**Medical Rhinoplasty – Profile Correction with Resorbable Fillers**

Alessio Redaelli

[17] Kubelka P. New contributions to the optics of intensity light scattering materials.

[18] Anderson R.R., Parish J.A. Selective photothermolysis precise microsurgery by selec‐

Part II: Nonhomogeneous layers. *J Opts Soc Am.* 1954;44:330-335.

tive absorption of pulsed radiation. Science 1983;220:524-527.

148 Miniinvasive Techniques in Rhinoplasty

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62066

#### **Abstract**

The correction of nasal profile is a typical surgical field dating back centuries. In the last decade, with the fabrication of resorbable fillers, a new technique, which is mini-invasive, has emerged. For this treatment, the study of patients is especially important. The proce‐ dure can be performed with needles or cannulas; is very simple and easy; and the results are immediate. It must become baggage of any aesthetic doctor.

**Keywords:** Medical rhinoplasty, rino-filler, hyaluronic acid, nasal profile, nasal bridge, Asian rhinoplasty, Far-East rhinoplasty, blunt cannula, nasal tip, Rhinion, Nasion, deep nasal bridge, nonsurgical rhinoplasty, nasal spine, beauty, symmetry, asymmetry

#### **1. Introduction**

I remember perfectly, when back in 2007, after having extensively corrected a lady for many problems of aging, something in her face seemed wrong and not beautiful. During a conver‐ sation, she mentioned that she had noticed also that her nose was getting progressively older. My patient did not have a particularly bad or hooked nose that required immediate correction. She had one of those typically European noses, with a slight plunge, with the root deeper than just the tip. The tip was typically slightly hypoprojected.

In that moment, all of a sudden it occurred to me that a small injection of resorbable filler, hyaluronic acid in this case, at the level of the nasal root might give an interesting aesthetic result, improving that "sad" nose.

I used a small portion of the gel in the syringe in my hand to get the required correction. The result was immediate and dazzling!

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I gave the lady a mirror to see the result. She looked in disbelief for a few seconds and blurted out: "Doctor, it is incredible. All my life I wanted to improve my nasal profile, but I had always been afraid to meet a surgeon for this."

In fact, the result obtained on nasal profile after correction with an absorbable filler is instantly visible in contrast to that obtained with the botulinum toxin for all mimic problems.

The route was mapped out.

Thereafter, it was easy to obtain the correction also of the nasal tip, in all hypoprojected noses; Finally, the correction of the columellar line allows the nasal base to be slightly rotated to achieve the typical, satisfactory result.

Subsequently, in 2008 [1], I published a scientific article with details of the technique that is described in this chapter.

Of course, there are a lot of anatomical differences among the races of the world and nasal defects widely differ.

The aim of this chapter is to demonstrate to the readers the technique I use on typical European patients. These corrections, however, can be used in patients of all races that present with these defects. According to my experience, these defects are more frequent in Caucasian ladies and men, and hence the title of this chapter: "Profile correction for European Patients."

## **2. Study of patients and good indication**

In my opinion, it is impossible to reduce nasal aesthetics to a standard template, but to understand exactly the best indication it is of fundamental importance to study our patients. The defects to be corrected are sometimes so minimal yet strongly visible; at other times, the defects are more significant but affect total aesthetic of the face to a lesser degree. I would like, in this section of the chapter, to quickly recall the main aesthetical angles of the nose, which are of fundamental importance and thereafter deal with the correction by filler.

The nose is an organ of central importance. It is in the center of the face and is obviously closely related to the neighboring areas and in particular to the frontal, malar-zygomatic, and chin areas.

The more important anatomical details have been discussed in the previous chapter and in other parts of this book, which the the reader, if needed, can access.

I recall here very briefly the skeletal classes by Angle, already mentioned in the previous chapter regarding the treatment of mimical patients, but much more important with regard to the treatment of nasal contouring.

I recount for readers who have opened the book at this page, that the skeletal classes by Angle, from a dental point of view, are very important from a purely aesthetic perspective, deter‐ mining with accuracy the mutual expression and projection of the chin and nasal tip [1-4].

```
Figure 1. Please add caption
```
I gave the lady a mirror to see the result. She looked in disbelief for a few seconds and blurted out: "Doctor, it is incredible. All my life I wanted to improve my nasal profile, but I had always

In fact, the result obtained on nasal profile after correction with an absorbable filler is instantly

Thereafter, it was easy to obtain the correction also of the nasal tip, in all hypoprojected noses; Finally, the correction of the columellar line allows the nasal base to be slightly rotated to

Subsequently, in 2008 [1], I published a scientific article with details of the technique that is

Of course, there are a lot of anatomical differences among the races of the world and nasal

The aim of this chapter is to demonstrate to the readers the technique I use on typical European patients. These corrections, however, can be used in patients of all races that present with these defects. According to my experience, these defects are more frequent in Caucasian ladies and

In my opinion, it is impossible to reduce nasal aesthetics to a standard template, but to understand exactly the best indication it is of fundamental importance to study our patients. The defects to be corrected are sometimes so minimal yet strongly visible; at other times, the defects are more significant but affect total aesthetic of the face to a lesser degree. I would like, in this section of the chapter, to quickly recall the main aesthetical angles of the nose, which

The nose is an organ of central importance. It is in the center of the face and is obviously closely related to the neighboring areas and in particular to the frontal, malar-zygomatic, and chin

The more important anatomical details have been discussed in the previous chapter and in

I recall here very briefly the skeletal classes by Angle, already mentioned in the previous chapter regarding the treatment of mimical patients, but much more important with regard to

I recount for readers who have opened the book at this page, that the skeletal classes by Angle, from a dental point of view, are very important from a purely aesthetic perspective, deter‐ mining with accuracy the mutual expression and projection of the chin and nasal tip [1-4].

men, and hence the title of this chapter: "Profile correction for European Patients."

are of fundamental importance and thereafter deal with the correction by filler.

other parts of this book, which the the reader, if needed, can access.

visible in contrast to that obtained with the botulinum toxin for all mimic problems.

been afraid to meet a surgeon for this."

achieve the typical, satisfactory result.

**2. Study of patients and good indication**

The route was mapped out.

150 Miniinvasive Techniques in Rhinoplasty

described in this chapter.

defects widely differ.

areas.

the treatment of nasal contouring.

**Figure 2.** Angle's skeletal classes.

Edward Angle, in the past century, determined exactly what the relationships between the dental arches are, clearly observed in the lateral projection, and then described the three main models that are precisely the three skeletal classes: the first class called normal, a second class when the jaw is in a position rearward from the upper jaw, and finally a third skeletal class in which the jaw is shifted forward and the lower incisors can be on the same axis of the superior if not exactly in front of them with a typical reversed bite.

**Figure 3.** Main nasal angles: (a) picture of the patient in profile position; (b) naso frontal angle: normally from 130° to 145°; (c) dorsal angle: normally straight; (d) naso labial angle: normally from 90° to 110°.

It is immediately evident that in the second skeletal class, often associated with a reduced projection of the malar-zygomatic area, the nose can sometimes appear hyperprojected and bigger than it really is. As I often say in my master classes, a mountain is a mountain also because at the sides it has deep valleys!

This confirms that the nose cannot be studied in isolation, but that all facial areas in their totality are of paramount importance.

The facial angles of the nose are also of fundamental importance [1,2]. We can see them in the pictures (Figure 3).

## **3. Indicated fillers**

when the jaw is in a position rearward from the upper jaw, and finally a third skeletal class in which the jaw is shifted forward and the lower incisors can be on the same axis of the superior

**Figure 3.** Main nasal angles: (a) picture of the patient in profile position; (b) naso frontal angle: normally from 130° to

It is immediately evident that in the second skeletal class, often associated with a reduced projection of the malar-zygomatic area, the nose can sometimes appear hyperprojected and

145°; (c) dorsal angle: normally straight; (d) naso labial angle: normally from 90° to 110°.

if not exactly in front of them with a typical reversed bite.

152 Miniinvasive Techniques in Rhinoplasty

Among commercial fillers, the most suitable for the correction of the nasal profile and used everyday in my surgery are those materials based on average cross-linked hyaluronic acid. It is of paramount importance that these gels are produced by pharmaceutical companies to absolute safety, with a well-known history and unequivocally perfect. I strongly advise all colleagues to avoid buying products only because they are cheap: a low price often hides a limitation in quality [2,4].

The fillers that I normally use for nasal profilometry are summarized in Table 1. I would like to emphasize that there are probably a lot of other fillers in the market that are not listed in the table, probably better than these, which I do not know of and therefore have not utilized.

**Table 1.** Fillers that I normally use for nasal profilometry.

As visible in the table here above, I'm not usual to use fillers made by HA too reticulated. In my opinion, the volumetrical fillers, for nasal reshape, are not indicated. For the same reason, I do not use Calcium-hydroxyl-apatite, which is, instead, very good for volumetrical correc‐ tions.

Also all nonresorbable fillers are not used in my practice.

Fillers based on Poli-levo-lactic acid are not indicated for nasal reshaping and not used by me.

## **4. Correction of the nasal profile in caucasian patients with needles**

The correction technique of the nasal profile in Caucasian patients with fillers foresees two techniques: with needles and cannulas.

