Rinoplastia Asiática Não-Cirúrgica com Preenchedores Dérmicos

Prévia do material em texto

INNOVATIVE TECHNIQUES NON-SURGICAL AESTHETIC
Structured Nonsurgical Asian Rhinoplasty
Peter Kim • Joon-Tae Ahn
Received: 2 July 2011 / Accepted: 7 December 2011 / Published online: 21 February 2012
� Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2012
Abstract The Asian nose is characterized by a flat nasal
bridge, indistinct dorsal aesthetic line, an underprojected and
broad nasal tip, and a short columella. Cosmetic procedures
to enhance these features are popular in Asians and surgical
rhinoplasty is the therapeutic gold standard for individuals
seeking to enhance the appearance of their nose. However, in
recent years, there appears to be an increasing number of
Asians seeking nonsurgical rhinoplasty and this tendency is
seen in both primary and revision cases. The biggest strength
of filler rhinoplasty is that it is minimally invasive, has a good
safety record, provides immediately visible results, and can
be done conveniently in the office setting without the
downtime of surgery. Despite its temporary longevity, it is
popular because it is simple, effective, and economical. This
article describes a ‘‘structured’’ nonsurgical Asian rhino-
plasty approach using dermal fillers that can produce a
comprehensive cosmetic enhancement of the Asian nose.
Keywords Rhinoplasty � Administration � Cutaneous �
Nose � Skin
Asians typically have a smaller and a less distinct nose and
thus cosmetic nose enhancement procedures are popular. For
decades, surgical rhinoplasty has been the therapeutic gold
standard for individuals seeking to improve the cosmetic
appearance of their nose. However, surgical rhinoplasty is an
invasive procedure that has both significant downtime and
complication rates [1]. In an effort to avoid these problems,
nonsurgical Asian rhinoplasty (NSAR) using an injectable
dermal filler has gained popularity for both primary and
revision nose enhancement procedures. In selected individ-
uals, soft tissue filler injections can provide an immediately
visible result in the convenience of the office setting, and the
procedure is minimally invasive and has a good safety
record. Despite its temporary longevity, it is popular because
it is simple, effective, and economical [2, 3].
Nonsurgical Asian rhinoplasty has been used successfully
and reliably to raise the nasal dorsum [4]. However, unlike
surgical rhinoplasty, it is limited in its ability to produce a
significant change in the caudal aspects of the nose. For NSAR
to produce a more natural, harmonious, and comprehensive
enhancement of the nose, often produced by surgical Asian
rhinoplasty [5], it needs to reliably lengthen the nose, raise the
tip, alter the nose profile in the basal view, and modify the
nostril shape and the columella-labial angle. So far, however,
outcomes following NSAR, at least in these particular areas,
have not been so consistent or reliably reproducible.
Comprehensive and successful NSAR requires an
approach that is ‘‘structured’’ so that like surgical rhino-
plasty, a combination of the corrections of various com-
ponents of the nose leads to a more holistic aesthetic
enhancement: structured NSAR. This article describes a
structured NSAR approach using dermal filler injections to
consistently produce a reliable and aesthetically pleasing
enhancement of an Asian nose.
Essential Aspects of Structured NSAR
There are three main aspects of the Asian nose that are
essential in a successful NSAR.
P. Kim (&)
Simply Beautiful Cosmetic Surgery & Laser Clinic, Suite 4,
Level 1, 9 Railway Street, Chatswood, NSW 2069, Australia
e-mail: dr.peterkim@yahoo.com.au
J.-T. Ahn
Lee & Ahn Cosmetic Surgery Clinic, Seoul, South Korea
123
Aesth Plast Surg (2012) 36:698–703
DOI 10.1007/s00266-012-9869-2
1. Dorsum nose profile (Fig. 1): A low dorsum tends to
make the bridge of the nose appear flat and indistinct
and the eyes appear farther apart. Often in Asians the
entire length of the dorsum needs to be elevated. A
degree of dorsal augmentation can be estimated by
relocating the radix to the level in the proximity of the
supratarsal fold at the horizontal gaze. An imaginary
line drawn between the new radix and the tip of the
nose marks the superior and inferior margins of the
nose to be injected with filler. The amount of filling
done should reflect femininity in females (yellow) and
masculinity in males (red). Also, amount of filler
injected should also be controlled to produce an
enhanced dorsal aesthetic line (dots), with the narrow-
est portion at the level of the nasion (arrow).
