Summary

Rhinoplasty is technically demanding surgery, and even in the best of hands, postoperative healing and the most exceptional aesthetic outcome can be unpredictable. In addition to the risks of general anesthesia and a protracted postoperative convalescence, rhinoplasty may lead to adverse cosmetic results. Even in patients with a first satisfactory outcome, slight asymmetries, depressions, and contour irregularities may present several years after surgery. Correcting these minor problems often requires surgical revision, and the available surgical options are limited in number, expensive, time-consuming, and prone to further complications.   Non-surgical rhinoplasty, injection rhinoplasty (filler, fat, or botox), has gained popularity for primary and revision nose enhancement procedures. In selected people, injection rhinoplasty can give a ready to vise result in the convenience of the office setting. The process is minimally invasive and has an excellent safety record. It has been proposed for patients. However, unlike surgical rhinoplasty, it is limited in its ability to produce a significant change in the caudal aspects of the nose.

Rhinoplasty is technically demanding surgery, and even in the best of hands, postoperative healing and the most exceptional aesthetic outcome can be unpredictable. In addition to the risks of general anesthesia and a protracted postoperative convalescence, rhinoplasty may lead to adverse cosmetic results. Even in patients with a first satisfactory outcome, slight asymmetries, depressions, and contour irregularities may present several years after surgery. Correcting these minor problems often requires surgical revision, and the available surgical options are limited in number, expensive, time-consuming, and prone to further complications.  Patients may also have functional complaints secondary to iatrogenic nasal valve disruption, leading to the dissatisfaction of both patients and surgeons. Non-surgical rhinoplasty, Filler rhinoplasty, or augmentation rhinoplasty using an injectable dermal filler has gained popularity for primary and revision nose enhancement procedures. In selected people, filler injections can give ready-to-vise results in the convenience of the office setting, and the process is minimally invasive and has an excellent safety record. An advantage of using fillers is that surgeons may sculpt the material after injection, offering options not available through traditional correction. It has been proposed to patients interested in less invasive techniques than conventional rhinoplasty. Minor post-rhinoplasty asymmetries, irregularities, and bony prominences may also address. However, unlike surgical rhinoplasty, it is limited in its ability to produce a significant change in the caudal aspects of the nose.

Injection Rhinoplasty. Who Need it?

The nose is one of the most critical cosmetic units of the face. Many patients dissatisfied with the appearance of their nose seek cosmetic improvement as early as during adolescence. Like other facial structures, the nose is affected by the aging process. Typically, nose tip drop is observed, along with loss of subcutaneous tissue, which highlights its undulating osteocartilaginous support. Discreet volumetric changes in the frontal-nasal angle, nasal dorsum, and columella–philtrum junction significantly affects our perception of nasal features. These areas can be injected with fillers to rejuvenate the nose or improve the nasal silhouette.

Injections Rhinoplasty. How do I look Like After?

A non-surgical procedure does not have the extended downtime associated with surgical rhinoplasty, which means less interruption of daily activities. It is relatively more affordable in the short term. However, surgical rhinoplasty may be more cost-effective in a long time. Patients are informed that they may experience some swelling, tenderness, and redness for 1–2 days, but no specific aftercare instructions are necessary. However, Radiesse does seem to produce more immediate swelling than HA fillers, so over-correction by about 10% does not seem to provide any untoward effect to place the dermal filler.  For this reason, linear threading is now used most commonly, which minimizes the risk of nodules.

Injections Rhinoplasty. Are Results Permanent?

The use of permanent fillers in the nose poses more risks of severe adverse reactions, skin necrosis, and extrusion, in addition to the almost complete difficulty evacuating the filler thoroughly and the apparent difficulties in future surgical planning. Recent use of dermal filler is in non-surgical ‘injection’ nose job to enhance the nasal profile and correct asymmetries, whether congenital, traumatic, iatrogenic, or due to aging. The aesthetic nasal and paranasal units can be treated as a whole or as aesthetic subunits individually as needed. Discreet volumetric changes in the frontonasal angle, nasal dorsum, and nasolabial angle lead to significant differences in our perception of the nasal aesthetic. HA and CaHA are the safest available agents and can be injected with local or no anesthesia. In our experience, the correction can last up to 2 years with Restylane, and three years with Radiesse, probably because of the relative immobility of the mid-face.

