57 Part A: Filler Finesse: Nose

Rod J. Rohrich and Ira L. Savetsky

Abstract

Soft-tissue fillers are an excellent method to augment or refine nasal irregularities. A systematic and comprehensive nasofacial analysis is critical to ensure soft-tissue filler success. The use of soft-tissue filler has broadened the rhinoplasty surgeon’s armamentarium. We review indications of soft-tissue filler injection into the nose as well as injection techniques and pearls.

Rhinoplasty – nasofacial analysis – filler – liquid rhinoplasty

57 Part A: Filler Finesse: Nose

Key Points

Soft-tissue fillers are an excellent modality to augment or refine nasal irregularities.
A comprehensive and systematic nasofacial analysis is the most critical initial step in establishing goals and formulating a precise injection plan for nasal soft-tissue filler.
Setting realistic expectations with the patient is critical in achieving high postinjection patient satisfaction.

57A.1 Injection Planning

57A.1.1 Defining Goals

Have the patients list their top three nasal aesthetic concerns and record them precisely.

57A.1.2 Focused Nasal History

The patient should be asked about any history of allergic or inflammatory disorders such as hay fever, asthma, rhinitis, and sinusitis.
Medications and dietary supplements such as acetylsalicylic acid, nonsteroidal anti-inflammatory drugs, and fish oil should be reviewed as they can increase ecchymosis.

57A.2 Nasofacial Proportions and Systematic Nasal Analysis (Table 57.1)

57A.2.1 “10–7–5” Nasal Analysis

The frontal view evaluation should include 10 key areas: Facial proportions, skin type/skin thickness, symmetry/nasal deviation, bony vault width, midvault asymmetry, dorsal aesthetic lines, tip shape/tip-defining points, alar rims/base, infratip lobular projection, and periapical hypoplasia/upper lip length.

**Table 57.1** Systematic nasofacial analysis
Nasal view	Analysis
Frontal
1. Facial proportions	Height (thirds), width (fifths), symmetry
2. Skin type/quality	Fitzpatrick type, thin or thick, sebaceous
3. Symmetry/nasal deviation	Midline, dorsal deviation, C-shaped, reverse C-shaped, or S-shaped deviation
4. Dorsal aesthetic lines	Straight, symmetric or asymmetric, well- or ill-defined, narrow or wide
5. Bony vault	Narrow or wide, asymmetric, short or long nasal bones
6. Midvault	Narrow or wide, collapse, inverted-V, saddle deformity
7. Nasal tip	Ideal/bulbous/boxy/pinched, supratip, tip-defining points, infratip lobule
8. Alar rims	Gull-shaped, facets, notching, retraction
9. Alar base	Width
10. Upper lip	Long or short, dynamic depressor septi, upper lip crease
Lateral
1. Nasofrontal angle and radix	Acute or obtuse, high or low radix, prominent or low nasion
2. Nasal length, dorsum, and supratip	Length: long or short; Dorsum: smooth, hump, scooped out; Supratip: break, fullness, pollybeak, over- or underprojected
3. Tip projection	Over- or underprojected
4. Tip rotation	Over- or underrotated
5. Alar–columellar relationship	Hanging or retracted ala, hanging or retracted columella, maxillary or soft-tissue deficiency
6. Periapical hypoplasia	Maxillary or soft-tissue deficiency
7. Lip–chin relationship	Normal, over- or underprojected chin
Basal
1. Nasal projection	Over- or underprojected, well- or ill-defined tip-defining points, columellar-to-lobule ratio
2. Nostril	Symmetry, long/narrow or short/wide nostril, nostril–tip ratio, concave or convex ala
3. Columella	Caudal septal deviation, flaring of medial crura
4. Alar base	Width
5. Alar flaring	Type I, II, III, or IV

In the profile view, 7 areas are evaluated: Radix height and position, dorsal convexity, nasal length, tip projection, tip rotation, alar–columellar relationship, and chin projection.
Use the base view to assess 5 areas: Nasal projection, nostril shape/symmetry, columella symmetry/width, alar base width, and alar rim flaring.

57A.3 Standardized Photography and Digital Imaging

Standardized photographs including frontal, lateral, oblique, and basal views should be obtained for every patient.
Digital imaging is an excellent tool for communicating with the patient and evaluating patient’s expectations.

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