2. Tip projection (Fig. 2): The tip of an Asian nose is
generally set back and is bulbous (white dot). Filler
injection should produce a better tip projection with
the dorsum length-to-columella ratio approximately
1:0.67. A pointier tip that is projected more anteriorly
and with less cranial rotation (red) is often desired.
3. Columella, columella-labial angle, and nostril shape
(Fig. 3): Asians tend to have a sharp columella-labial
angle, a short columella, and a roundish nostril. Filler
injection should produce a slightly obtuse columella-
labial angle of around 95�, an elongated columella that
produces an isosceles-shaped nose on the basal view,
and a teardrop-shaped nostril.
Technique
Mark the vertical midline, new radix at the level of the supr-
atarsal fold, nasion, tip, and the dorsal aesthetic line. Plain
xylocaine 2% injections are used for nerve block of the
infratrochlear and external nasal nerves. Additional small
boluses are injected into the tip and the columella-labial angle.
The sequence of the structured NSAR (Fig. 4) is as follows:
First Stage
In a single pass, with the entry point at the tip of the nose,
we begin with the augmentation of the columella-labial
Fig. 1 Lateral profile of the ideal dorsal aesthetic line
Fig. 2 Tip projection that can be achieved using NSAR
Fig. 3 Basal view of nose following NSAR
Aesth Plast Surg (2012) 36:698–703 699
123
angle. The needle is advanced along the subcutaneous
plane, just deep to the dermis, all the way down to the nasal
spine. Then Radiesse� (Merz Aesthetics) is injected
slowly, carefully observing the filling of the columella-
labial angle (Fig. 4, no. 1); this usually requires 0.4 ml.
Once the columella-labial angle is corrected, then the
needle is slowly withdrawn while injecting filler with the
intention of strengthening and raising the columella col-
umn (Fig. 4, no. 2). This maneuver corrects the columella-
labial angle and straightens, lengthens, and strengthens the
columella. This should produce tip projection that is more
anterior and with less cranial rotation. By lengthening the
columella, the nose should appear more isosceles-shaped
and the nostril more teardrop-shaped when seen from the
basal angle (Fig. 3).
Second Stage
In a single pass, with the entry point at the tip of the nose,
the second stage of NSAR begins with augmentation of the
entire length of the dorsum in the midline from the new
radix to the tip (Fig. 4, no. 3). The width of the dorsum can
be effectively controlled with the volume of the injected
filler in a single row rather than multiple rows of injection.
Filling should be sufficient and uniform to produce aes-
thetically pleasing dorsal aesthetic lines. The volume of the
injected filler requires a more precise titration should there
be a dorsal hump. Then the radix and forehead dorsum
angle are further augmented (Fig. 4, no. 4). The radix is the
most recessed part of the dorsum and it often requires
additional filler. Boluses of filler are injected perpendicu-
larly in the midline as a series of interrupted columns,
while using the fingers to grasp the radix to limit the risk of
the filler material spreading which can make the dorsum
appear bulky. The end point is to create a new radix at the
approximate level of the supratarsal fold, to create an
approximately 135� angulationof the nasal dorsum to the
forehead, and to create distinct and aesthetically pleasing
dorsal aesthetic lines.
Third Stage
The final aspect of structured NSAR is shaping the nasal tip
(Fig. 4, no. 5). The essential aspect of this stage is to inject
a few superficial small boluses into the tip to further the
appearance of tip lengthening in the anterior direction, to
lessen the appearance of cephalic rotation, and to make the
tip pointier. The injection plane is at the level of the deep
dermis. In a virgin nose, we usually use a softer hyaluronic
acid (HA) filler because it can be readily reversed, and we
pay close attention to the visual signs of ischemia imme-
diately after injection, with hyaluronidase readily available.