The primary advantages of using fillers in the nose are the lower costs and risks associated with anesthesia and major surgery. The disadvantages include potential damage to the nasal skin envelope, the need for repeated treatments to keep up the results, and a decrease in the surgeon’s drive to make the perfect result. The only excellent candidates for nasal fillers are patients needing minimal dorsal or sidewall correction who are not amenable to surgical intervention.

Fat transfer also shows itself as a first-line non-surgical alternative to the modeling of nasal shape and profile in primary and secondary cases of patients who refuse surgical rhinoplasty and accept limitations in the results. It also is possible to combine surgical rhinoplasty with lipo-implantation in the dorsum, radix, glabella, or pre-maxillary area to improve volume and shape in these areas without the need to use cartilage grafts or robust prostheses. Physicians who choose to inject the nose with fillers have a responsibility to follow their patients strictly for potential complications. Nostril reshaping can be performed by weakening the dilator nasi with small doses of Botox. Botox injections into the levator labii superioris alaeque nasi and the dilator nasi can help to narrow nasal flare. In contrast, the expansion of the nasal flare can be performed using HA products.

Nasal wrinkles called “bunny lines” refer to the wrinkles on the lateral part of the nose, which result from the contraction of the transverse section of the nasalis m. Several muscles contribute to bunny lines, but the nasalis is the most significant. Usually, bunny lines are not present in dynamic patients with a gentle smile. They only become apparent when smiling at most contractions. In hyperkinetic patients, bunny lines are found with a slight smile and worsen at most contractions. Patients should be asked to laugh, sniff, and squint intensely as if a very bright light is before their eyes. Bunny line wrinkles, which appear on the lateral/dorsal aspects of the nose, but may extend out to the lower eyelid, are naturally present in some people during expression, especially in Asian and Hispanic patients and in patients with thin skin and a fair complexion. Darker complexions and oily skin are more likely to produce wrinkles limited to the nasal dorsum.

Lower doses are used in the transversal areas of the nasal bone. The procedure may be less effective in patients who recruit these muscles excessively or have had earlier rhinoplasty. Furthermore, they may become more pronounced after glabellar and periorbital Botox treatment. The injections are 1–2 units per side of the upper nasalis and massage gently after the dose to help diffuse the toxin. Botox type A injection could flatten the upper third of the nasolabial fold and elongate the upper lip. In patients with a naturally shorter upper lip, 1U BTX-A into each lip elevator complex in the nasofacial groove will collapse the high aspect of the nasolabial fold and elongate the upper lip. A total dose of 3–6 U per injection site has shown excellent results. Lower doses should be injected initially, followed by equivalent doses after 7–15 days to avoid symmetries.

We ask patients to return in two to three weeks for a follow-up examination to take photographs and assess treatment responses. For patients who still have deep furrows at two weeks, one may consider adding a filler. Treatment of the nasolabial fold with BTX-A can result in ptosis of the upper lip and narrowing of the vermillion. Repeated Nasal Flare Some people present dilated or rhythmic contractions of the nostrils on certain occasions. Botox injections are shown on each side in the lower nasal fibers above the lateral nasal ala to treat this condition. Nasal Tip (Droop Nose) a drooping tip can lead to a harsh and aged appearance. “When the nose is pointed up, it creates a much softer look. A droopy tip can also cause the area between the end of the nose and the upper lip to look short—small, thin lips are typical of an aged look. Three causes of a droopy tip: Muscle movement & loss of volume: The force of gravity pulls the tissue of the nose down, causing it to droop, which is often accompanied by a loss of volume. Your nose may seem more significant with age because, as the size is lost from the face, the cheeks lose definition, in turn making the nose look disproportionate or even hooked. Inadequate support: “As support is lost in the nose, the tip begins to sag and point downwards,” says Prof Moawad, adding that it’s more common in those with thick skin, which weighs down the underlying supporting cartilage.

