This chapter summarizes how to inject soft-tissue fillers into the nose. Many patients desire a rhinoplasty without undergoing surgery, and the concept of a “liquid rhinoplasty” involves improving the appearance of the nose using soft-tissue filler. The nasal region is highly vascular, so in this chapter we present safe techniques for injection that will avoid injury to these vascular structures. The key is to remain deep during injection.
Key Points for Maximizing Filler Safety in the Nasal Region
Recommend using hyaluronic acid fillers because they can be reversed with hyaluronidase. Use less hydrophilic filler to prevent delayed swelling.
Inject small amounts with serial threading, and massage after each injection.
Use serial puncture technique for nasal tip and ala (Video 14.1).
Always inject deeply and superiorly to the alar groove for lateral injections. Never inject into the alar groove area in any layer, as this is the location of the lateral nasal artery (▶Fig. 14.1, ▶Fig. 14.2, ▶Fig. 14.3, ▶Fig. 14.4)
In the midline, keep injections in a deep plane to avoid injury to the superficial vasculature (▶Fig. 14.4) (Video 14.1).
The internal nasal valve can be widened with small deep injections in the midvault.
Do not inject along the alar rim or the nasal sidewall because the vasculature is superficial in these regions (▶Fig. 14.4).
Compress the dorsal nasal and angular arteries when performing injections adjacent to these blood vessels.
Be careful in patients who have prior rhinoplasty surgery because the anatomic planes are distorted secondary to scarring.
Fig. 14.1 Vasculature of the nasal aesthetic unit. The facial artery travels upward to become the angular artery. Important branches of the facial artery include the lateral nasal artery and inferior alar artery. The paired dorsal nasal arteries are located lateral to the midline along the dorsum of the nose.Fig. 14.2 Vasculature of the nose shown from a basal view. The inferior alar artery is a branch of the facial artery, which courses along the base of the nose. The columellar artery arises as a branch from the inferior alar artery and is divided during an open rhinoplasty. The marginal artery runs superficial along the alar rim.Fig. 14.3 Schematic of proper injection technique. Injections can be performed deep in the midline from the radix to the supratip break to avoid intra-vascular injection. If injections are performed laterally, they are performed deeply at the midpoint of the dorsal aesthetic line and the nasofacial groove to prevent inadvertent injury to the dorsal nasal artery and angular artery.Fig. 14.4 Schematic of improper injection technique. Injections in a superficial plane lateral to the midline place the dorsal nasal artery at risk. Injections in a superficial plane along the nasal sidewall place the angular artery at risk. Injections in a superficial plane along the alar groove can compromise the lateral nasal artery. Lastly, superficial injections in the midline of the tip can injure the columellar artery.
14.1 Safety Considerations in the Nasal Region
The layers of the nose are as follows: epidermis, dermis, subcutaneous fat, muscle, fascia, areolar tissue, perichondrium/periosteum, and cartilage/bone1(▶Fig. 14.5and ▶Fig. 14.6)
Vasculature in the nose is superficially located beneath the dermis. Injections should be carried out deep to the musculoaponeurotic layers (Video 14.2).
Do not inject superficially into the alar groove or the nasal tip (▶Fig. 14.4).
Nasal injections are the leading cause for tissue necrosis and the second most common site leading to visual loss (▶Fig. 14.7).2,3
Fig. 14.5 Frontal view of the nose with transverse cross section demonstrating the layer of the nose. The layers of the nose (from superficial to deep) in the midvault are as follows: epidermis, dermis, subcutaneous tissue, muscle, loose areolar tissue, and perichondrium. Note that the dorsal nasal arteries are lateral to the midline, making the midline of the nose a safe place for injection, from glabella to the supratip break.Fig. 14.6 Lateral view of the nose with sagittal cross section demonstrating the layers of the nose. The layers of the nose (from superficial to deep) in the midvault are as follows: epidermis, dermis, subcutaneous tissue, muscle, loose areolar tissue, and perichondrium.Fig. 14.7 Vascular anatomy of the periocular and nasal region. There are many potential routes for retrograde embolization to the ophthalmic vessels, including the angular and dorsal nasal arteries. Superficial injections into the nasal tip and alar groove can result in vascular compromise of the nasal tip, ala, sidewall, dorsum, and alar/cheek junction.
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