Final Stage
Injected filler feels like ‘‘play-doh’’ immediately after
injection and it can be easily molded and reshaped to fur-
ther sculpt the nose. Additional top-offs may be required at
this stage. Overcorrection is a matter of personal choice.
However, Radiesse does appear to produce more immedi-
ate swelling than HA fillers so overcorrection by about
10% does not appear to produce any untoward effect.
Case Studies
Case 1: A Typical Structured NSAR Case
The majority of Asians, such as this patient, would benefit
from a comprehensive nonsurgical nose enhancement. This
18-year-old woman had a low radix, an indistinct dorsal
aesthetic line at the radix, a blunted and underprojected
nasal tip, and a short-curved hanging columella with an
acute angulation at the level of the subnasal. A total of
0.8 ml of Radiesse was used to correct the upper part of the
nose and 0.8 cc was used to correct the tip and columella
region (Fig. 5).
Another typical NSAR case needed 0.9 ml of Radiesse
for dorsum augmentation and 0.7 ml for columella and
nose tip augmentation. Taking the swelling associated with
the injection into consideration, a small overcorrection of
10% does appear to be beneficial.
Case 2: Structured NSAR in Patient with Dorsal Hump
A 34-year-old female has a slightly low-set radix, low-set
dorsum, and a small but prominent dorsal hump inter-
rupting the continuity of the dorsal aesthetic line (Fig. 6).
Also, she had an ill-defined and retracted nose tip and a
short columella with a deep and acute columella-labial
angle. Injection of 0.7 cc of Radiesse in the dorsum above
the hump to the radix and of 0.4 cc below the hump to the
nasal tip corrected the dorsal profile. Radiesse (0.7 cc) was
Fig. 4 Sequence of filler injection in structured NSAR: 1 columella-
labial angle, 2 columella, 3 dorsum, 4 radix, 5 tip
700 Aesth Plast Surg (2012) 36:698–703
123
further injected to augment and strengthen the columella
down to the nasal spine; this produced a more aesthetically
pleasing continuity between the nose and the upper lip as
well as effectively projecting the tip. An additional 0.2 cc
of Restylane� (Medicis Aesthetics) was injected to sharpen
the tip of the nose (Fig. 7).
Case 3: NSAR to Correct Postrhinoplasty Complication
Surgical rhinoplasty of the Asian nose is a popular procedure.
Due to the inherent unpredictable outcome that is associated
with any surgical procedure, patients are warned of the pos-
sibility of minor asymmetries, slight depressions, and subtle
contour irregularities. This 26-year-old female sought a better
dorsal aesthetic profile 2 years after her initial rhinoplasty.
The patient wanted a more prominent dorsal aesthetic line,
correction of the dorsal aesthetic line defect on the right side
of the nose (white arrowhead), and a taller radix. Radiesse
(0.8 cc) was used to further elevate the radix and produce a
more prominent and straight dorsal aesthetic line (Fig. 8).
Discussion
In Asian patients seeking cosmetic enhancement of their
nose, surgical rhinoplasty is the gold standard. However, the
nonsurgical approach is becoming increasingly popular
because patients are increasingly demanding less invasive
cosmetic procedures with minimal down time to satisfy their
aesthetic demands. A nonsurgical procedure does not have
the long downtime that is associated with surgical rhinoplasty
which means less interruption of daily activities, and it is
relatively more affordable in the short term, although surgical
rhinoplasty may be more cost effective in the long term. From
the injector’s perspective, it requires much less training and a
much shorter learning curve to perform filler rhinoplasty than
surgical rhinoplasty and the above-mentioned advantages
drive a marketing advantage over surgical rhinoplasty.
A wide range of fillers are available for a successful
NSAR. Popular filler materials are HA-based fillers, cal-
cium hydroxylapatite, and more permanent polyacrylamide
gels. Each has its own pros and cons but the selection of the
primary filler for our NSAR was based on the following
considerations:
• Avoid using a permanent filler because if there is a
complication or the patient is dissatisfied, it is difficult
to remove it, especially when injected in a linear
fashion.
