be placed to replicate a shield graft. Also, the supratip area is modifiable with careful filler placement depending on the desired supratip break. NOTE: supratip augmentation should always be performed after tip projection maneuvers to avoid the risk of iatrogenic Polly beak deformity.

Tip rotation: Increasing the tip rotation using fillers represents an advanced technique in non-surgical rhinoplasty that is achievable in a variety of ways. Firstly, the illusion of increased rotation can be created by blunting the nasolabial angle with an injection placed deeply into the subnasale along the anterior nasal spine. Generally, approximately 0.5 mL of filler suffices. Secondly, filler can be deeply injected in the intercolumnar space between the medial crura footplates adjacent to the posterior septal angle (PSA). This deep intercolumnar space injection essentially acts as a columellar strut and lengthens the central leg of the tripod as described by Anderson, thus causing increased tip rotation (and projection).[29] Of note, the injection along the PSA also promotes anterior displacement of the medial crural footplates, which can help correct a retracted columella but alternatively can exacerbate any existing columellar show. Usually, 0.2 to 0.3 mL of filler is necessary in the columellar space. NOTE: pinching the membranous septum while injecting the columella and nasal spine area can help keep the filler midline and prevent migration into the nasal cavity causing resultant nasal obstruction.

Alar rim contouring: Similar to a rim graft’s effect on the contour of the ala, filler can be placed along the alar rim to correct slight alar retraction or asymmetry. Care is in order when injecting the alar rims in patients who have undergone previous rhinoplasty, as the blood supply post-operatively remains rather tenuous due to the previous marginal incision.

Functional applications: As mentioned previously, injectable fillers placed into the scroll, internal nasal valve, alar rims, and nasal sidewall have been used to address nasal valve insufficiency by simulating the effects of various functional grafts (e.g., spreaders, alar battens, butterfly grafts, strut grafts, alar rim grafts) or implants (e.g., poly-L-lactic acid). This application of fillers in non-surgical rhinoplasty, however, remains controversial.[19]

Complications

The patient should receive counseling that complications after rhinoplasty are generally mild and self-limited, though rare but serious complications certainly exist, some of which may not be reversible (e.g., blindness, stroke). Complications associated with non-surgical rhinoplasty are outlined below and categorized as either early or late-appearing.[22][2][23]

Early-onset (hours to days)

• Asymmetry – can be avoided with proper injection techniques, including staying as midline as possible
• Injection site reaction – pain, edema, erythema, ecchymosis, itching
• Hypersensitivity reaction – pain, fever, itching, and fever; treated with corticosteroids and warm compresses
• Infection – abscess/cellulitis; mycobacterial infection; herpes simplex virus infection (can be mitigated with prophylactic antivirals in high-risk patients)
• Tyndall effect – occurs when the filler is injected too superficially and creates a blue hue underneath the skin
• Surface irregularities and nodules – secondary to improper placement of fillers (e.g., too superficial)
• Vascular occlusion – a rare but devastating complication that can present as A) local tissue ischemia (pain and pallor with subsequent edema, mottling, ulceration, and necrosis), and/or B) vascular occlusion with retrograde embolization leading to blindness and/or stroke. Vascular occlusion can occur either with HA or CaHa and with needle or cannula technique as well. Clinicians performing nonsurgical rhinoplasty with fillers should have a readily available emergency kit (See above EQUIPMENT) and emergency access to an ophthalmologist as well as a center with stroke expertise. NOTE: over injecting may cause tissue ischemia secondary to pressure occlusion of the adjacent nasal vasculature. 

Delayed onset (weeks to years)

• Scarring
• Dyschromia
• Foreign body granuloma – an immune response typically associated with permanent (e.g., silicone) injections; treatment is with corticosteroid injection and/or surgical removal
• Biofilms – may require excision and/or long-term antibiotics

Despite these complications, the staff should reassure the patient that there exists a well-described body of literature supporting the overall effectiveness and safety of injectable fillers in nonsurgical rhinoplasty.[30]

Clinical Significance

Non-surgical rhinoplasty represents a quick, safe, and reliable modality for patients looking to enhance the appearance of the nose while avoiding the cost, recovery, and complications associated with surgical rhinoplasty. Despite its rising popularity, however, non-surgical rhinoplasty should be performed only on a case-by-case basis. It should always be compared to surgical rhinoplasty, which remains the gold standard for treating patients with cosmetic and/or functional deficits of the nose.[22] When performing non-surgical rhinoplasty with fillers, proper patient evaluation, and execution of a thorough, anatomic-based treatment plan can produce safe, reliable, and satisfactory outcomes.

Enhancing Healthcare Team Outcomes

It remains imperative to identify the risk factors and perform a thorough assessment of the patient before performing non-surgical rhinoplasty. An interprofessional team approach is an ideal way to limit the complications of this procedure. Before surgery, the patient should have the following done:

• Evaluation by a clinician experienced in selecting the appropriate patient for both surgical and non-surgical rhinoplasty
• Assessment by a clinician familiar with the contraindications to non-surgical rhinoplasty with fillers to ensure that the patient can safely undergo the procedure

An interprofessional team of an experienced injector and assistants should be involved during the non-surgical rhinoplasty to maximize outcomes. Nursing staff can prepare the patient for the procedure, assist and monitor during the procedure, and provide post-procedural care. Close follow-up during the initial post-procedural period, either by the clinician and/or the plastic surgery specialty nurse experienced in post-procedural care of nonsurgical rhinoplasty, should evaluate the patient for possible complications, including tissue ischemia and blindness. It is also essential to educate the patient on properly caring for the nose after the procedure by avoiding extensive manipulation of the nose for the first 24 to 48 hours post-procedure to mitigate complications. [Level 5]

Nursing, Allied Health, and Interprofessional Team Interventions

Pain is minimal after non-surgical rhinoplasty and pain medication is typically not required. Bleeding can be easily controlled with pressure, and bruising is uncommon though self-limiting if it does occur. In order to minimize edema and complications, however, the patient should avoid excessive manipulation of the nose, sleep with the head elevated, and avoid rigorous activity for the first 2-3 days. Pre-procedural Arnica montana and/or Bromelain may help lessen bruising and swelling.[31]Patients are asked to return to the clinic at 1-2 weeks, at which time they may be given a repeated injection if warranted. Photographic documentation should occur at around 1-2 weeks after the procedure. Patients should be advised that results may last up to 9-18 months after surgery (depending mainly on the type of filler used), and that additional filler will eventually be required to maintain results.

Nursing, Allied Health, and Interprofessional Team Monitoring

Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in post-procedural care of non-surgical rhinoplasty, should monitor the patient for possible complications including any signs of vascular occlusion (e.g., tissue ischemia, blindness).

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Disclosure: Blake Raggio declares no relevant financial relationships with ineligible companies.

Disclosure: Jamil Asaria declares no relevant financial relationships with ineligible companies.