Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

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762
C. Hopkins and D. Roberts
(Fig. 50.11 ). Unfortunately, one patient with a
Permacol sausage has had a reactivation of her
Wegener’s, yet despite this, the graft appears to be
stable, with no loss of dorsal height (Fig. 50.12 ).
50.8
Results
The authors have been using Permacol success-
fully in augmentation rhinoplasty for 8 years [ 11 ]
in a series of over 100 patients with layered
Permacol grafts and 10 rolled Permacol augmen-
tation patients. Two thirds of the patients had
undergone previous surgery (re ﬂ ecting the ter-
tiary referral nature of the practice of the operat-
ing surgeons). In 10% of cases, Permacol was
used primarily because of a thin skin envelope. In
all other cases, it was used for camou ﬂ age and
augmentation, in conjunction with cartilaginous
grafts, in 50% of the series. Minimum follow-up
in all cases has been 6 months, with 40 patients
undergoing further review at 12 months and half
at 24 months. Longer-term follow-up was thought
unnecessary in the absence of complications.
50.9
Complication Rates
and Infection Risks/Safety
There was one case of postoperative infection in
the authors’ series, although it is not clear whether
this directly relates to the use of Permacol, which
has not required removal. The infection settled
with oral antibiotics, although a suboptimal cos-
metic outcome resulted. In another case, a sterile
cyst formed over the graft 1 year after placement.
Interestingly, at the time of surgery to drain the
cyst, the graft appeared to have been replaced by
ﬁ brous tissue with no change in bulk and no cos-
metic defect. In one patient who required revi-
sion surgery to the tip (unrelated to the use of
Permacol), a biopsy was taken from the site of
Fig. 50.9 (continued)

763
50 Permacol in Augmentation Rhinoplasty
grafting. Histological comparison with Permacol
and the in vivo biopsy taken at 12 months demon-
strated that the collagen bundles persist but there
is integration with host connective tissue with
ingrowth of elastin ﬁ bres and incorporation of
smooth muscle. This will help prevent late extru-
sion or loss of volume.
50.10 Limitations of the Technique
As a porcine-based ﬁ ller, Permacol may not be a
universally acceptable material, especially in the
Muslim and Jewish communities. There remains
some theological discussion as to whether surgi-
cal use of porcine material constitutes ingestion,
Fig. 50.10 ( Upper ) Preoperative. ( Lower ) Postoperative after caudal extension cartilaginous graft with overlying
Permacol supratip graft

764
C. Hopkins and D. Roberts
but this is beyond the scope of this discussion and
should be dealt with by carefully informed con-
sent on a patient-by-patient basis.
If major reconstruction of the nose is required,
this technique is unlikely to offer suf ﬁ cient struc-
tural integrity, and other techniques such as rib
or calvarial bone grafting will still be required.
Conclusions
The authors believe Permacol to be an ideal
graft material and technique to achieve smooth
augmentation of the nasal dorsum. It is easily
used in the hands of any competent rhino-
plasty surgeon and has a very low risk of
complications.
Fig. 50.11 Vasculitis in a patient following dorsal augmentation with Permacol ‘sausage’ in patient with saddle defor-
mity secondary to Wegener’s granulomatosis. ( Upper ) Preoperative. ( Lower ) Postoperative

765
50 Permacol in Augmentation Rhinoplasty
References
1. Hunter B, Hopkins C, Roberts D (2010) Permacol in
augmentation rhinoplasty-Histopathological study of
in vivo permacol 12 months post implantation. Clin
Otol 35: 340-341
2. Pitkin L, Rimmer J, Lo S, Hosni A (2008) Aesthetic
augmentation rhinoplasty with Permacol: how we do
it. Clin Otolaryngol 33(6):615–618
3. Saray A (2003) Porcine dermal collagen (Permacol)
for facial contour augmentation: preliminary report.
Aesthetic Plast Surg 27(5):368–375
4. Benito-Ruiz J, Guisantes E, Serra-Renom JM (2006)
Porcine dermal collagen: a new option for soft-tissue
reconstruction of the lip. Plast Reconstr Surg 117(7):
2517–2519
5. Fu B, Qayyum A, Frosh A (2008) Experience with use
of Permacol in reconstructing nasal deformity. Clin
Otolaryngol 33(4):370–384
Fig. 50.12 Patient with saddle deformity secondary to Wegener’s granulomatosis had dorsal augmentation with
Permacol ‘sausage’. She had a reactivation of her Wegener’s, yet despite this, the graft appears to be stable, with no loss
of dorsal height. ( Upper ) Preoperative. ( Lower ) Postoperative

766
C. Hopkins and D. Roberts
6. Thinakarajan T, Srinivasan V (2008) Augmentation
rhinoplasty with Permacol and cartilage grafts.
Otolaryngol Head Neck Surg 139(2 Suppl):168
7. Gryskiewicz JM, Rohrich RJ, Reagan B (2005) The
use of AlloDerm for the correction of nasal contour
deformities. Plast Reconstr Surg 116(7):1999–2004
8. Lekakis P, Roberts D, Hopkins C (2010) A systematic
review of graft materials in augmentation rhinoplasty.
Presented at the aesthetic reconstructive surgery
annual meeting, Boston 2010
9. Erol OO (2000) The Turkish delight: a pliable graft for
rhinoplasty. Plast Reconstr Surg 105(6):2229–2241
10. Daniel RK (2008) Diced cartilage grafts in rhino-
plasty surgery: current techniques and applications.
Plast Reconstr Surg 122(6):1883–1891
11. Hopkins C, Walker R, Lee S (2009) Permacol in aug-
mentation rhinoplasty: how we do it. Clin Otolaryngol
34(1):68–76

767
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_51, © Springer-Verlag Berlin Heidelberg 2013
51
51.1
Introduction
In Japan, Aquamid (Contura S.A., Montreux,
Switzerland) has been used for 8 years, mainly as
a facial ﬁ ller. It is a well-known fact that Aquamid
is a permanent homogenous polymer ﬁ ller and
has been used successfully for many facial correc-
tions. The author has also used this ﬁ ller for rhi-
noplasty for 8 years. From December 2002 to
December 2010, more than 3,000 patients were
treated by the clinic group. Complications were
relatively minimal (0.11%) in comparison to other
ﬁ llers, and long-term effects were revealed [ 1, 2 ] .
Polyacrylamide hydrogel is approved for
facial contouring in Australia, Europe, South
America, and the Middle East under the brand
name Aquamid. It is composed of 2.5% poly-
acrylamide polymer and 97.5% pure sterile water.
Aquamid has not yet been approved by the US
Food and Drug Administration (FDA), but FDA-
approved clinical trials are currently ongoing. An
IDE application has been submitted by the manu-
facturer to initiate the approval process and start
clinical trials in the United States [ 3 ] .
51.2
Technique
Recently, the demands of silicone prosthesis have
been reduced in Japan for rhinoplasty. Instead of
silicone prosthesis, usage of injectable ﬁ ller has
increased tremendously because of their short
time requirement. The height of the Oriental nose
is lower than that of the Caucasian nose in gen-
eral. Japanese have longed for a high nose.
Injection therapy is a very easy method of achiev-
ing this desire without undergoing an invasive
surgical approach. Injected rhinoplasty using
Aquamid is the major part of treatment, consist-
ing of more than 35% in the author’s total
Aquamid treatment data. The average injection
dose was 2.126 mL (Table 51.1 ).
All injections were performed under local
anesthesia (nasal nerve block, supratrochlear
nerve block, and infraorbital nerve block with
1% Xylocaine with epinephrine). The injection
layer to be augmented is the deep subcutaneous
layer on the nasal bone periosteum. After injec-
tion, manual manipulation via hand massage is
effective in obtaining a favorable contour and lin-
ing of the nose (Figs. 51.1 and 51.2 ).
There are two simulating methods to show
patients their ﬁ nal completed images. First, when
injecting anesthesia to patients’ nasal dorsum, we
Use of Aquamid as a Filler
for Rhinoplasty in Orientals
Yoichi Yagi
Y. Yagi , M.D.
Aesthetic Plastic Surgery , Tokyo Aoyama Clinic ,
3F 5-12-6 Aoyamadainiwada-Building ,
Minami Aoyama, Minato-ku, Tokyo 107-0062 , Japan
e-mail: prs@tokyoaoyama.com
Table 51.1 Relationship between number and dosage
Volume
(mL)
1
2
3
4
5
Average
(mL)
Nose
286
1,049
449
29
3
2.126

768
Y. Yagi
will create a completed nose image using anes-
thesia’s liquid volume. After an estimate of the
amount of Aquamid, compared with local anes-
thesia’s volume, we can inject same amount of
Aquamid to the nose. The demerit of this fashion
is swelling due to double volume injection.
Second method is a direct injection image tech-
nique. At ﬁ rst, anesthetic local blocks of infraor-
bital nerves and slightly of nasal and supratrochlear
nerves are injected without direct anesthesia injec-
tion to nasal dorsum. In this method, the amount of
anesthesia does not intervene in ﬁ nal images. So we
can perform a rhinoplasty using Aquamid itself to
show patients the completed images. But we should
reconsider the swelling itself due to the in ﬂ ammation
of injections. Our experiences conclude that the
in ﬂ ammation and swelling of this operation make
the nose about 20 or 30% volume increase.
Therefore, before, amid, and after operation, we
have to explain to the patients about this volume
loss. Much claims will be occurred by the lack of
this explanations.
When estimating the dosages of Aquamid, the
authors classi ﬁ ed the patients into three groups
according to the height of the patient’s nose. This
classi ﬁ cation is a little bit vague and dif ﬁ cult to
comprehend but helps us to determine how much
amount is required to some extent.
Group A: No nasal root patient: the height of
nasion is very low. Please imagine
Southeast Asian people’s nasal root.
Group B: Middle amount level of nasal root
between Groups A and C.
Group C: The appearance of nasal root looks like
Caucasian’s higher nasal bridge and
boney component is apparent.
In Group A, the recommended dosage of
Aquamid was a minimum of 3 mL for these, but
a
b
Fig. 51.1 ( a ) Preoperative patient. ( b ) Postoperative 1.5 years after treatment with 3 mL of Aquamid to the patient’s nose

769
51 Use of Aquamid as a Filler for Rhinoplasty in Orientals
the actual average dose required was 2.19 mL
(Table 51.2 ). The primary request of the patients
in this group was to raise the nasion.
In Group B, the amount of Aquamid required
was 2–3 mL, to satisfy their needs for attainment of
an ideal nasal lining and the height of their nose
(average is 2.01 mL). Majority of the Japanese
patients fall into this category (Figs. 51.1 and 51.2 ).
In Group C, approximately 1 mL of Aquamid
was required (average: 1.62 mL) to attain the
desired results of the patient’s request.
51.3
Complications
The rate of complications was 0.11% (two of
1,816 patients). After treatment, gentamicin oint-
ment was applied to the treatment site, and oral
antibiotics were administered for 3 days. Facial
cleansing and the use of cosmetics were autho-
rized for the next morning. There was one case of
infection and one case of ischemic change.
The patient with infection had Aquamid admin-
istered to the nasal dorsum, and at 2 weeks follow-
ing treatment, signs of erythema, swelling, and
pus collection were noted at the site of treatment.
Oral antibiotics were administered, and drainage
with water irrigation improved the patient’s con-
dition to normal (Fig. 51.3 ). The patient did not
comply with the instructions, that is, not to touch
the site of treatment.
The patient with transient ischemic change
showed signs of ischemia when 1% Xylocaine
a
b
Fig. 51.2 ( a ) Preoperative patient. ( b ) Three years after treatment. Nasal root is higher than before
Table 51.2 Relationships between the three groups
(A, B, and C) and the dose of Aquamid administered. The
majority of the patients were categorized into Group B
Group 1
2
3
4
5
6
Average
(mL)
A
118
261
179
23
3
0
2.19
B
229
644
237
6
0
0
2.01
C
57
46
13
0
0
0
1.62