Facial expressions: Constant smiling compels the tip of the nose to move down and droop due to years of muscle contraction. There is a muscle between the nose and upper lip that can become overactive with time. “We can weaken that muscle, but it needs to be done conservatively. If too much of the muscle is weakened, it can potentially change the smile,” says Prof Moawad. The only way to permanently correct an aging nose is with surgery, and I must consider your age—the nose of a 70-year-old should not look like the nose of a 27-year-old. “In older patients, the nasal tip shouldn’t be as high,” By elevating a drooping tip to the proper place and adding support, we can bring the tip back up and prevent it from dropping back down.

In some cases, injectables may be used to lift the tip of the nose. “Botox-like injections help to stop the movement of the muscles that pull the tip down. They are also useful for a gummy smile because it raises the tip and makes the lip look longer. This is a proper treatment for people whose nose tip points down when smiling, laughing, or talking. By strategically placing a few units of Botox into a specific area of the nose, we can help to slightly lift the down point of the nose during animation by relaxing the active muscle that pulls downward. Experienced injectors should only perform this.  The perpendicular injection is recommended in a single site just below the nose tip in the columella and can produce a slight lift of the tip of the nose. Handling nasal deformities and those with ‘‘dropping’’ tips has always been a common area of interest in surgery. The non-surgical rhinoplasty for a ‘‘dropping’’ nose is a simple and very effective technique with immediate results, which consists of using only hyaluronic acid to correct nasal angles and Botox for patients with hyperactivity of the muscle. I can use it in those cases where patients are reluctant to undergo surgery or as a primary indication in correcting minor nose defects. Results are satisfactory, and no side effects have been reported so far. The results will last for a long time.

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What is  Radiesse (Calcium Hydroxylapatite) Filler Injection Nose Job?

Calcium hydroxylapatite (CaHA) is used for post-rhinoplasty deformities of the dorsum, supratip, sidewall, ala, saddle nose, and retracted columella deformities. CaHA has been the product favored by Prof Moawad for masking large nasal convexities. The CaHA is then placed deeply onto the bony cartilaginous skeleton and shaped into the dorsum, much like a sculptor working with terra cotta clay.  Functional internal valve collapse may be addressed with an endonasal ‘spreader’ injection of calcium hydroxylapatite (Radiesse) into the apex of the internal nasal valve. CaHA, in our experience, is a much more predictable product than HA. The persistence of correction is about 10 to 12 months and rarely longer. The product’s lack of hydrophilic properties also prevents skin and soft tissue expansion beyond the original placement. This ensures that the patient can be treated to complete correction per the discretion of the injector.

What is Hyaluronic Acid  Filler (Restylane and Juvederm) Injection Nose Job?

Because of its higher concentration of cross-linked hyaluronic acid and lower hydrophilicity, Restylane is preferred to treat the thin skin of the nasal dorsum and sidewalls. Juvederm is preferred for the nasal tip and alar rims because it is more easily molded to the desired contour, up to 1 week after injection. The longevity of hyaluronic acid fillers in the nose appears to be higher than in other areas of the face. As with collagen, patients should avoid all blood thinners for ten days before treatment. Before the patient undergoes treatment with soft-tissue fillers, they should be anesthetized to maximize comfort. Topical anesthetics are valid if the proper time interval elapses before injection. Alternatively, one can reconstitute 1 ml of dermal filler with 0.3 of 1% lidocaine. Another benefit of this mixing has decreased the viscosity and extrusion force to inject the product. Areas for correction are marked and ready with an alcohol wipe (70% Isopropyl alcohol).

How is Filler Injection Nose Job Done?

First Stage

In a single pass, with the entry point at the tip of the nose, we begin with the augmentation of the columella-labial angle. The needle is advanced along the subcutaneous plane, just deep to the dermis, all the way down to the nasal spine. Then Radiesse or Restylane is injected slowly, carefully observing the filling of the columella-labial angle; this usually requires 0.4 ml. Once the columella-labial angle is corrected, the needle is gradually withdrawn while injecting filler to strengthen and raise the columella column. This maneuver corrects the columella labial angle and straightens, lengthens, and increases the columella. This should produce a tip projection that is more anterior and with less cranial rotation. By extending the columella, the nose should seem more isosceles-shaped and the nostril more teardrop-shaped when seen from the basal angle.

