Boston Cosmetic
Boston Cosmetic

















Boston Cosmetic


Rhinoplasty is technically demanding surgery, and even in the best of hands, postoperative healing and ultimate aesthetic outcome can be unpredictable. In addition to the risks of general anaesthesia, and a protracted postoperative convalescence, rhinoplasty may lead to adverse cosmeticsequelae. The refinement of techniques to restore facial volume with dermal fillers, and widely available botulinum injections to treat dynamic facial rhytids, has led to a surge in demand for non-surgical rejuvenation procedures. An increasingly well informed and discerning patient population now seek better value procedures that require minimal downtime and have instant results. Discreet volumetric changes in the fronto-nasal angle, nasal dorsum and nasolabial angle lead to significant differences in our perception of the nasal aesthetic. These areas can be injected with dermal fillers to rejuvenate the nasal profile and correct asymmetries.

The Renaissance artists sought to define beauty using objective mathematical models. The Fibonacci sequence (1, 1, 2, 3, 5, 8…) led to Phi the ‘Golden Number’ that defined beauty by symmetry and the apparent ratio of adjacent structures. The golden ratio, 1.61803, is reflected throughout nature, architecture, music and DNA. Ideal aesthetic nasal parameters for tip projection (facial margin- tip ⁄ dorsum), nasal length (radix to the tip defining point to the upper vermillion), and width (radix-collumella line to alar margins) all achieve the golden ratio. A multitude of techniques and refinements have since been described to surgically achieve the nasal aesthetic ideal. Whilst this ideal is subjective and dependent on ethnic variation, the rules of lengths, ratios and angles should be respected when planning surgical or non-surgical rhinoplasty.

Dermal fillers
Han et al. first described the concept of injectable filler rhinoplasty in 2006. They combined autologous human fibroblasts with hyaluronic acid and injected the nasal dorsum. By adding fibroblasts, the authors hypothesized that permanent collagen would remain following hyaluronic acid resorption. The volume replacement is expected to be maintained for1 year; however the technique was limited by significant preparatory time as the fibroblasts had to be harvested and cultured in vitro prior to injection.

Fillers can be broadly classified into fat, collagen, silicone, poly-l-lactic acid (PLLA), hyaluronic acids and calcium hydroxylapatite. The latter two are most appropriate for injection rhinoplasty, due to their excellent safety profile, predictable volume replacement, moulding capability and temporary nature. Hyaluronic acid is a naturally occurring glycosaminoglycan polysaccharide composed of alternating residues of the monosaccharides d-glucuronic acid and N-acetyl-dglucosamine found in mammalian dermis. Injectable hyaluronic acid was first approved by the FDA in 2003. It is a viscous clear gel derived from the cock’s combs of domestic fowl (Hylaform!) or from fermentation by Streptococci (Perlane!, Restylane!; Uppsala, Sweden, Captique, Juvederm Ultra!; Allergan, and Elevess!; Annika Therapeutics, Massachussets, USA). After implantation into tissues, hyaluronic acid strongly binds water to form hydrated polymers. From 6 months it is metabolized into carbon dioxide and water and eliminated by the liver; however, in our experience, Juvederm Ultra xc Lasts much longer in the nose (at least 18 months as demonstrated) compared with correction of dynamic facial soft tissue rhytids and folds. Calcium hydroxylapatite (Radiesse!) consists of a 30% concentration of 25–45 lm spherical particles suspended in sodium carboxymethylcellulose gel. It is FDA approved for facial soft tissue augmentation specifically correction of moderate to severe facial lines and folds and correction of soft tissue loss from HIV lipoatrophy, vocal cord augmentation and as a radiological tissue marker. Following injection, the gel is phagocytised and the calcium hydroxylapatite microspheres displace surrounding soft tissue. Collagen proliferation and slow degradation of the microspheres leads to a prolonged duration of effect up to 2 years. The microspheres are excreted as calcium and phosphate via the urinary system.

Nasal Defomities Correctable by Non-surgical Options:
Dorsal hump due to deep nasofrontal angle / Radix
Saddle deformity
Tip ptosis
Under-projection of the tip
Supratip depression
Lateral bony concavity

Adverse effects
Potential major complications of injection rhinoplasty include infection, ischaemic necrosis from arterial embolism, pressure necrosis from overinjection of nasal tip and osteophyte from periosteal injection. These risks may be reduced, with effective nasal analysis, meticulous injection technique, and a good understanding of nasal cartilaginous and vascular anatomy. Radix and upper nasal third injections should be medially placed to avoid the dorsal and lateral nasal arteries. Pre-injection palpation may aid identification, and aspiration before injection is mandatory. Intravascular filler injection can lead to arterial embolisation and subsequent skin necrosis or retinopathy.
Injection rhinoplasty is not a substitution for surgical rhinoplasty. There are many indications where it will be insufficient to achieve the desired aesthetic outcome; however, it may be a safe and effective solution to many nasal deformities. Noses that are significantly overprojected, or overrotated, have a shallow radix, and tension noses are better suited to surgical correction. It is however also useful postoperative adjunct to surgery or in those patients contemplating rhinoplasty. The non-permanence and minimal morbidity of associated with degradable fillers is especially beneficial to those patients who seek cosmetic rhinoplasty but are discouraged by the risks and convalescence of surgery.

Dr. Edwin Ishoo is a skilled and experienced facial cosmetic surgeon. If you are considering a non-surgical rhinoplasty, contact Boston Cosmetic Specialists for a confidential and complementary consultation with Dr. Ishoo.