You are on page 1of 6

Filler Rhinoplasty


Davi A. de Lacerda, MD, and Pedro Zancanaro, MD, have indicated no significant interest with commercial

T he nose is one of the most important cosmetic

units of the face. Discreet variations in the nose
shape lead to marked physiognomy changes. Many
fillers to rejuvenate the nose or improve nasal

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


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
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,
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

The volume used in the nose was distributed ac-

cording to immediate visually perceived improve-
ment of the frontonasal or nasolabial angles, as well
as of the nasal dorsum and tip. At each point the goal
was to establish volumetric correction to empirically
improve the overall harmony of the nose in relation
to other facial cosmetic landmarks and remaining
treated areas (nasolabial folds and lips).

Case 1

Case 1 showed marked marionette lines, asymmet-

rical lower lip, nasal dorsum irregularities, flat and
descendent nasal tip with irregular skin surface
(Figures 1A, 1C, and 1E). Collagen was used for
nasolabial folds and lips, increasing symmetry and
providing a younger appearance (Figure 1B). A
quantity of 0.05 mL of collagen was used to open the
angle between the philtrum and the columela re-
sulting in the perception of tip elevation from profile
view (Figures 1D and 1F). A quantity of 0.30 mL
applied adjacent to the cartilage or subcutaneous
tissue was used to reshape nasal tip and smooth it
out, respectively. The latter was essential for the
impressive cosmetic improvement seen in the pa-
tient’s profile. The patient was extremely satisfied
during her last follow-up visit, 4 months after the

Case 2

Atrophic lips and marked marionette lines were ob-

served previously to the procedure. The nose had an Figure 1. Patient 1: Before (A, C, E) and 2 days after (B, D, F)
filling with collagen. Injection of the descending, irregular
irregular dorsum with prominent tip. The patient nasal tip (0.3 mL) and of the nasolabial angle (0.05 mL) pro-
considered it too long (Figures 2A and 2C). Lip vided remarkable cosmetic improvement. Marionette lines
augmentation and filling of nasolabial folds with and lips were also treated.

hyaluronic acid equilibrated the aesthetic features of

the lower face. In addition, 0.2 mL of hyaluronic effect was minimal edema or bruising which com-
acid was used to straighten the nasal dorsum pro- pletely disappeared by the fifth day.
viding a youthful look and resulting in the illusion
of a smaller nose. Long-lasting results were seen
after 1 year (Figures 2B and 2D).
Dermatologic patients are increasingly requesting
All patients were extremely pleased with the results. procedures that are safe, require minimal downtime,
The procedure was very well tolerated. The only side and lead to objective results. These prerequisites

33:S2:DECEMBER 2007 S209


Figure 3. Diagram illustrating the dramatic changes in nose

profile obtained from injecting specific areas. (A) Tip lifting
effect, as seen in Patient 1: filling of the columella base
widens the nasolabial angle (green) enhancing the benefits
from reshaping the tip (red). (B) Rejuvenation effect, as seen
in Patient 2: injecting the supratip (red) and radix (green)
straighten the dorsum and makes the nose look smaller.
Figure 2. Patient 2: Before (A, C) and 1 year after (B, D) filling
with hyaluronic acid to nasal supratip (0.15 mL) and naso- are doing: giving the illusion of a smaller nose and
frontal angle (0.05 mL) effaced the prominent rhinion and not of an ‘‘augmented’’ one.
made the nose look smaller. Marionette lines and lips were
also treated.
Filler rhinoplasty is particularly indicated when there
have made resorbable fillers the gold standard ap- is a need to increase volume in the cartilaginous tip.
proach for the correction of marionette lines and Fillers can be injected directly on top of the under-
volumetric enhancement of the lips. lying cartilage providing bulk and also in the sub-
cutaneous tissue or dermis leading to a homogenous
Many patients seeking dermatologic treatment of surface. When volume is added to the columella base
marionette lines and lip augmentation are also dis- the nasolabial angle opens. This can be used to create
satisfied with the shape of their nose. Although the illusion that the tip of the nose has been lifted.
traditional rhinoplasty usually offers excellent Case 1 illustrates the dramatic effect obtained when
results, it remains a very invasive and expensive pro- both the tip and the columella are treated.
cedure. Such patients benefit from alternative treat-
ments used to modify the appearance of the nose. Filler rhinoplasty is also a good alternative when
addressing the aged nose. Senescence causes loss of
Fillers can be injected under or inside the nasal skin subcutaneous tissue present in the dorsum of the
leading to impressive changes on nose silhouette as nose. A prominent rhinion is an undesirable feature
demonstrated in this case report and illustrated by for most patients and also contributes to the per-
Figure 3. We propose using the term filler rhino- ception of a long nose. Injection of fillers in the su-
plasty instead of augmentation rhinoplasty because it pratip area makes the rhinion less prominent and
expresses more realistically to our patients what we therefore leads to the impression of a smaller nose.