Second Stage

The second stage of NSR begins with the augmentation of the entire length of the dorsum in the midline from the new radix to the tip. I can effectively control the width of the dorsum with the volume of the injected filler in a single row, not multiple rows of injection. The filling should be enough and uniform to produce aesthetically pleasing dorsal aesthetic lines. The volume of the injected filler requires a more precise titration should there be a dorsal hump.

Then the radix and forehead dorsum angle is further augmented. The radix is the most recessed part of the dorsum, and it often requires more filler. Boluses of filler are injected perpendicularly in the midline as a series of interrupted columns while using the fingers to grasp the radix to limit the risk of the filler material spreading, making the dorsum appear bulky. The endpoint is to create a new radix at the about level of the supratarsal fold, create about 135 angulations of the nasal dorsum to the forehead, and create a distinct and aesthetically pleasing dorsal aesthetic lines. The nasal dorsum is best approached using small amounts of hyaluronic acid. After injection, I should gently massage the hyaluronic acid to help with even distribution, thus avoiding contour irregularities. After injection, the surgeon should allow 15 minutes to pass to give the soft tissues time to adjust and the product sufficiently diffuse. This step allows for a correct assessment of effect before further injection. I should regularly assess the volume of injection and skin color to avoid any vascular perfusion compromise to the nasal skin. Layering the hyaluronic acid from deep to superficial is preferred for volume restoration of the nasal dorsum. A threading technique along the long axis of the nasal dorsum should be used to keep up the proper nasal shape.

Third Stage

The nasal sidewall is also best addressed using small amounts of hyaluronic acid with post-injection massage and a 15-minute delay before reinjection. I should continually assess the skin of the nasal sidewall for any evidence of vascular compromise. The preferred injection method is through a crosshatching technique to do a steady volume expansion along the flat plane of the nasal sidewall. As mentioned earlier, Restylane is the preferred product to use under the thin skin of the nasal sidewall.

Fourth Stage

The last aspect of NSR is shaping the nasal tip. The essential element of this stage is to inject a few superficial small boluses into the tip to further the tip lengthening in the anterior direction, lessen the appearance of cephalic rotation, and make the tip pointier. The injection plane is at the level of the deep dermis. We usually use a softer hyaluronic acid (HA) filler in a virgin nose because I can readily reverse it. We pay close attention to the visual signs of ischemia immediately after injection, with hyaluronidase readily available. The use of small amounts of hyaluronic acid, post-injection massage, and 15-minute delay before reinjection also apply to the treatment of the nasal tip. More than any other area, I must treat the nasal tip skin with conservative volumes and continuous assessment of skin perfusion to avoid potentially disastrous sequelae of nasal tip skin compromise. Considering the aesthetically sharp contours of the nasal tip and ala, the ability to mold Juvederm after injection proves to benefit the patient and surgeon. Some injectors prefer Juvederm to treat the nasal tip and ala because of its malleability several days after injection. As mentioned, Juvederm is beneficial for the patient who wants more tip fullness, as it can post-injection swelling. Alternatively, Restylane can be used in the nasal tip if more control of the last volume augmentation is desired. When injecting Juvederm or Restylane for the nasal tip and ala, one should inject via a serial puncture technique to maximize precision and accuracy along this aesthetically critical area. Small volumes of hyaluronic acid in the range of 0.1 to 0.2 ml can result in significant contour improvement in the nasal tip.

However, some authors do not use HA in the soft tissues of the tip or the nasal base because of increased complication rates.  This angle may be opened further with two units of Botox injection into the depressor septi muscle. Regardless of which HA is used, slight under-correction is recommended to help compensate for the post-treatment expansion. Immediately following injection, digital pressure is applied, and the implant is molded into place. Bleeding stop with lightweight using a cotton-tipped applicator. Finally, an ice pack is applied to decrease postoperative bruising and edema. Injected filler feels like ‘‘play-doh’’ immediately after injection, and it can be easily molded and reshaped to sculpt the nose further. More top-offs may be required at this stage.

What are the Risks of Filler Injection Nose Job?

