Surgical rhinoplasty is the one of the most common cosmetic procedures in Asians. But there are limitations, such as down time, high cost, and a steep learning curve. Most complications are implant related. A safer and less invasive procedure is rhinoplasty using fillers. Good knowledge of the nasal anatomy is essential for rhinoplasty using fillers. Knowledge of nerves, blood supply, and injection plane allows avoiding complications. There are several planes in the nose. The deep fatty layer is recommended for injection, because it is wide and loose and there are less important neurovascular structures. Botulinum toxin also can be used for noninvasive rhinoplasty.
Key points
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The nose is the area in which most people make enquiries for procedures – especially filler augmentation, and the most important thing is to make the shape of nose that fits each person’s image.
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The nonsurgical nose augmentation procedure with filler is classified in 2 categories: the dorsum of the nose and the tip of the nose.
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After comparing and analyzing the ideal nose shape and the patient’s nose shape, decide which part is to be raised and by how much.
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The most common report of dissatisfaction of nonsurgical nose augmentation with filler is asymmetry. To prevent this, the tip of the needle should be located in the center line during the procedure.
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Filler must be injected to the deep fatty layer (between the perichondrium or periosteum and muscle layer) where important blood vessels are not located. That helps avoid severe side effects, such as skin necrosis.
Introduction
Rhinoplasty is one of the most common procedures in the field of aesthetic surgery. Asians, in particular, often have a flat nose and a wide nasal tip; hence, augmentation rhinoplasty is frequently performed in Asian countries. Existing techniques for rhinoplasty using implants and autologous cartilage are associated, however, with a long recovery time, high cost, and implant-related problems, so there often is a psychological barrier for patients considering surgery. Also, it is well recognized that there is a steep learning curve for rhinoplasty. As such, many patients prefer not to undergo a surgical rhinoplasty. This has led to an increase in popularity of rhinoplasty using fillers ( Fig. 1 ). The goal of this article is not to endorse the use of fillers but rather to provide education and guidance to improve outcome and reduce complications for the many physicians who do perform these procedures.
A filler is any material that can augment volume when injected into the body and is usually an injectable material. Well-known fillers include hyaluronic acid (HA) products, collagen, paraffin, liquid silicon. Fillers are usually classified by their components.
Fillers also are classified by their longevity. Fillers with duration of less than 2 years are called temporary fillers; those with duration of 2 to 5 years are called semipermanent fillers; and those lasting no less than 5 years after injection are called permanent fillers. Fillers can also be divided based on the mechanism of action, such as volumizing fillers and stimulatory fillers. Collagen and hyaluronic fillers, in which the injected material itself constitutes the augmented volume, are classified as volumizing fillers, and those that augment volume by stimulating fibroblasts to synthesize collagen or depositing fibrous tissues through inflammatory response are called stimulatory fillers.
Most fillers have a good safety profile. Serious side effects, however, such as granuloma formation and inflammation due to tissue reaction, have been reported with several filler products, so it is necessary to select a desirable filler by understanding the characteristics of each product. An ideal filler should have no tissue reaction, be long-lasting, be safe and easy to use, and have no intratissue migration or allergic reaction.
Restricting the paranasal muscular movement using botulinum toxin shows better and longer-lasting results than using filler alone.
Introduction
Rhinoplasty is one of the most common procedures in the field of aesthetic surgery. Asians, in particular, often have a flat nose and a wide nasal tip; hence, augmentation rhinoplasty is frequently performed in Asian countries. Existing techniques for rhinoplasty using implants and autologous cartilage are associated, however, with a long recovery time, high cost, and implant-related problems, so there often is a psychological barrier for patients considering surgery. Also, it is well recognized that there is a steep learning curve for rhinoplasty. As such, many patients prefer not to undergo a surgical rhinoplasty. This has led to an increase in popularity of rhinoplasty using fillers ( Fig. 1 ). The goal of this article is not to endorse the use of fillers but rather to provide education and guidance to improve outcome and reduce complications for the many physicians who do perform these procedures.
A filler is any material that can augment volume when injected into the body and is usually an injectable material. Well-known fillers include hyaluronic acid (HA) products, collagen, paraffin, liquid silicon. Fillers are usually classified by their components.
Fillers also are classified by their longevity. Fillers with duration of less than 2 years are called temporary fillers; those with duration of 2 to 5 years are called semipermanent fillers; and those lasting no less than 5 years after injection are called permanent fillers. Fillers can also be divided based on the mechanism of action, such as volumizing fillers and stimulatory fillers. Collagen and hyaluronic fillers, in which the injected material itself constitutes the augmented volume, are classified as volumizing fillers, and those that augment volume by stimulating fibroblasts to synthesize collagen or depositing fibrous tissues through inflammatory response are called stimulatory fillers.
