Overview of Filler Rhinoplasty
The use of injectable fillers to modify the shape or look of the nose, also known as nonsurgical rhinoplasty, is becoming increasingly popular. This method is appealing to many people because it doesn’t carry the same risks, costs, and recovery time typically associated with surgical nose jobs.
Despite these potential benefits, nonsurgical rhinoplasty can be complex and carries its own set of risks. Therefore, it should only be performed by highly-skilled professionals who are knowledgeable about the detailed structure of the nose and safe practices for injection.
Anatomy and Physiology of Filler Rhinoplasty
Knowing about the structure of the nose is very important for safe and successful non-surgical nose jobs using filler. Now, let’s try to understand the different parts of the nose you would encounter during a non-surgical nose job, starting from the outside and moving inward:
First is the skin, which is thickest at the tip and the root of the nose, and thinnest at the bridge. People of Asian and African background usually have thicker and oilier nose skin, which might make the procedure a bit trickier.
Next is the superficial fat, where major blood vessels are located. Then we have the superficial musculoaponeurotic system, a thin layer where major blood vessels may also be found.
Beneath that is the deep fat – an ideal place for injecting the filler because it has few blood vessels. Small branches of arteries may be found here, so the filler should be injected slowly and in small amounts to ensure precision and safety.
The perichondrium and periosteum are a thin layer covering the cartilage and bone. Last but not least are the nasal cartilages and bones.
The primary blood vessels in the nose come from the internal and external carotid systems, particularly from the ophthalmic and facial arteries. The upper part of the nose is supplied by the ophthalmic artery while the lower part is supplied by the facial artery.
When performing a filler nose job, the filler is usually injected into the deep fat area to avoid blocking the blood vessels, which can cause problems like skin death or even blindness. It is equally important to understand the relevant terminology.
For instance, “Anatomic dome” refers to the most forward-projecting part of the two lower side cartilages between their beginning and end. “Columella” is the pillar that separates the nostrils at the base of the nose. “Dorsum” refers to the frontal surface of the nose between the tip and the root.
A thorough analysis of the nose can be done only with a good understanding of the anatomy of the nose. This includes being familiar with the recognized proportions and angles relevant to the nose and face, and also taking cultural and ethnic preferences into account. Ultimately, the goals concerning the desired look of the patient are more important than classical ideas of attractiveness when deciding how to reshape the nose using injectable fillers.
Why do People Need Filler Rhinoplasty
A non-surgical nose job could be an option to fix minor cosmetic issues with the nose, especially for patients who want to avoid the cost, recovery time, and risks associated with traditional nose surgery. Basically, the types of problems that can be improved with non-surgical nose jobs are similar to those fixed by cartilage grafts (a procedure where cartilage is placed in different parts of the nose) done during a surgical nose job. However, non-surgical nose jobs often make more subtle changes.
A non-surgical procedure uses injectable fillers, or soft gels, to help fix things like a low or deep starting point of the nose, a bump in the nose, a shallow or flat brow bone (common in people of African or Asian descent), irregularities in the upper and middle third of the nose (for example, a crooked nose), a blunted nose tip, irregularities in the nostril rim, and minor asymmetries or irregularities after a surgical nose job.
Some experts argue that cleverly placed filler can also improve the functionality of the nose. This claim, however, remains controversial.
It’s important to note that while non-surgical nose jobs might seem appealing because of their simplicity, there’s also a safe, reliable, and permanent alternative in a well-executed surgical nose job. So, every patient considering a non-surgical nose job should also explore the possibility of a traditional surgical nose job.
When a Person Should Avoid Filler Rhinoplasty
Doctors who offer nonsurgical nose reshaping, or rhinoplasty, need to carefully assess which cases might be better suited for surgery. It’s generally the case that nonsurgical rhinoplasty won’t work as well for people with more severe nose issues, like distinct humps or severely crooked noses, noses that tilt up too much or noses with a lumpy or uneven tip. For people wanting to make a hump in their nose smaller, especially if the “nose bridge” is quite high, surgery is usually the best option. Doctors have to be clear with people that fillers, which are substances injected into the nose, can’t make the nose smaller. They can, though, make the nose look slimmer or more refined by adding volume to some areas, like the bridge of the nose or the tip. It’s important for doctors to manage people’s expectations about what can be achieved during the consultation.