770
Y. Yagi
with epinephrine was administered as local anes-
thetic to the patient’s nasal dorsum. From the day
of treatment to the next day, she felt pain and
abnormal sensation in the proximity of the right
nasal ala. The color gradually changed to pale
with a congestive appearance, and the nose ﬁ nally
became erythemic in appearance (Fig. 51.4 ). The
authors postulated that the vasoconstrictive effects
of epinephrine and the pressure of the ﬁ ller on the
marginal subcutaneous tissues resulted in vascu-
lar compromise. Thus, the ﬁ nal outcome was a
transient ischemic change. The patient’s nose
returned to normal 2 weeks after the event.
The authors have never experienced any aller-
gic reactions among the patients with Aquamid
as had occurred with other collagen or hyaluronic
acid cases.
51.4
Discussion
The authors have discussed the injection tech-
nique, analysis for determination of the appro-
priate and satisfactory dose of Aquamid, and
related complications encountered especially for
rhinoplasty.
It has been reported that the half-life of poly-
acrylamide in the human body is greater than
20 years. This may be true for large quantities;
however, the injection of 0.1 mL of Aquamid
appears to be absorbed by the human skin within
9 months [ 4 ] . The authors’ patients’ outcomes
indicate the longevity of Aquamid. The injection
technique in this area is not complicated and may
be easiest for physicians and surgeons just begin-
ning practice. The operator and the patients are
able to visualize the results immediately after treat-
ment, thus minimizing the incidence of claims.
There are only a few reports concerned with
rhinoplasty using injectable implant materials,
and it has not been published in any textbooks.
Fillers contribute to make the nasal roots and dor-
sum appear to have a sharper con ﬁ guration as
attained with a nasal prosthesis but without a pro-
longed recovery time. In Orientals who have a
lower nasal pro ﬁ le than Caucasians, this less
time-consuming method has been readily
accepted by the patients recently more than the
conventional rhinoplasty. Japanese mass media
Fig. 51.3 Appearance at 2 weeks after 2 mL of Aquamid
injected to patient’s nasal root. Abscess formation is
identi ﬁ ed in the region of her nasal dorsum. After several
punctures and irrigations, the abscess disappeared and
favorable and satisfactory results were attained
Fig. 51.4 Ischemic change probably resulted from
congestive or vascular compromise to the right ala and
nasal dorsum 5 days after treatment. Only 1 mL of
Aquamid was administrated to her nose for augmentation.
A nerve block was performed with 1% Xylocaine with
epinephrine. It is believed that epinephrine’s vasoconstric-
tive action and the pressure of the ﬁ ller on the marginal
subcutaneous circulation caused the ischemic state

771
51 Use of Aquamid as a Filler for Rhinoplasty in Orientals
calls this method the “petite operation,” and it is
evident that this procedure will become more and
more popular in the Japanese society.
When used to augment the bridge of the nose,
solid implants look and feel unnatural. The skin
overlying the implant can appear unnaturally
shiny. If the nose sits slightly to the left or right,
the solid implant will follow this direction. The
ﬂ exibility of Aquamid allows this direction to be
corrected so that the nose can be properly cen-
tered [ 5 ] . In cases of slightly nasal humps, the
hump can easily be “masked” by simply injecting
Aquamid above and below it [ 6 ] . The silicone
prosthesis is suitable for nasal tip and columellar
augmentation, so use of the ﬁ ller is mainly for
augmentation of the nasal root and dorsum. In
terms of producing a higher nasal bridge, rhino-
plasty using Aquamid gel is an innovative way of
achieving the same aesthetic result as obtained
with the conventional surgical method for a
selected group of patients. Extra precaution must
be exercised for Aquamid administrations to the
nasal tip because the nasal skin of Orientals is
extremely hard and thick. After treatment, the
nasal tip will appear to be rounder than antici-
pated by the patient or go against the patient’s
wishes for a sharper nasal tip appearance with
ﬁ llers. On the other hand, administration of an
excessive amount of Aquamid to the thin layer of
the subcutaneous tissue of pale-skinned and thin
patients will result in dark discoloration of the
injection site and the gel may become visible
through the nasal skin due to be ﬁ lled up.
It is worthy of merit to mention that the height
of the newly reconstructed nasal bridge immedi-
ately at the end of this procedure is approximately
20–30% higher than its actual height due to swell-
ing. It is of importance that we inform the patients
that within a month following treatment they are
expected to lose up to 30% of the reconstructed
nasal bridge height due to the dissipation of the
post-procedural swelling of the local tissue.
The authors have not experienced any allergic
reaction to Aquamid or granuloma lesions as
compared with hyaluronic acid treatment [ 7 – 9 ] .
Granulomatous reactions, which are generally
seen in foreign-body operations, were never seen
in our treatments. In addition, nonpermanent
ﬁ llers are expensive for patients because they
must be injected many times. Aquamid is very
useful, safe, and has a long-lasting effect as a
ﬁ ller, if one pays particular attention to the rules
and criteria. Therefore, higher biocompatibility is
expected to be guaranteed and complications are
rare.
Longer follow-up and more precise histologi-
cal research are required in the future studies.
References
1. Yagi Y (2009) Utilization of aquamid as a ﬁ ller for rhino-
plasty in orientals. Plast Reconstr Surg 123(1):26e–28e
2. Yagi Y, Kentaro K, Daisuke M, Kojiro M, Mitsuya O,
Ota M, Kataoka J, Yukawa N (2009) Use of Aquamid
as a ﬁ ller for facial rejuvenation in orientals. J Plast
Reconstr Aesthet Surg 62(10):1245–1249
3. von Buelow S, Pallua N (2006) Ef ﬁ cacy and safety of
polyacrylamide hydrogel for facial soft-tissue augmen-
tation in a 2-year follow-up: a prospective multicenter
study for evaluation of safety and aesthetic results in 101
patients. Plast Reconstr Surg 118(3 Suppl):85S–91S
4. Lemperle G, Morhenn V, Charrier U (2003) Human
histology and persistence of various injectable ﬁ ller
substances for soft tissue augmentation. Aesthetic Plast
Surg 27(5):354–366
5. Doggett C (2004) A new nose: instantly. Aust Cosm
Surg Mag 24:73
6. Peterson L (2004) Nose job without surgery. Aust
Cosm Surg Mag 24:48
7. Lemperle G, Rullan PP, Gauthier-Hazan N (2006)
Avoiding and treating dermal ﬁ ller complications. Plast
Reconstr Surg 118(3 Suppl):92S–107S
8. Coleman SR, Plastic Surgery Educational Foundation
DATA Committee (2006) Cross-linked hyaluronic acid
ﬁ llers. Plast Reconstr Surg 117(2):661–665
9. Grossman KL (2005) Hyaluronic acid gel ﬁ llers:
hypersensitivity reactions. Aesthet Surg J 25(4):
403–405

773
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_52, © Springer-Verlag Berlin Heidelberg 2013
52
52.1
Why Nonsurgical?
The growing market for a noninvasive rhinoplasty
exists because society is increasingly focusing on
procedures that offer marked change without
signi ﬁ cant downtime. Many patients are hesitant
to endure the pain and time away from social and
job-related activities due to an elective operation.
Research continues to support the idea that this
trend will persist and that “the future demand in
cosmetic surgery will be driven largely by non-
surgical procedures” [ 1 ] . Of note, this nonsurgi-
cal in ﬂ ux does not correlate statistically with
economic trends. The American Society of Plastic
Surgeons predicts that by 2015, its members will
be performing more than seven times the amount
of nonsurgical procedures than their surgical
counterparts [ 1 ] .
When dealing with a feature as pronounced and
centralized as the nose, some patients may be reluc-
tant to permanently change the appearance, espe-
cially as this change will be created by a surgeon
whose aesthetic vision may or may not be com-
pletely congruent with the patient. Though proce-
dures such as breast augmentation typically yield a
high degree of satisfaction [ 2 ] , delicate and increas-
ingly subjective facial changes are much more
dif ﬁ cult to gauge. Therefore, one of the most excit-
ing aspects of the nonsurgical rhinoplasty is that it
offers patients the opportunity to guide the proce-
dure in real time, customizing the result to their
preferences. This not only appeals to the patient,
but it removes a major burden from the provider.
Data also supports the notion that “more exten-
sive” (type change) procedures (e.g., rhinoplasty)
appear to require greater psychological adjust-
ment by the patient than “restorative” procedures
(e.g., facelift) [ 3 ] . Meaning, even among surgical
alterations, the “nose job” presents obstacles
unlike many other plastic surgeries. Consequently,
when applicable, the nonsurgical rhinoplasty lets
patients experiment with recontouring the nose
temporarily, allowing for mental preparation. It
can also serve as a trial precursor to traditional
rhinoplasty. This framework can provide helpful
feedback to the eventual surgeon, especially in
light of the fact that up to 20% of rhinoplasty
patients may express some degree of dissatisfac-
tion and desire for revision postoperatively [ 4 ] . In
light of this statistic, the nonsurgical rhinoplasty
is also useful in correcting post-rhinoplasty
defects or for revision of rhinoplasty.
Nonsurgical Rhinoplasty: Cosmetic
Nasal Contouring Through
the Use of Fillers
Cameron K. Rokhsar and Molly M. Murray
C. K. Rokhsar , M.D.
New York Cosmetic, Skin & Laser Surgery Center ,
260 East 66 Street , New York ,
NY 10065 , USA
Department of Dermatology ,
Albert Einstein College of Medicine,
Monte ﬁ ore and Jacobi Medical Centers ,
Bronx , NY , USA
e-mail: crokhsar@yahoo.com
M. M. Murray , B.S., P.A.-S ()
9581 Brentford Dr. , Highlands Ranch ,
CO 80130 , USA
e-mail: mollymurray11@gmail.com

774
C.K. Rokhsar and M.M. Murray
Other patients simply may ﬁ nd the invasive rhi-
noplasty non-feasible. Preexisting medical condi-
tions that contraindicate the use of anesthesia
certainly prevent some from being able to make a
rational commitment to rhinoplasty. However, “in
addition to the risks of general anesthesia, and a
protracted postoperative convalescence, rhinoplasty
may lead to adverse cosmetic sequelae of pollybeak
deformity, over-reduction of the body or cartilagi-
nous dorsum, inverted V deformity, alar retraction
and scarring, supratip depression and bossae” [ 5 ] .
Not risking these possible dysfunctions can seem
attractive to both patient and doctor (Fig. 52.1 ).
Many other reasons also support the use of the
nonsurgical approach. For example, it is important
to note that the nose changes with time, meaning
that an initially satisfactory rhinoplasty operation
may eventually require revision. Young adults or
teenagers that lack the permission or emotional
capacity to undergo a surgical procedure can also
bide time with a very realistic alternative.
52.2
History
Recontouring the nose through the use of ﬁ llers
has been performed in our practice (NY Cosmetic
Laser Skin Surgery Center) since 2003 with a
high degree of patient satisfaction. We published
the ﬁ rst study of injectable calcium hydroxylapa-
tite for nasal contouring in 2008. Using an inject-
able ﬁ ller to mold the nose was also investigated
by Han and colleagues in 2006, during a study in
which hyaluronic acid was mixed with autolo-
gous human ﬁ broblasts. This mixture was then
injected along the nasal dorsum. In theory, the
ﬁ broblasts would create a permanent collagen
scaffold, thus replacing the temporary hyaluronic
acid as it resorbed. While the theory was initially
successful, the lengthy preparatory time and mor-
bidity of in vitro ﬁ broblasts proved to be imprac-
tical [ 6 ] . Others have also proposed the idea of
substances to alter nasal appearance, including
Botox for relaxing the depressor septi nasi to
reduce nasal tip drooping [ 7 ] .
52.3
Candidates
An ideal nonsurgical rhinoplasty candidate pos-
sesses realistic expectations, improvable features,
and an understanding of the temporary nature of
the procedure. Patients of all ages, races, socio-
economic status, and gender can and do undergo
noninvasive rhinoplasty. The procedure is increas-
ingly being used for not only conventionally dis-
pleasing features, such as bumps and dents, but
currently plays a role in the “medicalization of
racial features” [ 8 ] .
The medicalization of racial features repre-
sents the idea of altering non-deformed, ethni-
cally determined facial features in order to make
them appear more desirable to the patient. This
concept is oftentimes discussed in regard to
blepharoplasty in Asian patients as a means to
change a stereotypically appearing eyelid. In the
nose, however, patients of Asian or African-
American descent often are characterized by “a
broad low dorsum, decreased tip projection, thick
lobular skin, wide lobule, abundant subcutaneous
fatty tissue, alarm ﬂ aring, retracted columella,
and a small osteocartilaginous framework” [ 8 ] .
Many Asian patients request a more “American”-
style nose or the intermediate, which is often
regarded as the “Japanese” nose, both of which
typically display a higher dorsum than the aver-
age Asian nose. African-Americans also fre-
quently ask for this heightened dorsum, which
can decrease the perception of nasal width.
Fig. 52.1 Alar retraction (Courtesy of A. John Vartanian,
M.D.)