Generally, all techniques with needles may be more dangerous due to the possibility of injecting directly into a vein or an artery. Regarding the nasal area in the strict sense, nasal sides are particularly dangerous for the presence of numerous small terminal arterioles coming from the facial artery. Particular attention must therefore be paid in the injection of this area, in particular in the subcutaneous tissue upon the triangular cartilage.

Also the area of the nasal tip can be dangerous for the possible onset of ischemia of the tip with consequent damage to the cutaneous trophism, both for matter of compression both for local injections of small terminal arterioles.

Finally, the intra-arterial injection of the columellar artery is reported with ischemia of the tissues of the nasal tip and base.

All these possible side effects have consequently introduced the use of blunt cannulas that allow us to bring down these risks to practically zero.

#### **4.1. Correction of the nasal root**

In most Caucasian patients we find the typical "Dorsal angle" over 180°.

In Fig. 5 we can see a case of a Caucasian patient during treatment. The nasal profile has the typical angle of about 190°. We use in this case a middle reticulated hyaluronic acid. The injection is made from Rhinion to Nasion. It is injected deep on the bone. It is mandatory to keep the first and second finger of the non-injecting hand closely on the sides of the nose to absolutely avoid the migration of the Hyaluronic acid on the sides of the nasal root. A migration even to the inferior eyelid is described. So great attention must be paid to this detail!

I normally use a linear retrograde technique arriving to inject 0,20,3 ml. It is better not to overcorrect. As always if the injection is not enough we can reinject. If we inject too much, it is difficult to retrace!

After the injection, a light massage to the area is useful to make uniform the implant. The result is definitely immediate (Fig. 5e).

**Figure 4.** Correction of the nasal root.

As visible in the table here above, I'm not usual to use fillers made by HA too reticulated. In my opinion, the volumetrical fillers, for nasal reshape, are not indicated. For the same reason, I do not use Calcium-hydroxyl-apatite, which is, instead, very good for volumetrical correc‐

Fillers based on Poli-levo-lactic acid are not indicated for nasal reshaping and not used by me.

The correction technique of the nasal profile in Caucasian patients with fillers foresees two

Generally, all techniques with needles may be more dangerous due to the possibility of injecting directly into a vein or an artery. Regarding the nasal area in the strict sense, nasal sides are particularly dangerous for the presence of numerous small terminal arterioles coming from the facial artery. Particular attention must therefore be paid in the injection of this area,

Also the area of the nasal tip can be dangerous for the possible onset of ischemia of the tip with consequent damage to the cutaneous trophism, both for matter of compression both for local

Finally, the intra-arterial injection of the columellar artery is reported with ischemia of the

All these possible side effects have consequently introduced the use of blunt cannulas that

In Fig. 5 we can see a case of a Caucasian patient during treatment. The nasal profile has the typical angle of about 190°. We use in this case a middle reticulated hyaluronic acid. The injection is made from Rhinion to Nasion. It is injected deep on the bone. It is mandatory to keep the first and second finger of the non-injecting hand closely on the sides of the nose to absolutely avoid the migration of the Hyaluronic acid on the sides of the nasal root. A migration

I normally use a linear retrograde technique arriving to inject 0,20,3 ml. It is better not to overcorrect. As always if the injection is not enough we can reinject. If we inject too much, it

After the injection, a light massage to the area is useful to make uniform the implant. The result

even to the inferior eyelid is described. So great attention must be paid to this detail!

**4. Correction of the nasal profile in caucasian patients with needles**

in particular in the subcutaneous tissue upon the triangular cartilage.

In most Caucasian patients we find the typical "Dorsal angle" over 180°.

Also all nonresorbable fillers are not used in my practice.

techniques: with needles and cannulas.

injections of small terminal arterioles.

allow us to bring down these risks to practically zero.

tissues of the nasal tip and base.

**4.1. Correction of the nasal root**

is difficult to retrace!

is definitely immediate (Fig. 5e).

tions.

154 Miniinvasive Techniques in Rhinoplasty

#### **4.2. Correction of the nasal spine**

The nasolabial angle is the second angle that is sometimes reduced. This angle can be modified for mimical reasons or for a volumetrical/skeletal problem.

The correction in mimical patients can be made with BTxA (see the specific chapter).

If the problem is volumetrical, the correction can be achieved with the injection of Hyaluronic acid at the columellar area.

Normally, naso-labial angle is around 90° to 110°. The injection of nasal spine allows both an improving of the columellar line, with an opening of this angle, and also a light rotation of the nasal tip, with a better projection. In Fig. 6b, it is possible to see a not too closed nasal angle (a little bit more than 90°), but there is indication for the rotation of the nasal tip.

The injection of the nasal spine is made with a 27G x 14 mm needle (the grey one). The angle on injection can be parallel to the nasal spine–Pogonion line (Fig. 6c) in all cases of reduced angles below 85°.

If instead we need an improving of volumes, we can inject with a 45° (Fig 6d).

It is better, before injecting that a quick aspiration is made with the same injecting hand, to confirm avoiding injecting of the columellar artery.

**Figure 5.** Injection of the nasal spine (c) and position of the contralateral fingers (d).

As visible in the figures above, the contralateral hand is helping to close the injection area and preventing loss of the product into depths where it would be not helpful to open the nasolabial angle. It is better to suggest the patient breathes with the mouth, since the nostrils will be closed with your fingers.

#### **4.3. Correction of the nasal tip**

The hypoprojected tips are the best indication.

The injection is made in the subcutaneous tissue, between the intermediate crus of the alar major cartilages. In Fig. 7b it is possible to see the exact point. The injecting doctor must decide if it is better to underline 1 or 2 tip defining points. Normally, I achieve this definition through the same entry point using a fun technique that allows us to distribute the HA gel in a perfect way.

Every nose is, of course, different from others and it is impossible give the readers a standard template.

The result is immediate and in Fig. 7d it is possible to see it in this particular patient, imme‐ diately after the procedure.

**Figure 6.** PLEASE ADD CAPTION

nasal tip, with a better projection. In Fig. 6b, it is possible to see a not too closed nasal angle (a

The injection of the nasal spine is made with a 27G x 14 mm needle (the grey one). The angle on injection can be parallel to the nasal spine–Pogonion line (Fig. 6c) in all cases of reduced

It is better, before injecting that a quick aspiration is made with the same injecting hand, to

little bit more than 90°), but there is indication for the rotation of the nasal tip.

If instead we need an improving of volumes, we can inject with a 45° (Fig 6d).

confirm avoiding injecting of the columellar artery.

**Figure 5.** Injection of the nasal spine (c) and position of the contralateral fingers (d).

As visible in the figures above, the contralateral hand is helping to close the injection area and preventing loss of the product into depths where it would be not helpful to open the nasolabial angle. It is better to suggest the patient breathes with the mouth, since the nostrils will be closed

The injection is made in the subcutaneous tissue, between the intermediate crus of the alar major cartilages. In Fig. 7b it is possible to see the exact point. The injecting doctor must decide if it is better to underline 1 or 2 tip defining points. Normally, I achieve this definition through

angles below 85°.

156 Miniinvasive Techniques in Rhinoplasty

with your fingers.

**4.3. Correction of the nasal tip**

The hypoprojected tips are the best indication.

#### **5. Correction of the nasal profile in caucasian patients with the cannula**

In the last months of the 2012, I was conducting a course on Medical Rhinoplasty in Singapore for the American Academy of Aesthetic Medicine. A very kind doctor let us use his private practice for our courses. The courses on medical Rhinoplasty are very famous and followed by many doctors here in Europe and in the Far East.

After finishing my presentation, we discussed some practical casesand also Dr Kelvin Chua showed us his technique with a blunt cannula. It was surprising and really amazing the ease with which the reshaping of the nasal profile could be performed. Immediately I also under‐ stood the possibility of reducing all side effects due to injection in the vascular vessels that could be avoided with a cannula in most cases.

**Figure 7.** Dr K. Chua.

Since then I have used this new technique in a lot of cases, both for Far Eastern patients as also in many cases of European profile corrections.

In this chapter of the book by Prof. Nikolay Serdev, I would want to deeply thank this colleague for his kindness and for having opened my mind to this "Columbus's Egg" of the mini-invasive techniques on the nose.

This technique is very easy, safe, and described in the following text.

#### **5.1. Indications**

The best indication for the correction of nasal profile with the blunt cannula are the irregular profiles from the nasal tip to the root. The best cannulas to be used in this case are 25G x 50 mm. It is possible to use also 27G x 40 mm, but these are in my opinion a little bit more dangerous and also painful. Anesthesia, anyway, is not needed except for anesthetic cream at the entry point.

Patients are asked to arrive in my clinic with no makeup. The entire nasal area is thoroughly disinfected.

The cannula is inserted at the nasal tip. It is important to make the entry point at the perfect level; the entry with the cannula should be neither too superficial nor too deep.

The subcutaneous tissue is the perfect layer.

In most patients, I use a needle 23G to make the entry point at the nasal tip (Fig. 9b). The 23 G needle allows a very easy entry of the cannula, while the pain is the same as of any other thinner needle. With the preparation with the anesthetic cream, this pain is really very tolerable.

