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Entry Point
Injection rhinoplasty is performed with various
techniques and through various entry points. Here,
we introduce the most common techniques.
The first technique is the perpendicular needle
injection at the nose.
With this technique, the needle is injected per-
pendicularly, and the bone surface is felt (Fig. 5).
After reaching the bone, fillers are injected in the
supraperiosteal layer. Fillers can be injected at
specific locations as determined by the surgeon.
However, the needle might reach the dorsal nasal
artery that crosses the midline. Moreover, this
technique requires multiple injections, possibly
leading to swelling and bruising.
The second technique commonly used is the
infralobular injection of a cannula (Fig. 6).
This technique has the advantage of relative
safety from vascular complications owing to the
blunt tip of the cannula. However, it has the
disadvantage of the possibility of the cannula tip
reaching the superficial fatty layer, where the
Fig. 3 Dorsal nasal artery pathway. The dorsal nasal artery sometimes crosses the midline at rhinion
Table 1 Needle/cannula gage and outer diameter
Needle/cannula gauge
Outer diameter (mm)
18
1.27
19
1.07
21
0.82
22
0.72
23
0.64
24
0.57
25
0.51
26
0.46
27
0.41
30
0.31
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Fig. 4 Relationship between the outer diameter of the cannula and the dorsal nasal artery
Fig. 5 Perpendicular injection of a needle
Fig. 6 Infralobular injection of a cannula
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dorsal nasal artery is located, particularly in
patients with a hump nose. Such vascular acci-
dents can cause serious complications, such as
skin necrosis or ocular complications.
Fate of Filler Injections
Unlike implants for rhinoplasty, fillers are sub-
stances with viscoelastic properties. Continuous
external forces, such as shearing, compressive,
or bending forces, can distort the elastic prop-
erty of the initially injected fillers. Additionally,
since fillers are injected in the deep fatty layer
to avoid vascular complications, muscle com-
pression might distort their elastic properties.
Accordingly, fillers should have relatively hard
rheologic properties. Nevertheless, continuous
external forces should be avoided because they
can result in a widely looking appearance
(Fig. 7).
Filler Types
Hyaluronic Acid Fillers
Hyaluronic acid fillers are composed of hyal-
uronic acid and a crosslinker, such as
1,4-butanediol diglycidyl ether. Hyaluronic acid
can be degraded by hyaluronidase, and this prop-
erty makes hyaluronic acid fillers the most com-
monly used filler type. Hyaluronic acid fillers can
be monophasic or biphasic depending on the
manufacturing process. However, they are vis-
cous and usually degrade within 18 months.
Semipermanent/Permanent Fillers
Polyacrylamide gel and polyalkylimide (Bio-
Alcamid™) have been conventionally used as
permanent fillers but are not often used currently.
Calcium hydroxyapatite fillers can be molded
a
b
Fig. 7 Widely looking appearance at the radix. (a) Six months after the injection of hyaluronic acid fillers. (b) After
degradation
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easily, but calcium particles are relatively hard
and difficult to use in secondary rhinoplasty.
Polycaprolactone fillers have the same disadvan-
tages as calcium fillers.
Complications
Nonvascular Complications
Infection
Infectious complications often accompany filler
injections. They often induce vascular comprise
but often occur without vascular events. Every
procedure should be performed under aseptic
conditions (Fig. 8).
Widely Looking Appearance
As aforementioned, the dorsal nasal artery and
intercanthal vein tend to run in the superficial
fatty layer. Therefore, fillers are usually injected
in the supraperiosteal layer. However, viscous
fillers, such as hyaluronic acid fillers, can be dis-
persed
under
continuous
external
forces.
Therefore, relatively hard fillers that can resist
external forces are recommended.
Vascular Complications
Skin Necrosis
Vascular compromise can occur because of
embolism or compression. The radix and rhinion
Fig. 8 Signs of general infection after a polyacrylamide
gel filler injection. Signs of infection manifested 5 days
after the polyacrylamide gel filler injection. Despite treat-
ment with systemic antibiotics, localized infection per-
sisted. Fillers and pus were aspirated through negative
pressure aspiration. (a) Before the polyacrylamide gel
injection. (b) Immediately after the injection. (c) Five
days after the injection, systemic antibiotics were applied.
(d) Three weeks after the injection, with signs of a local-
ized infection. Fillers were removed through negative
pressure aspiration. (e) Six months after filler removal. (f)
Removed pus and fillers
a
b
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d
c
Fig. 8 (continued)
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e
f
Fig. 8 (continued)
areas have loose skin, leading to skin necrosis
because of embolism. The tip area is composed
of dense tissues, leading to occasional compres-
sive ischemic changes. Ischemic changes range
from mild erythema to severe skin necrosis,
necessitating timely treatment (Fig. 9).
When hyaluronic acid fillers are injected,
hyaluronidase should be applied initially.
Hyaluronidase degrades hyaluronic acid fillers
but with variable potency across products.
Moreover, hyaluronic acid fillers contain varying
amounts of the crosslinker, hindering the calcula-
tion of the optimal therapeutic dosage. The dos-
age should be sufficient, and the injection should
be repeated to affect the ischemic skin lesion.
Usually, 1500 IU hyaluronidase is mixed with
2 mL of normal saline, and gentle massaging is
performed after the injection.
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Ocular Complications
Fewer than 100 cases of ocular complications of
filler injections have been reported (except fat
grafting), but there may be many unreported
cases. Among the reported cases, injection
rhinoplasty-induced visual compromise has a
high incidence because the dorsal nasal artery is
a branch of the ophthalmic artery. The mecha-
nism is that a retrograde injection to the dorsal
nasal artery and embolism of the ophthalmic
artery branch induces ocular complications
(Fig. 10).
