ArticleLiterature Review

Superficial Nasal Filler Injections–How I do It

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Abstract

Nasal enhancement is one of the most challenging and intriguing of aesthetic procedures. Although the nose is the most central and prominent facial feature, it should not be dominant while maintaining both a harmonious relationship with the face and its own intrinsic beauty. In this article, the first author shares his experience on how to specifically apply intradermal soft-tissue fillers (for particular indications) in nasal enhancement and incorporates patient assessment, anatomy of the nose, and injection techniques to provide guidance. Intradermal injections are required for specific regions, as for example in the treatment of internal and external valve collapse; however, several precautionary measures need to be implemented to minimize risks resulting in vascular compromise.

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Background: The purpose of this article is a presentation of the existing knowledge on the anatomy of the supratrochlear artery based on a comprehensive review of the available literature in close correlation with minimally invasive cosmetic procedures in the facial area such as soft-tissue fillers injections. Methods: A literature review was performed concerning the anatomy of the supratrochlear artery and its modern clinical significance with close correlation to soft tissue filler injections , the possible adverse effects and their safe application based on anatomy. Results: Supratrochlear artery consists a terminal branch of the ophthalmic artery. Exiting the orbit, it exhibits a quite constant course ascending the forehead in a paramedian position. In its typical pattern, the supratrochlear artery branches off proximal to the corrugator supercilli muscle , giving rise to a superficial and a deep periosteal branch .Its superficial course, as well as the rich, variable anastomotic network that it forms with the supraorbital, angular and dorsal nasal artery make the canulation of the supratrochlear artery and ultimately, the risk of embolization of the central retinal artery in a retrograde fashion, possible after soft-tissue filler injections in the nasoglabellar and central forehead area. Conclusion: Although the risk of complications from the use of soft tissue fillers is rare, once happen, the results could be devastating for the quality of life of patients. Consequently, it is important for injecting physicians to have a deep understanding of the anatomy of the supratrochlear artery, so that optimal cosmetic outcome can be provided safely.
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Rhinoplasty is one of the top 5 aesthetic surgical procedures performed in plastic surgery. A methodical evaluation based on solid and up-to-date scientific evidence in different key areas of nasal and facial analysis is presented, the 10-7-5 method. This represents the most important preoperative step for a successful rhinoplasty. The 10-7-5 method for nasal analysis is a useful instrument that provides the rhinoplasty surgeon a deep comprehension of nasal anatomy. Understanding the nasal structures' main relationships and consequences of each surgical maneuver on nasal framework assists on establishing the appropriate surgical goals for each patient, both in primary and secondary rhinoplasty cases. This systematic analysis of patient's frontal, lateral, and basal nasal views provides a background to identify changes to ideal aesthetic proportions and how to surgically restore them while maintaining gender and ethnic congruency.
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Background: Soft tissue filler product distribution and tissue integration have been shown to depend on myriad factors including the injector type, injector size, and injection angle. Aim: This study aims to investigate the magnitude of product spread across fascial soft tissue layers in relation to product viscoelastic properties. Patients/methods: A total of 168 injection procedures were conducted in two female Caucasian body donors with a mean age of 80 years (range: 79-81) and a mean body mass index of 23.6 kg/m2 (range: 21.0-26.6). The injection procedures were performed in the forehead, scalp, zygomatic arch, mandible, clavicle, and sternum. The injected materials included Belotero® Soft, Belotero® Balance, Belotero® Intense, Belotero® Volume, Radiesse® , and Radiesse® Plus. Layer-by-layer dissections were performed to investigate the vertical distribution of the injected product. Results: The mean product spread was for Belotero® Soft 4.54 ± 0.91; Belotero® Balance 3.85 ± 1.19; Belotero® Intense 3.04 ± 1.34; Belotero® Volume 2.58 ± 1.27; Radiesse® 1.31 ± 0.47; and Radiesse® Plus 1.27 ± 0.45 with P < .001. Bivariate correlations between product spread and storage modulus (G') revealed an inverse relationship of moderate strength with rp = -0.651 and P < .001. Conclusion: The results of the present study revealed that products that were more fluid and less viscous distributed into more superficial fascial layers than products that were less fluid and more viscous (P < .001). This relationship held true irrespective of injected location.