In this case I am using, as in most patients, a 25G cannula x 50 mm. The cannula is inserted gently at the entry point, and the right plain is found, where the cannula proceeds without an important pressure. The proceeding of the cannula must be easy and totally painless.

The first and second fingers of the non-injecting hand are positioned on the sides of the nose, just near the cannula to avoid spreading of the gel on the sides of the nose. This is also very useful to have a narrow nasal profile.

The cannula can arrive, however, also on the nasal sides to improve the little defects between the nasal cartilages.

Results are immediate. I suggest patients come back for a possible retouch in 15 days, since there is quite frequently a modest decrease in the result.

The result in most patients is very long-lasting, normally at least 1 year, and in many cases also 2 years.

**Figure 8.** Please add caption

**Figure 7.** Dr K. Chua.

158 Miniinvasive Techniques in Rhinoplasty

techniques on the nose.

**5.1. Indications**

the entry point.

disinfected.

in many cases of European profile corrections.

The subcutaneous tissue is the perfect layer.

Since then I have used this new technique in a lot of cases, both for Far Eastern patients as also

In this chapter of the book by Prof. Nikolay Serdev, I would want to deeply thank this colleague for his kindness and for having opened my mind to this "Columbus's Egg" of the mini-invasive

The best indication for the correction of nasal profile with the blunt cannula are the irregular profiles from the nasal tip to the root. The best cannulas to be used in this case are 25G x 50 mm. It is possible to use also 27G x 40 mm, but these are in my opinion a little bit more dangerous and also painful. Anesthesia, anyway, is not needed except for anesthetic cream at

Patients are asked to arrive in my clinic with no makeup. The entire nasal area is thoroughly

The cannula is inserted at the nasal tip. It is important to make the entry point at the perfect

In most patients, I use a needle 23G to make the entry point at the nasal tip (Fig. 9b). The 23 G needle allows a very easy entry of the cannula, while the pain is the same as of any other thinner needle. With the preparation with the anesthetic cream, this pain is really very tolerable.

In this case I am using, as in most patients, a 25G cannula x 50 mm. The cannula is inserted gently at the entry point, and the right plain is found, where the cannula proceeds without an

important pressure. The proceeding of the cannula must be easy and totally painless.

level; the entry with the cannula should be neither too superficial nor too deep.

This technique is very easy, safe, and described in the following text.

#### **6. The profile correction for far eastern patients: the deep nasal bridge**

In the previous chapter, we discussed and examined how to improve the nasal profile in Caucasian patients, especially central-European patients, both in women and in men.

I learnt of another interesting indication, and a very special one, in my many trips to the Far East and Africa during the correction of the nasal profile in these particular patients.

In these patients we find a very deep and flat nose profile that helps make their faces round and flat. It is possible to raise their nasal profile in order to let theface emerge, making it more visible and detailed.

The correction can be done by needle or cannula, but personally I prefer this second solution for the perfect uniformity on the profile and for the better safety profile that assures.

In the few pages that follow we can see some practical case studies from the pre-picture through the practical decisions during the procedure to the final result.

*Example 1: A case treated with needle*

**Figure 9.** Patient study: 52 year old, Fitzpatrick photo-type 3-4. She is studied before the procedure during a medical course. The nasal profile is quite deep. There is also present an initial depression of the tears valley. I study the patient also in mimical phase and I do not see a particular mimical defect. So I decide to treat the nasal bridge with a middle reticulated absorbable filler. In this case, I use the technique with needle.

Anyway, normally, 0.2–0.3 ml of gel. Then I decide where to start the 1st injection for the nasal profile. Normally I inject from Rhinion to Nasion, deep on the bone. (c).

Immediately it is possible to see the bump caused by the injection of the gel. Gently, with the right hand, I proceed to the massage from up to down (e). During the injection, it is mandatory to keep the first and second fingers of the noninjecting hand on the sides of the nose, to avoid spreading of the gel in this area. I have seen many cases of migration of the gel also in the inferior eyelid. Pay a lot of attention to this in particular.

Immediately after, I proceed to the second injection just below the previous (f) always pushing the usual 2 fingers on the sides of the nose. I proceed then to the gently massage with both the right and left hands (g). Then I proceed to the final injection in the lower part of the nose to underline a little bit also the nasal tip (h). This is also a very fine passage. The compression of the nose, during the procedure (i). If the nose bleeds too little. immediately it becomes difficult to understand exactly the right correction. For this reason it is very important to avoid important ecchymosis of this area. I proceed to do a little correction also of the sides of the nose, between the alar great cartilage and the triangular (immediately above) to try to reduce nasal flaring (l-m).

In the preliminary study, I observed an important regression also of the chin. All the areas of the face are strictly connected to each other and a good aesthetic doctor must always have a three-dimensional approach. In so many Asian patients it is possible to see this little defect (2nd skeletal classes are so frequent). I inject for this reason at the Pogonion, down on the bone, 1 ml of Hyaluronic acid gel to get an improvement with a little protrusion of the chin (n).

In these patients we find a very deep and flat nose profile that helps make their faces round and flat. It is possible to raise their nasal profile in order to let theface emerge, making it more

The correction can be done by needle or cannula, but personally I prefer this second solution

In the few pages that follow we can see some practical case studies from the pre-picture through

**Figure 9.** Patient study: 52 year old, Fitzpatrick photo-type 3-4. She is studied before the procedure during a medical course. The nasal profile is quite deep. There is also present an initial depression of the tears valley. I study the patient also in mimical phase and I do not see a particular mimical defect. So I decide to treat the nasal bridge with a middle

Anyway, normally, 0.2–0.3 ml of gel. Then I decide where to start the 1st injection for the nasal

Immediately it is possible to see the bump caused by the injection of the gel. Gently, with the right hand, I proceed to the massage from up to down (e). During the injection, it is mandatory to keep the first and second fingers of the noninjecting hand on the sides of the nose, to avoid spreading of the gel in this area. I have seen many cases of migration of the gel also in the

Immediately after, I proceed to the second injection just below the previous (f) always pushing the usual 2 fingers on the sides of the nose. I proceed then to the gently massage with both the right and left hands (g). Then I proceed to the final injection in the lower part of the nose to underline a little bit also the nasal tip (h). This is also a very fine passage. The compression of the nose, during the procedure (i). If the nose bleeds too little. immediately it becomes difficult to understand exactly the right correction. For this reason it is very important to avoid important ecchymosis of this area. I proceed to do a little correction also of the sides of the nose, between the alar great cartilage and the triangular (immediately above) to try to reduce

In the preliminary study, I observed an important regression also of the chin. All the areas of the face are strictly connected to each other and a good aesthetic doctor must always have a three-dimensional approach. In so many Asian patients it is possible to see this little defect (2nd skeletal classes are so frequent). I inject for this reason at the Pogonion, down on the bone, 1 ml of Hyaluronic acid gel to get an improvement with a little protrusion of the chin (n).

for the perfect uniformity on the profile and for the better safety profile that assures.

the practical decisions during the procedure to the final result.

reticulated absorbable filler. In this case, I use the technique with needle.

inferior eyelid. Pay a lot of attention to this in particular.

profile. Normally I inject from Rhinion to Nasion, deep on the bone. (c).

visible and detailed.

160 Miniinvasive Techniques in Rhinoplasty

nasal flaring (l-m).

*Example 1: A case treated with needle*

**Figure 10.** The procedure: I start the procedure in the malar-zygomatic area (a and b). I draw a line 1.3 cm under the orbital bone. I inject normally in 2 or 3 points, down on the bone. It is impossible to say exactly how much. Normally I say "not too much!!"

**Figure 11.** The results are immediate, as always while using a resorbable filler. They will last for many months, nor‐ mally more than 1 year.

I finish the procedure with the correction of all the little defects that are is possible to see in the nasal bridge (o).

At the end, the correction must be perfect in all the projections of the nose.

The patient is studied also in mimical phase. The smile appears to be more balanced, visible in an important way, during movements (impossible to render just with some pictures) (p).

After 15 days it is a good rule to see the patients for a follow-up, to take pictures, but many times also for a little touchup, which in particular will allow you to have better and longerlasting results.

Normally, patients come back after 1 year to make a new correction to maintain results.

The correction of nasal profile in Far Eastern and African patients can be made, of course, also with the cannula. I use as well the 25G cannula x 50 mm. Results are immediate and longlasting.

All the passages are exactly the same as in all other patients. The suggestion, in this case, can be that of keeping the usual fingers of the noninjecting hand just near the sides of the cannula to obtain finally a narrow bridge that is more normally enjoyed by these patients.

### **7. Conclusions**

The correction of nasal profile is a safe and easy technique. Results are immediate and longlasting, more than in other facial areas.

The rules to obtain perfect results must be followed mainly to avoid side effects, which in this area can be unpleasant and also long-lasting. However, all possible side effects and especially skin necrosis heal well with time (2–3 months).

The perfect understanding of the genesis of the possible defects is the right way to use the right technique and finally have a good result.

It must become technical baggage of every aesthetic doctor.