The treatment has not been established.
Therefore, prevention of complications in para-
mount. Table 2 lists the prevention guidelines.
Suggestive treatments are retrobulbar, intra-
arterial, intravenous, and subtenon hyaluroni-
dase injections, but their effectiveness have not
been proven. Further scientific evidence is
required.
Fig. 9 Treatment effect in a case of severe localized skin
necrosis. Localized severe skin necrosis developed 36 h
after the injection of hyaluronic acid fillers into the nose.
(a) The area 36 h after the injection. Multiple pustules
appeared before 36 h, indicating that aggressive treatment
was required because of severely compromised vascular-
ity. (b) The area 2 days after the injection, following the
first treatment and before the second treatment. Pustules
were removed with the first treatment but recurred 4 h
later. Repeated removal is required in cases of severely
compromised vascularity. (c) The area 3 days after the
injection and before the second treatment. Multiple pus-
tules are visible. (d) The area 3 days after the injection,
following the second treatment. (e) The area 4 days after
the injection. Since pustules were invisible, a wet dressing
was applied once a day. (f) The area 5 days after the injec-
tion. Since the swelling reduced and signs of infection
decreased, hyaluronidase was used to dissolve hyaluronic
acid fillers. (g) The area 7 days after the injection. Since
the swelling reduced and signs of infection decreased,
hyaluronidase was used to dissolve hyaluronic acid fillers.
(h) The area 8 days after the injection. Minimal swelling
occurred. (i) The area 13 days after the injection. The
patient almost recovered. (j) The area 27 days after the
injection. Small pustules and a slight color change are vis-
ible. Such patients should be observed for at least
6 months. (k) The area 32 days after the injection showing
aggravated symptoms
a
b
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Fig. 9 (continued)
e
f
c
d
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Fig. 9 (continued)
i
j
g
h
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k
Fig. 9 (continued)
Fig. 10 Ophthalmic artery pathway. The supratrochlear, supraorbital, and dorsal nasal arteries arise from the ophthal-
mic artery branches. Retrograde injections commonly cause visual compromise
Table 2 ABC Prevention of filler injection-induced
visual compromise
A Anatomy (Doppler ultrasound) and Aspiration with
the proper technique
B Big cannula
C Compression
D Direction of injection
E Emergency kit
F Filler technique for augmentation or wrinkle
correction
G Gentle injection of a small amount
H History of operations or injections
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Further Reading
Choe HR, Woo SJ. Subtenon retrobulbar hyaluronidase
injection for ophthalmic artery occlusion follow-
ing facial filler injection. Int J Ophthalmol. 2020 Jul
18;13(7):1170–2.
Choi DY, Bae JH, Youn KH, Kim W, Suwanchinda A,
Tanvaa T, Kim HJ. Topography of the dorsal nasal
artery and its clinical implications for augmentation
of the dorsum of the nose. J Cosmet Dermatol. 2018
Aug;17(4):637–42.
DeLorenzi C. New high dose pulsed hyaluronidase proto-
col for hyaluronic acid filler vascular adverse events.
Aesthet Surg J. 2017 Jul 1;37(7):814–25.
Koh IS, Lee W. Visual complications of filler injections.
In: Koh IS, Lee W, editors. Filler complications.
Singapore: Springer; 2019. p. 93–110.
Lee W. Prevention of hyaluronic acid filler-induced blind-
ness. Dermatol Ther. 2020 Jul;33(4):e13657.
Lee W, Yang EJ. Reply: effectiveness of retrobulbar hyal-
uronidase injection in an iatrogenic blindness rabbit
model using hyaluronic acid filler injection. Plast
Reconstr Surg. 2020 Mar;145(3):659e–61e.
Lee W, Kim JS, Oh W, Koh IS, Yang EJ. Nasal dor-
sum augmentation using soft tissue filler injection.
J Cosmet Dermatol. 2019a Jun 3;18(5):1254–60.
Lee W, Oh W, Ko HS, Lee SY, Kim KW, Yang
EJ. Effectiveness of retrobulbar hyaluronidase injec-
tion in an iatrogenic blindness rabbit model using
hyaluronic acid filler injection. Plast Reconstr Surg.
2019b Jul;144(1):137–43.
Lee W, Oh W, Oh SM, Yang EJ. Comparative effec-
tiveness of different interventions of perivascu-
lar hyaluronidase. Plast Reconstr Surg. 2020a
Apr;145(4):957–64.
Lee W, Koh IS, Oh W, Yang EJ. Ocular complications
of soft tissue filler injections: a review of literature. J
Cosmet Dermatol. 2020b Apr;19(4):772–81.
Moon HJ. Injection rhinoplasty using filler. Facial Plast
Surg Clin North Am. 2018 Aug;26(3):323–30. https://
doi.org/10.1016/j.fsc.2018.03.006.
Moon HJ, Lee W, Do Kim H, Lee IH, Kim SW. Doppler
ultrasonographic anatomy of the midline nasal dor-
sum. Aesthet Plast Surg. 2020 Nov 2;45(3):1178–83.
Pavicic T, Webb KL, Frank K, Gotkin RH, Tamura
B, Cotofana S. Arterial wall penetration forces in
needles versus cannulas. Plast Reconstr Surg. 2019
Mar;143(3):504e–12e.
Injection Rhinoplasty