S210 D E R M AT O L O G I C S U R G E RY

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.

Special attention should be taken when treating the

upper nose and glabellar area. Fillers should be
placed more medially to avoid large branches of the
dorsal nasal arteries and veins. The dorsal nasal
1. Constantinidis J, Daniilidis J. Aesthetic and functional rhinopla-
vessels originate from the ophthalmic ones which sty. Hosp Med 2005;66:221–6.
anastomose widely with the lateral nasal vessels,
2. Bracaglia R, Fortunato R, Gentileschi S. Secondary rhinoplasty.
branches of the angular artery, and veins.17,18 In- Aesthetic Plast Surg 2005;29:230–9.
travascular injection of fillers can lead to em- 3. Beer KR. Nasal reconstruction using 20 mg/ml cross-linked
bolization of such vessels with potential necrosis of hyaluronic acid. J Drugs Dermatol 2006;5:465–6.

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.

5. Ghersetich I, Lotti T, Campanile G, et al. Hyaluronic acid in cu-

A thorough understanding of the vascular anatomy taneous intrinsic aging. Int J Dermatol 1994;33:119–22.
of the upper nose and glabellar area is essential for 6. Bernstein EF, Underhill CB, Hahn PJ, et al. Chronic sun
decreasing the risks associated with filler rhinoplasty. exposure alters both the content and distribution of dermal
glycosaminoglycans. Br J Dermatol 1996;135:255–62.
Palpating the area before performing the injection
7. Fernandez EM, Mackley CL. Soft tissue augmentation: a review.
may also be helpful. The pulse of the lateral nose
J Drugs Dermatol 2006;5:630–41.
artery and dorsal nasal artery is palpable in many
8. Gladstone HB, Cohen JL. Adverse effects when injecting facial
patients. A blunt small bore cannula can be used to fillers. Semin Cutan Med Surg 2007;26:34–9.
avoid vascular perforation. Other prevention points 9. Duranti F, Salti G, Bovani B, et al. Injectable hyaluronic acid gel
for this region are: (1) placement of fillers superfi- for soft tissue augmentation: a clinical and histological study.
Dermatol Surg 1998;24:1317–25.
cially, (2) aspiration before injection, and (3) avoid-
10. Klein AW. Soft tissue augmentation: filler fantasy. Dermatol Ther
ing overcorrection. In case of complications from
hyaluronic acid fillers, treatment with hyaluronidase
11. Rostan E. Collagen fillers. Facial Plast Surg Clin North Am
can be helpful. If there are signs of thrombosis, an- 2007;15:55–61, vi.
ticoagulation should be considered.21 Visual im- 12. Han SK, Shin SH, Kang HJ, Kim WK. Augmentation rhinoplasty
pairment shortly after treatment with dermal fillers using injectable tissue-engineered soft tissue: a pilot study. Ann
Plast Surg 2006;56:251–5.
warrants emergent ophthalmologic consultation to
exclude retinal embolism. 13. Nicolau PJ. Long-lasting and permanent fillers: biomaterial in-
fluence over host tissue response. Plast Reconstr Surg
The duration of results is variable depending on 14. Hamilton MM, Hobgood T. Emerging trends and techniques in
which filler is used. When working with resorbable male aesthetic surgery. Facial Plast Surg 2005;21:324–8.

fillers, one should avoid injecting large volumes in a 15. Baumann L. Dermal fillers. J Cosmet Dermatol 2004;3:249–50.

33:S2:DECEMBER 2007 S211


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.

19. Shanz S, Schippert W, Ulmer A, et al. Arterial embolization caused

Address correspondence and reprint requests to: Davi A.
by injection of hyaluronic acid (Restylanes). Br J Dermatol de Lacerda, MD, Av. Angélica, 2530 Cj 46, São Paulo,
2002;146:928–9. SP 01228-200 Brazil, or e-mail:

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.

New Haven, CT

S212 D E R M AT O L O G I C S U R G E RY