Non-surgical and surgical nose reshaping treatments
Reshaping the Nose without Surgery

Rhinoplasty, otherwise known as a “nose job,” is the third most common plastic surgery procedure among male and female patients. In fact, it is the most commonly performed facial operation of all. However, rhinoplasty is also 1 of the most technically challenging surgeries. And, it is a very invasive procedure with a long recovery period, making it an unattractive option for many patients. As such, there has recently been an increased demand for non-surgical nose reshaping procedures. With its heightened safety profile, non-surgical nose reshaping using dermal fillers is a popular choice—plus, it instantly delivers visible results.

Non-surgical and surgical nose reshaping can be used to treat a range of dimensional abnormalities, including inadequate or excessive radix projection, inadequate or excessive nasal tip projection, and inadequate or excessive nasal length. Apart from that, they also help to correct acquired or congenital deformities. While the correction of excessive nasal dimensions requires a surgical rhinoplasty, patients who have minor deficits in the nasal skeleton or inadequate nasal dimensions may benefit from dermal fillers.

In general, it is not recommended to use permanent graft ingredients, such as silicone, in the nose. With a high rate of complications (e.g. extrusion), these grafts are mostly unreliable and unsafe. Therefore, nose reshaping using permanent graft ingredients is not a viable treatment option. Non-absorbable fillers such as Artecoll or Aquamid are also available, although they are not commonly used for this purpose.

Indicated for nasal tip enlargement, fat grafting using the Coleman method is able to generate predictable and good results without causing severe complications or adverse effects. This method can also be used for concealing irregularities of the underlying bone and cartilage. However, this procedure involves autologous fat transfer, and requires a longer time to complete than dermal filler injections. This also results in a higher treatment cost.

Using injectable hyaluronic acid dermal fillers is the most common method for defining the nose tip and augmenting the dorsum. These fillers can also be used to correct minor defects, such as Polly beak deformity, saddle nose, slight asymmetry, and retracted columella. With a good safety profile, dermal fillers can be used in revision rhinoplasty to fill out a small region. They are also suitable for use in primary rhinoplasty. However, while fillers can provide good results, they are not as effective as the conventional surgical rhinoplasties. Usually, the treatment needs to be repeated in order to maintain the results. Patients should be aware of these facts before undergoing the procedure.


Benefits and limitations of fillers in nose augmentation

Benefits

  • Effective in treating acquired and congenital nasal defects
  • Suitable for patients who prefer a non-surgical approach or patients who are contraindicated in the use of general anesthesia
  • Can be performed in combination with rhinoplasty
  • Significant aesthetic enhancement
  • More affordable than surgical options
  • Minimally invasive
  • Less risk of complications
  • Better safety profile
  • Minimal downtime
  • Reversible results
  • Only require topical anesthesia
  • Fast treatment and almost instant results

Limitations

  • Results are not permanent
  • Limited application
  • Risk of causing skin thinning and necrosis
  • Ineffective in correcting nasal functional issues
  • Ineffective when there are excessive nasal dimensions

Nasal Aesthetics

The nose is an incredibly prominent facial feature—especially in profile view. As such, it is imperative to perform a 3-dimensional examination of the nasal osteo-cartilaginous skeleton. This includes the frontal, profile, and caudal views. To ensure optimal treatment outcome, practitioners should carefully assess all the parameters affecting the nasal appearance. For example, even with the nasal dorsal asymmetry corrected, facial balance cannot be achieved if there are missing frontal teeth, a retracted chin, or accentuated smoker’s lines.


Other facial features that affect the nasal appearance


1. Nasal skin

Mistakes such as overcorrection and poor administration techniques tend to have fewer effects on thick nasal skin. Plus, a thick-skinned nose is less likely to develop bumps or lumps after an injection. In contrast, it is easier to create definition in a thin-skinned nose.


2. Chin projection

An under-projected chin could increase the apparent size of the nose in the profile view.


3. Malar contour

Enhanced mid-face/malar volume can decrease the perceived size of the nose.


4. Contour of lips and philtrum

A well-defined philtrum and full lips help to enhance the nasolabial angle.


Nasal Anatomy

The skeleton supporting the nose consists of both hyaline and bone cartilage. To avoid complications during this treatment, doctors should have a good understanding of the course ofthe angular vein and artery, as well as the structure of the nose.
Novice practitioners who are not familiar with the ideal nasal dimensions can refer the following measurements.


