Aesth Plast Surg
https://doi.org/10.1007/s00266-020-01836-6
ORIGINAL ARTICLE
Hyaluronic Acid Filler in the Treatment for Drooping Tip:
Anatomical Concepts and Clinical Results
Helena Hotz Arroyo Ramos1 • Ingrid Paula Lückmann Bernardino2
Ritha de Cássia Capelato Rocha3
Received: 8 May 2020 / Accepted: 9 June 2020
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020
Abstract The plunging nasal tip is a challenging condition
because, although it is predominantly a dynamic deformity
which occurs during smiling, it also indicates a structural
problem. When a person smiles, the paired depressor septi
nasi muscles pull the tip caudally at the same time as the
levator labii superioris alaeque nasi muscles pull the alar
base and lateral lip cephalically. This movement causes
straightening of the alar rim. Even though surgical rhino-
plasty is the gold standard to restore nasal appearance, the
procedure may fail to treat the dynamic cause of the
drooping tip. This article outlines the anatomical concepts
that lead to a drooping tip and presents a technique that can
treat both the dynamic and structural causes of the droop-
ing tip using hyaluronic acid filler. Cases are also presented
that illustrate these concepts.
Level of evidence IV This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Fillers  Nose filler  Augmentation
rhinoplasty  Hyaluronic acid  Injectables  Aesthetic facial
procedures
Electronic supplementary material The online version of this
article (https://doi.org/10.1007/s00266-020-01836-6) contains sup-
plementary material, which is available to authorized users.
& Helena Hotz Arroyo Ramos
contato@drahelenaramos.com.br
1
Vitoria, Brazil
2
Florianopolis, Brazil
3
Maringa, Brazil
RHINOPLASTY
•
Introduction
Rhinoplasty is the third most common cosmetic plastic
surgery procedure. However, in 2018, the number of pro-
cedures showed a slight decrease when compared to 2017
[1]. On the other hand, the number of patients requesting
procedures using soft tissue fillers continued to increase
[1], including nonsurgical rhinoplasty with hyaluronic acid
(HA) filler [2]. This may be due to the less invasive nature
of these procedures and minimal downtime compared to
surgical cosmetic procedures. Even though surgical
rhinoplasty is the gold standard for reshaping the nose,
nonsurgical rhinoplasty can lead to good outcomes and
includes procedures to rectify a drooping nasal tip [3].
The plunging nasal tip is a challenging condition
because, although it is predominantly a dynamic deformity
which occurs during smiling, it also indicates a structural
problem [4, 5]. There is no consensus on whether the tip
actually droops during smiling due to the combined action
of upper lip elevators and the downward pull of the
orbicularis oris, myrtiformis, and depressor septi nasalis
(DSN) muscles or whether this is an illusion caused by a
disproportionate elevation of the alar crease and the pos-
terosuperior movement of the subnasale [6]. As a conse-
quence, various management techniques have been
described for its correction, such as DSN transection and
transposition [7], release of the levator labii superior
alaeque nasi (LLSAN) muscles [5], rhinoplasty surgical
techniques that increase tip rotation [8], and even botuli-
num toxin injections into the DSN and LLSAN muscles to
correct tip ptosis [9]. However, very few studies have been
published regarding the treatment for this deformity using
HA filler, especially addressing the myomodulatory effect
of HA [10].
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The aim of this article is to introduce a method of
treating the plunging tip with HA filler based on anatomical
concepts and to present cases that illustrate the use of this
approach.
Materials and Methods
This is a descriptive study that discusses some of the pearls
in approaching patients with drooping nasal tip using
hyaluronic acid filler.