775
52 Nonsurgical Rhinoplasty: Cosmetic Nasal Contouring Through the Use of Fillers
A surgical approach to the aforementioned
issues typically implicates the use of implant
material (oftentimes silicone) or autologous car-
tilage (particularly costal) to modify platyrrhine
nasal characteristics. Unlike most rhinoplasties,
which usually necessitate reduction, many Asian
and African-American patients require this aug-
mentation. Unfortunately, the outcomes may be
unpredictable and dif ﬁ cult to achieve. However,
the use of injectable ﬁ ller allows for quick and
simple nasal augmentation with the constant
input of the patient. Therefore, the desired result
can be achieved nonsurgically, with “less com-
plex, invasive, and brutal protocol” [ 7 ] .
52.4
Contraindications
In any discussion of candidates, it is imperative
to note which patients may not achieve maxi-
mum bene ﬁ t or whose circumstances exclude
them from being ﬁ t for the procedure. Just as
important, it is vital to remember that the nonsur-
gical rhinoplasty is not a replacement of its sur-
gical alternative but an alternative in certain
individuals.
Though the nonsurgical nose job is capable of
camou ﬂ aging bumps, bumps that are consider-
able in size may need large amounts of ﬁ ller,
resulting in a straighter, yet undesirably large
nose. Patients whose necessity for a rhinoplasty
involves repair of structures involved in breathing
cannot receive functional bene ﬁ t from the non-
surgical alternative. For instance, a noninvasive
ﬁ ller-based rhinoplasty can provide remarkable
aesthetic change for “saddlenose,” a congenital
or acquired (traumatic or iatrogenic) condition.
However, if the saddlenose condition is such that
it impairs respiration, those changes can only be
achieved with surgical treatment (Fig. 52.2 ).
Changes to the septa are also not feasible with
the nonsurgical “nose job,” and it is not a substitute
for any patient needing septoplasty. Additionally,
it is obvious that nasal reduction of any kind is not
to be achieved nonsurgically at this point in time.
Thus, those wishing to reduce columella width, tip
projection, or alar size, width, and/or placement
are not ideal candidates for the procedure and
would instead indicate surgery.
52.5
Consultation
Patients seeking nonsurgical rhinoplasty should
ﬁ rst and foremost be made aware of a realistic
outcome. This involves preparing the patient in a
variety of areas. Consultations should ideally be
provided with two mirrors so that the patient can
adequately view both the frontal and pro ﬁ le views
and thoroughly explain their goals. Marking the
nose with a skin marker can also help in verifying
that the patient and physician desired outcomes
are compatible.
52.6
Safety
Calcium hydroxylapatite is a natural substance
found in human bones and teeth. It is made
of calcium hydroxylapatite microspheres sus-
pended in an aqueous gel carrier [ 9 ] . Thus, it is
extremely biocompatible and the chance for
Fig. 52.2 Saddlenose (Courtesy American College of
Rheumatology)

776
C.K. Rokhsar and M.M. Murray
allergic reaction is remote when injected in a
medically sound and sterile fashion. It is the
same substance commonly utilized in hip
replacements and dental implants and to replace
amputated bone. It possesses two FDA approvals
and is indicated for facial lipoatrophy, moderate
to severe facial wrinkles, folds such as nasola-
bial, oral and maxillofacial defects, vocal fold
insuf ﬁ ciency, and radiographic tissue marking.
52.7
Side Effects
Like any pre-procedure consultation, the nonsur-
gical rhinoplasty discussion must include an
overview of realistic side effects. These include:
1. Swelling
Immediate swelling can and will occur and
•
can worsen within the ﬁ rst hours and days.
This
edema
should
subside
within
1–2 weeks and can be alleviated with anti-
in ﬂ ammatory medications and frequent
application of cool compresses. A pilot
study found that 64% of patients had edema
for 2–5 days post-procedure [ 10 ] . It is
extremely important to warn and reassure
patients that the swelling created by injec-
tion must be taken into consideration when
viewing the initial result. If patients mis-
take temporary swelling for permanent
bumps or protrusions, they may express
displeasure with the procedure. Emphasizing
that ﬁ nal judgment should be withheld until
swelling subsides is crucial.
2. Bruising
Bruising may occur in patients prone to it,
•
or in the rare instance that a vessel is punc-
tured during injection. Like swelling, the
bruise should subside in no more than
1 week. Recent research suggests that the
use of Arnica montana may reduce the
duration of bruising. In a pilot study of the
nonsurgical rhinoplasty, 57% of patients
exhibited ecchymoses for 2–7 days [ 10 ] .
3. Pain
The application of a topical numbing
•
cream or gel can greatly reduce patient
perception of procedure pain. However,
injection will still oftentimes be felt.
Injection pain is often described as worst
when injecting through the columella in
order to reach the nasal tip. Patients also
typically ﬁ nd the sense of pressure caused
by the injectable substance to be unpleas-
ant or unsettling, but relatively quick to
dissipate (1–2 days).
4. Risk of skin necrosis
The risk of skin necrosis is remote and is
•
likely secondary to intravascular implanta-
tion of the injectable or pressure necrosis
in the nasal tip [ 10 ] .
52.8
Common Patient Questions
1. “What if I don’t like it? Can it be reversed?”
(a) Certain injectable formulas such as
hyaluronic acid (often branded as Restylane)
can be reversed with hyaluronidase enzyme.
However, hyaluronic acid may not always
be the ideal substance, as it is a softer ﬁ ller
with less structural rigidity and more pro-
pensity to disperse. Choosing the correct
substance is an important decision that
should be discussed thoroughly with each
patient on a case-by-case basis.
2. “Is there anything I can do to make it last
longer?”
(a) The substance breaks down over time
regardless of patient habits. However,
patients would be wise to avoid excessive
manipulation of the nose. Calcium hydrox-
ylapatite lasts longer in the tip (around
1 year) and around 6–12 months on the
bridge. Hyaluronic acid ﬁ llers last less in
duration. The disparity in degradation
based on location is likely due to vascula-
ture in the area [ 10 ] .
3. “You’re injecting something into my nose.
Isn’t this going to make it look even bigger?”
(a) “Filling the valleys to hide the hills” can
be a helpful analogy when explaining to
patients that injecting ﬁ ller will not neces-
sarily result in a larger-looking nose.
People generally perceive features (and
anything for that matter) by connecting
with a focal point, oftentimes the largest
area of an object. Therefore, by creating a

777
52 Nonsurgical Rhinoplasty: Cosmetic Nasal Contouring Through the Use of Fillers
ﬂ at plane rather than a bumpy one, the
illusion of a thinner and longer nasal rhin-
ion can be accomplished. Making the nose
more symmetrical allows for it to ﬁ t better
and more proportionally within the frame
of the face, decreasing perceived size
(Fig. 52.3 ).
52.9
Pre-procedure
Like any cosmetic procedure, progress photo-
graphs and consent should be signed, and any
questions answered. A topical numbing agent
(lidocaine, or a 6% lidocaine/6% tetracaine
cream, etc.) should be applied on the dorsal nasal
surface and placed under occlusion (to facilitate
penetration through the stratum corneum) for
approximately 30 min.
The nasal surface and surrounding area should
be marked and prepped in a sterile fashion.
Providing a stress ball for patients to squeeze can
prove helpful in eliminating movements that may
disrupt the injection. Raising the feet to a hori-
zontal position and reclining the exam chair to a
70–80° angle can also provide minimized move-
ment, increased patient comfort, and enhanced
visibility for the provider.
52.10 Procedure
A 27 × ½ in. gauge needle should be applied to the
syringe. The ﬁ ller is then delivered using a ﬁ ne lin-
ear threading technique, dispensing a continual line
of ﬁ ller as the syringe moves backward and for-
ward at multiple insertion sites, as needed. Injection
usually occurs approximately at least 1 millimeter
below the area to be augmented. Common inser-
tion sites include nasion, rhinion, supratip, ala, and
tip [ 7 ] . The ﬁ ller is injected in the submuscular or
subcutaneous space, in the superperiosteal plane.
The mean volume of hydroxylapatite ﬁ ller used in
one of the ﬁ rst studies of the procedure was around
0.27 mL, with a range of 0.15–0.4 mL [ 10 ] . Nasal
bridge augmentation often requires larger volumes.
Digital pressure is then applied to mold and achieve
desired aesthetics while providing minimal
hemostasis. The duration of this pressure varies
with amount of time needed for hemostasis as
well as adequate stability of the substance.
In patients with an undesirable bump in the mid-
dle of the nose, camou ﬂ aging it means injecting into
the depressed spaces, creating a ﬂ attened plane.
When attempting to decrease perceived width
of a nose, augmenting bridge height is the key to
achieving desired effect. “Droopy” tips can also
be made to appear higher when the superior
aspect of the greater alar cartilage is augmented
(Figs. 52.4 , 52.5 , 52.6 , 52.7 , and 52.8 ).
52.11 Post-procedure Aftercare
Immediately following the injection, patients
should be provided with ice to decrease swelling
and possible bruising, particularly ice that is non-
rigid and lightweight (cold malleable gel packs,
small bags of crushed ice, etc.). A disposable and
moldable option is a 4 × 4 in. gauze square, folded
in half, wet, and frozen inside a 2 × 3 in. 2 mL plas-
tic self-sealing bag. Patients can be instructed to
cool the area with minimal pressure for 5–10 min.
It is prudent to advise patients not to touch the area
(even lightly) to avoid contamination and altera-
tion while the substance is still pliable.
Patients should be warned not to manipulate
the area, to avoid contact sports for 1 week, and
to refrain from wearing glasses or sunglasses for
Filler
Fig. 52.3 Two common ﬁ ller injection sites (Image cour-
tesy Molly Murray)

778
C.K. Rokhsar and M.M. Murray
1 week. This can assure that the area is not altered
during this more vulnerable stage.
The concept of a follow-up appointment is up
to the discretion of the provider. Many patients are
comforted by the option of “touch-ups,” after they
have had time to adequately adjust and analyze the
nose post-procedure and after bruising and/or
swelling have subsided. However, physicians
should ﬁ rst perform a risk/bene ﬁ t analysis as to the
value of this service. While it may incentivize cau-
tious patients, it is also unknown how sterile the
substance in the syringe remains after opened. It
is also possible for the substance to dehydrate,
making further injection impossible. Doctors who
wish to offer follow-up appointments should cre-
ate protocol, including how long the substance will
be kept on hold for the patient, how it will be kept
as sterile as possible, how it will be identi ﬁ ed, and
if there will be any cost for a follow-up service.
52.12 Patient Satisfaction
In the ﬁ rst report of nonsurgical rhinoplasty,
authors found that of 14 patients undergoing sub-
cutaneous or submuscular injections, all tolerated
a
b
Fig. 52.4 Filler injected above dorsal hump and into tip to create illusion of straighter nose. ( a ) Left , preoperative;
right , postoperative. ( b ) Left , preoperative; right , postoperative

