Non-Surgical Nose Reshaping

Despite the fact that rhinoplasty is the most common facial operation in aesthetic plastic surgery - among both men and women, and overall the third most common - it is one of the most technically difficult surgical procedures and is quite often associated with complications and poor aesthetic results. Over the last few years non-surgical nose reshaping using dermal fillers seems to be gaining popularity due to its safety profile, almost instant results and high patient satisfaction for well selected individuals.

Patients seeking surgical or non-surgical nose reshaping often have dimensional abnormalities such as the following.

• Excessive or inadequate nasal length
  
• Excessive or inadequate nasal tip projection
  
• Excessive or inadequate radix projection
  
• Congenital or acquired deformities (e.g. “saddle nose” or previous over reduction of the bony dorsum, the so-called “ski slope” appearance).
  

The excessive dimensions need a surgical rhinoplasty whereas patients with inadequate nasal dimensions or minor deficits in the nasal skeleton would potentially be very good candidates for dermal fillers. The use of silicone and other permanent graft materials in the nose is generally not advocated. These tend to be unreliable and the rate of extrusion and other complications is too high to make such grafts a viable and safe option.
My experience with non-absorbable fillers such as Aquamid or Artecoll is limited and therefore I cannot advise for or against these. Fat grafting by the Coleman method can give good and predictable results when used to disguise visible irregularities of the underlying cartilage and bone and enlarge the nasal tip with virtually no complications or serious side effects. However autologous fat transfer will inevitably prolong the procedure and make it more costly for the patient. Injectable hyaluronic acid or CaHA fillers are by far the most commonly used augmentation of the dorsum, definition of the tip and correction of minor defects such as retracted columella, slight asymmetry, saddle nose or pollybeak deformity. Fillers offer a safe alternative to both primary and revision rhinoplasty when there is a small area to be filled out. Although great results can be achieved with dermal filllers, they are not comparable with those obtained by surgical rhinoplasties, and this is an important issue to discuss with the prospective patient. In addition, the patient should be made aware of the fact that repeat injections are likely to be necessary to maintain the result. 

Nasal Anatomy

The supporting skeleton of the nose is composed of bone and hyaline cartilage (Fig. 1). The bony part of the nose consists of nasal bones, frontal processes of maxillae and nasal part of the frontal bone and its nasal spine. The cartilaginous part consists of five main cartilages: two lateral cartilages, two greater alar (or lower lateral) cartilages and a septal cartilage. The bony part is covered with periosteum, which is continous with the perichondrium over the cartilaginous part. Please note that the angular branch (A) of the facial artery (F) runs along the nasolabial fold, branching off the superior labial artery (SL). The alar branch is a terminal branch of the angular artery, which is the main feeding blood vessel for the nasal ala. The superior labial artery and the dorsal branch (D) of the supratrochlear artery (ST) communicate with the alar branch around the nasal tip (Fig. 2). Fig. 3 shows the course of the angular artery and vein across the side of the nose as they approach the medial canthus. Bearing this image in mind can help practitioners to avoid injecting into these important blood vessels. 

TERMINOLOGY  Glabella is the smooth, slightly depressed area on the frontal bone between the superciliary arches. Nasion is the intersection of the frontonasal and internasal sutures.   Nasal Root or Radix is a point on the midline nasal dorsum at the level of the supratarsal folds. If a supratarsal fold is not present, then the root of the nose can be reliably measured in the midline 6mm above the inner canthus.  Tip is the midline point found at the level of the dome-projecting points of the lower lateral cartilages.

Frontal View

• Symmetry
• Tip Defining Points
• Alar width
- Equals Intercanthal distance
- Half of Interpupillary distance
- 70% of Nasal length
• Nasal length
- 1/3 of the face

Profile View

• Dorsal Humps
• Nasal Length
• Naso-Frontal Angle (NFA)
• Naso-Facial Angle (NFcA)
• Nasolabial Angle (NLA)

Caudal View

• Equilateral Triangle
• Columella:Lobule = 2:1
• Ala (A):Lobule (L) = 1:1
• Columellar Show = 2 - 4mm 

Injection technique

For correcting humps, augmenting the bridge or defining the dorsum of the nose I prefer using either Radiesse or HA filler such as Juvederm Ultra 4. VOLUMA can also be used when greater volumes are required such as in cases of westernisation of a depressed bridge in an Asian nose (Fig 4). By using a 27G x 0.5inch sterile hypodermic needle (0.4x13mm) I usually start near the nasion where I deposit, on average, anything between 0.2-0.5ml over the bridge of the nose depending on the degree of the augmentation I want to achieve. I use the same size needle to inject both the nasal dorsum and tip. Moving caudally, in a straight line connecting the glabella to the supratip, and by using a linear threading technique I deposit threads of about 0.1-0.2ml per injection until the desired dorsal definition and augmentation has been achieved. Please note that by increasing the height of the dorsum, the nasofacial angle will decrease. 