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The aim of this study is to analyze the psychological outcomes for patients undergoing non-surgical correction of nasal defects using injections of cross-linked hyaluronic acid. We assessed changes in the subjective perception of nasal appearance after non-surgical rhinoplasty using the Rhinoplasty Outcomes Evaluation (ROE) questionnaire, which is validated and widely used in the literature. One hundred adult subjects without prior history of surgical or non-surgical rhinoplasty underwent non-surgical recontouring using the hyaluronic acid filler from December 2016 to December 2018. The points of inoculation have been standardized by the authors and are divided according to the aesthetic subunits of the nose. A final 74 patients (65 females and 9 males) completed a one-year follow-up and were included in the present study. The ROE questionnaire consists of six questions and assesses the way patients perceive the appearance of their nose and the way they think the people around them view the appearance of their nose. The results of each question were analyzed for each patient, comparing the preoperative results over a 12-month time-frame. Candidates for rhinoplasty, either medical or surgical, are among the most difficult to treat and, interestingly, there is substantial literature showing that among these patients, there is a higher rate of psychiatric disorders. Many of these patients seek aesthetic surgery and are often dissatisfied with the outcome of their surgery. The authors suggest that the use of ROE is not only a valid method of assessing patient satisfaction, but it could also be used as a tool to highlight some of the psychological characteristics of patients long before performing any treatment and could help identify potentially problematic patients.
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Background: Soft tissue filler is commonly used for facial contouring. However, incorrect use can lead to severe ocular complications. Even though filler injections are quite different from fat grafts, they are considered similar procedures. However, to date, there are no proven preventive measures or treatments for blindness secondary to soft tissue filler injections. Objectives: This literature review aimed to investigate visual compromise secondary to soft tissue filler injection and discuss the related vascular anatomy, pathophysiology, and prevention of ocular complications of soft tissue filler injections. Methods: A literature search until July 2018 was performed for reports on visual compromise after filler injections. We evaluated the previous literature and eliminated cases using fat grafts and unknown fillers. Results: A total of 50 reports of filler-induced visual compromise were identified. Analysis of these cases showed that the procedure with greatest risk was nasal augmentation, followed by glabellar wrinkle treatment. Within the last 3 years searched, 35% of reported cases involved treatment of the nose. There were no reports of blindness from injections into the temple or chin and relatively few case reports involving forehead injections. Conclusion: The most common injection site associated with blindness in a previous report was the glabella; however, the most common site currently associated with blindness due to filler injections was the nose. Extreme caution is necessary when performing nasal augmentation or glabellar wrinkle correction using soft tissue fillers to avoid the branches of the internal carotid artery.
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Background: It can be hypothesized that safety during soft tissue filler injection could be enhanced if the product could be positioned between the periosteum and the bone surface i.e. subperiosteal. Aim: This study investigated the feasibilityof subperiosteal injections. Patients/methods: We analysed 126 injection procedures performed in seven Caucasian body donors (4 males, 3 females) with a mean age of 75.29 ± 4.95 years [range: 70 - 87] and a mean body mass index of 23.53 ± 3.96 kg/m2 [range: 16.46 - 32.23]. The injection procedures were performed in the forehead, scalp, zygomatic arch and the mandible bilaterally. Injection procedures were conducted using 25G, 27G and 30G sharp-tip needles (TSK Laboratory, Tochigi, Japan) and at various angles from the bone surface measured with a goniometer: 90 degrees (perpendicular), 45 degrees and 10 degrees (as tangential as possible to bone surface). Results: Cadaveric dissections of the injection sites showed that no product was located deep to the periosteum in any of the investigated regions. This indicates that all performed injection procedures positioned the product superficial to the periosteum (100%) with a zero-success rate of subperiosteal injections. Conclusion: In the setting of this cadaveric investigation, despite varying needle size and injection angle, subperiosteal injection could not be achieved. This indicates that the product can spread uncontrolled into more superficial layers yielding an increased risk for adverse aesthetic and vascular events.