There are some people who shouldn’t use fillers at all. This includes people who have a history of autoimmune diseases, which is when the body’s immune system attacks its own cells, people with bleeding disorders, and people who have had an allergic reaction to any of the components in the filler, such as lidocaine (used to numb the area). If there’s any inflammation or infection near where the injection would be given, fillers should be avoided. They should also not be used by pregnant or breastfeeding women. People who have frequent flare-ups of the herpes simplex virus (the virus that causes cold sores) are advised to take antiviral medication beforehand.
People who have had a nonsurgical nose reshaping procedure before using silicone, or an unknown injection material, should avoid having a nonsurgical rhinoplasty. People who are suspected of or known to have body dysmorphic disorder (BDD), a mental health condition where a person obsesses over perceived flaws in their appearance, should be referred to a psychiatrist before considering nonsurgical rhinoplasty. This is because they often feel dissatisfied after such procedures and may cause trouble for those who perform them. Up to 43% of people seeking cosmetic nose reshaping may have BDD.
Specifically for nonsurgical rhinoplasty with fillers, people who are currently taking blood thinners, platelet inhibitors (which stop blood clots), and non-steroidal anti-inflammatory drugs (NSAIDs, which reduce pain and inflammation) should be cautious due to the increased risk of bleeding and bruising. The same goes for people taking certain herbal medications or supplements, such as chondroitin, ephedra, echinacea, glucosamine, ginkgo biloba, goldenseal, milk thistle, ginseng, kava, and garlic. To lessen the chance of problems like bleeding and bruising, these should be stopped a few days before and after the procedure. Extra care is needed for people who have had a nose implant or a previous nose reshaping procedure, due to potential complications like infection and poor circulation in the tissues. That’s why some experts recommend waiting a year after having nose surgery before having injections.
Equipment used for Filler Rhinoplasty
In non-surgical nose reshaping, the most commonly used fillers are hyaluronic acid (HA) and calcium hydroxyapatite (CaHa). The choice of which filler to use depends on certain key characteristics. These include whether the filler can be reversed, how long it lasts, and how firm or stiff it is. Other practical factors like what’s available in the patient’s country can also influence this decision. More details on the varieties of filler for non-surgical nose jobs can be found in the review article by Friedman and Wang.
The safest fillers are those that can be easily dissolved and reversed. A good example is HA, which can be quickly dissolved with an enzyme called hyaluronidase. This feature makes it particularly safe especially if there’s a risk of blocking blood vessels and enables corrections of overdone or misplaced injections.
Another important factor to consider is how long the filler lasts. Generally, HA fillers work for 6 to 12 months, while CaHa fillers can last up to 18 months, and even longer due to collagen production from repeated treatments. It’s important that patients understand that maintaining results of a non-surgical nose job requires regular injections, no matter what type of filler is used.
The stiffness of the filler, known scientifically as the ‘elastic coefficient’ or ‘G-prime’, is also crucial. Stiffer fillers like CaHa resist change in shape providing a good filling with less product, but they can cause more swelling and discomfort after the procedure and may feel less natural than softer options like HA.
Permanent fillers like silicone and polymethylmethacrylate should usually be avoided because they can cause lumps (granulomas) and irreversible problems, including damage to blood vessels.
The ideal filler for non-surgical nose reshaping combines safety, ease of injection, and lasting support for the nose. Because it is safe and causes minimal distortion, HA is preferred by about 80% of practitioners. However, some doctors prefer CaHa for its longer duration, ability to be shaped, and increased firmness. The ultimate decision depends on the specific needs and preferences of each patient.
The type of injection technique can also impact the procedure. A small blunt instrument called a cannula, may reduce the risk of blocking blood vessels. Despite this, cases of tissue damage and blindness have been reported with its use. When larger, flatter areas need to be injected, using a cannula can be advantageous as it minimizes tissue trauma and makes the procedure quicker by reducing the number of injection points. A small needle, on the other hand, provides precision and accuracy. Regardless of the method, a careful injection technique is critical.
Commonly required items for the procedure include disinfectant wipes, topical anaesthetic, a marking pen, gauze (for controlling bleeding), and a lubricant for reshaping the nose.
Every doctor performing non-surgical nose jobs with fillers should have an emergency kit ready in case of blood vessel blockages. This should include items like nitroglycerin paste, nitroglycerin tablets, aspirin, warm compresses, hyaluronidase (the enzyme that can dissolve HA), topical timolol (a medication to reduce intraocular pressure), corticosteroids (used to treat inflammation), and mannitol / acetazolamide (used to relieve eye or brain swelling).