Anatomy of the Lower Third of the Nose Focused
on HA Filler
External Contours
The nasal tip is a complex three-dimensioned structure and
should be analyzed mainly in frontal and profile views. The
oblique view can be complementary. The frontal view
requires more detailed analyses than the profile view. This
is because, when viewed from the front, highlights and
shadows are formed on the nasal surface as a consequence
of structures along the vertical, horizontal, and anteropos-
terior directions. The first light reflections that can be seen
appear along the most prominent convexities, i.e. the gla-
bella, dorsum, and nasal tip. An outline of the highlights
cast on the nose should form a subtle hourglass shape,
created by two lines that extend superiorly from each
medial brow, overlying the supraorbital rim to join the
radix, then gradually narrowing to form relatively parallel
lines along the dorsum, and then smoothly diverging to
reach the tip-defining points [11] (Fig. 1). This concept of
highlights and shadows is crucial when reshaping the nose
Fig. 1 Two slightly curved divergent lines of the ideal nasal dorsum
in frontal view
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Aesth Plast Surg
with HA filler, as these injections create new convexities
that change the light reflections and, therefore, the shape of
the nose. For instance, one can create an impression that
the tip narrows by injecting filler into the tip midline [3].
The tip profile requires a two-dimensional analysis
focusing on the supratip, tip, infratip lobule, and columella
(Fig. 2a). The desired tip–supratip relationship is when the
tip-defining points lead the supratip by 1 to 2 mm, so that
the tip projects above the dorsum with a supratip break.
The transition from the tip to the infratip lobule is graceful
and the transition to columellar–lobular angle is soft,
having a proportional alar–columellar relationship. The
ideal nasolabial angle is 93.9 to 97.3 degrees for men and
96.8 to 100.2 degrees for women [12]. The tip-defining
points also play an important role in profile view because
they are the final landmarks of nasal length that can be
defined as a line from the radix to the tip (Fig. 2b). One can
change the tip-defining points by injecting the filler
somewhere more cranially (to shorten the nose) or caudally
(to elongate the nose) from the original tip.
In both views, skin thickness assessment is helpful
before injections to determine how well the external
envelope will cover the underlying filler. Medium-thick-
ness skin is the most ideal setting. Skin that is excessively
thick masks the underlying filler leading to decreased
definition or refinement. Overly thinned skin has the
opposite effect and can lead to altered skin color compli-
cations, such as the Tyndall effect, creating a blue-tinted
hue in bright light.
Anatomic Support in the Lower Third of the Nose
The classic three major structures that provide tip support
are the following: (1) intrinsic integrity of the alar carti-
lages; (2) medial crural footplates to the caudal septum;
and (3) the scroll junction between the upper lateral and
lower alar cartilages [13].
More recently, Daniel and Palhazi [14] postulated a
more dynamic concept for the nasal tip. Through anatom-
ical studies, they concluded that a solid foundation for the
lower third of the nose begins with the intrinsic integrity of
the alar cartilages, which are held together by ligaments.
These cartilages are then encased in the nasal superficial
muscular aponeurotic system (SMAS). Thus, the alar car-
tilages are controlled by the SMAS and act as a dynamic
structure that abuts the cartilaginous framework.
In any event, the lower lateral cartilages (LLC) play an
important role in the structuring of the nasal tip. Each
lower lateral cartilage is composed of medial, intermediate,
and lateral crura (Fig. 3). The medial crura are crucial for
tip foundation, and they should extend down to the base or
pedestal (Fig. 3), which is composed of the nasal spine and
medial crural footplates. Patients more likely to have good
Aesth Plast Surg
Fig. 2 a Important anatomic landmarks in profile view. b Schematic drawing of the nasolabial angle, columellar/lobular angle and nasal length
Fig. 3 Anatomy of the lower lateral cartilages
tip projection are those with long and strong medial crura
that extend to the nasal spine, which should be positioned
as anteriorly as possible. On the other hand, those patients
who have short medial crura that do not completely extend
down to the nasal spine, have flaring footplates at the
midcolumella and are more likely to have a droopy nasal
tip [11]. This is a delicate situation, and if they are good
candidates for HA injections, the injector should be careful
not to widen the nasal base and then narrow the nostrils.