779
52 Nonsurgical Rhinoplasty: Cosmetic Nasal Contouring Through the Use of Fillers
the procedure, one-third requested touch-ups,
and 100% expressed “extreme satisfaction.” At
the 6-month follow-up, 92% reported being
“satis ﬁ ed,” and 0% reported dissatisfaction. This
degree of satisfaction is signi ﬁ cantly higher than
its surgical counterpart [ 10 ] .
Conclusions
While ﬁ llers have long been used for lips,
cheeks, nasolabial folds, and suborbital
regions, their introduction to the nose is an
exciting addition for patients and physicians
alike. Relying on the basic principles of fea-
ture perception, the nonsurgical rhinoplasty
can enhance the appearance of the nose in a
wide variety of ways. Whether it is
camou ﬂ aging bumps or dents, creating a thin-
ner, higher bridge, or raising a tip, it is inter-
esting to see how proportions can be made
more desirable with ﬁ ller. As various sub-
stances continue to be developed and intro-
duced, perhaps 1 day a more permanent yet
equally safe and effective injectable may mean
the possibility for longer-lasting noninvasive
nasal revisions. Until this time, it is logical to
predict that the number of both doctors offer-
ing and patients requesting the nonsurgical
rhinoplasty will continue to increase as a result
of its simplicity, ease, economic feasibility,
and high satisfaction.
a
b
Fig. 52.5 Raising a droopy tip can have profound aesthetic effects. ( a ) Left , preoperative; right , postoperative. ( b ) Left ,
preoperative; right , postoperative

780
C.K. Rokhsar and M.M. Murray
a
b
Fig. 52.6 Raising the tip and straightening the bridge with ﬁ ller in Latin-American patients. ( a ) Left , preoperative;
right , postoperative. ( b ) Left , preoperative; right , postoperative

781
52 Nonsurgical Rhinoplasty: Cosmetic Nasal Contouring Through the Use of Fillers
a
b
Fig. 52.7 Forming a straight bridge with ﬁ ller can alter the facial symmetry and appearance. ( a ) In a female. Left ,
preoperative; right , postoperative. ( b ) In an Asian male. Left , preoperative; right , postoperative

782
C.K. Rokhsar and M.M. Murray
References
1. Liu T, Miller T (2008) Economic analysis of the future
growth of cosmetic surgery procedures. Plast Reconstr
Surg 121(6):404–412
2. Handel N, Cordray T, Gutierrez J, Jensen A (2006) A
long-term study of outcomes, complications, and
patient satisfaction with breast implants. Plast Reconstr
Surg 117(3):757–767
3. Castle DJ, Honigman RJ, Phillips KA (2002) Does
cosmetic surgery improve psychosocial wellbeing?
Med J Aust 176(12):601–604
4. Guyuron B, Bokhari F (1996) Patient satisfaction fol-
lowing rhinoplasty. Aesthetic Plast Surg 20(2):153–157
5. Bray DJ, Hopkins C, Roberts DN (2010) Injection rhino-
plasty: non- surgical nasal augmentation and correction
of post-rhinoplasty contour asymmetries with hyaluronic
acid: how we do it. Clin Otolaryngol 35(3):227–230
6. Han SK, Shin SH, Kim WK (2006) Augmentation
rhinoplasty using injectable tissue-engineered soft tis-
sue: a pilot study. Ann Plast Surg 56(3):251–255
7. Braccini F, Ehrenfest D (2008) Medical rhinoplasty:
rationale for atraumatic nasal modeling using botuli-
num toxin and ﬁ llers. Rev Laryngol Otol Rhinol
(Bord) 129(4):233–238
8. Ahn J, Honrad C, Horn C (2004) Augmentation rhi-
noplasty in Asian patients. Arch Facial Plast Surg
6(2):120–123
9. Jacovella PF (2006) Calcium hydroxylapatite facial
ﬁ ller (Radiesse): indications, technique, and results.
Clin Plast Surg 33(4):511–523
10. Rokhsar C, Ciocon D (2008) Nonsurgical rhinoplasty:
an evaluation of injectable calcium hydroxylapatite
ﬁ ller for nasal contouring. Dermatol Surg 34(7):
944–946
a
b
Fig. 52.8 Creating the illusion of a slimmer nose by forming an enhanced bridge. ( a ) Asian female. Left , preoperative;
right , postoperative. ( b ) African-American female. Left , preoperative; right , postoperative

783
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_53, © Springer-Verlag Berlin Heidelberg 2013
53
53.1
Introduction
Collapse of the internal nasal valve (INV) from
trauma, post-rhinoplasty sequela, or inherent
upper lateral cartilage (ULC) weakness can be a
chronic and debilitating problem. Constriction of
air ﬂ ow at the INV is not uncommon since this is
the narrowest portion of the nasal passage [ 1 ] .
Initial therapy for INV constriction includes nasal
sprays, decongestants, antihistamines, and exter-
nal nasal splints. When these modalities fail to
bring relief, surgical options may be considered.
Sheen ﬁ rst described the placement of autolo-
gous cartilage as grafting material to improve the
patency through a narrowed internal nasal valve
in 1984 [ 2 ] . Since then, multiple procedures and
techniques have been described to effectively
increase the area within the nasal valve, but these
have been primarily surgical in nature. Nonsurgical
hyaluronic acid [ 3 ] and calcium hydroxylapatite
(CaHA) [ 4 ] spreader grafting to improve nasal
air ﬂ ow through the INV has been previously
described.
This chapter details the step-by-step, nonsurgical
technique for strengthening the region of the
internal nasal valve with spreader graft injec-
tions using CaHA. The CaHA gel is provided in
the form of Radiesse ® , a sterile, nonpyrogenic,
cohesive material comprised of CaHA micro-
spheres in a sodium carboxymethylcellulose
carrier gel (Merz Aesthetics). This biomaterial
is used widely for aesthetic facial augmentation,
HIV-related facial lipoatrophy, and vocal-fold
medialization.
53.2
Consent
Informed consent should be obtained from all
patients undergoing spreader graft injection with
CaHA. Patients should be informed that spreader
graft injection with CaHA is not currently FDA
approved and its use is strictly off-label.
While injection problems are few, patients
should also understand the potential risks and
complications of the procedure, which include
lumps, visible deformity, infection, bleeding,
need for additional injections, overcorrection,
undercorrection, and unforeseen complications.
It is prudent to have patients stop any blood thin-
ners they are taking 10 days prior to the proce-
dure, and prophylactic antibiotics are generally
not necessary. Patients will experience some
middle vault tenderness after injections, but pain
medicine is usually not warranted.
Patients should be informed that there is some
tolerance involved with the procedure. It is not
Spreader Graft Injection
with Calcium Hydroxylapatite
Christopher P. Nyte
C. P. Nyte , D.O.
Maple Valley Surgical Arts ,
27539 Maple Valley-Black Diamond Rd SE ,
Maple Valley , WA 98038 , USA
Department of Otolaryngology ,
St. Elizabeth Hospital ,
1455 Bttersby Ave, Enumclaw , WA , USA
e-mail: cpnyte@yahoo.com

784
C.P. Nyte
unusual for a patient to maintain an anatomically
improved INV angle after spreader graft injec-
tion, but they may perceive some degree of
obstruction, especially after a few weeks when
the carboxymethylcellulose carrier gel has dissi-
pated. Patients get used to improved air ﬂ ow
through the nasal valve over time after initial
improvement with CaHA spreader graft injec-
tion, so even a small amount of INV narrowing
may be perceived as frank obstruction. These
patients may bene ﬁ t from additional injections as
long as no visible distortion exists over the nasal
dorsum, although it is not unusual to see some
fullness over the middle vault after injections.
53.3
Procedure Considerations
In order to be considered a good candidate for
spreader graft injection, one must have a history
of nasal congestion and restricted nasal air ﬂ ow,
especially with nasal inspiration. Physical exam
will reveal varying degrees of collapse of the
ULC against the nasal septum. Figure 53.1 shows
a normal INV with an angle of 9–15° at rest.
Generally speaking, the unobstructed INV will
narrow to some extent but maintain an open angle
with physiologic nasal inspiration.
While many patients will experience relief
with spreader graft injection, the ideal candidate
for the procedure will have a weakness of the
ULC causing it to collapse primarily with nasal
breathing. Figure 53.2 shows the left and right
INV of one patient at rest. Notice that the ULC is
not collapsed against the septum. Figure 53.3
reveals near complete collapse of both the left
and right ULCs respectively against the septum
with physiologic nasal inspiration.
Figure 53.4 denotes key spreader graft injec-
tion points. The primary injection point is where
the majority of the CaHA buttress will be placed
and maximal elevation of the ULC will be
observed. The secondary injection points serve a
supportive role only and are generally necessary
if the ULC remains ﬂ accid with only minimal
elevation after primary injection.
Apex angle
9–15∞
Upper
lateral
cartilage
Nasal septum
Fig. 53.1 Normal INV anatomy
a
b
Fig. 53.2 ( a ) Left INV. ( b ) Right INV

785
53 Spreader Graft Injection with Calcium Hydroxylapatite
Patients with complete collapse of the ULC
against the septum at rest will bene ﬁ t minimally
from spreader graft injection. This is because it
will require a substantial volume of CaHA to
move the ULC off of the septum, and this usually
results in visible distortion of the nasal dorsum
over the middle vault. Other nonideal candidates
for spreader graft injection include those with
spurs or septal de ﬂ ections at the INV causing the
ULC to lose its angle with the septum. Injection
may only exacerbate the problem, and these
patients usually require a septoplasty for de ﬁ nitive
treatment. Finally, patients with severe INV dis-
tortion, scar formation, and altered anatomy due
to previous surgical or traumatic events may
expect limited results at best.
53.4
Procedure
53.4.1 Step 1: Assemble Instruments
Figure 53.5 shows the instruments and supplies
necessary to perform CaHA spreader graft injec-
tion. The following are indicated:
1. Tetracaine 1% solution/naphazoline 0.05%
solution mixed to a 1:7 ratio
2. Headlamp
3. Medium nasal speculum
4. Bayonet forceps
5. Calcium hydroxylapatite syringe
6. Straight 23G 1-in. needle
7. Cotton
8. Q-tips
53.4.2 Step 2: Anesthetize INV Area
The patient is placed in a semireclining position,
and using a headlamp and medium nasal speculum,
the INV is visualized. The nasal vestibule and INV
is sprayed with a topical anesthetic/decongestant
a
b
Fig. 53.3 ( a ) Left INV collapse with nasal inspiration. ( b ) Right INV collapse with nasal inspiration
Spreader graft injection points
Primary
injection
Secondary
injections
Fig. 53.4 Key spreader graft injection points

786
C.P. Nyte
spray. Next, topical cotton pledgets containing a
mixture of tetracaine/naphazoline are placed into
the INV angle depicted by the arrow in Fig. 53.6 .
Care is taken to ensure that the anesthetic pledget
covers the INV angle, especially the anterior-
medial extent of the ULC for 10 min.
53.4.3 Step 3: Primary Injection
Remove the topical pledget from the INV. A
medium nasal speculum is used to displace the ala
and medial aspect of the ULC away from the
septum. Under direct vision with a headlamp,
CaHA is injected with a 23-g, 1-in. straight needle
using a 0.05-mL aliquot of CaHA. The injection is
directed at an angle range of 45–90° to the INV
apex. The needle is advanced deep enough to allow
material to ﬂ ow out easily and should pierce the
submucosal and/or submucoperichondral region at
the junction of the ULC and nasal septum.
Figure 53.7 shows the primary injection site at
the weak left INV seen in Fig. 53.3a and can be
directed slightly under the ULC surface if possi-
ble to assist with its elevation as the CaHA is
injected. After injection of 0.05 mL of CaHA, a
visible increase in the INV valve area should be
evident. Also shown is the injected CaHA at the
ULC and septal junction, which creates a buttress
or strut effect. The ULC should begin to resist
collapse with brisk nasal inspiration.
Figure 53.8 shows primary injection at the
right INV apex of the patient with ULC collapse
seen in Fig. 53.3 . Again, the needle is directed
slightly to the underside of the ULC where it
meets the septum. Also shown is the buttressed
INV after primary injection. The ULC now resists
inspiratory collapse.
A Q-tip can be used between injections to
remove any excess CaHA or blood at the INV.
Between injections, it is sometimes helpful to
place additional anesthetic pledgets within the
INV at the apex to support hemostasis and aug-
ment the local anesthesia.
Fig. 53.5 Spreader graft injection instruments and supplies
Internal nasal valve
Apex angle
9–15∞
Upper
lateral
cartilage
Cotton
pledget
Nasal septum
Fig. 53.6 Arrow denotes correct location of cotton pledgets