• Use temporary filler that can be reversed should there
be a complication; this is especially relevant with
superficial injections.
Fig. 5 Case 1
Fig. 6 Case 2 oblique view
Aesth Plast Surg (2012) 36:698–703 701
123
• Use a temporary filler that has the greatest longevity.
• Use filler that can be injected with ease and is simple to
mold and shape after it is injected.
• Use a filler with high viscosity and elasticity that
provides volume-efficient lifting and stable postinjec-
tion contours [6].
For these reasons we routinely use Radiesse for all our
structured NSAR. In the tip of the nose, where the injec-
tions need to be more superficial to create a pointier tip, we
use HA filler which can be readily dissolved should there
be any ischemia; this is especially important in a virgin
nose. With the availability of better filler materials in the
future [7], we hope to be able to produce a longer-lasting
result.
General guidelines for a successful structured NSAR
are:
• Mastery of both nasal anatomy and precise surgical
technique is mandatory before performing nasal cor-
rections with fillers [8].
• Using both hands is the key to a successful structured
NSAR.
• Use a 25- or 27 G needle that is 1.2 in. long.
• Inject filler in a retrograde fashion only after verifying
the negative flashback to avoid inadvertent vascular
injection.
• Inject the filler just deep to the dermis except when
injecting HA filler to the tip of the nose where it should
be intradermal.
• The sequence of injection is important; start with
columella enhancement, then the dorsum, and finish
with tip refinement.
• The right hand is used for injection of filler smoothly,
measurably, and directionally.
• The left ‘‘smart’’ hand is used to guide the placement,
to mold, and to avoid inadvertent spreading of the
injected filler [9]. This is particularly important when
injecting the dorsum as slight ‘‘misspreading’’ of the
injected filler creates noticeable asymmetry.
• Slow and steady correction provides the safest means of
achieving the best results.
• Immediately discontinue injection should there be any
ischemic changes of the skin of the nose.
• Avoid excessive overcorrection but overcorrection by
10% to account for the swelling associated with filler
injection appears to be safe and reasonable. Further
incremental corrections are always possible at a later
date.
• Avoid excessive molding after injection as Radiesse-
injected tissue tends to swell more than HA-filled
tissue.
• Avoid large volumes of superficial injections as this
may cause external vascular compression to the extent
of causing skin ischemia and necrosis. This is espe-
cially important in the tip and glabella region.
• Closely monitor the nose after the NSAR for any signs
of ischemia, particularly in those patients with a history
of previous rhinoplasty, as their vascular supply may be
rearranged and compromised as the resultof it. Should
there be any sign of ischemia, be ready to extrude the
injected filler and be ready to use hyaluronidase to
dissolve the HA filler.
• Avoid unnecessary external compression of the nose
after the injection, such as wearing glasses, for at least a
few days.
Fig. 7 Case 2 basal view
Fig. 8 Case 3
702 Aesth Plast Surg (2012) 36:698–703
123
Complications from NSAR are fortunately not common
and range from trivial bruising and swelling to delayed
granulomatous reactions to a more serious skin necrosis
[10]. Skin necrosis of the tip of the nose is of particular
concern in NSAR as it inevitably leads to permanent dis-
figurement. However, correction of the nasal dorsum
without correction of the tip does not produce a compre-
hensive aesthetic enhancement so we do inject filler into
the tip but with extreme caution. Inadvertent intravascular
filler injection would lead to irreversible skin necrosis, but
if the ischemia is the result of filler compressing the artery,
it may be reversed by either dissolving the HA filler or by
extruding the calcium-hydroxylapatite filler. For this rea-
son, we recommend injection of filler only after check-
ing the backflush, and we recommend close observation
immediately after filler rhinoplasty and to be ready to inject
hyaluronidase and/or extrude the Radiesse. Following these
simple safety steps, fillers can be a good tool for a safe and
comprehensive nonsurgical Asian nose enhancement.