Most fillers have a good safety profile. Serious side effects, however, such as granuloma formation and inflammation due to tissue reaction, have been reported with several filler products, so it is necessary to select a desirable filler by understanding the characteristics of each product. An ideal filler should have no tissue reaction, be long-lasting, be safe and easy to use, and have no intratissue migration or allergic reaction.
Restricting the paranasal muscular movement using botulinum toxin shows better and longer-lasting results than using filler alone.
Anatomy for rhinoplasty using filler
Rhinoplasty using filler can only be successfully performed if the surgeon has a good understanding of nasal anatomy. Rhinoplasty using filler is a procedure of reshaping the nose by injecting filler into the space between the bony–cartilaginous structure of the nose and the skin. The solid frame of the nose functions as the supporting structure to maintain the shape of the injected filler and to achieve an aesthetic result. Therefore, a satisfactory result cannot be expected after the procedure if the frame of the nose is deformed or weakened. Rhinoplasty using filler is said to reflect the personal ability of the surgeon, the anatomic characteristics of the patient’s nose, and the surgeon’s recognition of such individual variation. When performing rhinoplasty using filler, all structures of the nose, including the thickness and properties of the skin and the soft tissue and the size, shape, and strength of the cartilage and bone, must be taken into consideration.
Soft Tissue of the Nose
It is important to assess the skin of the nose before performing filler rhinoplasty. In general, Asians have thicker skin than white people with rich and oily subcutaneous tissue. The soft tissue of the nasal bridge is the thickest at the nasion and the thinnest at the rhinion, which is the junction of the upper lateral cartilages and the nasal bones. There are 4 layers between the skin and the bony–cartilaginous framework: superficial fatty layer, fibromuscular layer, deep fatty layer, and periosteum or perichondrium.
It may be more difficult to perform filler rhinoplasty on patients with thick, oily skin because they may experience severe postprocedure edema more often, and creating a pleasing 3-D shape is challenging. On the other hand, in such patients, minute irregularities or asymmetry is camouflaged more easily compared with patients with thin skin. Major blood vessels of the external nose are located in the superficial muscular aponeurotic system (SMAS) layer or the superficial fatty layer. Therefore, the ideal layer for filler injection is the deep fatty layer located between the SMAS and the perichondrium or periosteum, to minimize damage to the vessels ( Fig. 2 ).
Understanding the location, size, and function of the muscles of the nose is essential because some of them are sometimes paralyzed using botulinum toxin to enhance the effect of rhinoplasty using filler. The depressor septi nasi muscle originates from the orbicularis oris and terminates at the medial crura of the lower lateral cartilage. This muscle lowers the nasal tip when smiling or making a facial expression, and it is often paralyzed by injecting botulinum toxin to inhibit the function. It is better to paralyze the procerus muscle located at the glabella with botulinum toxin beforehand because filler injected at the glabella may move when the procerus muscle contracts intensely. The levator labii superioris alaeque nasi muscle causes flaring of the nasal ala and nasal tip ptosis when smiling; hence, it is also often paralyzed using botulinum toxin in patients who have dynamic nasal tip ptosis or alar flaring. The dilator naris muscle can be paralyzed if the nasal ala is too wide.
Vascular Supply of the External Nose
The most feared complications of filler injection are intra-arterial embolization into the blood vessel and dermal necrosis due to vascular compression. The surgeon must be familiar with the vascular supply of the external nose to prevent such consequences.
Both the internal carotid artery and the external carotid artery supply blood to the external nose via the ophthalmic artery and the facial artery, respectively. The ophthalmic artery mainly supplies blood to the upper part of the nose via the external nasal branch of the anterior ethmoid artery and the dorsal nasal artery; the facial artery gives rise to the angular and superior labial arteries, which supply the lower part of the nose. Each of these branches out to the lateral nasal artery and the columellar artery. The nasal tip receives blood supply from the dorsal nasal artery superiorly and the lateral nasal artery and the columellar artery inferiorly.
Selection of target patient
The physician must be able to select patients who are suitable for rhinoplasty using filler. This requires a thorough understanding of ideal nasal aesthetics and anatomy (described previously). If physicians have not been trained and do not have thorough knowledge, they should not embark on injecting fillers in the nose. Patients in whom good results cannot be achieved with filler should be offered surgery instead. The patient group that generally has good results includes those with mild dorsal hump, mildly deviated nose, high nasal tip with flat radix, slight imbalance from surgery. Those with moderate to severe dorsal hump, severely deviated nose, upturned nose, and bulbous nose are not expected to have good results from filler alone. Physicians should be cautious when offering this procedure to patients who have had nasal implants inserted or those with history of paraffin or liquid silicon injections, because skin irregularities and vascular compromise may occur.
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