Filler Rhinoplasty

DAVI A. DE LACERDA, MD, AND PEDRO ZANCANARO, MDy

Davi A. de Lacerda, MD, and Pedro Zancanaro, MD, have indicated no significant interest with commercial
supporters.

T he nose is one of the most important cosmetic

units of the face. Discreet variations in the nose
shape lead to marked physiognomy changes. Many
fillers to rejuvenate the nose or improve nasal
silhouette.3

patients dissatisfied with the appearance of their
nose seek cosmetic improvement as early as during
adolescence. Similar to 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. Dermatologic patients
are increasingly requesting procedures with minimal
downtime. In our practice, several patients coming
for facial rejuvenation are interested in undergoing
nasal rejuvenation procedures, but they usually
do not bring up the issue spontaneously because
they believe it would need extensive surgical
correction.
Rhinoplasty has been successfully used to improve
the appearance of the nose through changes in bone
and cartilage structures, as well as through the
placement of prosthetic devices.1 It remains an in-
vasive procedure that may lead to scars, however. In
addition, some patients remain dissatisfied with the
results, frequently submitting themselves to multiple
procedures, increasing the risk of postsurgical func-
tional impairment.2
Discreet volumetric changes in the frontal-nasal an-
gle, nasal dorsum, and columella–philtrum junction
produce significant differences in our perception of
nasal features. These areas can be injected with
Fillers have been broadly used in dermatology for the
correction of wrinkles, acne scars, and lip augmen-
tation, as well as for age or medication-related
lipoatrophy. They can be easily applied under the
skin in a minimally invasive fashion. They can also
be used to improve nasal deformities secondary to
trauma or surgery. Dermatologists are quite familiar
with the use of fillers for the above indications.4
The rationale for the traditional use of hyaluronic
acid and collagen is based on their natural occur-
rence yet diminished and altered properties on pho-
toaged skin.5,6 The atrophic subcutaneous tissue
observed on the aging face brings the reticular der-
mis closer to the underlying musculature forming
concave areas in the midcheeks and nasolabial folds.
These areas respond quite well to soft tissue fillers.7,8
Tolerance and excellent results for the above appli-
cations have been well established, both for collagen
and for hyaluronic acid.9–11 Nevertheless, there are
very few reports on the use of small amounts of re-
sorbable fillers to achieve cosmetic results compa-
rable to surgical rhinoplasty.12–14
Filler rhinoplasty, also known as augmentation rhi-
noplasty, is an evolving field.12 It has been proposed
to patients interested in less invasive techniques
than traditional rhinoplasty. An advantage of using
fillers is that surgeons may sculpt the material after

Hospital Local de Sapopemba and Departamento de Dermatologia, Hospital das Clı́nicas da Universidade
de São Paulo, Sao Paulo; yHospital Universitário de Brası́lia HuB/Universidade de Brası́lia, Brasilia, Brazil

& 2007 by the American Society for Dermatologic Surgery, Inc.
Published by Blackwell Publishing

ISSN: 1076-0512
Dermatol Surg 2007;33:S207–S212
DOI: 10.1111/j.1524-4725.2007.33362.x

