Professional Documents
Culture Documents
Davi A. de Lacerda, MD, and Pedro Zancanaro, MD, have indicated no significant interest with commercial
supporters.
patients dissatisfied with the appearance of their Fillers have been broadly used in dermatology for the
nose seek cosmetic improvement as early as during correction of wrinkles, acne scars, and lip augmen-
adolescence. Similar to other facial structures, the tation, as well as for age or medication-related
nose is affected by the aging process. Typically, lipoatrophy. They can be easily applied under the
nose tip drop is observed, along with loss of skin in a minimally invasive fashion. They can also
subcutaneous tissue, which highlights its undulating be used to improve nasal deformities secondary to
osteocartilaginous support. Dermatologic patients trauma or surgery. Dermatologists are quite familiar
are increasingly requesting procedures with minimal with the use of fillers for the above indications.4
downtime. In our practice, several patients coming
for facial rejuvenation are interested in undergoing The rationale for the traditional use of hyaluronic
nasal rejuvenation procedures, but they usually acid and collagen is based on their natural occur-
do not bring up the issue spontaneously because rence yet diminished and altered properties on pho-
they believe it would need extensive surgical toaged skin.5,6 The atrophic subcutaneous tissue
correction. observed on the aging face brings the reticular der-
mis closer to the underlying musculature forming
Rhinoplasty has been successfully used to improve concave areas in the midcheeks and nasolabial folds.
the appearance of the nose through changes in bone These areas respond quite well to soft tissue fillers.7,8
and cartilage structures, as well as through the Tolerance and excellent results for the above appli-
placement of prosthetic devices.1 It remains an in- cations have been well established, both for collagen
vasive procedure that may lead to scars, however. In and for hyaluronic acid.9–11 Nevertheless, there are
addition, some patients remain dissatisfied with the very few reports on the use of small amounts of re-
results, frequently submitting themselves to multiple sorbable fillers to achieve cosmetic results compa-
procedures, increasing the risk of postsurgical func- rable to surgical rhinoplasty.12–14
tional impairment.2
Filler rhinoplasty, also known as augmentation rhi-
Discreet volumetric changes in the frontal-nasal an- noplasty, is an evolving field.12 It has been proposed
gle, nasal dorsum, and columella–philtrum junction to patients interested in less invasive techniques
produce significant differences in our perception of than traditional rhinoplasty. An advantage of using
nasal features. These areas can be injected with fillers is that surgeons may sculpt the material after
Hospital Local de Sapopemba and Departamento de Dermatologia, Hospital das Clı́nicas da Universidade
de São Paulo, Sao Paulo; yHospital Universitário de Brası́lia HuB/Universidade de Brası́lia, Brasilia, Brazil
& 2007 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing
ISSN: 1076-0512 Dermatol Surg 2007;33:S207–S212 DOI: 10.1111/j.1524-4725.2007.33362.x
S207
FILLER RHINOPLASTY
injection, offering options not available through threading technique adjacent to the perichondrium
traditional correction.15,16 to enhance tip bulk, followed by filling of dermis or
superficial subcutaneous tissue to smooth out fine
The volume of material used for filler-based surface irregularities, using multiple injection points
rhinoplasty usually ranges from 0.1 to 0.4 mL.7 as needed from the infratip up to the supratip until
This feature makes filler-based rhinoplasty an achieving a desired effect. The latter required
excellent indication for patients who will be 0.10 mL.
treated with fillers for improvement of the lips
and nasal labial folds and are unsatisfied with Molding was done manually for the deeper planes
their nose. We present below two cases where immediately after injection and pressure kept for a
those treatments were combined leading to couple of minutes to stop bleeding. While perform-
excellent cosmetic results and increased patient ing dermal injections on the nasal tip, vigorous
satisfaction. molding was avoided to minimize filler extrusion.
Hemostasis of dermal injections was performed by
very light pressure using cotton tips. Pictures were
Technique taken before and two days after injection.
Informed consent was obtained from patients.