This will lead to an apparent decrease in nasal tip projection. This is why I tend, almost always, to refine the tip with every nose reshaping procedure. My favourite form of topical anaesthesia for a non-surgical nose reshaping is application of cold packs around the injection site which, in addition to instant pain relief, will also produce vasoconstriction minimising any swelling or bleeding. 

Dermal fillers can also help in the case of a significant nasal asymmetry such as deviated septum or nasal bone deformity. Fig 6 shows the example of a 42-year-old lady whom I treated quite recently. The patient has had two surgical rhinoplasties following an assault 10 years ago. She was left with a deviated septum, a C-shaped nasal dorsum and a bulbous tip. I injected 0.7ml of Juvederm Grade 4 across the dorsum as described above and 0.3ml in order to redefine the tip. That has resulted in the illusion of a straighter and better defined dorsum and slightly more projected tip.

Sculpturing the nasal tip

The nasal tip, on lateral view, influences the refinement, inclination, length, and width of the nose. Changing the nasal tip contour will change both the apparent nasal length and dorsal height. 

INDICATIONS FOR NASAL TIP REFINEMENT	METHOD
Nasal tip volume reduction	Surgical
Interdomal distance reduction	Surgical
Cranial rotation	Surgical
Increasing tip projection	Non-surgical/Surgical
Decreasing tip projection	Surgical

Sound knowledge of the blood supply to the tip will allow practitioners to inject safely in this area. The superior labial artery supplies the nostril sill and the base of the columella. The columellar artery of the superior labial artery, which is a substantial branch, ascends in the columella just superficial to the medial crura (Fig. 7). My experience in redefining the tip lies mainly with hyaluronic acid fillers and therefore I cannot recommend or reject any alternative non-HA filler. Dermal filler injections in the tip can be used instead of 
• a spreader graft to restore the vault shape support between the upper lateral cartilage and the septum
• a columellar graft in order to reinforce the medial crus and increase the nasal tip projection
• a tip graft for tip projection and to correct the proportion between the nostril and the nasal tip thus avoiding any potential risks and complications associated with nasal tip surgery and general anaesthesia. 

Nasal tip technique

I insert my needle through the columella and caudal aspect of the septal cartilage approximately 3-5mm below the tip defining points near the infratip break in a superoanterior direction. Bearing in mind the columellar arteries I inject boluses of 0.2-0.3ml between and over the domes as far as the suspensory ligament of the tip. The dome is formed by the junction between the middle and lateral crura of the greater alar cartilage - some rhinoplasty surgeons also call it lower later cartilage. Ideally the projected tip of the nose should have a triangular appearance with its superior apex lying approximately 2 mm above the dorsum and this is what we try to recreate by injecting fillers in the dome area. This is a relatively safe area to inject as there are no end arteries other than anastomoses as shown in figure 7. Finally I apply a lightweight aluminium external nasal splint for 24 hours which molds to any shape of nose and can be trimmed easily to adjust size, but remains rigid once applied (Fig. 9). The splint provides protection for the nose against trauma as well as preventing excessive soft tissue swelling which may precipitate filler migration altering the desired shape and size. 

Summary

Non-surgical nose reshaping has increasingly become a very popular alternative to the traditional surgical rhinoplasty due to its safety, quick results and high patient satisfaction when used for the appropriate indications. A thorough three dimensional examination of the nose and application of nasal aesthetics can guide you to a very satisfactory outcome. Remember that documented evaluation of all parameters that contribute to the appearance of the nose such as the thickness of the nasal skin must also be made. No matter how well defined the underlying osteo-carilaginous nasal skeleton may be, you may not be able to achieve optimal definition of the dorsum or projection of the tip in the thick skinned nose. In a future article I will share my experience in using intradermal 10mg/1ml steroid injections for the thick nasal skin. Finally, you can always complement a non-surgical nose enhancement by injecting a few units of BTX-A (i.e. 2 units per side) in the alaeque nasi for the bunny lines, in the nasalis and levator alae nasi for the flaring of nostrils, and in the depressor septi nasi for the plunging tip.