We have performed 87 structured NSARs. There
appears to be a 20–30% reduction in the volume of the
injected filler in the first 2–3 months. The absolute lon-
gevity is difficult to assess but without any top-off injec-
tions, the results tend to last 12 months with modest
satisfaction, which is similar to other published results
[4, 9]. There were four complications in our cohort. One
was asymmetry of the dorsum of the nose which was
corrected with further injections. One was overinjection of
Radiesse that presented as a white nodule on the frenulum
of the upper lip; this was successfully treated with extrusion
of Radiesse 1 week after the injection. Another complication
was related to inadvertent intradermal injection of Radiesse
that caused local erythema and inflammation that settled
with intradermal steroid injection; this case further rein-
forced the importance of injecting Radiesse into the subcu-
taneous plane. The fourth complication was a dermatitis-like
skin reaction 3 days after the injection which spontaneously
settled with a course of prophylactic antibiotics.
The limitations of this series of cases are that it was not
a quantitative study and the sample size is small with
unpredictable follow-up rates. With only 87 cases together
with an unreliable and short follow-up, no real conclusions
can be made on the choice of ideal filler material in Asian
nose enhancement and the precise longevity of structured
NSAR treatment. Furthermore, it is possible that there are
more complications that went unnoticed in addition to
those described in this article. This article hopes to serve as
a pilot to a prospective quantitative study to document the
efficacy, longevity, and safety profile of this structured
NSAR approach.
Conclusion
Successful NSAR requires an in-depth knowledge of the
nasal anatomy, appreciation of the aesthetics of a beautiful
Asian nose, and a clear expectation of what can be
achieved with filler rhinoplasty. By breaking down the
NSAR into smaller, specific, and more manageable com-
ponents, and by performing filler rhinoplasty in a structured
and a sequential manner (structured NSAR), a reproducible
and satisfying cosmetic outcome can be achieved without
surgery in selected patients.
Conflict of interest The authors have no conflicts of interest to
disclose.
References
1. Constantinidis J, Daniilidis J (2005) Aesthetic and functional
rhinoplasty. Hosp Med 66:221–226
2. Beer KR (2006) Nasal reconstruction using 20 mg/ml cross-
linked hyaluronic acid. J Drugs Dermatol 5:465–466
3. Murray CA, Zloty D, Warshawski L (2005) The evolution of soft
tissue fillers in clinical practice. Dermatol Clin 23:343–363
4. Siclovan HR, Jomah JA (2009) Injectable calcium hydroxylapa-
tite for correction of nasal bridge deformities. Aesthet Plast Surg
33:544–548
5. Toriumi DM (2002) Structural approach to primary rhinoplasty.
Aesthet Surg J 22:72–84
6. Sundaram H, Voigts B, Beer K, Meland M (2010) Comparison of
the rheological properties of viscosity and elasticity in two cat-
egories of soft tissue fillers: calcium hydroxylapatite and hyalu-
ronic acid. Dermatol Surg 36:1859–1865
7. Han SK, Shin SH, Kang HJ, Kim WK (2006) Augmentation
rhinoplasty using injectable tissue-engineered soft tissue: a pilot
study. Ann Plast Surg 56:251–255
8. Fagien S (2006) Evalution of a calcium hydroxylapatite-based
implant (Radiesse) for facial soft-tissue augmentation. Plast
Reconstr Surg 118(Suppl):31S–33S
9. Jacovella PF (2008) Use of calcium hydroxylapatite (Radiesse�)
for facial augmentation. Clin Interv Aging 3(1):161–174
10. Park T, Seo S, Kim J, Chang C (2011) Clinical experience with
hyaluronic acid-filler complications. J Plast Reconstr Aesthet
Surg 64(7):892–896
Aesth Plast Surg (2012) 36:698–703 703
123
	Structured Nonsurgical Asian Rhinoplasty
	Abstract
	Essential Aspects of Structured NSAR
	Technique
	First Stage
	Second Stage
	Third Stage
	Final Stage
	Case Studies
	Case 1: A Typical Structured NSAR Case
	Case 2: Structured NSAR in Patient with Dorsal Hump
	Case 3: NSAR to Correct Postrhinoplasty Complication
	Discussion
	Conclusion
	Conflict of interest
	References