#### **Author details**

Alessio Redaelli\*

Address all correspondence to: mail@docredaelli.com

Visconti di Modrone Medical Center, Milan, Italy

#### **References**

I finish the procedure with the correction of all the little defects that are is possible to see in

The patient is studied also in mimical phase. The smile appears to be more balanced, visible in an important way, during movements (impossible to render just with some pictures) (p).

After 15 days it is a good rule to see the patients for a follow-up, to take pictures, but many times also for a little touchup, which in particular will allow you to have better and longer-

The correction of nasal profile in Far Eastern and African patients can be made, of course, also with the cannula. I use as well the 25G cannula x 50 mm. Results are immediate and long-

All the passages are exactly the same as in all other patients. The suggestion, in this case, can be that of keeping the usual fingers of the noninjecting hand just near the sides of the cannula

The correction of nasal profile is a safe and easy technique. Results are immediate and long-

The rules to obtain perfect results must be followed mainly to avoid side effects, which in this area can be unpleasant and also long-lasting. However, all possible side effects and especially

The perfect understanding of the genesis of the possible defects is the right way to use the right

to obtain finally a narrow bridge that is more normally enjoyed by these patients.

Normally, patients come back after 1 year to make a new correction to maintain results.

At the end, the correction must be perfect in all the projections of the nose.

the nasal bridge (o).

162 Miniinvasive Techniques in Rhinoplasty

lasting results.

**7. Conclusions**

**Author details**

Alessio Redaelli\*

lasting, more than in other facial areas.

skin necrosis heal well with time (2–3 months).

It must become technical baggage of every aesthetic doctor.

Address all correspondence to: mail@docredaelli.com

Visconti di Modrone Medical Center, Milan, Italy

technique and finally have a good result.

lasting.


#### **Chapter 14**

## **Nonsurgical Rhinoplasty**

#### Alexander Z. Rivkin

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62065

#### **Abstract**

The goal of this chapter is to acquaint the experienced injector with the technique of Non‐ surgical Rhinoplasty (NSR). This is an advanced technique and I am assuming that read‐ ers will be thoroughly familiar with how to perform cosmetic injections. I am also assuming that readers are knowledgeable about the various fillers and injectables availa‐ ble today in the United States.

NSR provides the first noninvasive alternative to surgical rhinoplasty, accomplishing the cosmetic goals of contour improvement without the risks and downtime of surgery. NSR is not a replacement for rhinoplasty and is appropriate in a specific subgroup of rhino‐ plasty candidates, which will be characterized. The procedure is currently being per‐ formed in a variety of ways, as described in the literature review. This chapter will detail the optimal methods of carrying out NSR based on a 10-year, 2500-patient experience with the technique. Discussion will also include critical safety concerns, tips on how to get the best results possible, and complication management. Being prepared for compli‐ cations is a particular concern with NSR because timely intervention is so critical in cases of ischemic events. Patient selection, knowledge of the anatomy, meticulous technique, and a focus on safety is the key to success with this procedure. Overall, NSR is safe, pre‐ cise, effective, and versatile. My patients are thrilled with their results, and I have made it the foundation of a thriving practice.

**Keywords:** Rhinoplasty, injection, nonsurgical, Artefill, methyl methacrylate, Radiesse, calcium hydroxylapatite, Voluma, hyaluronic acid, Restylane, Juvederm, nose job, ne‐ crosis, vascular embolism, ischemia, plastic surgery

#### **1. Introduction**

Surgical rhinoplasty remains one of the most popular cosmetic procedures performed on the face. Statistics from the American Academy of Facial Plastic Surgery and the American Society of Aesthetic Plastic Surgery put the number of rhinoplasties performed in the United States in

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

2012 at around 190,000 [1,2]. This number is relatively unchanged from what it was in 1997, prior to the FDA approval of cosmetic botulinum toxin and hyaluronic acid fillers. As with any surgical procedure, patients undergoing rhinoplasty are subject to significant risks, recovery time and expense. Until recently, patients who wanted to avoid surgery have never had a viable alternative procedure that could accomplish the cosmetic goals of rhinoplasty noninvasively. With the advent of long-lasting injectable fillers, however, physicians and patients have embraced a nonsurgical surrogate.

I first performed primary Nonsurgical Rhinoplasty (NSR) using calcium hydroxyapatite injectable filler in 2003, prior to the publication or report of such a procedure being done in the United States. The novelty of the procedure caught the attention of the media, and I performed it on several prominent national news programs and shows. This sparked the interest of the public and doctors around the country began to offer NSR to their patients. Several small studies have documented the safety and efficacy of the procedure since then [3,4,5]. Due to the simplicity and efficacy of NSR, it has steadily grown in popularity over the last decade. Since 2003, I have had the privilege to perform over 2500 of these procedures in my clinic, using a variety of injectable fillers, with great success.

#### **2. History**

The idea of injecting substances under the nasal skin to improve cosmesis is not new. Corning and Gersuny first described injecting liquid paraffin into the nose to correct saddle nose deformity at the beginning of the nineteenth century. The practice was quickly embraced but just as quickly abandoned because of the severe long-term adverse effects of paraffin [6]. In 1919, Bruning tried to correct postoperative cosmetic nasal imperfections with fat injection [7]. The technique was ultimately not very well accepted because the fat grafts showed poor survival duration [8]. In 1986, Webster presented a 20-year retrospective study of microdroplet silicone injection into the nasal bridge to correct postsurgical nasal defects [9]. The study reported mostly positive results, but many physicians, aware of horrific reports of complica‐ tions from the 1960s and 1970s, have remained wary of silicone injections.

The first modern study of NSR was published by Han *et al.* in 2006 [10]. It was an 11-patient pilot study, looking at the safety and efficacy of dorsal augmentation NSR using hyaluronic acid (Restylane, Medicis, Scottsdale, Ariz.) mixed with autologous fibroblasts. Hyaluronic acid (HA) is a glycosaminoglycan that is a major component of connective, dermal, and neural tissue in most mammals. Cross-linked HA has been widely used as an injectable filler since it was FDA approved in 2003. Because of its biocompatibility, no allergy testing is required. The HA in Restylane is produced by bacterial fermentation. The authors injected an average of 0.8 cc into the nasal dorsum of their patients, overcorrecting by 20%. Of the 6 patients that Han *et.al* were able to get follow-up data on, there were no adverse events and the augmentation effect was still persisting at 12 months. Later that year, Beer published a case report where he successfully corrected a dorsal cosmetic defect with Restylane [11].

Also that year, *Laryngoscope* published a report by Nyte where he successfully injected calcium hydroxyapatite (CaHA, Radiesse, Merz, San Mateo, CA) to correct collapse of the internal nasal valve in 23 patients [12]. Radiesse is a suspension of 30% of CaHA microspheres, 25–45µm in size, in a mix of glycerin, carboxymethyl-cellulose, and water. It is fully biocompatible because CaHA is identical to the mineral portion of human bone and teeth [13]. Radiesse was first approved as a radiologic marker and for use in vocal fold augmentation. FDA approval for cosmetic use came in 2006. Nyte's technique of injecting through the inside of the nose seemed to show some cosmetic correction along with the functional improvement. This is, however, the only study that advocated intranasal injection.

2012 at around 190,000 [1,2]. This number is relatively unchanged from what it was in 1997, prior to the FDA approval of cosmetic botulinum toxin and hyaluronic acid fillers. As with any surgical procedure, patients undergoing rhinoplasty are subject to significant risks, recovery time and expense. Until recently, patients who wanted to avoid surgery have never had a viable alternative procedure that could accomplish the cosmetic goals of rhinoplasty noninvasively. With the advent of long-lasting injectable fillers, however, physicians and

I first performed primary Nonsurgical Rhinoplasty (NSR) using calcium hydroxyapatite injectable filler in 2003, prior to the publication or report of such a procedure being done in the United States. The novelty of the procedure caught the attention of the media, and I performed it on several prominent national news programs and shows. This sparked the interest of the public and doctors around the country began to offer NSR to their patients. Several small studies have documented the safety and efficacy of the procedure since then [3,4,5]. Due to the simplicity and efficacy of NSR, it has steadily grown in popularity over the last decade. Since 2003, I have had the privilege to perform over 2500 of these procedures in my clinic, using a

The idea of injecting substances under the nasal skin to improve cosmesis is not new. Corning and Gersuny first described injecting liquid paraffin into the nose to correct saddle nose deformity at the beginning of the nineteenth century. The practice was quickly embraced but just as quickly abandoned because of the severe long-term adverse effects of paraffin [6]. In 1919, Bruning tried to correct postoperative cosmetic nasal imperfections with fat injection [7]. The technique was ultimately not very well accepted because the fat grafts showed poor survival duration [8]. In 1986, Webster presented a 20-year retrospective study of microdroplet silicone injection into the nasal bridge to correct postsurgical nasal defects [9]. The study reported mostly positive results, but many physicians, aware of horrific reports of complica‐

The first modern study of NSR was published by Han *et al.* in 2006 [10]. It was an 11-patient pilot study, looking at the safety and efficacy of dorsal augmentation NSR using hyaluronic acid (Restylane, Medicis, Scottsdale, Ariz.) mixed with autologous fibroblasts. Hyaluronic acid (HA) is a glycosaminoglycan that is a major component of connective, dermal, and neural tissue in most mammals. Cross-linked HA has been widely used as an injectable filler since it was FDA approved in 2003. Because of its biocompatibility, no allergy testing is required. The HA in Restylane is produced by bacterial fermentation. The authors injected an average of 0.8 cc into the nasal dorsum of their patients, overcorrecting by 20%. Of the 6 patients that Han *et.al* were able to get follow-up data on, there were no adverse events and the augmentation effect was still persisting at 12 months. Later that year, Beer published a case report where he

tions from the 1960s and 1970s, have remained wary of silicone injections.

successfully corrected a dorsal cosmetic defect with Restylane [11].

patients have embraced a nonsurgical surrogate.