Who is needed to perform Filler Rhinoplasty?
Other than the doctor who carries out the treatment, an assistant is also involved in the process. The assistant’s job includes preparing the required treatment substance, cleaning the area on the skin to be treated, and applying a pain numbing cream. Moreover, the assistant can also keep track of where and how much of the substance has been used. The assistant may also use methods like gentle shaking or massage to lessen any discomfort you might feel during injections.
Preparing for Filler Rhinoplasty
Before a non-surgical nose job, your doctor will thoroughly check your medical history and examine your nose, making sure there are no conditions that may prevent you from getting this procedure. They’ll also take photos of your nose before the procedure and again one or two weeks after it. This is done to see the changes in your nose. Your doctor may also use digital imaging software, which can help you understand what your nose may look like after the treatment and ensure that your expectations are realistic.
Before the procedure starts, they’ll clean your skin with disinfectant wipes with a compound called chlorhexidine gluconate – these are specially designed to kill any bacteria on your skin. After that, they’ll apply a special cream, called a topical anesthetic (usually lidocaine), to numb your nose. This is done about half an hour before the procedure to ensure your comfort.
Then, your doctor will use a special pen to mark key points on your nose. This helps them accurately shape your nose and highlights the areas they need to pay special attention to. These points could include the straight line right down the middle of your face (midline), the area between your eyes at the top of your nose (nasion), the top of the bridge of your nose (rhinion), and the tip of the nose. Any areas where the shape of your nose dips in (concavities) or any other irregularities will also be marked to help your doctor know where to apply the treatment.
How is Filler Rhinoplasty performed
It’s very important to note when performing a non-surgical nose job that safe injection techniques must be followed. This involves injecting filler into an area with few blood vessels, keeping the injections in the center of the nasal area to avoid a lopsided result, pulling back the plunger of the needle slightly to ensure the needle isn’t inside of a blood vessel, injecting slowly in small amounts, and trying to use as few injection sites as possible. Using a needle with a blunt tip may lower the risk of injecting filler into a blood vessel. Also, using both hands — one for injecting and the other for steadying the needle or molding the injected filler, may result in safer, more consistent results.
A non-surgical nose job is fairly simple and focused on enhancing the natural structure of the nose bit by bit with injections of filler. There are many ways to do this, different types of fillers to use, and different injection methods, but the key is to use safe injection practices and to base the treatment plan on the individual’s facial anatomy. For doctors who have been trained in surgical nose reshaping, the use of filler in a way that simulates the application of grafts (or tissue transplants) within the nose, may be an intuitive way to go.
Here are a few areas of the nose that can be addressed with a non-surgical nose job, and the simple steps required to create good results:
The elevated part of the nose, right between the eyes (the radix), and the ridge of the nose (the dorsum) can be enhanced by determining the desired height and shape of these areas, and using a needle to carefully inject filler into the selected areas. The injection is made straight down into the middle of the nose. A cannula, which is less sharp than a needle, can also be used to enhance these areas by injecting filler under the skin and above the facial muscles. If you go this route, be careful not let the filler spread too far and always massage the skin after injection to create a smoother shape.
If you have a bump on the nose, this can be minimized by injecting filler above and/or below the bump on the ridge (dorsum) of the nose, which can create the illusion of a smoother nose. Like with the previous method, you must decide on the desired shape and height before injecting.
A crooked nose can be corrected by injecting filler into the nasal sidewall in addition to the dorsum to camouflage the irregular shape. But be careful when injecting in this area because it is full of blood vessels. Refrain from injecting the filler near the groove between the nose and the cheek to avoid injecting into a blood vessel. Midline injections are preferable, and the filler can be spread to the sides, if needed, through massaging and molding.
If the base of the nasal area has an asymmetrical shape, this can cause asymmetry of the nose tip and the areas between the nostrils to be out of rotation. Filler can be injected deep into the base of the nose, just like a tissue transplant in a surgical nose job, to correct this asymmetry. Always take care to inject in the middle of the nasal base to avoid blood vessels. We recommend using a cannula for better precision and safety when injecting filler in this area.