787
53 Spreader Graft Injection with Calcium Hydroxylapatite
53.4.4 Step 4: Assess Distortion
and INV Patency
A visual inspection of the nasal dorsum at the
middle vault should be undertaken.
If a small 1–2 mm lump appears externally, it
can be manually pressed to distribute the CaHA and
avoid distortion. This is accomplished by pinching
the middle vault with thumb and index ﬁ nger. A
small amount of visible distortion is normal and can
be tolerated without long-term aesthetic compro-
mise. Resolving swelling and dissipation of the
carboxymethylcellulose component of the gel will
result in noticeable improvement in the ﬁ rst 1–2
weeks post-injection.
After successful injection of CaHA into the
INV, ask the patient to briskly inhale through
the nose (mouth closed) several times to assess
for ULC collapse against the septum. The end
point for injection is minimal movement of the
ULC with brisk nasal inspiration. If improve-
ment of the INV area is minimal, or if collapse
on nasal inspiration continues to be evident,
inject additional 0.05-mL aliquots into the pri-
mary area. It is not unusual to inject 0.15 mL per
side or 0.3 mL total for bilateral INV weakness.
a
b
Fig. 53.7 ( a ) Primary injection site at left INV apex. ( b ) Visible CaHA buttress after left INV injection
a
b
Fig. 53.8 ( a ) Primary injection site at right INV apex. ( b ) Buttressed right INV after injection

788
C.P. Nyte
Always reassess the external nasal dorsum after
each injection.
53.4.5 Step 5 : Secondary Injections
Additional injections may be needed to stiffen
the ULC near the primary injection site. The vol-
ume of CaHA used for secondary injections is
approximately half as much as that used for pri-
mary injections with the goal of adding additional
support to the ULC.
Figure 53.9 shows the placement of a second-
ary injection site at the edge of the left ULC seen
in Fig. 53.3 . The injection can be placed 1–2 mm
from the primary site on the anterior surface or
edge of the ULC to provide additional support
and resistance to collapse on inspiration. The
right ULC did not require secondary injection.
Usually one or two secondary injections will pro-
vide adequate support for the ULC, and external
distortion is usually not a problem.
53.4.6 Step 6: Reassess INV Patency
After primary and secondary injections, ask the
patient to inhale briskly through the nose while
observing the ULC for collapse against the septum.
Success is usually measured by the lack of visible
collapse of the ULC despite brisk nasal inspiration.
Of course, the patient will often tell you nasal
breathing is markedly improved. However, because
the pretreatment decongestant effect generally con-
tributes to this, it is important to follow up with
them in 1 week to reassess patency.
53.5
Discussion
A key component to this procedure is selection of
appropriate candidates for CaHA spreader graft
injection. There is a temptation to want to inject
everybody who has nasal obstruction, but not
everyone will bene ﬁ t to the greatest extent. There
is certainly a place for surgical correction of the
middle vault as is the case with complete collapse
of the ULC with resulting obstruction at the INV,
especially when observed at rest with quiet nasal
inspiration. Corrective surgical spreader grafting
and/or alar batten grafting with autologous carti-
lage is necessary for de ﬁ nitive treatment under
these conditions.
Spreader graft injection with CaHA is best
suited for people with weakness and inspiratory
narrowing of the INV. People that snore due to
ULC weakness as a contributing factor may also
bene ﬁ t from spreader graft injection.
While CaHA can last between 6 and 18
months, patients should be counseled that they
might need one or two additional injections as
necessary to maintain patency and that tolerance
can develop despite adequate anatomical correc-
tion. It is important to follow up with patients
after injections at 1 week, 1, 6 months, and 1
year. Some external swelling or fullness over the
middle vault is usually evident when successful
correction of INV weakness has been accom-
plished. It is important to reassure patients that
most of the swelling will dissipate in the ﬁ rst 1–3
weeks. Overcorrection may result in a visible
lump externally, and that will persist for several
months until the material is broken down. This is
why it is important to compress visible lumps
while performing the procedure. Compression
will inevitably express some of the CaHA back
through the injection site thereby improving the
middle vault fullness externally. This maneuver
may also temper the INV patency correction
Fig. 53.9 Secondary injection to support left ULC

789
53 Spreader Graft Injection with Calcium Hydroxylapatite
obtained prior to compressing the lump, so one
has to reassess for inspiratory collapse as neces-
sary. There is usually a point in the correction
where external deformity is too great a risk and
one must settle for improvement over complete
correction. This is not a problem because even
small improvements in INV area will be per-
ceived as success by the patient.
Conclusions
Each patient’s anatomy and tolerance for
external changes in the middle vault must be
carefully evaluated. Spreader graft injection
with CaHA is not designed to be the panacea
for nasal obstruction secondary to INV weak-
ness, but it gives patients who have failed
medical therapy an intermediate option prior
to considering surgical correction.
References
1. Kerr A (ed) (1997) Rhinology. In: Scott-Brown’s oto-
laryngology, 6th edn. Butterworth-Heinemann, Oxford
2. Sheen JH (1984) Spreader graft; a method of recon-
structing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg 73:230–239
3. Nyte CP (2007) Hyaluronic acid spreader-graft injec-
tion for internal nasal valve collapse. Ear Nose Throat
J 86(5):272–273
4. Nyte CP (2006) Spreader graft injection with calcium
hydroxylapatite: a nonsurgical technique for internal
nasal valve collapse. Laryngoscope 116:1291–1292

791
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DOI 10.1007/978-3-642-28053-5_54, © Springer-Verlag Berlin Heidelberg 2013
54
54.1
Introduction
The nonsurgical treatment of the nose, or medi-
cal rhinoplasty, has become one of the high-
lighted indications in the aesthetic treatment of
the face [ 1– 6 ] . The absence of important
mechanical constraints (dynamic facial rela-
tively poor on this level) associated with the sta-
bility of the supports of the nasal pyramid
(cartilage and bone) offer to the ﬁ llers “a par-
ticularly favorable bed.”
The duration of ﬁ lling is thus more important
than on the level of the other areas of the face.
The satisfaction of the patients is strongly
improved. Initially reserved for the corrections of
the surgical imperfections post surgery, the indi-
cations of treatment are very wide today.
In very many cases, it is possible to offer these
as ﬁ rst indication of the treatment of nasal cos-
metic disgraces, associated or not with the botuli-
num toxin injections in the event of muscle
hyperactivities (depressor septi nasi muscle,…).
These meetings of treatment can moreover serve
as true “morphing medical” for patients who will
take then the plunge towards a surgery. These
medical techniques are not in any case concurrent
with the surgery.
The rhinoplasty remains before as a whole
highly surgical procedure (Fig. 54.1 ), but the
intrusion of the ﬁ llers and botulinum toxin oblige
us to differently understand the indications of
treatment and our council. The objectives of the
treatment arise from the artistic analysis of the
naked nose: “nose and the face.”
The treatment is modi ﬁ ed by:
1. The nose in its own unit and volumes that cor-
respond to nasal volumetry
2. The nose within the face that references
towards the total harmony of the face (in par-
ticular contact angles to the face and the upper
lip)
3. The contemporary treatment of the lip and the
chin with the ﬁ llers realizes, moreover, a true
“medical pro ﬁ loplasty”
54.2
Anatomical Basics
Anatomical basics are essential to understand the
seat of the treatment and to understand the pos-
sible risks related to the injections. Occupying on
Filler, Botulinum Toxin,
and Rhinoplasty: The Medical
Rhinoplasty Concept
Frédéric Braccini and Alessio Redaelli
F. Braccini , M.D. (*)
F.P.S. Riviera Institute ,
25 avenue Jean Médecin , 06000 Nice , France
Clinique des Hôpitaux en ORL et Chirurgie
Cervico-Faciale , CHU Timone ,
Marseille , France
Chirurgie Face et Cou , ORL ,
25 Avenue Jean Médecin , 06000 Nice , France
e-mail: contact@braccini.net
A. Redaelli , M.D.
Via Di Vittorio 24 , 20070 Dresano, Milan , Italy
e-mail: mail@docredaelli.com

792
F. Braccini and A. Redaelli
the average a third of the face, the nose appears as
a hollow triangular pyramid of osteocartilaginous
structure with a top corresponding to the root of
the nose and a base where the openings of the
nares are.
On this osteocartilaginous frame (Fig. 54.2 ) is
placed an envelope with perichondrium and perios-
teum, a muscular plane, then the skin. It confers to
each individual an anatomical feature determining
the beauty and the harmony of a face.
a
b
Fig. 54.1 ( a , b ) Surgical result for rhinoplasty
Fig. 54.2 Anatomical supports

793
54 Filler, Botulinum Toxin, and Rhinoplasty: The Medical Rhinoplasty Concept
There is:
1. A ﬁ xed portion, formed by the frontal notch,
the rising branches of the jawbones, the clean
bones, the higher side cartilages (triangular),
and the septum
2. A mobile portion, corresponding essentially to
the lower side cartilages (wing) but also to the
higher side cartilages (lower portion) which play
a crucial role in the nasal valve. The relationship
between the ﬁ xed and mobile elements of the
nose is fundamental in the aesthetic analysis and
the medico-surgical project of a rhinoplasty.
The applications that arise from these interre-
lationships make reference to the concepts of
morpho-dynamic anatomy. What is thus funda-
mental before carrying out treatment of rhino-
plasty by medical ﬁ lling is on the knowledge of
the structures of the nasal frame.
The skin that is very rich in sebaceous glands in
particular compared to the cartilaginous nose and
its thickness varies in an important way according
to the areas. It thickens very ﬁ ne on top and towards
the point and is in particular compared to the weak
triangle of converses. Mobile in the segment of the
osseous frame, it becomes adherent with the subja-
cent planes in the portion that corresponds to the
cartilages. This adherence is especially intimate on
the lobule, the wings, and under the partition. The
cellular fabric under the cutaneous area is little
developed and low in oils, it forms a quite clear
layer only on the level of the mobile nose.
The muscles (Fig. 54.3 ), innervated by the facial
nerve, are connected between them by the SMAS
and are the elevator muscles, depressors, and com-
pressors or dilating of the nostrils. Their role is gen-
erally modest apart from the depressor of the
septum (m. depressor septi nasi). They are perfectly
accessible to the action from botulinum toxin.
The deep envelope consists of perichondrium
and periosteal ﬁ bers that are interconnected and
solidarized between them the components of the
nasal pyramid.
54.3
Vessels and Nerves (Fig. 54.4 )
There is a high risk for vascular or nerve injuries,
depending on the ﬁ ller injection
For the vascularization, it is very rich, and ves-
sels are safe small sizes on the level of the angular
area of the eye. This vascularization is from the
arterial branches of the internal carotid networks
(ophthalmic artery) and external carotid (facial
artery). The veins drain towards the angular vein
essentially but also towards the facial vein.
Fig. 54.3 Muscles of the nose
Fig. 54.4 Vessels of the nose