S207
 FILLER RHINOPLASTY
injection, offering options not available through
traditional correction.15,16
The volume of material used for filler-based
rhinoplasty usually ranges from 0.1 to 0.4 mL.7
This feature makes filler-based rhinoplasty an
excellent indication for patients who will be
treated with fillers for improvement of the lips
and nasal labial folds and are unsatisfied with
their nose. We present below two cases where
those treatments were combined leading to
excellent cosmetic results and increased patient
satisfaction.
Technique
Informed consent was obtained from patients.
Blocking of the infraorbital and mentalis nerves was
achieved using 2% lidocaine with 1:100,000 epi-
nephrine before injecting fillers with a 27-gauge
needle. Blocking of the columella was not per-
formed so as to not induce volume distortion from
the anesthesia.
Images were obtained with a digital camera. Photo-
graphs were trimmed, and blue ovals over the eyes
placed with computer software (Coreldraw, Ottawa,
Ontario, Canada). No additional modifications were
performed.
Age, sex, volume of material used, filling tech-
nique for the rhinoplasty, and approximated
interval between before and after pictures were
as follows:
Case 1
Case 1 was a 45-year-old female. A total of 2 mL of
porcine collagen (Evolence, Colbar, Herzliya, Israel)
was used for treatment of the nose, nasal labial folds,
and lips. A total of 0.35 mL was required for the
filler rhinoplasty and used as follows: (1) 0.05 mL to
the nasolabial angle (angle formed between the base
of columella and the upper lip) with a single punc-
ture. (2) For the nose tip, 0.20 mL was applied using
S208 D E R M AT O L O G I C S U R G E RY
threading technique adjacent to the perichondrium
to enhance tip bulk, followed by filling of dermis or
superficial subcutaneous tissue to smooth out fine
surface irregularities, using multiple injection points
as needed from the infratip up to the supratip until
achieving a desired effect. The latter required
0.10 mL.
Molding was done manually for the deeper planes
immediately after injection and pressure kept for a
couple of minutes to stop bleeding. While perform-
ing dermal injections on the nasal tip, vigorous
molding was avoided to minimize filler extrusion.
Hemostasis of dermal injections was performed by
very light pressure using cotton tips. Pictures were
taken before and two days after injection.
Case 2
Case 2 was a 52-year-old female. A total of 2.00 mL
of hyaluronic acid (Voluma, Corneal, Paris, France)
was used, from which 0.2 mL was used for the nose as
follows: (1) 0.15 mL in the deep dermis or subcuta-
neous of the supratip; because of mild asymmetry of
the nose more volume was used on the right side and
(2) 0.05 mL was applied in the radix (frontonasal
angle). Before injecting the upper nose, the area was
examined by gentle touch with the intent to feel any
pulsation from larger arteries. The filler was placed
more medially and we avoided puncturing areas
where such arteries were palpable. Before injecting,
aspiration maneuver was attempted; there was no
blood return. Pictures were taken before and 1 year
after injection. Treatment of nasolabial folds and lips
was done with standard retrograde threading or
multiple-point injection techniques.7
Results
All patients tolerated the procedure well with min-
imal discomfort under local anesthesia as above.
Follow-up of 1 year for Patient 1 and of 4 months for
Patient 2 did not reveal medium-term side effects.
 DE LACERDA AND ZANCANARO

The volume used in the nose was distributed ac-

cording to immediate visually perceived improve-
ment of the frontonasal or nasolabial angles, as well
as of the nasal dorsum and tip. At each point the goal
was to establish volumetric correction to empirically
improve the overall harmony of the nose in relation
to other facial cosmetic landmarks and remaining
treated areas (nasolabial folds and lips).

Case 1

Case 1 showed marked marionette lines, asymmet-

rical lower lip, nasal dorsum irregularities, flat and
descendent nasal tip with irregular skin surface
(Figures 1A, 1C, and 1E). Collagen was used for
nasolabial folds and lips, increasing symmetry and
providing a younger appearance (Figure 1B). A
quantity of 0.05 mL of collagen was used to open the
angle between the philtrum and the columela re-
sulting in the perception of tip elevation from profile
view (Figures 1D and 1F). A quantity of 0.30 mL
applied adjacent to the cartilage or subcutaneous
tissue was used to reshape nasal tip and smooth it
out, respectively. The latter was essential for the
impressive cosmetic improvement seen in the pa-
tient’s profile. The patient was extremely satisfied
during her last follow-up visit, 4 months after the
procedure.

Case 2

Atrophic lips and marked marionette lines were ob-

served previously to the procedure. The nose had an
irregular dorsum with prominent tip. The patient
considered it too long (Figures 2A and 2C). Lip
augmentation and filling of nasolabial folds with
Figure 1. Patient 1: Before (A, C, E) and 2 days after (B, D, F)
filling with collagen. Injection of the descending, irregular
nasal tip (0.3 mL) and of the nasolabial angle (0.05 mL) pro-
vided remarkable cosmetic improvement. Marionette lines
and lips were also treated.

hyaluronic acid equilibrated the aesthetic features of

the lower face. In addition, 0.2 mL of hyaluronic
acid was used to straighten the nasal dorsum pro-
viding a youthful look and resulting in the illusion
of a smaller nose. Long-lasting results were seen
after 1 year (Figures 2B and 2D).
All patients were extremely pleased with the results.
The procedure was very well tolerated. The only side
effect was minimal edema or bruising which com-
pletely disappeared by the fifth day.
Conclusion
Dermatologic patients are increasingly requesting
procedures that are safe, require minimal downtime,
and lead to objective results. These prerequisites