Blocking of the infraorbital and mentalis nerves was
achieved using 2% lidocaine with 1:100,000 epi- Case 2
nephrine before injecting fillers with a 27-gauge
Case 2 was a 52-year-old female. A total of 2.00 mL
needle. Blocking of the columella was not per-
of hyaluronic acid (Voluma, Corneal, Paris, France)
formed so as to not induce volume distortion from
was used, from which 0.2 mL was used for the nose as
the anesthesia.
follows: (1) 0.15 mL in the deep dermis or subcuta-
neous of the supratip; because of mild asymmetry of
Images were obtained with a digital camera. Photo-
the nose more volume was used on the right side and
graphs were trimmed, and blue ovals over the eyes
(2) 0.05 mL was applied in the radix (frontonasal
placed with computer software (Coreldraw, Ottawa,
angle). Before injecting the upper nose, the area was
Ontario, Canada). No additional modifications were
examined by gentle touch with the intent to feel any
performed.
pulsation from larger arteries. The filler was placed
more medially and we avoided puncturing areas
Age, sex, volume of material used, filling tech-
where such arteries were palpable. Before injecting,
nique for the rhinoplasty, and approximated
aspiration maneuver was attempted; there was no
interval between before and after pictures were
blood return. Pictures were taken before and 1 year
as follows:
after injection. Treatment of nasolabial folds and lips
was done with standard retrograde threading or
Case 1 multiple-point injection techniques.7
Case 1 was a 45-year-old female. A total of 2 mL of
porcine collagen (Evolence, Colbar, Herzliya, Israel)
was used for treatment of the nose, nasal labial folds,
Results
and lips. A total of 0.35 mL was required for the
filler rhinoplasty and used as follows: (1) 0.05 mL to All patients tolerated the procedure well with min-
the nasolabial angle (angle formed between the base imal discomfort under local anesthesia as above.
of columella and the upper lip) with a single punc- Follow-up of 1 year for Patient 1 and of 4 months for
ture. (2) For the nose tip, 0.20 mL was applied using Patient 2 did not reveal medium-term side effects.
S208 D E R M AT O L O G I C S U R G E RY
DE LACERDA AND ZANCANARO
Case 1
Case 2
S210 D E R M AT O L O G I C S U R G E RY
DE LACERDA AND ZANCANARO
Placing fillers in the radix or in the inferior portion single place because the filler will tend to vanish
of the glabella alters the frontonasal angle. This area faster, whereas when permanent fillers are used, the
can also be addressed when performing filler rhino- risk of long-term complications should be taken into
plasty as illustrated by Case 2. account.
Filler rhinoplasty can be performed as a single pro- In summary, filler rhinoplasty represents an excellent
cedure. Nevertheless, patients with mild to moderate alternative for patients who do not wish to undergo
nasal deformities coming primarily for the treatment surgery. It is a minimally invasive and cost-effective
of marionette lines or lip augmentation are excellent office procedure. It may lead to more harmonious
candidates for concomitant filler rhinoplasty because facial features and significantly enhances patient’s
usually only small amounts of material are required. satisfaction.
the retina or skin areas irrigated by the supratroch- 4. Brandt FS, Cazzaniga A. Hyaluronic acid fillers: Restylane
and Perlane. Facial Plast Surg Clin North Am 2007;15:
lear artery.19,20 63–76, vii.
fillers, one should avoid injecting large volumes in a 15. Baumann L. Dermal fillers. J Cosmet Dermatol 2004;3:249–50.
16. Gurney TA, Kim DW. Applications of porcine dermal collagen 20. Peter S, Mannel S. Retinal branch artery occlusion following in-
(Enduragen) in facial plastic surgery. Facial Plast Surg Clin North jection of hyaluronic acid (Restylane). Clin Experiment Ophtal-
Am 2007;15:113–21, viii. mol 2006;34:363–4.
17. Netter FH. Atlas of human anatomy. Basel, Switzerland: Ciba- 21. Glaich A, Cohen J, Goldberg L. Injection necrosis of the glabella:
Geigy; 1989. plate 17. Protocol for prevention and treatment after use of dermal fillers.
18. Janfaza P, Cheney ML. Superficial structures of the face, head, and Dermatol Surg 2006;32:276–81.
parotid region. In: Janfaza P, Nadol JB, Galla R, et al., editors.
Surgical anatomy of the head and neck. Philadelphia: Lippincott
Williams & Wilkins; 2001. pp. 24–5.
COMMENTARY
This article nicely outlines the technique of nasal augmentation with hyaluronic acid–based fillers and
represents yet another example of substituting fillers for traditional surgery. Of note, this technique also
works quite well with calcium hydroxyl apatite as the filling agent and is a useful for filling in small nasal
defects secondary to rhinoplasty or Mohs surgery. The concept of altering proportions to make the nose
appear smaller is the take-home message of this article. This can be accomplished as described here by
directly addressing the nose or by increasing the cheek volume and anterior projection of the midface
thereby causing a relative diminution in the proportion of the nose to the face as a whole. One word of
caution: when ‘‘blending’’ a dorsal nasal hump, the best candidates are noses where the hump appears in
the middle third of the dorsum and not high at the nasal root.
LISA DONOFRIO, MD
New Haven, CT
S212 D E R M AT O L O G I C S U R G E RY