794
F. Braccini and A. Redaelli
For the innervation, the branching engines
come from the facial nerve, and the sensitive
branches emanate from the trigeminal via the
external nasal nerve, from the infraorbital nerve,
and from the nerve naso-lobulaire.
54.4
Fillers
The authors use very many products of ﬁ llings in
these indications. Taking into account the smooth-
ness of the cutaneous coating, it is necessary that
the product injected bene ﬁ t a perfect balance
between its homogeneity, its potential of diffusion
in ﬁ lled spaces, and, of course, its harmlessness.
The authors never use permanent ﬁ llers.
Among the many ﬁ llers available on the
market currently, the choice “was gradually
tightened” on hyaluronic acid, which can be
injected in safety in all the areas, at the same
time on the level of the ﬁ xed nose but also on
the level of the nasal point where the cutaneous
tension is very important and where the toler-
ance of the product must be optimal. The prod-
uct must contribute high reticulation for a stable
result. It is necessary to use products whose tol-
erance and safety are “absolute today” (e.g.,
XHA 3* Filorga, Juvederm* Allergan, Teosyal*
Teoxane…).
54.5
Injection Technique (Fig. 54.5 )
Ideally, the procedure is performed after applica-
tion of anesthesia cream. It can, however, be car-
ried out without any anesthesia. The nasal point
is the most signi ﬁ cant part. It is necessary to draw
up well its plan of treatment before beginning the
injections. Indeed, the nasal cutaneous tension in
particular on the level of the point is such that if
too many injections are carried out, the product
tends to be extruded.
54.6
Procedures of Treatment
54.6.1 Filling the Hump
The needle is introduced with an obliqueness of
45° until the osseous contact. It is held by the
dominant hand. It is necessary with the inch
and the index of the other hand to carry out a
pressure on the side walls of the clean bones to
prevent that the product diffuses laterally. This
a
b
c
Fig. 54.5 ( a – c ) Filling procedures (hump and tip)

795
54 Filler, Botulinum Toxin, and Rhinoplasty: The Medical Rhinoplasty Concept
accidental diffusion of the product can go up to
the level of the area of the rings and the valley
of the tears and must thus be prevented. It is
sometimes necessary to ﬁ ll the nasofrontal
angle by a side access to perfect the treatment
of this area (injection dorsum by side access).
Once the product is injected, it is set up by a
careful massage.
54.6.2 De ﬁ nition of the Tip
It is necessary to avoid multiplying the injection
points. One or two points of penetration are thus
carried out. They make it possible to distribute in
a radiating manner on the point, the whole of the
product. The pressure of the injection is essential
here. The procedure should be slow and progres-
sive to avoid involving a cutaneous problem able
to lead to necrosis. The point should not “blanch”
the effect of the ﬁ lling.
54.7
Treatment of the Columella
and Opening of the
Nasolabial Angle
Treatment with botulinum toxin is not carried
out in same time as use of a ﬁ ller. One injects
directly in-depth the product that is deposited in
contact with the nasal spine to open the angle.
The lines of columelle are then balanced more
super ﬁ cially.
Botulinum toxin A that can be used for
these treatments is the only botulinum toxin
permitted for aesthetic use in each country, in
particular:
1. Vistabel/Vistabex/Cosmetic Botox, derived
from Botox, Allergan, Irvin California. It can
be in packs of 50 or 100U to be kept in the
refrigerator between 2° and 8°.
2. Azzalure, approved in Europe for a few
months, distributed in Europe by Galderma,
and directly derived from Dysport, Ipsen. It is
moderately stronger than Botox; it is in 125U
packs and must be stored in a refrigerator
between 2° and 8°.
The different preparations are not interchange-
able, and the speci ﬁ c units are diverse, just like
their action in the tissues.
54.8
Objectives and Details
of Injections (Fig. 54.6 )
The sites to inject are:
1. Two injections of 2.5U Vistabel or 5U Azzalure
in each elevator muscle of lip and nasal wing,
tangentially to the nasal wing.
2. 5U Vistabex or 10U Azzalure at the nasion
level.
3. 5U Vistabex or 15U Azzalure at the level of
the nasal spine divided into two planes, the
ﬁ rst injection must be subcutaneous and the
other deeply in contact with the bone.
54.9
Protocol
The protocol of treatment is standardized. We
carry out a ﬁ rst procedure without over-correc-
tion then a control at the 15th day. In the event of
need a reinjection or technical re ﬁ nements is
a
b
Fig. 54.6 ( a , b ) Botulinum toxin injection

796
F. Braccini and A. Redaelli
carried out. The result is then remarkably stable
on 12–18 months for the ﬁ llers and stable for
4 months for the botulinum toxin effect.
54.10 Indications
All rhinoplasties cannot be carried out medi-
cally! ….The indications rise from the artistic
analysis and the realization of the project, as
well as a surgical rhinoplasty. A data-processing
morphing can moreover also carried out before
the treatment.
After surgical rhinoplasty, all the irregularities
(asymmetry, deviation…) can be ﬁ lled by a ﬁ ller.
The indications of these ﬁ llings are same with
that of the cartilaginous grafts.
In ﬁ rst intention, “the principal indication” is
the camou ﬂ age of osteocartilaginous kyphosis.
The treatment of the point and ﬁ llings of the con-
tact angles with the lip or the face give remark-
able results.
The control of mimical facial wrinkles using
botulinum toxin A (BTxA) is presently a well-
known process, even in all “off-label” uses, but its
use at the level of the nasal muscles is more recent.
This new therapeutic target presently opens a very
wide application area and, relying on the more
general concept that includes facial rejuvenation,
it recently plans the use of small doses of BTxA
on a regular basis. The use of botulinum toxin into
the nasal muscles counts an approach to be con-
sidered complementary to the ﬁ ller.
54.11 Contraindications
54.11.1 Fillers
The contraindications related to the product and
its technical information include:
1. No use of permanent ﬁ ller and ﬁ ller different
than hyaluronic acid.
2. In addition, it is necessary to respect contrain-
dications speci ﬁ c to the hyaluronic acid (cuta-
neous infection in progress, pregnancy…).
3. The technical contraindications and cosmetics.
4. Use of anticoagulants must ideally be stopped
before the treatment.
The psychological dimension of the nasal
modi ﬁ cation must always be taken into account.
Contraindications are directly related to the psy-
chological and artistic analysis pre-therapeutic,
and in certain cases, only the surgery will allow
an adapted result, in particular in the reduction
rhinoplasty.
54.11.2 Botulinum Toxin
Contraindications to the use of botulinum
toxin are allergy to the drug and infection or
in ﬂ am mation at the proposed injection site(s).
Safety for use during pregnancy or lactation
has not been established. Therefore, it is pru-
dent to avoid botulinum toxin therapy for
elective procedures in women of childbearing
age until absence of pregnancy or adequate
contraception is assured. Relative contrain-
dications include diseases of neuromuscular
transmission, coagulopathy (including thera-
peutic anticoagulation), and inability of the
patient to cooperate. In the more complex
disorders, botulinum toxin therapy should not
be used unless a skilled interdisciplinary team
and sophisticated instrumentation are avail-
able to ensure valid diagnosis, state-of-the-
art treatment, and appropriate follow-up. The
physician administering this drug should be
trained in its use and quali ﬁ ed to manage any
complications.
Conclusions
Medical rhinoplasty is a minimal invasive pro-
cedure, temporary with impressive outcomes
(Figs. 54.7 , 54.8 , and 54.9 ). It is a remarkable
procedure which gives surprising results with
a stability higher than that of the treatments of
other parts of the face. It requires technical
training and an artistic approach of the indica-
tions as well as the surgical rhinoplasty.

797
54 Filler, Botulinum Toxin, and Rhinoplasty: The Medical Rhinoplasty Concept
a
b
Fig. 54.7 ( a , b ) Medical rhinoplasty (hump ﬁ lling, tip de ﬁ nition, botulinum toxin in depressor septi nasi muscle)
a
b
Fig. 54.8 ( a , b ) Medical rhinoplasty for deviated nose ( ﬁ lling treatment)
a
b
Fig. 54.9 ( a , b ) Medical secondary rhinoplasty (treatment of the hump defect by ﬁ lling)

798
F. Braccini and A. Redaelli
References
1. Braccini F, Dohan Ehrenfest DM (2010) Advantages of
combined thérapies in cosmetic médicine for face age-
ing: botulinum toxin ﬁ ller and mesotherapy. Rev
Laryngol Otol Rhinol (Bord) 131(2):89–95 (French)
2. Redaelli A, Braccini F (2010) Medical rhinoplasty.
Basic principles and clinical practice. OEO, Firenze
3. Redaelli A (2008) Medical rhinoplasty with hyaluronic
acid and botulinum toxin A: a very simple and quite
effective technique. J Cosmet Dermatol 7(3):210–220
4. Braccini F, Dohan Ehrenfest DM (2008) Medical
rhinoplasty: rationale for atraumatic nasal modelling
using botulinum toxin and ﬁ llers. Rev Laryngol Otol
Rhinol 129(4–5):233–238
5. Braccini F, Porta P, Thomassin JM (2006) Mini-
rhinoplasty. Rev Laryngol Otol Rhinol 127(1–2):15–20
6. Braccini F, Berros P, Belhaouari L (2006) Botulinum
toxin, description and clinical applications in the treat-
ment of the face wrinkles. Rev Laryngol Otol Rhinol
(Bord) 127(1–2):105–111 (French)

799
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_55, © Springer-Verlag Berlin Heidelberg 2013
55
55.1
Introduction
The nose is one of the most important subunits of
the face de ﬁ ning much of the middle third. Age
and ethnicity are, in part, characterised by nasal
pro ﬁ le, and variations from the aesthetic ideal
lead many patients to seek surgical rhinoplasty
as early as adolescence. Likewise, aging weakens
the cartilaginous nasal framework and, with pyri-
form remodelling, leads to tip ptosis. Tip ptosis,
with atrophy of soft tissue envelope, highlights
the underlying osteocartilaginous structure and,
with maxillary resorption, leads to a narrowed
nasolabial angle.
Rhinoplasty is technically demanding surgery,
and even in the best of hands, postoperative healing
and ultimate aesthetic outcome can be unpredict-
able. In addition to the risks of general anaesthe-
sia and a protracted postoperative convalescence,
rhinoplasty may lead to adverse cosmetic seque-
lae of pollybeak deformity, overreduction of the
bony or cartilaginous dorsum, inverted V defor-
mity, alar retraction, supratip depression and bos-
sae. Patients may also have functional complaints
secondary to iatrogenic nasal valve disruption.
Even in patients with an initial satisfactory out-
come, slight asymmetries, depressions and con-
tour irregularities may present several years after
surgery. Despite these risks, cosmetic rhinoplasty
is increasingly popular. A recent survey of UK
cosmetic practice by members of the British
Association of Aesthetic Plastic Surgeons found
that rhinoplasty accounted for 9% of all cosmetic
surgery in 2008 and 23% of all male cosmetic
surgery [ 1 ] .
The re ﬁ nement of techniques to restore facial
volume with dermal ﬁ llers, and widely available
botulinum injections to treat dynamic facial
rhytids, has led to a surge in demand for non-sur-
gical rejuvenation procedures. An increasingly
well-informed and discerning patient population
now seeks better value procedures that require
minimal downtime and have instant results.
Discrete volumetric changes in the fronto-
nasal angle, nasal dorsum and nasolabial angle
lead to signi ﬁ cant differences in our perception
of the nasal aesthetic. These areas can be injected
with dermal ﬁ llers to rejuvenate the nasal pro ﬁ le
and correct asymmetries [ 2 ] .
55.2
Injection Rhinoplasty
Technique
1. Informed consent is obtained from all patients
for off-label treatment with Restylane® lido-
caine for soft tissue augmentation.
Non-surgical Nasal Augmentation
and Correction of Post-rhinoplasty
Contour Asymmetries
with Hyaluronic Acid
Dominic Bray
D. Bray , M.D., FRCS
Department of Otolaryngology ,
Guy’s Hospital , London , UK
e-mail: dbray@doctors.org.uk