Nasal tip projection (the furthest point the nose tip extends from the face) can also be improved through precise injection of small amounts of filler under the skin on the nose tip that will give the nose a more tip-defining point. The injection should be done at the depth of the layer that contains fibrous, connective tissue atop the cartilage and muscle. Be careful not to inject filler into the area directly between the domes of the nose tip, which can cause the nose to seem wider. If you need to enhance the area right under the nose tip (infratip lobule), additional filler can be carefully placed specifically to mimic a surgical tissue graft. Filler can also be carefully placed just above the nose tip (supratip) area to give it the desired shape, while still considering potential risk of an over-rotated nose tip.
Increasing the rotation or the angle the nose tip makes with the upper lip can be done with fillers, which requires several advanced techniques. First, the illusion of an upturned nose tip can be achieved by blunting or reducing the angle between the nose and the upper lip by injecting filler deeply at the junction where the nose meets the upper lip. Second, injecting filler deeply in the area between the two branches of the cartilage in the middle of the nose near the posterior septal angle lends support to the nose tip and increases projection and rotation. Lastly, during injection, the soft part of the nasal septum needs to be pinched to keep the filler in the middle and prevent it from migrating into the nasal cavity and causing nasal obstruction.
Like with surgical nose jobs, alar rim contouring that makes the nostril and nose angle more balanced is also possible in a non-surgical nose job. Filler can be used on the alar rim to correct minor retraction or asymmetry. However, it’s crucial to be careful when injecting the alar rims in patients who’ve undergone previous nose jobs as the blood supply could be compromised because of previous incisions and the presence of scar tissue may complicate injection.
Finally, like how functional grafts or implants are used in surgical nose jobs to address nasal valve insufficiency, fillers can also be placed into the scroll (the area of the nose through which you breathe), internal nasal valve, alar rims, and nasal sidewall for the same effect. However, this application of fillers remains controversial.
Possible Complications of Filler Rhinoplasty
When someone gets a nose job, or rhinoplasty, usually, any problems after the procedure are minor and get better on their own. However, in rare cases, serious issues can occur, like blindness or a stroke. These risks are associated with non-surgical nose jobs and can appear shortly after the treatment or months and years later.
Problems that happen soon after non-surgical nose jobs might include:
– Unmatched sides of the nose, which can be avoided with proper injection techniques, like staying in the middle as much as possible.
– Reactions at the injection site, causing pain, swelling, redness, bruising, and itchiness.
– Allergic reactions, causing pain, fever, and itchiness. Steroids and warm compresses can help reduce these symptoms.
– Infections, including an abscess, bacterial infection, or herpes simplex virus infection. They can lessen infection chances by giving antivirals to high-risk patients beforehand.
– A blue color under the skin (the Tyndall effect) if the filler is injected too close to the skin’s surface.
– Bumps and uneven skin due to improper placement of fillers.
A very rare, but serious, complication is vascular occlusion, a blockage in the blood vessels. This can occur with specific types of fillers and be associated with needle and cannula techniques. This blockage can cause pain, paleness, swelling, discoloration, sores, and dead tissue, or even backflow into the blood vessels, leading to blindness and stroke. To deal with these risks, doctors should have an emergency kit on hand and be near a specialist in eye health and stroke care. Injecting too much filler can cause tissue damage due to pressure on the nearby blood vessels in the nose.
Problems that take longer to show up after non-surgical nose jobs might include:
– Scarring and changes in skin color.
– Granuloma, which is an immune response usually associated with permanent injections like silicone. This can be treated with a steroid injection, surgical removal, or both.
– Biofilm formations, which may need to be surgically removed, treated with long-term antibiotics, or both.
Despite these risks, healthcare providers should reassure patients that there is plenty of research supporting the overall effectiveness and safety of using injectable fillers in nonsurgical nose jobs.
What Else Should I Know About Filler Rhinoplasty?
Nonsurgical rhinoplasty is a quick, safe and dependable method for people who want to improve their nose appearance without the costs, recovery time, and potential risks associated with a surgical rhinoplasty. Even though it’s becoming a popular choice, this procedure should be considered on an individual basis and compared to a surgical nose job, which is still viewed as the best approach for treating cosmetic and functional issues with the nose.
To get safe and reliable results that satisfy the patient, it is critical to do a proper evaluation of the patient beforehand. Then, a detailed, anatomy-based treatment plan should be followed when doing nonsurgical rhinoplasty with fillers (which are substances injected under the skin to improve shape).
