INDICATIONS
Nonsurgical rhinoplasty, also known as liquid rhinoplasty, involves using dermal fillers to alter the shape of the nose without surgery. Some common indications for this procedure include:
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Dorsal hump correction: To smooth out or reduce the appearance of a dorsal hump on the bridge of the nose.
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Nasal bridge augmentation: To enhance and raise the height of the nasal bridge.
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Minor asymmetry: To correct minor irregularities and asymmetry in the nose.
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Nasal tip refinement: To refine and lift the nasal tip.
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Deviated septum: To improve the appearance of the nose when surgery is not necessary for functional reasons.
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Postsurgical revision: To correct minor imperfections or irregularities after a previous surgical rhinoplasty.
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Saddle nose deformity: To address a depression or collapse in the middle of the nasal bridge.
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Nasal deficiency: To add volume and definition to a nose that appears flat or under-projected.
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Camouflage scars or irregularities: To conceal scars or irregularities on the nose.
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Nonsurgical alternative: For individuals seeking a temporary and less invasive alternative to surgical rhinoplasty.
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Bulbous tip reduction: To refine and reshape a bulbous or rounded nasal tip.
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Crooked nose correction: To straighten and improve the alignment of a crooked nose without surgery.
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Minor bridge irregularities: To address minor bumps or irregularities on the nasal bridge.
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Volume restoration: To restore lost volume due to aging or injury, giving the nose a more youthful appearance.
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Minimize posttraumatic deformities: To correct minor deformities resulting from injuries or accidents without surgical intervention.
TECHNIQUES
Safety is of paramount importance when performing dermal filler injections in and around the nose. Thorough understanding of the vascular anatomy is critical to performing this procedure safely. The layers of the nose encountered during this procedure, ordered from superficial to deep, consist of:
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Skin—thickest at the tip and radix, thinnest at the rhinion
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Superficial fat—containing major vessels.
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Superficial musculoaponeurotic system (SMAS)—a thin fibromuscular layer with major vessels.
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Deep fat—a relatively avascular plane suitable for filler injection; caution is warranted due to potential small artery perforators.
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Perichondrium and periosteum—thin fibrous layers covering cartilage and bone.
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Nasal cartilages and nasal bones.
The vascular supply during nonsurgical rhinoplasty stems from both the internal and external carotid systems through the ophthalmic and facial arteries, respectively. Despite various branching patterns and anastomoses, the main arterial supply to the nose includes the ophthalmic artery (from the internal carotid system), which supplies the upper nose through the dorsal and external nasal arteries, and the facial artery (from the external carotid system), which supplies the lower nose with the superior labial and angular arteries, which then further branch into the columellar and lateral nasal arteries.
CONSULTATION AND ASSESSMENT
The appointment should start with a thorough consultation for the injector to understand the patient’s concerns and goals. The injector should clarify whether the patient has had previous surgery on the nose (rhinoplasty, biopsies, surgical intervention for skin cancer) or prior filler injected into the nose. The physical exam should entail assessing the patient’s nasal anatomy, quality of skin, and ability for the skin to respond well to filler. Potential risks should be clearly communicated to the patient prior to obtaining informed consent.
Prior to injection, the injector should communicate with the patient how effective the procedure will be in attaining the patient’s goals, with a discussion of limitations of the procedure and expected outcomes.
MARKING AND PLANNING
Injectors who are novices at the nonsurgical rhinoplasty technique should start with marking the areas on the nose where filler is intended to be injected. Areas of concavity and convexity should be highlighted. The midline and tip defining points should be marked as well so that injections respect these areas. Topical anesthesia or applying a cold compress on the injection area prior to injection may be used to provide comfort to the patient.
Skin Preparation
Minimizing risk of infections and biofilm formation is important anywhere on the face, but especially on the nose. Proper skin preparation prior to injection is important to prevent infection or delayed onset nodules.
Prior to starting injections, the nose should be cleaned of any makeup, skincare products, and sunscreen. The area should then be prepped with alcohol at a minimum. The author routinely preps the nasal skin with hypochlorous acid.
INJECTION TECHNIQUE
The injector may decide to use needle or microcannula for injection depending on individual preference. For the purposes of this chapter, the author will focus only on needle injection. Fine-gauge needles are preferred for these injections, with some injectors choosing to transfer product from the original syringe into smaller 0.3 mL BD syringes to depot very small quantities of filler per injection point. Attend to any specific concerns like dorsal hump reduction, tip refinement, or bridge augmentation, as outlined here. Filler placement must be continuously assessed and adjusted to achieve the intended results. After injection, the injector may massage the filler to ensure even distribution and natural contours.
Regardless of the area of the nose that is being injected, a few main considerations need to be respected to maintain safety and avoid catastrophic consequences. (1) Injections should be placed in very small aliquots (less than 0.05 mL per injection). (2) The injections should be performed in a very slow manner such that the pressure exerted with each injection is low. Reports have shown that the pressure of the injections and the volume of the filler bolus are correlated with vascular occlusion. (3) Care should be taken to stay midline whenever possible to avoid the majority of vessels, which tend to enter laterally. (4) Effort should be made to stay in the sub-SMAS, supraperiosteal, and supraperichondrial planes, all of which tend to be avascular regions. (5) Consideration may be given to using a microcannula for injection by potentially decreasing the likelihood of intravascular injection.
The particular technique used depends on the area or concern to be treated.
Dorsal Augmentation
The preferred height of the radix and dorsum is determined at first. The selected areas of the radix and/or dorsum are then injected using a series of droplets placed in the midline, on the periosteum/perichondrium, with the needle at a 90-degree angle to the tissues. The area is filled up to the height of the desired augmentation but not beyond the nasion. Consideration may be given to tent the skin upward to mitigate vascular occlusion. Two fingers of the noninjecting hand may be used to apply pressure over the supratrochlear arteries to prevent intravascular injection and retrograde flow. Similarly, some recommend placing a finger above the radix to prevent superior filler migration.
Dorsal Hump Camouflage/Correction
For the correction of a dorsal hump, at least two injection points should be planned. The first injection point is superior (cranial) to the dorsal bump, with all of the injections in the supraperiosteal plane. The volume of each aliquot of filler deposited should be 0.05 mL or less to minimize risk of vascular compromise. Once an adequate total volume of filler has been administered to match the level of the bump, attention may be given to the region inferior (caudal) to the dorsal hump. Additional filler may be placed in this region to further create a straight nasal profile. Any asymmetries from the front view may be adjusted by placing filler into any areas of concavity.
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