800
D. Bray
2. Standardised pretreatment frontal, lateral and
3/4 view photographs are taken. Topical local
anaesthetic with EMLA™ 5% cream (lidocaine
25 mg, prilocaine 25 mg) is applied to the radix,
dorsum, tip and columella for 30 min.
3. The patient is positioned semirecumbent on a
couch.
4. Areas for correction are marked and prepared
with 70% isopropyl alcohol.
5. Restylane ® lidocaine (Q-MED, Sweden) is
injected in the subcutaneous plane just super ﬁ cial
to perichondrium or periosteum using a
30-gauge 1 / 2 ″ needle following aspiration to pre-
vent inadvertent arterial embolisation.
6. Linear threading, serial puncture and/or fan-
ning techniques are used depending on the area
and volume requiring correction (Fig. 55.1 ).
Injection super ﬁ cial to the deep dermis is
avoided to prevent local ischemia and extru-
sion of the implant.
7. Immediately following injection, digital pres-
sure is applied and the implant moulded into
position.
8. Haemostasis is achieved with light pressure
using a cotton-tipped applicator.
Finally, an ice pack is applied to minimise
postoperative bruising and oedema. Patients are
informed that they may experience some swell-
ing, tenderness and redness for 1–2 days, but no
speci ﬁ c aftercare instructions are necessary.
Underprojection and under-rotation of the tip
and/or dorsal cartilaginous humps may be cor-
rected with injections into the deep dermis at
columellar base, super ﬁ cial to perichondrium in
the supratip, and into the subdermal radix. This
softens the convexity of nasal pro ﬁ le on lateral
Fig. 55.1 Injection techniques. ( a ) Serial puncture. For
punctate correction of supratip depressions and softening
nasolabial angle in overrotated nasal tips. ( b ) Linear
threading. Dorsal correction in saddlenose deformity. ( c )
Fanning. ( d ) Cross-hatching. Stepwise volumetric
enhancement of radix and nasal tip

801
55 Non-surgical Nasal Augmentation and Correction of Post-rhinoplasty Contour Asymmetries
view without signi ﬁ cantly increasing nasal ‘vol-
ume’ (Fig. 55.2 ). Injectable subdermal radix aug-
mentation also effectively corrects pro ﬁ le in
saddlenose deformity (Fig. 55.3 ).
In patients with depressed supratip areas,
injection of Restylane in the supratip concavity
straightens the dorsum and leads to an apparent
deprojection of the nasal tip (Fig. 55.4 ). Patients
with ptotic or deprojected nasal tips are also ame-
nable to ﬁ ller correction. Injection of ﬁ ller
super ﬁ cial to anterior septal cartilage perichon-
drium projects the tip de ﬁ ning point. The degree
of correction can be built up with fanning and
cross-hatching injection techniques (Fig. 55.5 ).
Occasionally, even successful rhinoplasty patients
return with relatively minor concerns regarding
asymmetry or pro ﬁ le. Injectable ﬁ ller may circum-
vent secondary rhinoplasty and satisfactorily address
these concerns in the of ﬁ ce (Fig. 55.6 ).
The Renaissance artists sought to de ﬁ ne
beauty using objective mathematical models.
The Fibonacci sequence (1, 1, 2, 3, 5, 8…) led to
phi, the ‘golden number’, that de ﬁ ned beauty by
symmetry and the apparent ratio of adjacent
structures. The golden ratio, 1.61803, is re ﬂ ected
throughout nature, architecture, music and DNA.
Ideal aesthetic nasal parameters for tip projec-
tion (facial margin tip/dorsum), nasal length
(radix to the tip-de ﬁ ning point to the upper ver-
million) and width (radix-columella line to alar
margins) all achieve the golden ratio.
A multitude of techniques and re ﬁ nements have
since been described to surgically achieve the nasal
aesthetic ideal. Whilst this ideal is subjective and
dependent on ethnic variation, the rules of lengths,
ratios and angles should be respected when plan-
ning surgical or non-surgical rhinoplasty.
Han et al. [ 3 ] was the ﬁ rst to describe the con-
cept of injectable ﬁ ller rhinoplasty in 2006. He
combined autologous human ﬁ broblasts with
hyaluronic acid and injected the nasal dorsum.
By adding ﬁ broblasts, the authors hypothesised
that permanent collagen would remain following
hyaluronic acid resorption. The volume replacement
Fig. 55.2 Dorsal hump and
tip ptosis. ( a ) ( Left )
Preoperative. ( Right )
Postoperative. ( b ) ( Left )
Preoperative. ( Right )
Postoperative

802
D. Bray
Fig. 55.3 Saddlenose
deformity corrected with radix
augmentation. ( Left )
Preoperative. ( Right )
Postoperative
Fig. 55.2 (continued)
was maintained at 1-year follow-up; however,
the technique was limited by signi ﬁ cant prepara-
tory time as the ﬁ broblasts had to be harvested
and cultured in vitro prior to injection.
Whilst a comprehensive review of the available
dermal ﬁ llers such as that published by the American
Society of Dermatologic Surgery [ 4 ] is beyond the
scope of this chapter, familiarity with the available
ﬁ llers and injection techniques is essential before
embarking on injection rhinoplasty. Fillers can be
broadly classi ﬁ ed into fat, collagen, silicone, poly-
l -lactic acid (PLLA), hyaluronic acids and calcium
hydroxylapatite. The latter two are most appropriate
for injection rhinoplasty due to their excellent safety
pro ﬁ le, predictable volume replacement, moulding
capability and temporary nature.

803
55 Non-surgical Nasal Augmentation and Correction of Post-rhinoplasty Contour Asymmetries
Fig. 55.4 Supratip depression corrected with serial
puncture injections. ( a ) ( Left ) Preoperative. ( Right )
Postoperative. ( b ) ( Left ) Preoperative. ( Right ) Postoperative.
( c ) ( Left ) Preoperative. ( Right ) Postoperative. ( d ) Splayed
lower lateral cartilages leading to intercartilaginous con-
cavity of nasal tip corrected with serial puncture. ( Left )
Preoperative. ( Right ) Postoperative
a
b

804
D. Bray
c
d
Fig. 55.4 (contined)

805
55 Non-surgical Nasal Augmentation and Correction of Post-rhinoplasty Contour Asymmetries
Fig. 55.5 Deprojected nasal
tip corrected with ﬁ ller
‘shield’ graft built up with
fanning technique. ( Left )
Preoperative. ( Right )
Postoperative
Fig. 55.6 ( a ) Volume
replacement to tip scar
following primary excision of
tip lesion. ( Left ) Preoperative.
( Right ) Postoperative. ( b )
Right upper lateral endonasal
injectable spreader graft to
correct right internal nasal
valve dysfunction. ( Left )
Preoperative. ( Right )
Postoperative

806
D. Bray
Fig. 55.6 (continued)
Hyaluronic acid is a naturally occurring
glycosaminoglycan polysaccharide composed
of alternating residues of the monosaccharides
d -glucuronic acid and N -acetyl- d -glucosamine
found in mammalian dermis. Injectable hyalu-
ronic acid was ﬁ rst approved by the FDA in
2003. It is a viscous clear gel derived from the
cock’s combs of domestic fowl (Hylaform ® ) or
from fermentation by Streptococci (Perlane ® ,
Restylane ® , Captique ® , Juvéderm ULTRA ® and
ELEVESS ® ). After implantation into tissues,
hyaluronic acid strongly binds water to form
hydrated polymers. From 6 months, it is
metabolised into carbon dioxide and water and
eliminated by the liver; however, in my experi-
ence, Restylane ® lasts much longer in the nose
(at least 18 months) compared with the correc-
tion achieved with dynamic facial soft tissue
rhytids and folds.
Calcium hydroxylapatite (RADIESSE ® ) con-
sists of a 30% concentration of 25- to 45- m m
spherical particles suspended in sodium car-
boxymethylcellulose gel. It is FDA approved for
facial soft tissue augmentation speci ﬁ cally for the
correction of moderate to severe facial lines and
folds and correction of soft tissue loss from HIV
lipoatrophy, vocal cord augmentation and as a
radiological tissue marker. Following injection, the
gel is phagocytised and the calcium hydroxylapa-
tite microspheres displace surrounding soft tissue.
Collagen proliferation and slow degradation of
the microspheres leads to a prolonged duration of
effect up to 2 years. The microspheres are excreted
as calcium and phosphate via the urinary system.
Injection augmentation of a deep radix will
soften the fronto-nasal angle and may disguise a
prominent rhinion and dorsal cartilaginous hump.
Medial linear subcutaneous threading of the bony
and cartilaginous dorsum will narrow a broad nose
and lengthen a shortened nose. Saddlenose defor-
mity and/or upper lateral collapse may be dis-
guised with injection super ﬁ cial to perichondrium.
Functional internal valve collapse may be
addressed with an endonasal ‘spreader’ injection
of calcium hydroxylapatite (RADIESSE ® ) into the
apex of the internal nasal valve [ 5 ] . An under-
projected tip may be built up by supratip injection
followed by moulding to the desired aesthetic
result. Nasal tip ptosis can be addressed with sin-
gle puncture injection into the columellar base to
open the nasolabial angle. This angle may be
opened further with injection of two units of
Botox ® (Allergan, Inc.) into the depressor septi
muscle. Complications of surgical rhinoplasty
may also be treated with ﬁ ller injection. Columellar
and alar retraction may be corrected. These are
often complicated by scarring and the absence of a
bony plate to stabilise the implant; however, prior
in ﬁ ltration of local anaesthetic can help stretch the
scarred tissue before injection of ﬁ ller [ 6 ] . Minor

807
55 Non-surgical Nasal Augmentation and Correction of Post-rhinoplasty Contour Asymmetries
post-rhinoplasty asymmetries, irregularities and
bony prominences may also be addressed [ 7 ] .
Potential major complications of injection rhi-
noplasty include infection, ischemic necrosis from
arterial embolism, pressure necrosis from over-
injection of nasal tip and osteophyte from periosteal
injection [ 8 ] . These may be reduced with effective
nasal analysis, meticulous injection technique and
a good understanding of nasal cartilaginous and
vascular anatomy. Radix and upper nasal third
injections should be medially placed to avoid the
dorsal and lateral nasal arteries. Pre-injection pal-
pation may aid identi ﬁ cation, and aspiration before
injection is mandatory. Intravascular ﬁ ller injection
can lead to arterial embolisation and subsequent
skin necrosis [ 9 ] or retinopathy [ 10 ] . Visual impair-
ment following middle facial third ﬁ ller injection
mandates urgent ophthalmological review to
exclude retinal embolism. Prompt anticoagulation
and hyaluronidase injection may be a useful adjunct
should complications arise [ 11 ] .
Injection rhinoplasty is not a substitute for sur-
gical rhinoplasty. There are many indications where
ﬁ ller alone will be suf ﬁ cient to achieve the desired
aesthetic outcome. Noses that are signi ﬁ cantly
overprojected, or overrotated, have a shallow radix,
and tension noses are better suited to surgical cor-
rection. It is however a useful postoperative adjunct
to surgery or in those patients contemplating rhino-
plasty. The non-permanence and minimal morbid-
ity of associated with degradable ﬁ llers is especially
bene ﬁ cial to those patients who seek cosmetic rhi-
noplasty but are discouraged by the risks and con-
valescence of surgery.
References
1. British Association of Aesthetic Plastic Surgeons
Survey of Members. Press release 26 Jan 2009
2. De Lacerda DA, Zancanaro MD (2007) Filler rhino-
plasty. Dermatol Surg 33(Suppl 2):S207–S212
3. Han SK, Shin SH, Kang HJ, Kim WK (2006)
Augmentation rhinoplasty using injectable tissue
engineered soft tissue: a pilot study. Ann Plast Surg
56(3):251–255
4. Alam M, Hayes G, Kramer E, Murphy JP Jr, Nouri K,
Neuhaus IM, Spencer JM, Spenceri E, Van Dyke S,
Ceilley RI, Lee KK, Menaker G, Monheit GD,
Orentreich DS, Raab B, Smith KC, Solish NJ (2008)
American Society for Dermatologic Surgery: ASDS
guidelines of care: injectable ﬁ llers. Dermatol Surg
34(Suppl 1):S115–S148
5. Nyte CP (2006) Spreader graft injection with calcium
hydroxylapatite: a nonsurgical technique for internal
nasal valve collapse. Laryngoscope 116(7):1291–1292
6. Becker H (2008) Nasal augmentation with calcium
hydroxylapatite in a carrier-based gel. Plast Reconstr
Surg 121(6):2142–2147
7. Stupak HD, Moulthrop THM, Wheatley P, Tauman AV,
Johnson CM Jr (2007) Calcium hydroxylapatite gel
(Radiesse) injection for the correction of postrhino-
plasty contour de ﬁ ciencies and asymmetries. Arch
Facial Plast Surg 9(2):130–136
8. Rokhsar C, Ciocon DH (2008) Nonsurgical rhino-
plasty: an evaluation of injectable calcium hydroxy-
lapatite ﬁ ller for nasal contouring. Dermatol Surg
34(7):944–946
9. Schanz S, Schippert W, Ulmer A et al (2002) Arterial
embolisation caused by injection of hyaluronic acid
(Restylane ® ). Br J Dermatol 146(5):928–929
10. Peter S, Mannel S (2006) Retinal branch occlusion
following injection of hyaluronic acid (Restylane®).
Clin Exp Opthalmol 34(4):363–364
11. Glaich A, Cohen J, Goldberg L (2006) Injection
necrosis of the glabella: protocol for prevention and
treatment after use of dermal ﬁ llers. Dermatol Surg
32(2):276–281