The transition from medial crus to intermediate crus
creates a lateral flare, and the divergence of the interme-
diate crura creates the columellar–lobular angle, or double
break [11] (Fig. 2b). The domes are the most projecting
points of the lower lateral cartilages where the intermediate
crura bend sharply to form the lateral crura (Fig. 3).
Anderson’s Tripod Theory is a well-accepted principle
in rhinoplasty [15]. Each lateral crus represents one leg of
the tripod, whereas the medial crura together represent the
third leg. The bone support around the piriform aperture
also contributes to the lifting ability of the tripod. On the
other hand, a wider bone around the piriform aperture may
result in the appearance of nose elongation and drooping
nasal tip noticed with aging of the boney elements [16].
Rotation of the tip can be accomplished by shortening the
lateral crura with an overlay surgical procedure, which is
not possible with HA fillers. The other mechanisms of tip
rotation are lengthening the medial crura or setting the
entire tripod on a more prominent base, and this is the aim
of the technique described in this article. For instance, the
medial crural leg of the trip can be lengthened with
placement of filler under the base of the medial crura [3]. In
this manner, HA filler in the nose can only accomplish an
augmentation. However, if positioned in the right place, it
can create an illusion that the nose is shorter or thinner.
Understanding the Drooping Tip
Lack of Support
A widened piriform aperture contributes to the appearance
of to the drooping nasal tip and nose elongation, similar to
what happens in the aging nose [16]. A lack of projection
of the anterior nasal spine also contributes to the lack of
support that distorts the nose position. In some patients,
this condition is accompanied by an underdeveloped col-
umella, and a deficit in the projection of the upper maxilla.
The lack of structural and mechanical support results in
excessive movement of the upper lip levators (LLSAN,
levator labii superioris, and zygomaticus minor), which
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leads to collapse of the tip of the nose and widening of the
nasal flare [10]. These are the same mechanisms that result
in a gummy smile. For this reason, the physician must pay
attention to the patient’s smile before performing the liquid
rhinoplasty in order to preserve or alter the smile according
to the patient’s requirements.
Muscular Dynamics
According to Daniel and Palhazi [14], the alar cartilages
are dynamically mobile and controlled by the SMAS that
act as a dynamic structure that abuts the cartilaginous
framework. In this sense, it is reasonable to understand
why the tip moves when making facial expressions, espe-
cially when smiling.
There are two different theories for the plunging tip.
Many authors believe that the tip truly droops during
smiling due to the combined action of the upper lip ele-
vators while the orbicularis oris, myrtiformis, and depres-
sor septi nasalis (DSN) muscles pull the tip caudally [7].
Another group advocates that the plunging tip is an illusion
because, when smiling, the alar crease rises, the subnasale
moves posterosuperiorly, and the alar rim straightens
(Fig. 4). This, combined with the alar crease–cheek junc-
tion rising above the nasal tip-defining points, gives the
plunging tip illusion [6].
Addressing the Plunging Tip with Injectable Fillers
Choosing the Filler
Because the injections are made just above the periosteum
and the perichondrium, a high elastic modulus (G’) filler
must be used [17]. This choice can be justified not only for
Fig. 4 When a person smiles,
the paired depressor septi nasi
muscles pull the tip caudally at
the same time as the levator
labii superioris alaeque nasi
muscles pull the alar base and
lateral lip cephalically. This
movement causes straightening
of the alar rim. A deficient nasal
spine leads to posterosuperior
movement of the subnasale.
Secondary effects include a
midphiltrum crease and gummy
smile
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Aesth Plast Surg
its lifting capacity, but also for its longevity, minimal
possibility of migration, and lower product usage [18].
A filler with a high degree of cross-linking may require a
greater volume of hyaluronidase to resolve an overcorrec-
tion or to treat vascular complications [19].