33:S2:DECEMBER 2007 S209

 FILLER RHINOPLASTY
Figure 2. Patient 2: Before (A, C) and 1 year after (B, D) filling
with hyaluronic acid to nasal supratip (0.15 mL) and naso-
frontal angle (0.05 mL) effaced the prominent rhinion and
made the nose look smaller. Marionette lines and lips were
also treated.
have made resorbable fillers the gold standard ap-
proach for the correction of marionette lines and
volumetric enhancement of the lips.
Many patients seeking dermatologic treatment of
marionette lines and lip augmentation are also dis-
satisfied with the shape of their nose. Although
traditional rhinoplasty usually offers excellent
results, it remains a very invasive and expensive pro-
cedure. Such patients benefit from alternative treat-
ments used to modify the appearance of the nose.
Fillers can be injected under or inside the nasal skin
leading to impressive changes on nose silhouette as
demonstrated in this case report and illustrated by
Figure 3. We propose using the term filler rhino-
plasty instead of augmentation rhinoplasty because it
expresses more realistically to our patients what we
S210 D E R M AT O L O G I C S U R G E RY
Figure 3. Diagram illustrating the dramatic changes in nose
profile obtained from injecting specific areas. (A) Tip lifting
effect, as seen in Patient 1: filling of the columella base
widens the nasolabial angle (green) enhancing the benefits
from reshaping the tip (red). (B) Rejuvenation effect, as seen
in Patient 2: injecting the supratip (red) and radix (green)
straighten the dorsum and makes the nose look smaller.
are doing: giving the illusion of a smaller nose and
not of an ‘‘augmented’’ one.
Filler rhinoplasty is particularly indicated when there
is a need to increase volume in the cartilaginous tip.
Fillers can be injected directly on top of the under-
lying cartilage providing bulk and also in the sub-
cutaneous tissue or dermis leading to a homogenous
surface. When volume is added to the columella base
the nasolabial angle opens. This can be used to create
the illusion that the tip of the nose has been lifted.
Case 1 illustrates the dramatic effect obtained when
both the tip and the columella are treated.
Filler rhinoplasty is also a good alternative when
addressing the aged nose. Senescence causes loss of
subcutaneous tissue present in the dorsum of the
nose. A prominent rhinion is an undesirable feature
for most patients and also contributes to the per-
ception of a long nose. Injection of fillers in the su-
pratip area makes the rhinion less prominent and
therefore leads to the impression of a smaller nose.

Placing fillers in the radix or in the inferior portion
of the glabella alters the frontonasal angle. This area
can also be addressed when performing filler rhino-
plasty as illustrated by Case 2.
Filler rhinoplasty can be performed as a single pro-
cedure. Nevertheless, patients with mild to moderate
nasal deformities coming primarily for the treatment
of marionette lines or lip augmentation are excellent
candidates for concomitant filler rhinoplasty because
usually only small amounts of material are required.
Special attention should be taken when treating the
upper nose and glabellar area. Fillers should be
placed more medially to avoid large branches of the
dorsal nasal arteries and veins. The dorsal nasal
vessels originate from the ophthalmic ones which
anastomose widely with the lateral nasal vessels,
branches of the angular artery, and veins.17,18 In-
travascular injection of fillers can lead to em-
bolization of such vessels with potential necrosis of
the retina or skin areas irrigated by the supratroch-
lear artery.19,20
A thorough understanding of the vascular anatomy
of the upper nose and glabellar area is essential for
decreasing the risks associated with filler rhinoplasty.
Palpating the area before performing the injection
may also be helpful. The pulse of the lateral nose
artery and dorsal nasal artery is palpable in many
patients. A blunt small bore cannula can be used to
avoid vascular perforation. Other prevention points
for this region are: (1) placement of fillers superfi-
cially, (2) aspiration before injection, and (3) avoid-
ing overcorrection. In case of complications from
hyaluronic acid fillers, treatment with hyaluronidase
can be helpful. If there are signs of thrombosis, an-
ticoagulation should be considered.21 Visual im-
pairment shortly after treatment with dermal fillers
warrants emergent ophthalmologic consultation to
exclude retinal embolism.
The duration of results is variable depending on
which filler is used. When working with resorbable
fillers, one should avoid injecting large volumes in a
DE LACERDA AND ZANCANARO
single place because the filler will tend to vanish
faster, whereas when permanent fillers are used, the
risk of long-term complications should be taken into
account.
In summary, filler rhinoplasty represents an excellent
alternative for patients who do not wish to undergo
surgery. It is a minimally invasive and cost-effective
office procedure. It may lead to more harmonious
facial features and significantly enhances patient’s
satisfaction.
References
1. Constantinidis J, Daniilidis J. Aesthetic and functional rhinopla-
sty. Hosp Med 2005;66:221–6.
2. Bracaglia R, Fortunato R, Gentileschi S. Secondary rhinoplasty.
Aesthetic Plast Surg 2005;29:230–9.
3. Beer KR. Nasal reconstruction using 20 mg/ml cross-linked
hyaluronic acid. J Drugs Dermatol 2006;5:465–6.
4. Brandt FS, Cazzaniga A. Hyaluronic acid fillers: Restylane
and Perlane. Facial Plast Surg Clin North Am 2007;15:
63–76, vii.
5. Ghersetich I, Lotti T, Campanile G, et al. Hyaluronic acid in cu-
taneous intrinsic aging. Int J Dermatol 1994;33:119–22.
6. Bernstein EF, Underhill CB, Hahn PJ, et al. Chronic sun
exposure alters both the content and distribution of dermal
glycosaminoglycans. Br J Dermatol 1996;135:255–62.
7. Fernandez EM, Mackley CL. Soft tissue augmentation: a review.
J Drugs Dermatol 2006;5:630–41.
8. Gladstone HB, Cohen JL. Adverse effects when injecting facial
fillers. Semin Cutan Med Surg 2007;26:34–9.
9. Duranti F, Salti G, Bovani B, et al. Injectable hyaluronic acid gel
for soft tissue augmentation: a clinical and histological study.
Dermatol Surg 1998;24:1317–25.
10. Klein AW. Soft tissue augmentation: filler fantasy. Dermatol Ther
2006;19:129–33.
11. Rostan E. Collagen fillers. Facial Plast Surg Clin North Am
2007;15:55–61, vi.
12. Han SK, Shin SH, Kang HJ, Kim WK. Augmentation rhinoplasty
using injectable tissue-engineered soft tissue: a pilot study. Ann
Plast Surg 2006;56:251–5.
13. Nicolau PJ. Long-lasting and permanent fillers: biomaterial in-
fluence over host tissue response. Plast Reconstr Surg
2007;119:2271–86.
14. Hamilton MM, Hobgood T. Emerging trends and techniques in
male aesthetic surgery. Facial Plast Surg 2005;21:324–8.
15. Baumann L. Dermal fillers. J Cosmet Dermatol 2004;3:249–50.
33:S2:DECEMBER 2007 S211
 FILLER RHINOPLASTY