Complications related to CaHA injection are more difficult to reverse than HA. Therefore, HA must be the first choice for inexperienced surgeons using fillers for the first time. With time and experience, the use of CaHA might be considered. As opposed to hyaluronic acids, which can be treated with hyaluronidase or needle aspiration, the particulate fillers or permanent fillers are challenging to remove if there is an irregularity. Erythema edema and bruising are common after treatment and typically last a few days. A bluish Tyndall effect can be seen when injected too superficially, which is visible hyaluronic acid seen through the translucent epidermis. Fortunately, these bluish cysts are easily corrected by nicking the skin with a small-gauge needle (30 gauge) or No. 11 blades and expressing the superficial, unwanted dermal filler. Occasionally, palpable nodules can be felt under the skin, which occurs when the multiple-puncture technique is used, or depot injections are performed.

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It is essential to understand that accurate nasal modeling is obtained by improving bone and cartilage architectural elements, leaving to adapt to changes and draw the result. Fat injection applied to nasal aesthetics works oppositely by altering only soft tissues to mask structural imbalances or irregularities except when combined with rhinoplasty to supplement deficient bone in the radix, glabella, and premaxillary region. For these reasons, fat injection to the nose is a sign only for some selected nasal deformities of patients who refuse rhinoplasty as the primary choice and clearly understand the limitations in the results. Based on skin quality improvement, fat injection to the nose could be the first choice for some selected cases where a high degree of scarring or adherence might jeopardize dissection or blood supply during open or closed rhinoplasty. It is essential to tell the patient that this technique only camouflages imperfections and does not give any improvement in respiratory function. We will face patients with bone or cartilage architectures that fat grafts cannot conceal.

Fat transfer is performed at MSI on an outpatient basis and usually under local anesthesia. Medication to ease any pain will be given one hour before the procedure if needed. The entire procedure takes one hour. Fat transfer is a two-step process. Typically, fat is extracted from the abdomen, buttocks, thighs, or knees and re-injected beneath the skin in areas where cosmetic correction is needed. Before fat can be re-injected, it must be processed to get viable fat cells. Prof Moawad can take advantage of the two first tissue planes when injecting fat into the nose. The SMAS plane and the subcutaneous plane. Fat is injected routinely retroactively using 1.2- to 1.4-mm blunt-tip cannulas or 22-24-gauge microcannula and applying very gentle pressure on the plunger. The glabella and radix were approached from the middle frontal region 1 cm above the eyebrows. The premaxillary region was approached from the nasolabial fold 2 cm lateral to the nasal ala. To correct minor irregularities, 0.3 to 0.8 mL of cryopreserved micro fat graft material is injected 1 to 3 times; 1 to 6 mL was injected 3 to 6 times for significant abnormalities or defects.

The clinician must have in mind all danger zones and vascular territories of the nose to prevent an unwanted intravascular injection, especially when approaching the glabellar or supratip regions. In secondary cases, the surgeon should be cautious because I will not find the injection plane with ease, and different degrees of fibrosis will impair cannula advancement and fat placement. It is essential to understand that accurate nasal modeling is obtained by improving bone and cartilage architectural elements, leaving to adapt to changes and draw the result. Fat injection applied to nasal aesthetics works oppositely by altering only soft tissues to mask structural imbalances or irregularities except when combined with rhinoplasty to supplement deficient bone in the radix, glabella, and premaxillary region. For these reasons, fat transfer to the nose is a sign only for some selected nasal deformities of patients who refuse rhinoplasty as the primary choice and clearly understand the limitations in the results.

Based on skin quality improvement, fat transfer to the nose could be the first choice for some selected cases where a high degree of scarring or adherence might jeopardize dissection or blood supply during open or closed rhinoplasty. It is essential to tell the patient that this technique only camouflages imperfections and does not give any improvement in respiratory function. We will face patients with bone or cartilage architectures that fat grafts cannot conceal. Autologous fat injection meets ideal augmentation materials’ fundamental criteria, most minor reported complications, and longer survivability. The best of all is fat injection is forgivable while the mistake of permanent filler is “permanent,” Prof Moawad says. Recently, fatty tissue has been considered a potential source of stem cells with the regenerative ability and proved the ability to release tightly adherent skin in a way that supplies better conditions and makes secondary surgical rhinoplasty safer.

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