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Background Soft tissue filler injection is a common procedure for augmentation rhinoplasty. Various techniques for augmenting the nasal dorsum using a soft tissue filler have been attempted considering the size of the needle, the anatomical layer where the filler is injected, and the vascular distribution. The purpose of this paper was to evaluate the course of the dorsal nasal artery in patients scheduled for nasal augmentation using a soft tissue filler and to propose a method of nasal augmentation that minimizes vessel damage during soft tissue filler injection by confirming the distribution pattern of blood vessels through ultrasound. Methods Patients underwent augmentation rhinoplasty using a soft tissue filler. All patients underwent ultrasound examination before the filler injections. Results From July to September 2018, ultrasound studies were conducted before augmentation rhinoplasty in 50 consecutive patients. Forty patients (80%) had a well‐known lateral arterial pathway, while in 10 patients (20%), the dorsal nasal artery was found at the midline of the nose. In four cases (8%), the artery travelled just beneath the preperiosteal layer, which is under the nasalis muscle. Additionally, in seven cases (14%), the dorsal nasal artery coursed superficially, just beneath the subdermal layer. Conclusion Injecting the filler into the preperiosteal layer either via a needle or cannula is considered relatively safe but there remains the possibility of vascular compromise. Using a large diameter cannula and injecting the filler into the preperiosteal layer using a gentle approach may be the safest approach.
Article
Background Sudden loss of vision secondary to filler treatments is a rare but catastrophic complication. Objective To update the published cases of blindness after filler injection which have occurred since we published our review of 98 cases in 2015, and to discuss prevention and management strategies. Methods A literature review was performed to identify all cases of visual complications from filler between January 2015 and September 2018. Results Forty-eight new published cases of partial or complete vision loss after filler injection were identified. The sites that were highest risk were the nasal region (56.3%), glabella (27.1%), forehead (18.8%), and nasolabial fold (14.6%). Hyaluronic acid filler was the cause of this complication in 81.3% of cases. Vision loss, pain, ophthalmoplegia, and ptosis were the most common reported symptoms. Skin changes were seen in 43.8% of cases and central nervous system complications were seen in 18.8% of cases. Ten cases (20.8%) had complete recovery of vision whereas 8 cases (16.7%) had only partial recovery. Management strategies varied greatly and there were no treatments that were shown to be consistently successful. Conclusions Although the risk of blindness from fillers is rare, practitioners who inject filler should have a thorough knowledge of this complication including prevention and management strategies.
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Analysis of the face is an essential component of facial plastic surgery. In training, we are taught standards and ideals based on neoclassical models of beauty from Greek and Roman art and architecture. In practice, we encounter a wide range of variation in patient desires and perceptions of beauty. Our goals seem to be ever shifting, yet our education has provided us with a foundation from which to draw ideals of beauty. Plastic surgeons must synthesize classical ideas of beauty with patient desires, cultural nuances, and ethnic considerations all the while maintaining a natural appearance and result. This article gives an overview of classical models of facial proportions and relationships, while also discussing unique ethnic and cultural considerations which may influence the goal for the individual patient.
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Background Injections of filler into the nose for dorsum augmentation have a higher risk of complications due to the complicated blood supply and anastomotic channels in this area. Objectives The aim of this study was to determine the anatomical features and location of the dorsal nasal artery (DNA), and to provide clinical anatomical information to reduce side effects and severe complications in the perinasal area. Methods Using the 31 cadaveric noses in Asians, dissections and histologic examinations were performed to identify the location and depth of the vascular structures including DNA. Results Dorsal nasal artery ran downward at 20.3 ± 3.5 mm from the intercanthal line and the communicating branch that connected the bilateral DNAs was located 8.5 ± 3.5 mm inferior to the intercanthal line. The DNA was located at 4.4 ± 3.2 mm, 4.6 ± 4.4 mm, and 5.2 ± 4.4 mm lateral to the midline of the nose on the intercanthal, quadrisected, and bisected lines, respectively. At the level of nasal bone, DNA was located superficial to the muscular layer and it runs inferolaterally on dorsum on nose. It was running more deeply and located beneath the fibromuscular layer at the cartilaginous portion of the dorsum of nose. Conclusions Injection into deep fatty layer may reduce the risk of arterial injury and the consequent complications. However, in a hooked nose, the tip of the needle traveling along the deep layer approaches the superficial layer due to the convexity of the hump as it passes over it, which can increase the probability of damaging the DNA.