166 Miniinvasive Techniques in Rhinoplasty

variety of injectable fillers, with great success.

**2. History**

Several papers emerged in the next year, including two small studies of Radiesse for cosmetic improvement of the nose. In the paper by Stupak *et al.,* the authors reported on a 13-patient prospective single-arm trial with blinded evaluators of before and after pictures [5]. They injected post-rhinoplasty patients seeking minor contour improvement. Areas injected included dorsum, supratip, nasal sidewall, and ala. Mean amount injected was 0.18cc. They did not inject the nasal tip due to concern that Radiesse would diffuse after injection and the tip would lose definition. There were no adverse events and patient satisfaction and evaluator ratings were good, but follow-up was only 2 months. Dayan *et al.* described their experience with Radiesse NSR in 8 patients over the span of 2 years [14]. The volume they used ranged from 0.3cc to 1.6cc and the corrections were mostly to the dorsum, radix, and supratip. Duration of effect was estimated to be around 1 year. They encountered no complications. At the end of their paper they made a point of mentioning that Dayan had performed revision rhinoplasty on a patient who had received Radiesse 14 months earlier without complication.

The other paper that year was by De LaCerda *et al*. from Brazil [15]. They presented a 2-patient experience with NSR using small amounts of porcine collagen on one patient (0.35 cc) and hyaluronic acid (Voluma, Allergan, Irvine, Calif.) on the other (0.20 cc); follow-up was 4 months and 1 year, respectively. Areas injected included the nasofrontal angle, nasolabial angle, the dorsum, and the tip.

In 2009, Humphrey and Dayan published a paper describing their preferences and techniques of NSR in 22 patients with HA and an unspecified number with CaHA [16]. They advocated using CaHA over HA because the latter absorbed water unpredictably. They considered injecting significant amounts of HA into virgin noses dangerous due to the risk of vascular compromise from the hydrophilic swelling of the product. They recommended injecting filler subdermally and avoiding the tip and supratip area. The only complications that they observed from the technique came after injecting HA into the tip area of two post-rhinoplasty patients, one by Dayan and one by an outside injector. These were both cases of ischemia. Dayan's patient was a mild case of Raynaud's-like phenomenon on the nasal tip and had no sequelae due to treatment with Hyaluronidase. The outside injector's case was a more serious case of ischemia that resolved with Nitropaste and Hyaluronidase. Although necrosis was avoided, they report that the patient developed aesthetically displeasing skin changes 1 year afterward. Notably, they again write that Dayan has had no trouble performing rhinoplasty on post-CaHA NSR patients. This is interesting because it contradicted numerous anecdotal accounts by other rhinoplasty surgeons at meetings and on the Internet that injectable fillers were causing catastrophic scarring and damage to the nasal tissues [17].

In 2010, we published our 4-year experience with CaHA NSR, comprising 385 patients [18]. We injected virgin noses as well as patients who had undergone rhinoplasty surgery in the past. We used volumes ranging from 0.3 cc to 0.5 cc of CaHA. We showed the procedure to be extremely safe. Two serious complications were encountered in patients who had undergone multiple revision rhinoplasties. They consisted of ischemia that progressed to small areas of tissue necrosis at the tip and ala despite treatment with Nitropaste and oral steroids. The rate of minor complications like cellulitis, prolonged swelling, or prolonged bruising was very low. Interestingly, a history of previous rhinoplasty surgery did not increase the risk of minor complications. The only exception was that post-rhinoplasty patients did have an increased incidence of prolonged erythema. We documented successful injection of all areas of the nose, including the tip, ala, dorsum, sidewall, and radix. We were surprised that the cosmetic effect of CaHA did not, on average, last as long as we expected. A significant number of patients showed evidence of resorption of the material as early as six months after injection.

In 2012, Kim and Ahn published a paper on a standardized NSR technique for Asian patients using mostly CaHA (except for tip injection, where they used HA) [19]. They reported their experience with 87 patients. Unlike most authors, they used 2% Xyocaine for anesthesia, injecting the infratrochlear and external nasal nerves as well as placing boluses at the nasal tip and the columnella-labial angle. Their technique consists of three steps. First, the columnella and columnella-labial angle is augmented with an injection from the tip down to the nasal spine. Second, the dorsum is augmented with a single injection, advancing the needle from the tip to the radix and injecting upon withdrawal, as in the first step. The third step involves shaping the tip with small, superficial bolus injections of HA. Four minor complications are reported, none of them ischemic. They end the paper with a series of sensible guidelines to avoid complications and achieve optimal cosmetic results.

In 2013, Kurkjian and Rohrich published their recommendations on technique for NSR [20]. The extent of their experience with the technique is not stated. They advocate low-pressure injection with HA fillers only, using the smallest possible needles. According to them, Sculptra and Radiesse should be avoided due to their irreversibility and the danger of long-term palpability under relatively thin nasal skin. For patients desiring permanent nonsurgical correction, permanent fillers should be avoided and fat should be used instead. They recom‐ mend using Restylane in all areas of the nose because it is relatively less hydrophilic. The exception is the tip, where Juvederm is also recommended, taking advantage of postinjection hydrophilic swelling for patients who want to increase tip fullness. In their experience, HA has much higher longevity in the nose, lasting up to 2–3 years in some areas (I have not seen evidence of this kind of duration in my HA NSR patients). They consider filler injection to be useful in the correction of post-rhinoplasty contour irregularities.

This year I published a prospective, blinded study on the safety and efficacy of injecting methyl methacrylate (Artefill, Suneva, Santa Barbara, CA) to correct nasal contour deficiencies [21]. Artefill is a third-generation methyl methacrylate filler in a collagen carrier that was FDA approved in 2006 for nasolabial fold correction. The filler is 20% methyl methacrylate and 80% bovine collagen. Allergy testing for the carrier is commonly done 2 weeks prior to injection. The particles are smooth and 30–50 microns in size. I have been using Artefill off-label for NSR since 2006 with no complications in about 750 patients. In my experience, 3–5 injection sessions are necessary because the body quickly absorbs the collagen carrier and the methyl metha‐ crylate stimulates fibroblast proliferation to a variable degree. For the study, I injected the product over 3 sessions, spaced 1 month apart. Results were evaluated by me, an independent, blinded MD evaluator, and the patient. With 1 year follow-up on 19 patients, we all observed excellent cosmetic effect and no complications of any kind. An example of the results we obtained is illustrated in Fig. 3.

## **3. Technique**

by other rhinoplasty surgeons at meetings and on the Internet that injectable fillers were

In 2010, we published our 4-year experience with CaHA NSR, comprising 385 patients [18]. We injected virgin noses as well as patients who had undergone rhinoplasty surgery in the past. We used volumes ranging from 0.3 cc to 0.5 cc of CaHA. We showed the procedure to be extremely safe. Two serious complications were encountered in patients who had undergone multiple revision rhinoplasties. They consisted of ischemia that progressed to small areas of tissue necrosis at the tip and ala despite treatment with Nitropaste and oral steroids. The rate of minor complications like cellulitis, prolonged swelling, or prolonged bruising was very low. Interestingly, a history of previous rhinoplasty surgery did not increase the risk of minor complications. The only exception was that post-rhinoplasty patients did have an increased incidence of prolonged erythema. We documented successful injection of all areas of the nose, including the tip, ala, dorsum, sidewall, and radix. We were surprised that the cosmetic effect of CaHA did not, on average, last as long as we expected. A significant number of patients

showed evidence of resorption of the material as early as six months after injection.