The Four-Step Technique
1. Piriform aperture
The authors suggest using a 27-gauge needle that must
touch the bone. Aspiration for 10 s is mandatory, and a
new needle must be used on each side. A bolus of
0.15–0.3 mL, on average, must be slowly injected at
each point at the supraperiosteum level.
2. Premaxilla/columella
For this step, the authors suggest using a 22-gauge
cannula with the port site created by a 20-gauge
needle. The product must be injected at the projection
of the anterior nasal spine on the periosteum. The
amount injected must be no more than 0.2 mL, so as
not to compromise the smile of the patient. The pinch
technique (that is, the injector places his or her fingers
on each side of the medial crural footplates) helps to
place the HA filler correctly and to avoid its unnec-
essary spread. The same port site can be used to fill the
columella by orientating the cannula in an upward
direction. The filler must be placed in the intercrural
space, with a retrograde linear threading technique.
Typically, 0.1–0.2 mL is required for this maneuver.
3. Tip
The authors suggest another entry point in the infratip
lobule. The skin and soft tissue envelope can be tented
up to reduce the risk of intravascular injection. The
cannula can serve as a guide, and the physician can
choose the location for placement of the filler by
Aesth Plast Surg
looking at the profile while moving the cannula
(Fig. 5). The HA will be placed right on the
perichondrium layer of the tip cartilages and supratip.
The filler can then be shaped with the fingers to better
accommodate the product. The suggestion is to inject
0.02 to 0.08 mL at each of the desired new tip-defining
points. In some cases, a central point injection is
needed to create a smoother tip or to make it narrower.
4. Radix
It is common for patients with a plunging nasal tip to
have a low radix. If so, the authors suggest filling this
area to better balance the nose using a 27-gauge needle
that must touch the bone. Aspiration for 10 s is
mandatory and a new needle must be used. A bolus of
0.02–0.4 mL can be injected in this area, preferring
midline injections and the supraperiosteal level.
The authors suggest that the total volume injected should
not exceed 1 mL per session. If any additional filler is
needed, a second ‘‘touch-up’’ injection can be proposed to
correct as few remaining imperfections as possible. No
antibiotics are needed before or after injections.
Post-procedural care is of great importance and there are
four important restrictions:
1. Do not bandage as it can mask any complications,
especially the vascular ones.
2. Do not ask the patient to massage because it can
change the result.
3. Do not apply a cold compress as it may compromise
local vascularization.
4. Do not use glasses for 7 days because they can leave
unwanted marks.
Fig. 5 Cannula acting as a guide to choose the position for the filler
deposit
Results
We present cases that illustrate the use of this approach.
In Case 1 (Fig. 6), before the injections, the alar crease–
cheek junction rose above the nasal tip-defining point when
the patient smiled and the alar rim straightened. The
depressor muscles of the nose were less efficient in this
case. After treatment, the action of the levator muscles
decreased, and the tip became less free to move.
Case 2 (Fig. 7) is a good example of a young woman
who presented with the subnasale moving posterosuperi-
orly when smiling, mainly due to a short medial crura and
posterior nasal spine. After treatment, an appearance of
lengthening of the medial crura was achieved, as well as
blocking the movement of the subnasale and the alar
crease.
Case 3 (Fig. 8) is a young patient with a long nose and
lack of tip projection that became droopy on smiling. After
injection, it is notable that the length of the nose was
shortened, tip projection was enhanced, and cephalic tip
rotation was achieved.
In Case 4 (Fig. 9), a young woman presented with a
strong depressor septi nasi muscle pulling the tip down
when smiling, combined with a deficient nasal spine, and
this led to a retracted columella and a midphiltrum crease.
After the four-step filling procedure, a more restrained nose
was achieved when smiling, the crease was softer, and a
more attractive columella–ala relationship was created.
Case 5 (Fig. 10) illustrates a 1-year follow-up of a
nonsurgical rhinoplasty: it is possible to note that the filler
had been reabsorbed but the appearance of the nose was not
the same as before the first procedure.