Article
The nose is an essential feature when considering the aesthetic appeal of the face. As aesthetic preferences vary from person to person, the concept of the "ideal™ nose must be applied on a case-by-case basis, with respect to the classical patterns of anthropometry, sex, ethnic group, and psychosocial factors. Interest in less invasive procedures for nasal correction has increased considerably, among which is the emerging use of hyaluronic acid for nonsurgical rhinoplasty. In this article, the authors present an objective review of the anatomy of the nasal region, the evaluation and indications of nasal filling with hyaluronic acid, a description of the technique, and brief discussion of associated complications.
Article
Background: Facial plastic surgeons and patients benefit from knowledge about how psychological aspects can influence the outcome of cosmetic surgery. The influence of preoperative self-consciousness of appearance and its effect on benefit after surgery in rhinoplasty patients has not been explored before in other studies. Method: A prospective study was conducted on patients undergoing (septo)rhinoplasty for a combination of cosmetic and functional problems. Before the operation subjects were asked to complete two questionnaires, the Derriford Appearance Scale (DAS59) to measure distress associated with self-consciousness of appearance and the Rhinoplasty Outcome Evaluation (ROE) to measure satisfaction with their nose. Three months after surgery, they were asked to complete the ROE again and the Glasgow Benefit Inventory to measure benefit of the surgery in daily life. Scores of the pre- and postoperative questionnaires were analyzed and compared. Statistical analysis was performed to determine change after surgery and correlations between the scores. Subjects: Fifty-five consecutive patients undergoing (septo)rhinoplasty received a letter in which they were asked to participate in the study. Thirty-three patients completed both pre- and postoperative questionnaires. Their mean age was 28 years. Main findings: Patient satisfaction improved significantly after the surgery. Lower self-consciousness of appearance before surgery was positively correlated with more benefit after the surgery and a greater change in patient satisfaction with their nose. Males have a lower benefit scores than females. Conclusions: Patients seeking rhinoplasty have more distress associated with self-consciousness of appearance than a general unconcerned population. They can benefit a lot from a well-executed procedure. A significant improvement in quality of life can be achieved by rhinoplasty. Although males are equally satisfied as females, they benefit less from the surgery in daily life.
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The external nasal valve is a complex entity comprised of multiple structures and tissue types. As such, there is no single operation that can address all problems of the external valve. This article reviews the relevant anatomy, pathologic conditions, and treatments for external nasal valve dysfunction, including a detailed review of the nasal muscles and their contribution to external nasal valve patency. Surgical and nonsurgical options for treatment and the evidence supporting the importance of proper external nasal valve function on quality-of-life measures are discussed.
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The nose is a complex structure important in facial aesthetics and in respiratory physiology. Nasal defects can pose a challenge to reconstructive surgeons who must re-create nasal symmetry while maintaining nasal function. A basic understanding of the underlying nasal anatomy is thus necessary for successful nasal reconstruction.
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The nasal valve area is the functional area that allows airflow regulation. It could be divided in an internal area and an external one, basing on the anatomical landmarks. Many conditions can damage these areas with a consequently nasal obstruction, more often in particular extended rhinoplasty and sequels of facial trauma. To restore this area many techniques were advocated during the last decades.In this article the authors investigate on valve areas deficiency in sequel of rhinoplasty proposing a structural approach through alar batten grafts to correct internal-external nasal valves collapse.
Article
Introduction: With the increased use of filler and fat injections for aesthetic purposes, there has been a corresponding increase in the incidence of complications. Vision loss as an uncommon but devastating vascular side effect of filler injections was the focus of this paper. Methods: A review committee, consisting of plastic surgeons, aesthetic medical practitioners, ophthalmologists and dermatologists from Singapore, was convened by the Society of Aesthetic Medicine (Singapore) to review and recommend methods for the prevention and management of vision loss secondary to filler injections. Results: The committee agreed that prevention through proper understanding of facial anatomy and good injection techniques was of foremost importance. The committee acknowledged that there is currently no standard management for these cases. Based on existing knowledge, injectors may follow a proposed course of action, which can be divided into immediate, definitive and supportive. The goals were to reduce intraocular pressure, dislodge the embolus to a more peripheral location, remove or reverse central ischaemia, preserve residual retinal function, and prevent the deterioration of vision. Dissolving a hyaluronic acid embolus remains a controversial option. It is proposed that injectors must be trained to recognise symptoms, institute immediate actions and refer patients without delay to dedicated specialists for definitive and supportive management. Conclusions: Steps to prevent and manage vision loss based on current evidence and best clinical practices are outlined in this paper. Empirical referral to any emergency department or untrained doctors may lead to inordinate delays and poor outcomes for the affected eye.