In 2012, Kim and Ahn published a paper on a standardized NSR technique for Asian patients using mostly CaHA (except for tip injection, where they used HA) [19]. They reported their experience with 87 patients. Unlike most authors, they used 2% Xyocaine for anesthesia, injecting the infratrochlear and external nasal nerves as well as placing boluses at the nasal tip and the columnella-labial angle. Their technique consists of three steps. First, the columnella and columnella-labial angle is augmented with an injection from the tip down to the nasal spine. Second, the dorsum is augmented with a single injection, advancing the needle from the tip to the radix and injecting upon withdrawal, as in the first step. The third step involves shaping the tip with small, superficial bolus injections of HA. Four minor complications are reported, none of them ischemic. They end the paper with a series of sensible guidelines to

In 2013, Kurkjian and Rohrich published their recommendations on technique for NSR [20]. The extent of their experience with the technique is not stated. They advocate low-pressure injection with HA fillers only, using the smallest possible needles. According to them, Sculptra and Radiesse should be avoided due to their irreversibility and the danger of long-term palpability under relatively thin nasal skin. For patients desiring permanent nonsurgical correction, permanent fillers should be avoided and fat should be used instead. They recom‐ mend using Restylane in all areas of the nose because it is relatively less hydrophilic. The exception is the tip, where Juvederm is also recommended, taking advantage of postinjection hydrophilic swelling for patients who want to increase tip fullness. In their experience, HA has much higher longevity in the nose, lasting up to 2–3 years in some areas (I have not seen evidence of this kind of duration in my HA NSR patients). They consider filler injection to be

This year I published a prospective, blinded study on the safety and efficacy of injecting methyl methacrylate (Artefill, Suneva, Santa Barbara, CA) to correct nasal contour deficiencies [21]. Artefill is a third-generation methyl methacrylate filler in a collagen carrier that was FDA approved in 2006 for nasolabial fold correction. The filler is 20% methyl methacrylate and 80%

causing catastrophic scarring and damage to the nasal tissues [17].

168 Miniinvasive Techniques in Rhinoplasty

avoid complications and achieve optimal cosmetic results.

useful in the correction of post-rhinoplasty contour irregularities.

NSR corrects mild or moderate cosmetic nasal irregularities. I perform this procedure to achieve the following cosmetic goals:


Injectors around the world have used a variety of materials to achieve the aesthetic recon‐ touring of NSR. Currently, hyaluronic acid (HA) is the most popular filler material due to its reversibility (via injection of Hyaluronidase). There are a number of reports and editorials on technique in the literature. Most of these have been summarized above.

I consider HA, in its most common formulations of Juvederm and Restylane, to be the best material for the beginner or the occasional injector of the nose. The ability to dissolve HA is a critical safety feature for injectors who are not yet experts in the technique. Juvederm and Restylane are effective for basic NSR goals, such as augmenting the bridge and camouflaging minor dorsal bumps. These fillers struggle to perform, however, in the more advanced applications of this technique. Juvederm and Restylane are relatively soft materials. They can only provide moderate augmentation of the dorsum, they cannot lift a drooping tip very much and they are poor at sculpting defining points of the tip and the sidewall of the nose. In my experience, these HA fillers last an average of 6–8 months.

Perlane is a formulation of HA that is an improvement over Juvederm and Restylane for NSR. Its increased density permits the advanced injector to sculpt more effectively. It has less of a

**Figure 1.** CaHA NSR to lift a ptotic nasal tip and augment the nasal radix. The "Before" pictures are on top, "After" on the bottom. The net result is a straighter nose on profile that appears smaller because it blends better into the rest of the face.

**Figure 2.** HA NSR to camouflage a dorsal hump. The patient wanted to use a minimum of product to make her profile straighter. She believed a slight curve would make her nose look more natural.

tendency to spread, so better definition can be achieved. Perlane also lasts somewhat longer in the nose than Juvederm and Perlane – about 8 months in my experience. Prior to the FDA approval of Voluma, I used Perlane for patients who wanted the added safety of a reversible filler.

I have used calcium hydroxyapatite (CaHA – Radiesse, MERZ Aesthetics Inc., San Mateo, CA) in most of my NSR procedures. Radiesse received FDA approval in 2006 for correcting moderate to severe wrinkles and HIV-related facial volume changes. Prior to that it was approved for vocal cord augmentation and I was using it off-label in the nose. As a non-HA filler, CaHA is not reversible. Hypersensitivity reactions to CaHA are extremely uncommon and reports of other adverse events do not differ significantly from reports for HA fillers. Side effects noted of CaHA include:


tendency to spread, so better definition can be achieved. Perlane also lasts somewhat longer in the nose than Juvederm and Perlane – about 8 months in my experience. Prior to the FDA approval of Voluma, I used Perlane for patients who wanted the added safety of a reversible

**Figure 2.** HA NSR to camouflage a dorsal hump. The patient wanted to use a minimum of product to make her profile

straighter. She believed a slight curve would make her nose look more natural.

**Figure 1.** CaHA NSR to lift a ptotic nasal tip and augment the nasal radix. The "Before" pictures are on top, "After" on the bottom. The net result is a straighter nose on profile that appears smaller because it blends better into the rest of the

I have used calcium hydroxyapatite (CaHA – Radiesse, MERZ Aesthetics Inc., San Mateo, CA) in most of my NSR procedures. Radiesse received FDA approval in 2006 for correcting

filler.

face.

170 Miniinvasive Techniques in Rhinoplasty


The advantages of CaHA are its relative persistence of effect (average of 9–10 months in my experience, but quite variable between 6 and 12 months) and its high density. This last quality allowed me to effectively sculpt noses to my patients' satisfaction. It is possible to significantly elevate a droopy tip without excessive rounding. In fact, CaHA makes it possible to precisely create aesthetically pleasing tip defining points in patients with rounded and poorly defined tips. CaHA also makes it possible to significantly raise and add real definition to an underde‐ veloped dorsum – a quality that my Asian patients particularly appreciate.

With the FDA approval of Voluma in October of 2013, injectors gained a valuable new tool that seems to confer longer duration of effect than any other filler. Voluma is more cross-linked than other HA fillers and has a higher percentage of low molecular weight hyaluronic acid, making it exceptionally smooth, viscous, and cohesive. Increased cross-linking makes the filler more resistant to enzymatic degradation. Under study conditions, duration of effect was up to 2 years [22], but anecdotal reports from the investigators indicate the filler to be even longer lasting than that. Because of the duration of effect and its reversibility, I have been using Voluma for the majority of my NSR cases over the last 5 months. It performs well for the most part, but I find that in patients that need extensive elevation of their tip or dorsum, Radiesse is still the only filler thick enough to provide the desired lift. In these patients, my NSR combines Voluma and Radiesse.

I perform this procedure with the patient sitting up straight in the chair, as in Fig. 5. After taking standardized photographs, I use a compounded triple anesthetic cream for 15–20 min prior to the procedure (the materials I use are pictured in Fig. 4). My assistant will remove the cream and the patient will ice the area to be injected. During the injection, my assistant taps the patient's contralateral shoulder to distract their attention from the injection. I have found that alcohol works fine to clean the area and prevent infections. I prefer a thin-walled 29 gage half-inch needle when using any of the fillers – Voluma, Radiesse, or Artefill. If that is not available, I use a thin-walled 28 gage one-inch needle. I perform injections for the most part as shallow linear threads, placing small amounts of filler as I withdraw the needle. I will place filler into the area of the radix, dorsum, sidewall, tip, columnella, and ala as needed to correct each individual irregularity. I will then massage and mold the filler to blend into the desired contour. The patient goes home with instructions to avoid alcohol and strenuous exercise that

**Figure 3.** Artefill NSR to refine and straighten the dorsum and tip from both the profile and straight on views. This patient wanted to have a thinner appearing nose from the frontal view and a straighter and more refined looking dor‐ sum and tip from the profile.

day, as well as heavy sunglasses for two weeks. I agree with Kim and Ahn's observation that the volume effect of most fillers decreases by about 25% within the first month or two [19]. For this reason, my procedure includes a complementary follow-up visit 3 weeks after the initial injection, where I can touch-up the results.

In my experience, there are several types of patients that seek NSR. Most commonly, it is the younger patient who cannot afford the time or resources required for postsurgical recovery. They hear about the procedure through friends and the Internet. They mostly present with mild or moderate cosmetic irregularities. Having studied the before and after pictures and read about the procedure, they understand that it is not a technique that can physically reduce the size of the nose, so I rarely see patients with severely large noses.

**Figure 4.** Equipment necessary for NSR. Radiesse, Voluma, and Perlane are all displayed with the first two as presplit half syringes (using a Luer-Lock connector and a 1cc syringe). I try to use the smallest possible needle gage – 27 or 28 G thin-walled needles are my preference. The photograph displays the four main methods of pain control in my injecta‐ bles practice. Topical numbing cream is a compounded 23% Lidocaine, 7% Tetracaine mixture. Ice and a stress ball are important, but most important is my assistant's hand, which distracts the patient by tapping on the shoulder opposite to where I am standing.

About a third of my NSR patients are Asian, as in Fig. 6. These patients commonly desire an increase in the height and definition of their dorsum and radix, as well as improvement in the definition and projection of their nasal tip. These patients are usually young and cannot afford surgery. They are also often wary of unnatural surgical results, describing people with visible or overly large dorsal grafts that they have seen in the Asian community. Like many patients who opt for this procedure, they want to see the cosmetic change they desire, but only if their nose retains a natural appearance and no one can tell that they have had an aesthetic procedure.

day, as well as heavy sunglasses for two weeks. I agree with Kim and Ahn's observation that the volume effect of most fillers decreases by about 25% within the first month or two [19]. For this reason, my procedure includes a complementary follow-up visit 3 weeks after the initial

**Figure 3.** Artefill NSR to refine and straighten the dorsum and tip from both the profile and straight on views. This patient wanted to have a thinner appearing nose from the frontal view and a straighter and more refined looking dor‐

In my experience, there are several types of patients that seek NSR. Most commonly, it is the younger patient who cannot afford the time or resources required for postsurgical recovery. They hear about the procedure through friends and the Internet. They mostly present with mild or moderate cosmetic irregularities. Having studied the before and after pictures and read about the procedure, they understand that it is not a technique that can physically reduce

the size of the nose, so I rarely see patients with severely large noses.

injection, where I can touch-up the results.

sum and tip from the profile.