No botulinum toxin injections were performed with HA
fillers in any case.
Discussion
Rhinoplasty remains one of the most technically and
artistically challenging procedures in plastic surgery [20]
and sometimes has unpredictable outcomes. For this rea-
son, alternative techniques that achieve good shaping of the
nose with less invasive maneuvers and without incurring
major periods of convalescence continue to arise. The
technique proposed in the present study aims to treat a
drooping nasal tip by reshaping the nose through changes
in both structural and dynamic mechanisms that lead to a
plunging nasal tip when a person speaks or smiles. If the tip
is dynamically mobile [14] and the drooping tip is
emphasized when smiling, it is reasonable to try to atten-
uate this freedom of movement of the plunging tip.
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 Aesth Plast Surg

Fig. 6 Case 1 first line: before treatment, when smiling, the plunging volume: bilateral piriform aperture: 0.2 mL on each side; premaxilla:
tip was mainly due to a nasal flare in an upward direction because 0.05 mL; columella: 0.1 mL; tip: 0.15 mL; radix: 0.1 mL. A
there was an over-contraction of the levator labii superioris alaeque complementary volume of 0.1 mL was injected into the supratip
nasi (LLSAN) muscles. Proposed treatment: product: Restylane Lyft; area for a more accurate outcome. Second line: right after treatment

Fig. 7 Case 2 first line: before treatment, a short medial crura and volume: bilateral piriform aperture: 0.25 mL on each side; premax-
posterior nasal spine led to the subnasale moving posterosuperiorly illa: 0.1 mL; columella: 0.1 mL; tip: 0.12 mL; radix: 0.03 mL.
when the patient smiled. Proposed treatment: product: Restylane Lyft; Second line: right after treatment

Filling the piriform aperture can lead to three effects: (1) by filling the concave space, which diminishes the gliding
a decrease in the sliding effect of the muscles in this area zone; (2) promotion of myomodulation of the LLSAN

123
Aesth Plast Surg

Fig. 8 Case 3 first line: before, the tip had insufficient support. Proposed treatment: product: Restylane Lyft; volume: bilateral piriform aperture:
0.1 mL on each side; premaxilla: 0.2 mL; columella: 0.1 mL; tip: 0.2 mL; radix: 0.1 mL. Second line: right after treatment

Fig. 9 Case 4 first line: before treatment, the patient presented a treatment: product: Restylane Lyft; volume: bilateral piriform aper-
strong depressor septi nasi muscle that pulled the tip down when ture: 0.3 mL on each side; premaxilla: 0.1 mL; columella: 0.1 mL;
smiling, a retracted columella and a midphiltrum crease. Proposed tip: 0.7 mL; radix: 0.1 mL. Second line: right after treatment

muscles; and (3) support for the lateral crus of the LLC, Augmentation of the columellar–labial junction with
which has a bearing on tip projection (according to the plumping cartilage grafts provides the illusion of nasal
tripod theory discussed earlier). shortening [21]. The same effect can be accomplished with
filler. Moreover, filler can also improve nasal tip projection

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Fig. 10 Case 5: This patient was first injected with Juvederm Ultra Plus with the four-step technique. After 1 year postoperatively, the filler had
been reabsorbed but the appearance of the nose was not the same as before the first procedure
[22]. In addition, the depressor septi nasalis (DSN) muscles
can also be affected by myomodulation, pulling the tip
down weakly.
Tip projection and rotation can be enhanced by the
injection of HA filler at a point more cranially than the
original tip, as with an on-lay tip graft. At the end of this
step, it is possible to notice that the original tip-defining
points have become the intermediate crura as part of the
columellar–lobular angle, and the original supratip is filled
and becomes the tip (Fig. 11). With this maneuver, the
Fig. 11 The four steps in the HA filler procedure are represented in
green. Note the change in tip support and tip contour. The former tip-
defining point is now part of the lobule and the new tip contour is
placed more cranially
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Aesth Plast Surg
physician can shorten the nose while increasing tip rotation
and projection. Filling the tip and radix in the same pro-
cedure causes a stretch in the lax tissue, expanding the
superficial muscular aponeurotic system (SMAS) of the
nasal dorsum, which may also help to decrease tip droop
when smiling.
