Nonsurgical rhinoplasty with fat grafting and dermal fillers
The concept of nonsurgical nose reshaping using dermal fillers or autologous fat is becoming more common.B Patients want an improvement of the nasal shape without surgery.B After a primary rhinoplasty, asymmetries, depressions and contour irregularities can present immediately or several years after surgery.B B Common adverse sequelae from surgery include pollybeak deformity, over resection of dorsum cartilage or bone, tip deformities and visible lateral osteotomies.
Nonsurgical treatment of rhinoplasty complications was documented in 1904 by A. Stein.B He injected paraffin to correct a saddle nose deformity.1
Below is a graft of the nasal muscles and profile points.2
Hyperactivity of the depressor septi-nasi muscle moves down the nasal tip durning speaking and laughing.B The tip can be elevated by injecting 1.5 units of BotoxR or XeominR on each side of the base of the columella for a total of 3 units.B The columella is the midline structure between the base of the nose and the tip.B This will prevent movement of the tip with dynamic actions and it can also elevate the tip in someB cases.
The rhinion is the dorsal part of the nose where bone and cartilage meet.B This can be more visible and irregular after a primary rhinoplasty when a dorsal hump is aggressively shaved down.
Throughout history artist like Leonardo da Vinci studied the aesthetic correct proportions of the human face.B B These divine proportions are used as a guide and useful in planning corrections to be made and understanding what can be realistically achieved.
The above graft shows the most important nasal angles.2
During surgical and medical rhinoplasty, one tries to achieve those angles.B There will be some minor differences between males and females.B Sometimes, one will not be able to achieve those angles without surgical rhinoplasty.
The graft above shows the most important nasal angles.2
The blood supply is from the internal (upper) and external (lower) carotid arteries.B The proximal blood supply to the nose has connections to the retinal arteries.B Embolization durning injection in the area of the dorsum, radix or glabella can cause blindness or brain infraction (stroke).B The blood supply at the tip and alar regions or side of the nose if embolized can cause ischemic changes due to decreased blood supply.
Below is a graph of the blood supply to the nose with danger zones.3
The arrows represent danger zones regarding fat injections.B STA supratrochelar artery, DNA dorsal nasal artery, AA angular artery, IOA infraorbital artery, LNA lateral nasal artery, LA superior labial artery, FA facial artery.3
To avoid complications I use a blunt-tip cannula which reduces the chance of perforating the artery and entering the lumen.B Pressure applied to the syringe should be minimal to deposit fat in small parcels and to decrease the chance of propelling fat through the lumen of the vessel.
Below is a graft of the entry points and injection paths to the zones being corrected.4
The radix and dorsum of the nose are filled by an entry point in the glabella.B I like to use blunt tip Tulip cannulas which is about 16 guage or 18 guage in size.B I usually inject about 1-3 cc in the dorsum of the nose.B Demormities from osteotomies (fractures performed durning surgery)B can be seen as irregularites on the side of the nose.B The entry point can be on the lateral ala or side of the base of the nose.B I have also filled this area from the incision more laterally when I fill the tear trough.B I just reach more medially and fill in the defect on the lateral nose. This usually requires 1-2/side. The tip of the nose can be projected by grafting the columella and tip.B The entry point is the base of the nose in the midline.B Another 1-2 cc can be place in this zone.B Usually most patient require 2-6 cc of fat in one session.
The majority of patients only need one session to reshape the nose and correct irregularities from a rhinoplasty procedure.B The skin is thicker in the superior and inferior region with the mid dorsal region being thinner.B The skin on the dorsum thins with age, hence defects will be seen years after the primary procedure.B Building up this layer also improves the result of a secondary rhinoplasty is needed.
Injection techniques with fillers are pretty similar to fat grafting except I use a smaller cannula to inject the filler.B I use primarily Restylane or Radiesse to correct the areas.B I inject these fillers in the subcutaneous plane just above the periosteum.B I always aspirate before injection.B I use the same entry points as for fat grafting to the nose and apply digital pressure to mould the filler into position.B Filler last longer in the nose than other parts of the face, being present up to 18 months.
Below is my patient that had a previous rhinoplasty with over resection of the cartilage in the dorsum of her nose and she had contour irregularities in her lateral cartilage from a osteotomies.B This is after 1 session and about 4 cc of fat was grafted.
Before B B B B B B B B B B B B B B B B B B B After Fat Grafting to Dorsum and Lateral Sides of Nose
Before B B B B B B B B B B B B B B B B B B B After Notice Improvement in front nasal frontal angle
In conclusion, nonsurgical reshaping of the nose with fat or dermal fillers is a reliable and effective procedure that is safe and has minimal down town.
- Stein A.B Paraffin-injektionen.B Therorie und Praxis 1904:79-114.
- Radaelli, A.B Medical rhinoplasty with hyaluronic acid and botulinum toxin A: a very simple and quite effective technique. Journal of Cosmetic Dermatology (2008)7:2010-220.
- Monreal J. Fat Grafting to the Nose: Personal Experience with 36 Patients. Aesth Plast Surg(2011)35:916-922.
- Baptista C, Nguygen PSA, Desouches C, et al.B Correction of sequelae of rhinoplasty by lipofilling. Journal of Plastic, Reconst & Aesthetic Surgery(2013) 66:805-811.