16. Gurney TA, Kim DW. Applications of porcine dermal collagen 20. Peter S, Mannel S. Retinal branch artery occlusion following in-
(Enduragen) in facial plastic surgery. Facial Plast Surg Clin North jection of hyaluronic acid (Restylane). Clin Experiment Ophtal-
Am 2007;15:113–21, viii. mol 2006;34:363–4.

17. Netter FH. Atlas of human anatomy. Basel, Switzerland: Ciba- 21. Glaich A, Cohen J, Goldberg L. Injection necrosis of the glabella:
Geigy; 1989. plate 17. Protocol for prevention and treatment after use of dermal fillers.
18. Janfaza P, Cheney ML. Superficial structures of the face, head, and Dermatol Surg 2006;32:276–81.
parotid region. In: Janfaza P, Nadol JB, Galla R, et al., editors.
Surgical anatomy of the head and neck. Philadelphia: Lippincott
Williams & Wilkins; 2001. pp. 24–5.

19. Shanz S, Schippert W, Ulmer A, et al. Arterial embolization caused

Address correspondence and reprint requests to: Davi A.
by injection of hyaluronic acid (Restylanes). Br J Dermatol de Lacerda, MD, Av. Angélica, 2530 Cj 46, São Paulo,
2002;146:928–9. SP 01228-200 Brazil, or e-mail: dLacerda@usp.br

COMMENTARY
This article nicely outlines the technique of nasal augmentation with hyaluronic acid–based fillers and
represents yet another example of substituting fillers for traditional surgery. Of note, this technique also
works quite well with calcium hydroxyl apatite as the filling agent and is a useful for filling in small nasal
defects secondary to rhinoplasty or Mohs surgery. The concept of altering proportions to make the nose
appear smaller is the take-home message of this article. This can be accomplished as described here by
directly addressing the nose or by increasing the cheek volume and anterior projection of the midface
thereby causing a relative diminution in the proportion of the nose to the face as a whole. One word of
caution: when ‘‘blending’’ a dorsal nasal hump, the best candidates are noses where the hump appears in
the middle third of the dorsum and not high at the nasal root.

LISA DONOFRIO, MD
New Haven, CT

S212 D E R M AT O L O G I C S U R G E RY