809
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_56, © Springer-Verlag Berlin Heidelberg 2013
56
56.1
GORE-TEX Implants
in Rhinoplasty
The use of alloplasts for structural support, resto-
ration of vascular continuity, or volume augmen-
tation is well established in modern surgery. Many
different materials have been tried in rhinoplasty.
Silicon rubber (Silastic; AART Inc., Reno, NV)
implants well tolerated elsewhere have a high
incidence of extrusion from the nose. Mesh mate-
rials (Mersilene; Ethicon, Summerville, New
Jersey) and supramid (Ethicon), although better
tolerated than silicon, due to tissue ingrowth, are
very troublesome should their extraction become
necessary. Multiple removal attempts are usually
required with possible resulting damage to the
surrounding anatomy. AlloDerm, a freeze-dried
acellular allogenic cadaveric dermis (AlloDerm;
LifeCell Corp., Palo Alto, CA), undergoes partial
resorption in large proportion of patients within
12 months [ 1 ] . Should there be a need for second-
ary exploration, it can only be removed by a sharp
dissection and almost unavoidable changes to the
overlying dermis become apparent (Fig. 56.1 ).
The popularity of these alloplasts has faded in
recent years, and some surgeons abandoned their
use altogether because of the unnatural look and
feel that they produce and the high rates of com-
plication – at times occurring many years after
implantation [ 2, 3 ] .
Injectable ﬁ llers are the latest addition to a
long list of previously used implants. Their phys-
ical and chemical properties and tissue retention
vary. Some of them may stimulate ﬁ broblastic
activities, desirable in other areas of the face but
may lead to irregularities in the nasal contour
which are very dif ﬁ cult to correct. It would appear
that autologous grafts, because of their biological
compatibility, are the most appropriate material
to be used in rhinoplasty. It is recognized how-
ever that they also present problems related to
their esthetic shortcomings except when used
around the nasal tip or columella. Incidence of
their warping, absorption, and fragmentation is
well documented [ 4, 5 ] . We have now learned
that the requirements for special properties of the
implant and graft material to succeed in the nose
are higher than in other areas of the body, includ-
ing other sites of the face. It is due to the thin skin –
soft tissue covering, micromobility, and the
occurrence of frequent incidental minor trauma
to the nose.
GORE-TEX Implants in Rhinoplasty
Krzysztof Conrad and Andrew J. Conrad
K. Conrad , M.D., FRCS, FRCSC, FACS (*)
Department of Facial Plastic Surgery ,
9955 Yonge Street , Richmond Hill ,
ON L4C 9M6 , Canada
Division of Facial Plastic and Reconstructive Surgery,
Department of Otolaryngology – Head and Neck
Surgery , University of Toronto, Mount Sinai Hospital ,
600 University Ave. , Toronto , ON M5G 1X5 , Canada
e-mail: lduquette@bellnet.ca
A. J. Conrad , Hon., B.Sc.
58 Macamo Court , Maple , ON L6A 1G1 , Canada
McMaster University ,
Hamilton , ON , Canada
e-mail: aj_con@hotmail.com

810
K. Conrad and A.J. Conrad
A rhinoplastic surgeon may be faced with a
dif ﬁ cult decision when choosing between grafts
and implants because an ideal augmentation
material in rhinoplasty does not exist. However,
more than 20 years of experience with GORE-
TEX
(expanded
polytetra ﬂ uoroethylene
or
ePTFE) (W. L. Gore & Associates Inc., Flagstaff,
Arizona) in rhinoplasty provides evidence of
excellent performance of this alloplast in prop-
erly selected patients. In many circumstances, its
application can be considered a practical and
even better solution, from an esthetic standpoint,
than the use of autografts [ 5– 8 ] .
56.2
GORE-TEX Characteristics
It is a polymer of carbon bound to ﬂ uorine. It is
microporous, thus allowing tissue ingrowth into
10- to 30- m pores, resulting in greater stability of
Fig. 56.1 Supratip AlloDerm removal was necessary to
correct a pollybeak deformity. It resulted in permanent
skin damage despite very careful dissection
a
d
e
f
g
b
c
Fig. 56.2 ( a , b , c ) GORE-TEX membrane – 1-mm thickness on the right and .6-mm on the left side to correct the
lateral wall depressions following ( d , e , f , g ) an otherwise very successful rhinoplasty

811
56 GORE-TEX Implants in Rhinoplasty
the implant and reduced likelihood of infection.
The small diameter of the pores, while promoting
tissue ﬁ xation, is also allowing implant removal,
at any stage if necessary, without disturbing the
surrounding tissues [ 5, 9 ] . It is biocompatible and
noncarcinogenic. It has no rigidity, and due to its
pliable consistency, it conforms well to tissue
contours. It is available in sheets of 0.6-, 1-, and
2-mm thickness.
Implants of variable thickness, shape, and
dimension can be made preoperatively to suit the
individual nose for primary correction, for a
small minimally invasive secondary “tune-up”
(Figs. 56.2 and 56.3 ) procedure, or to achieve
signi ﬁ cant improvement during dif ﬁ cult revision
operations (Fig. 56.4 ). It mimics the character of
the underlying tissue – feels like bone if overly-
ing the bony dorsum or like cartilage if overlying
a
b
d
e
c
Fig. 56.3 A soft tissue pollybeak ( a – e ) was corrected by a supratip dorsal subcutaneous soft tissue excision and place-
ment of a 2-mm GORE-TEX implant in the upper 1/3 of the nasal dorsum ( b , c , e )

812
K. Conrad and A.J. Conrad
the cartilaginous framework. The implants are
virtually undetectable on inspection. The mate-
rial is easily resterilized without changing its
properties, and it is nondegradable. A more than
20-year patient follow-up has shown its excel-
lent stability [ 5, 6, 8, 10 ] .
a
b
c
d
Fig. 56.4 ( a ) Preoperative 23-year-old patient with mul-
tiple traumatic facial fractures. ( b ) Nasal symmetry and
function was restored by septal correction and overlay
GORE-TEX implant to the left lateral nasal wall and
dorsum. ( c ) Three-dimensional radiograph showing
multiple facial fractures corrected by plating, making
nasal osteotomies impossible. ( d ) Positioning of the
dorsal (4-mm-thick) and left lateral (2-mm-thick) GORE-
TEX implants (Reprinted with permission from Conrad
et al. [ 5 ] . Copyright 2008, Applications of Gore-Tex
Implants in Rhinoplasty Re-examined After 17 Years.
Archives of Facial Plastic and Reconstructive Surgery
10(4):224–231 American Medical Association. All rights
reserved)

813
56 GORE-TEX Implants in Rhinoplasty
56.3
Patient Selection
Not every patient biologically suitable for treat-
ment with implant material is a good candidate.
Some individuals will not accept any form of
alloplast for psychological reasons. A surgeon
must discuss the advantages and disadvantages of
various options and obtain a written informed
consent.
There are well-established biological crite-
ria deciding a patient’s suitability for receiving
implants. They are designed to minimize the risk
of infection and extrusion. All the conditions that
might interfere with normal wound healing, such
as diminished supply of glucose, protein, or oxy-
gen, may lead to implant failure. Patients with
diabetes mellitus, AIDS or on immunosuppres-
sant medication including steroids and those who
are undernourished, smokers, or with allergy to
multiple antibiotics are at high risk of extruding –
infection.
Recurrent bacteremia originating from either
local or remote sites, especially from local sites,
such as chronic sinusitis, septal perforation, or
dental abscesses, will endanger the “survival” of
nasal implants. Under such circumstances, some
patients have been able to receive successful
GORE-TEX implants using a staging technique.
The implant was ﬁ rst imbedded in the soft tissue
over the mastoid periosteum and replanted after a
minimum of 6 weeks into the “high-risk” nasal
site. The ingrowth of ﬁ broblasts into the microp-
orous implant placed in the area promoting better
healing than the nose is thought to increase the
“survival” of the material once it is placed in its
ﬁ nal site (Fig. 56.5 ).
56.4
Surgical Technique
Successful tissue retention of an implant in
quali ﬁ ed patients depends not only on the proper-
ties of the implant but also on meticulous surgical
technique, especially in such a “high-risk” area
as the nose. This includes sterility of the surgical
site, detailed surface marking, delineating the
implant pocket, handling of the implant, the
method of insertion, and wound closure.
Unfortunately, details of the surgical technique
have not been emphasized uniformly in publica-
tions while stating the rate of nasal GORE-TEX
complications which, not surprisingly, differs
among the authors [ 5 ] . Surface contamination of
the implant, even with sterile particles, may have
adverse consequences. No hands, even gloved,
may touch the material. The implant must be pro-
cessed with the use of instruments preoperatively
prior to sterilization as well as during the surgical
procedure from the time it is removed from its
sterile wrapping.
The microporosity of GORE-TEX allows vac-
uum in ﬁ ltration with an antibiotic solution
(Fig. 56.6 ). Compressing the membrane with for-
ceps is contraindicated.
The most common areas requiring augmen-
tation include the nasal dorsum and lateral nasal
walls. No data are available about the success-
ful use of GORE-TEX in the nasal rim or tip
lobule. The proximity of these sites of implan-
tation to the port of entry for insertion of the
implant is likely to increase the incidence of
extrusion. Trimming of the nasal vibrissae and
skin preparation of the nasal inlet with good
suctioning of blood and secretions is needed to
decrease implant contamination on its way to
the prepared subcutaneous pocket. A pull-in
with guide suture method rather than placement
with forceps is recommended unless an open
rhinoplasty is being performed. An even spread-
ing of the implant membrane will prevent sur-
face irregularities. If adequate correction
requires greater thickness, usually in the dor-
sum, the implant layers should be sutured
together with 4-0 or 5-0 catgut sutures (Fig. 56.7 ).
The insertion of the implant is aided by Keith
needles housed in the Conrad Introducer [ 11 ]
(Fig. 56.8 ) (Anthony Products Inc., Indianapolis,
Indiana) attached to the guide sutures– usually
two (more if necessary for the even spreading
of the membrane) (Figs. 56.9 and 56.10 ). The
loops of the guide sutures are cut once they are
delivered through the skin and the sutures are
removed.
The incisions for insertion must be spaced at
least 1 cm from the caudal edge of the implant
and closed with absorbable sutures. The use of
nasal packing is optional and depends on the
requirement related to other septorhinoplasty

814
K. Conrad and A.J. Conrad
a
b
c
d
Fig. 56.5 ( a , c ) Severe nasal deformity following a
transnasal hypophysectomy. Total septal perforation con-
traindicated the use of a primary GORE-TEX implant.
( b , d ) Postoperative. Rib cartilagegrafts were used to the
nasal dorsum and lateral nasal walls overlying the upper
lateral cartilages. Six weeks later, staged Gore-Tex
implants were added for better re ﬁ nement of the nasal
contour