57 Part B: Filler Finesse: Nose

Lara Devgan, Annette K. Kaminaka, and Elizabeth Klein

Abstract

Nonsurgical rhinoplasty can be performed to provide lasting structural and aesthetic changes to the nose. When performed with precise measurement, marking, and injection technique, it is an effective and predictable alternative to surgical rhinoplasty. Nonsurgical rhinoplasties are nonreductive, relying on a change in light and shadows on the nose, rather than a reduction or reshaping of bones or cartilage. As it is not possible to perform narrowing maneuvers, the procedure may be less suitable for wide, overprojected, or very large noses. Results are temporary, lasting 1 to 2 years. Deep periosteal and perichondrial injection in an avascular tissue plane is the safest approach to avoid rare, though serious, vascular complications, including tissue necrosis and permanent blindness.

Nonsurgical rhinoplasty – hyaluronic acid – rhinoplasty – filler – injectables – facial optimization

57 Part B: Filler Finesse: Nose

Key Points

Nonsurgical rhinoplasty is an effective and predictable alternative to surgical rhinoplasty for improving nasal contour in a nonreductive manner.
Deep periosteal and perichondrial injection in the midline is the safest approach to avoid vascular complications.

57B.1 Preoperative Steps

57B.1.1 Analysis

A thorough analysis of anatomy, including radix height, dorsal profile alignment, nasofrontal angle, nasolabial angle, ideal tip position, slant of central axis of the nose, dorsal nasal aesthetic lines, tip-defining points, skin thickness, and presence or absence of prior surgical scars. Analysis of front view, profile view, base view, and internal nasal examination are performed on all patients.
Risk factors for vascular compromise, including prior surgical rhinoplasty, presence of transcolumellar or subnasal scars, medical history, and history of smoking, vaping, or drug use, should be considered.
Thorough understanding of a patient’s goals and expectations is important, as nonsurgical rhinoplasty has significant limitations: it is additive rather than reductive, it is temporary, and it is not possible to perform narrowing maneuvers such as alar base reduction, tip suspension, or cartilage struts.
A detailed informed consent discussion, including risks of rare but catastrophic complications such as vascular compromise, tissue necrosis, and permanent blindness, must be performed.

57B.2 Operative Steps

See Video 57B.1.

57B.2.1 Preparation

Topical numbing and sterilization of the nose are performed.
A high viscosity, high density, high Gʹ hyaluronic acid filler is prepared. Prior to any hyaluronic acid filler injection, a full complement of emergency supplies, including 20,000 IU of hyaluronidase, nitropaste, aspirin, hot compresses, and an on-call ophthalmologist prepared to perform retrobulbar injection, must be secured.

57B.2.2 Injection Technique

Upon needle entry, aspiration of the syringe is performed to assess for safety of the intended augmentation site.
Filler is injected deeply and in the midline using a microdroplet injection technique, injecting on withdrawal of the needle and continuously moving to mitigate concerns about intravascular injection.
Injection is carried out in the avascular tissue plane immediately overlying the periosteum or perichondrium.
Injection is carried out deep and in the midline of the nose for highest likelihood of avoiding the variant and complex vasculature of the nose.
In performing nonsurgical rhinoplasty, I think of the injectable filler as if it were a surgical cartilage graft, using the lifting vector of the filler to perform a tip flip or elevation of the nasolabial angle.