172 Miniinvasive Techniques in Rhinoplasty

Both of these kinds of patients usually choose the temporary procedure using a CaHA filler like Radiesse or an HA filler like Perlane or Voluma. They are aware that I commonly use Artefill for long-lasting to permanent results but want to try out the effect before they commit. Once the effect fades, some of these patients decide to continue with the temporary filler but many switch over to Artefill.

Another common category of patients presenting for this procedure are the ones who have desired cosmetic improvement in their nose for a long time, but have been afraid of surgical

**Figure 5.** Correct patient position for NSR. She is relaxed and sitting comfortably with her head resting on the back of the chair. Movement is minimized. There is no tissue redistribution, as there would be if the patient was lying flat, so cosmetic results are optimally accurate.

and anesthesia risks. These patients present with a variety of aesthetic complaints. Most are appropriate for the NSR technique, but some require reduction and have to be turned away.

An important subset of the above patient group is those who consider their aesthetic complaint to be too minor to undergo surgical correction. They are bothered by their small bump or mild asymmetry but feel that surgery exacts too high of a price (both financial and temporal). These patients are mostly ideal candidates for NSR. A small amount of contour correction to restore symmetry or camouflage a small bump makes them very happy.

About a quarter of my patients have already had one or more surgical rhinoplasties. These patients present with a variety of aesthetic complaints, but all of them are disappointed in the aesthetic result of their surgery (or surgeries) and desire an effective alternative. Some opt for temporary fillers, but many choose methyl methacrylate so that they can "get it over with." Figure 7 illustrates one of those patients. Anyone who performs NSR must be aware that these patients present with technically challenging problems. Postsurgical scarring stiffens the skin

**Figure 6.** CaHA NSR to augment and better define a nasal bridge and tip in an Asian patient.

and anesthesia risks. These patients present with a variety of aesthetic complaints. Most are appropriate for the NSR technique, but some require reduction and have to be turned away.

**Figure 5.** Correct patient position for NSR. She is relaxed and sitting comfortably with her head resting on the back of the chair. Movement is minimized. There is no tissue redistribution, as there would be if the patient was lying flat, so

An important subset of the above patient group is those who consider their aesthetic complaint to be too minor to undergo surgical correction. They are bothered by their small bump or mild asymmetry but feel that surgery exacts too high of a price (both financial and temporal). These patients are mostly ideal candidates for NSR. A small amount of contour correction to restore

About a quarter of my patients have already had one or more surgical rhinoplasties. These patients present with a variety of aesthetic complaints, but all of them are disappointed in the aesthetic result of their surgery (or surgeries) and desire an effective alternative. Some opt for temporary fillers, but many choose methyl methacrylate so that they can "get it over with." Figure 7 illustrates one of those patients. Anyone who performs NSR must be aware that these patients present with technically challenging problems. Postsurgical scarring stiffens the skin

symmetry or camouflage a small bump makes them very happy.

cosmetic results are optimally accurate.

174 Miniinvasive Techniques in Rhinoplasty

and limits the lift that can be achieved with filler injection. Injectors need to take care not to over-promise these patients. Their results are going to be, for the most part, relatively subtle. Most importantly, postsurgical skin has a more tenuous blood supply, especially around the tip and ala. The risk of ischemia and necrosis are significantly increased in these patients. Only the most experienced injectors should be treating them, since the complications of necrosis can be catastrophic.

Complications of NSR are relatively rare. This is not surprising, since the overall major complication rate for filler injections has been estimated to be less than one hundredth of one percent [4]. As described above, published studies are meager and mostly small, but they report few serious adverse events. Bruising, transient erythema, and short-term swelling represents most of the issues documented. The exceptions are the disturbing case reports that detail blindness and major necrosis of nasal tissue [5,6,7]. Since the doctors treating the complications and not those who injected the patients write most of these reports, conclusions about needle type, injection technique, and even material used are often difficult. Of the reports published by the actual injectors, we know that sudden pain, blanching, duskiness, and ecchymosis in the area being injected are all danger signals for ischemia and necrosis. Com‐ promise of the blood supply to the skin in cases of filler injection can be caused by either intravascular embolism or small vessel compression by the filler.

Opthalmalgia and visual loss within minutes are signs of retinal artery embolism. Other signs of ophthalmic vasculature embolism include immediate diaphoresis, nausea, headache, opthalmoplegia, and ptosis [4].

In my experience, these complications can best be avoided by understanding the anatomy, always practicing safe injection technique, and having well-prepared protocols ready to launch

**Figure 7.** Artefill NSR to correct postsurgical contour irregularities and asymmetry of the dorsum and to lift the nasal tip. Lower series are 1 year after the last of three sessions of Artefill injections.

at any sign of danger. Our traditional understanding of the vascular anatomy of the external nose is illustrated in Fig 8.

A good injector is especially careful when injecting the radix and nasal sidewall, to avoid the dorsal nasal and angular branches,respectively. Based on Fig. 8, keeping one's injection points in the midline seems to ensure safety. This is surely true to some degree, but a recent paper by Saban *et al.* proposes that the external nasal vasculature is more interconnected than we think [23]. Using cadaver dissection and ultrasonography study of live subjects, the au‐ thors conclude that anastomoses between the internal and external carotid vascular sys‐ tems are plentiful in the external nose. This plexus of vessels is located in the SMAS layer. Safe injection technique should therefore focus on keeping the needle deep instead of trying to avoid specific vessels.

**Figure 8.** External arterial anatomy of the nose. Vessels originating from the External Carotid are in red, whereas those in black come from the Internal Carotid via the Opthalmic Artery.

Some clinicians have recommended aspiration prior to injection of filler in order to avoid vascular embolism. In my experience, this is a cumbersome practice with questionable benefits. Most fillers are thick gels. Building up enough negative pressure for aspiration of blood takes a lot of hand force and would only work for Voluma due to its smooth viscoelastic properties. Even in experienced hands, by the time one aspirates and then injects, the needle is no longer in the same place, rendering the test useless.

Rather than aspirating, I think that following accepted best practice standards for injecting filler is a more reliable way of preventing complications [8,9]:

**1.** Needles should be as small as possible so that filler flow rate is low.

at any sign of danger. Our traditional understanding of the vascular anatomy of the external

**Figure 7.** Artefill NSR to correct postsurgical contour irregularities and asymmetry of the dorsum and to lift the nasal

tip. Lower series are 1 year after the last of three sessions of Artefill injections.

A good injector is especially careful when injecting the radix and nasal sidewall, to avoid the dorsal nasal and angular branches,respectively. Based on Fig. 8, keeping one's injection points in the midline seems to ensure safety. This is surely true to some degree, but a recent paper by Saban *et al.* proposes that the external nasal vasculature is more interconnected than we think [23]. Using cadaver dissection and ultrasonography study of live subjects, the au‐ thors conclude that anastomoses between the internal and external carotid vascular sys‐ tems are plentiful in the external nose. This plexus of vessels is located in the SMAS layer. Safe injection technique should therefore focus on keeping the needle deep instead of trying

nose is illustrated in Fig 8.

176 Miniinvasive Techniques in Rhinoplasty

to avoid specific vessels.


Some authors advocate blunt tipped cannulas for all filler injection as a way to reduce complications and discomfort [10,11]. I think this is not a good idea in the nose. The weakness of cannulas is precision. It is much easier to know the exact location of a needle tip than the tip of a cannula that bends easily as it is advanced through the tissue. The aesthetics of the nose are particularly sensitive to the smallest contour asymmetries. One millimeter of fullness difference between two sides of the tip is clearly noticeable. One-millimeter deviation from the midline, when augmenting a dorsum, makes the nose appear off-center.

The literature contains reports of severe complications from every type of filler available, and I have successfully used a variety of materials in the nose. I do not believe that there is a material contraindicated for nasal injection. It is the skill and knowledge of the injector that is para‐ mount to the success of the procedure.

While not really a complication, vaso-vagal episodes can be disturbing to the novice injector. Diaphoresis, sudden pallor, a sensation of nausea are all warning signs of an impending episode. It is more likely to happen if the patient has not eaten much prior to their appointment. In the setting of cosmetic injections, patients become vaso-vagal primarily because they are holding their breath in anticipation of pain. The frequency of these episodes dropped dramat‐ ically once we began to routinely remind our patients to breathe. Distraction shoulder tapping also helps them tolerate the injections without excessive anxiety. If the patient does become vaso-vagal, our routine is to immediately place them in reverse Trendelenberg position, increasing blood flow to the brain. We place an ice bag behind their neck and give them something sweet to drink like orange juice or Coke. We monitor their pulse and blood pressure manually. Most patients will recover fully within a few minutes. We have not yet had to use smelling salts.