Filler complications are traditionally divided into four
categories: allergic, infective, late-onset nodules/inflam-
mation, and intravascular events [23]. It is crucial for
physicians to be aware of the management of potential
complications, especially vascular ones [24]. A detailed
understanding of the anatomy of the area to be injected is
very important to avoid accidental intravascular compli-
cations that can lead to vision loss with or without skin
ischemia [25]. These complications can be reduced or even
prevented by a vigilant, systematic approach [26]. For
injections into the supraperiosteal level, such as the piri-
form aperture and radix, direct percutaneous injection with
a needle is preferred by the authors, because this can allow
a more accurate injection into a deep level, which can
reduce complications [27]. Aspiration before injection is
always warranted, although it is not a guarantee of
extravascular location [28]. The authors choose to aspirate
for an average of 10 s based on the study of Van Loghem
et al., who found that the reliability of aspiration was 37%
(positive within 1 s) and 74% (positive up to 10 s of
aspiration), when using needles [29]. Furthermore, Wang
et al. evaluated syringes of ten commonly used HA fillers
and the mean time to flash was 3.1 s with a maximum of
Aesth Plast Surg
10.5 s [30]. Although the waiting times to view flashback
may be affected by physiochemical and rheological prop-
erties such as elastic modulus (G0 ), viscous modulus (G00 ),
and complex modulus (G*), aspirating for 10 s can be safer
than less. For the other areas (premaxilla, columella, and
tip), the authors preference is a 22G cannula. If the
physician faces a complication, even performing the pro-
cedure with the ideal approach, it is prudent to have easily
accessible practice protocols and algorithms to ensure the
optimal management of untoward events [26]. The authors
follow the Global Aesthetics Consensus [23].
Although HA filler is known to be reabsorbed, the
authors have subjectively observed that it seems to leave
healing legacies that may lead to persistent long-term
minor effects. There are no clinical trials that support this
information, but Mochizuki et al. [31] demonstrated, in a
rat model, that part of the volume injected can be main-
tained in the long term by replacing part of the injected
hyaluronic acid filler with autologous tissue. The last case
(Fig. 10) presented here illustrates a 1-year follow-up of a
nonsurgical rhinoplasty.
It is also important to stress that, if the patient has any
airway obstruction or a concern about frontal view
appearance, surgical rhinoplasty must be considered
because, with nasal filler, the most important changes are
seen in profile view and no functional improvement can be
achieved [32].
This study has several limitations. First, it is based on
subjective observations of the authors, which should be
considered when interpreting this data. Subsequent studies
should objectively measure the length of the nose, the
enhancement of tip projection, and the cephalic tip rotation
achieved by the nasal filler. As the same way, studies with
a larger population and with a longer postoperative period
are needed.
Conclusions
Although surgical rhinoplasty is the gold standard for
reshaping the nose and treating nasal obstructions, hya-
luronic acid filler is a possible treatment for drooping tip
because it can address the main causes of the deformity.
With this treatment, the dynamic deformity is resolved and
the structural support is enhanced. However, it is not a
permanent procedure and both physician and patient should
be aware of the limitations and complications, especially
vascular ones.
Funding The authors received no financial support for the research,
authorship, and publication of this article.
Compliance with Ethical Standards
Conflict of interest The authors declare no potential conflicts of
interest with respect to the research, authorship, and publication of
this article.
Ethical Approval For this type of study, formal consent is not
required (retrospective study).
Informed Consent All patients provided written consent for the use
of their images.
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