1. Frontal View

  • Tip defining points
  • Symmetry
  • Alar width—70% of nasal length, half of interpupillary distance(IPD), and equal to the intercanthal distance
  • Nasal length—1/3 of the face

2. Profile View

  • Naso-Frontal angle (NFA)
  • Nasal length
  • Dorsal humps
  • Nasolabial angle (NLA)
  • Naso-Facial angle (NFcA)

3. Caudal View

  • Columella : Lobule = 2:1
  • Equilateral triangle
  • Columellar show should be 2–4mm
  • Ala(A) : Lobule(L) = 1:1

Terminology

Nasion refers to the intersection of the internasal and frontonasal sutures, whereas glabella refers to the slightly depressed, smooth region of the frontal bone. It is located between the superciliary arches.

The nose tip is defined as the mid-line point at the level of the dome-projecting points in the lower lateral cartilage.

The nasal radix or rootis found on the mid-line of the nasal dorsum at the level of the supratarsal fold. If there is no supratarsal fold, measure the root of the nose in the mid-line 6mm above the inner canthus.


Injection techniques

It is recommended to use Juvederm Ultra (a hyaluronic acid-based filler) or Radiesse when defining the nasal dorsum, augmenting the bridge, or correcting humps. Use Voluma when a larger volume of filer is needed (e.g. for westernization ofthe depressed nasal bridge in Asian patients). Deposit 0.2ml to 0.5ml of filler into the nasion over the nasal bridge with a 27G x 0.5” (0.4x13mm) hypodermic sterile needle. The volume required varies based on the desired degree of augmentation. Move caudally in a straight linethat connects the supratip to the glabella. Use the linear threading method to deposit threads of approximately 0.1mL to 0.2mL for each injection, until the desired dorsal augmentation and definition have been achieved. Keep in mind that the nasofacial angle will be reduced when theheight of the dorsum is increased.

Fillers can also be used to correct severe nasal asymmetries, such as nasal bone deformity or a deviated septum. For example, Juvederm Grade 4 can be used to treat patients with a bulbous tip, C-shaped nasal dorsum, or deviated septum. Inject 0.7ml of the filler across the dorsum. Use 0.3ml to redefine the tip. This helps to create an illusion of a more projected tip and a more defined, straighter dorsum.

Practitioners should always refine the tip after a nose reshaping procedure. To minimize pain and swelling, apply cold packs to the injection sites as a topical anesthetic. This also helps to reduce bleeding through the production of vasoconstriction.


How to sculpture the nasal tip

When viewed laterally, the nasal tip can greatly influence the perceived width, length, inclination, and refinement of the nose. The apparent dorsal height and nasal length will be altered depending on the contour of the nasal tip. Nasal tip refinement can be used to decrease tip projection, interdomal distance, and nasal tip volume. Tip projection can be increased surgically or non-surgically.

Hyaluronic acid-based fillers are commonly used to redefine the tip. Alternatively, a tip graft may be used to alter the tip projection and the proportion between the nasal tipand nostril.


Nasal tip technique

Insert the needle through the caudal and columella aspect of the septal cartilage in a superoanterior direction approximately 3–5mm under the tip-defining points around the infratip break.

Inject boluses of 0.2mL to 0.3mL into columellar arteriesover and between the domes. Otherwise known as the lower lateral cartilage, the dome forms at the junction between the lateral and middle crura of the greater alar cartilage.

After injecting the filler into the dome region, the projected tip of the nose should be triangular in shape, with the superior apex sitting about 2mm above the nasal dorsum. Due to its lack of end arteries (except anastomoses), this is relatively safe region.

After treatment, apply a lightweight aluminum external nasal splint for a day. The splint can be easily molded into any desired shape of nose and trimmed for size adjustment. Once applied, it becomes rigid. It offers protection against trauma while helping to prevent the excessive swelling of the soft tissue (and hence, the migration of filler).

Due to its superior safety profile, non-surgical nose reshaping has been gaining popularity among patients who want to augment their nose. In comparison to conventional forms of surgical rhinoplasty, non-surgical nose reshaping delivers faster results and has a higher rate of patient satisfaction. To optimize the treatment outcome, it is essential to conduct a detailed, 3-dimensional assessment of the nose. This will ensure the best possible results for each patient.