Complication management starts with the preventative measures outlined above. If, however, the clinician suspects that an ischemic event is unfolding, there are immediate steps that he or she should be ready to take. First, injection should stop immediately. The area should be massaged vigorously in an effort to restore blood flow and Hyaluronidase should be injected into the area. A dose of 50–80 units should be sufficient. Even if a non-hyaluronic acid filler has been used, Hyaluronidase is useful because it dissolves some native hyaluronic acid and decreases interstitial pressure, easing blood flow. Topical 2% Nitroglycerin paste (Nitro-bid. Savage Labs, Melville NY) should be in the room and readily available to anyone performing this procedure. It is a great vasodilator that acts very quickly. In situations of potential ischemia, a small amount should be applied to the area in question and it should stay on for at least 15 min. The patient should take aspirin 325 mg immediately. If the skin becomes pink again and remains so after a period of observation of 15 min or so, I would feel comfortable sending the patient home on aspirin every 4 h for a day, warm compresses, and periodic massage of the area. If the skin becomes dusky, I would reapply the Nitropaste for another 30 min and consider reinjecting the area with Hyaluronidase. I would observe the patient in the office for the next hour or so, applying warm compresses and massaging the area. At this point, the patient should begin oral steroid therapy and oral antibiotics. I would give them a Medrol dose pack and make sure that they take the first dose right away. At this point, the patient should be seen in the office on a daily basis to monitor the progression of tissue damage. If damage continues to unfold, the injector should consider hyperbaric oxygen therapy and referral to a plastic surgeon. My in-room safety kit, a.k.a. injectables "crash cart" is illustrated in Fig. 9.

Some authors advocate blunt tipped cannulas for all filler injection as a way to reduce complications and discomfort [10,11]. I think this is not a good idea in the nose. The weakness of cannulas is precision. It is much easier to know the exact location of a needle tip than the tip of a cannula that bends easily as it is advanced through the tissue. The aesthetics of the nose are particularly sensitive to the smallest contour asymmetries. One millimeter of fullness difference between two sides of the tip is clearly noticeable. One-millimeter deviation from the

The literature contains reports of severe complications from every type of filler available, and I have successfully used a variety of materials in the nose. I do not believe that there is a material contraindicated for nasal injection. It is the skill and knowledge of the injector that is para‐

While not really a complication, vaso-vagal episodes can be disturbing to the novice injector. Diaphoresis, sudden pallor, a sensation of nausea are all warning signs of an impending episode. It is more likely to happen if the patient has not eaten much prior to their appointment. In the setting of cosmetic injections, patients become vaso-vagal primarily because they are holding their breath in anticipation of pain. The frequency of these episodes dropped dramat‐ ically once we began to routinely remind our patients to breathe. Distraction shoulder tapping also helps them tolerate the injections without excessive anxiety. If the patient does become vaso-vagal, our routine is to immediately place them in reverse Trendelenberg position, increasing blood flow to the brain. We place an ice bag behind their neck and give them something sweet to drink like orange juice or Coke. We monitor their pulse and blood pressure manually. Most patients will recover fully within a few minutes. We have not yet had to use

Complication management starts with the preventative measures outlined above. If, however, the clinician suspects that an ischemic event is unfolding, there are immediate steps that he or she should be ready to take. First, injection should stop immediately. The area should be massaged vigorously in an effort to restore blood flow and Hyaluronidase should be injected into the area. A dose of 50–80 units should be sufficient. Even if a non-hyaluronic acid filler has been used, Hyaluronidase is useful because it dissolves some native hyaluronic acid and decreases interstitial pressure, easing blood flow. Topical 2% Nitroglycerin paste (Nitro-bid. Savage Labs, Melville NY) should be in the room and readily available to anyone performing this procedure. It is a great vasodilator that acts very quickly. In situations of potential ischemia, a small amount should be applied to the area in question and it should stay on for at least 15 min. The patient should take aspirin 325 mg immediately. If the skin becomes pink again and remains so after a period of observation of 15 min or so, I would feel comfortable sending the patient home on aspirin every 4 h for a day, warm compresses, and periodic massage of the area. If the skin becomes dusky, I would reapply the Nitropaste for another 30 min and consider reinjecting the area with Hyaluronidase. I would observe the patient in the office for the next hour or so, applying warm compresses and massaging the area. At this point, the patient should begin oral steroid therapy and oral antibiotics. I would give them a Medrol dose pack and make sure that they take the first dose right away. At this point, the patient should be seen in the office on a daily basis to monitor the progression of tissue damage. If

midline, when augmenting a dorsum, makes the nose appear off-center.

mount to the success of the procedure.

178 Miniinvasive Techniques in Rhinoplasty

smelling salts.

**Figure 9.** My in-room safety kit. Pictured are Hyaluronidase, Nitopaste, Aspirin, Kenalog, Solu-medrol, and smelling salts. These are the medications important to have on hand in every room.

When performed safely and correctly by an experienced and well-trained injector, NSR is a procedure that yields excellent patient satisfaction. It is not a replacement to rhinoplasty for all patients and I continue to refer those that are not candidates (mostly patients who need significant reduction) to my surgical colleagues. This procedure does, however, provide a valuable alternative to traditional surgery. It increases the pool of people wanting cosmetic correction of the nose, bringing in a significant population of patients who would never do surgery. In fact, recalling the statistics from AAFPRS and ASAPS, over the last 10 years that this procedure has become popular, it has not cut into the number of patients receiving surgical rhinoplasty [1,2]. For the patients who are candidates, it saves them expense, risk, and downtime. Finally, the precision of filler injection means that this procedure is in some cases superior to surgery in accomplishing patients' cosmetic goals. I have built a large practice upon this procedure and continue to receive many referrals from happy patients.

#### **Acknowledgements**

The author would like to thank Mimi Lam for her assistance with the layout and proofreading of this chapter.

#### **Author details**

Alexander Z. Rivkin

Address all correspondence to: arivkin@westsideaestehtics.com

Department of Dermatology, Division of Medicine, David Geffen, UCLA School of Medi‐ cine, Westside Aesthetics, Los Angeles, CA, USA

Conflict of interest: The author is on advisory boards and educational faculty for Allergan, Galderma, Merz, Solta Pharmaceuticals.

#### **References**


**Acknowledgements**

180 Miniinvasive Techniques in Rhinoplasty

of this chapter.

**Author details**

Alexander Z. Rivkin

**References**

The author would like to thank Mimi Lam for her assistance with the layout and proofreading

Department of Dermatology, Division of Medicine, David Geffen, UCLA School of Medi‐

Conflict of interest: The author is on advisory boards and educational faculty for Allergan,

[1] http://www.aafprs.org/wp-content/themes/aafprs/pdf/AAFPRS-2012-REPORT.pdf

[2] http://www.plasticsurgery.org/Documents/news-resources/statistics/2012-Plastic-

[3] Jacovella PF. Aesthetic nasal corrections with hydroxylapatite facial filler. Plast Re‐

[4] Rokhsar C, Ciocon DH. Nonsurgical rhinoplasty: an evaluation of injectable calcium hydroxylapatite filler for nasal contouring. Dermatol Surg. 2008 Jul;34(7):944-6

[5] Stupak HD, Moulthrop TH, Wheatley P, Tauman AV, Johnson CM Jr. Calcium hy‐ droxylapatite gel (Radiesse) injection for the correction of postrhinoplasty contour deficiencies and asymmetries. Arch Facial Plast Surg. 2007 Mar-Apr;9(2):130-6.

[6] Glicenstein J. The first "fillers," vaseline and paraffin From miracle to disaster. Ann

[7] Bruning P. Contribution a l'etude des greffes adipeuses. Bull Acad R Med Belg.

[8] Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr Surg.

Surgery-Statistics/full-plastic-surgery-statistics-report.pdf

constr Surg. 2008 May;121(5):338e-339e.

Chir Plast Esthet 2007;52:157–61.

1919;28:440.

1950;5:217.

Address all correspondence to: arivkin@westsideaestehtics.com

cine, Westside Aesthetics, Los Angeles, CA, USA

Galderma, Merz, Solta Pharmaceuticals.


## *Edited by Nikolay Serdev*

This book is divided into two parts. The first part describes mini-invasive surgical techniques, sufficient to perform the most important tasks in rhinoplasty, such as: tip rotation and projection; closure of the open roof after humpectomy; alignment and stabilization of the columella; refinement of the nasal tip, lower third and medial third; narrowing of the alar base. The second part concerns medical rhinoplasty techniques using nerve blocks, injectable fillers etc., which aim is to achieve similar results, despite their temporary effect. Currently, the request for such procedures and their number exceeds this of surgical operations and demonstrates their importance. Although minimally invasive techniques will not totally replace surgical rhinoplasty, this book will serve as a tool to enhance refinement of rhinoplasty and clinical aesthetics.This first textbook in minimally invasive rhinoplasty techniques will be of great help to many doctors and will provoke further development of time-saving, atraumatic and mini-invasive techniques with preservative attitude toward nasal tissues in the modern art of nasal and face beautification.

Photo by fabrizio siboldi / iStock

Miniinvasive Techniques in Rhinoplasty

Miniinvasive Techniques in

Rhinoplasty

*Edited by Nikolay Serdev*