Article
This study is a quantitative evaluation of the influence of the lower component of the nasofrontal angle on perceived attractiveness and threshold values of desire for rhinoplasty. The nasofrontal angle of an idealized silhouette male Caucasian profile image was altered incrementally between 106 and 148 degrees. Images were rated on a Likert scale by pretreatment patients (n = 75), laypeople (n = 75), and clinicians (n = 35). The results demonstrated that a nasofrontal angle of approximately 130 degrees is ideal, corresponding to a lower component of 60 degrees, with a range of 127 to 142 degrees deemed acceptable. Angles above or below this range are perceived as unattractive, and anything outside the range of 118 to 145 degrees is deemed very unattractive. Reduced nasofrontal angles, simulating a nasal hump deformity, of less than 115 degrees were deemed the least attractive. In terms of threshold values of desire for surgery, for all groups a threshold value of 148 degrees indicated a preference for surgery: for patients, the threshold value was 121 degrees or less; for lay people, the threshold value was 124 degrees or less; and similarly for clinicians, the threshold value was 118 degrees or less. Clinicians were the least critical, and patients appeared to be less critical than lay people. This stresses the importance of using patients as observers, as well as laypeople and clinicians, in facial attractiveness research. From the results of this study, it is recommended that in rhinoplasty planning, the range of normal variability of the nasofrontal angle, in terms of observer acceptance, is taken into account as well as the threshold values of desire for surgery.
Article
Background Dorsal nasal augmentation is an essential part of injection rhinoplasty on the Asian nose. Aesthetic physicians require detailed knowledge of the nasal anatomy to accurately and safely inject filler. Methods One hundred and thirty-five histological cross sections were examined from 45 longitudinal strips of soft tissue harvested from the midline of the nose, beginning from the glabella to the nasal tip. Muscles and nasal cartilage were used as landmarks for vascular identification. Results At the nasal tip, a midline longitudinal columellar artery with a diameter of 0.21 ± 0.09 mm was noted in 14 cadavers (31.1 %). At the infratip, subcutaneous tissue contained cavernous tissue similar to that of the nasal mucosa. The feeding arteries of these dilated veins formed arteriovenous shunts, into which retrograde injection of filler may be possible. All of the nasal arteries present were identified as subcutaneous arteries. They coursed mainly in the superficial layer of the subcutaneous tissues, with smaller branches forming subdermal plexuses. A substantial arterial anastomosis occurred at the supratip region, in which the artery lay in the middle of the subcutaneous tissue at the level of the major alar cartilages. These arteries had a diameter ranging between 0.4 and 0.9 mm and were found in 29 of 45 specimens (64.4 %). This was at the level midway between the rhinion above the supratip and the infratip. This anastomotic artery also crossed the midline at the rhinion superficial to the origin of the procerus on the lower end of the nasal bone. Here the arterial diameter ranged between 0.1 and 0.3 mm, which was not large enough to cause arterial emboli. Fascicular cross sections of the nasalis muscle directly covered the entire upper lateral cartilage. The subdermal tissue contained few layers of fat cells along with the occasional small artery. The procerus arose from the nasal bone and was continuous with the nasalis in 16 cadavers (35.6 %). There was fatty areolar tissue between the procerus and the periosteal layer and no significant arteries present. The procerus ascended beyond the brow to insert into the frontalis muscle with very few cutaneous insertions. The supratrochlear vessels and accompanying nerve were occasionally found on the surface of the frontalis muscle. Conclusion Most nasal arteries found in the midline are subcutaneous arteries. Filler should be injected deeply to avoid vascular injury leading to compromised perfusion at the dorsum or filler emboli at the nasal tip. Level of Evidence V This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www. springer. com/ 00266.
Article
We report a case of unilateral blindness and panophthalmoplegia after hyaluronic acid injection into the dorsum of the nose in a healthy young woman. Microspheres of hyaluronic acid are popular fillers for facial rejuvenation. While ocular side effects from injections in the nose and face have been reported following turbinate injection, rhinoplasty and infraorbital nerve block, ocular side effects from injection into the dorsum of the nose are extremely rare. We presume that the symptoms were due to obstruction of the branches of the ophthalmic artery. Under high injection pressure, the microspheres travelled to the ophthalmic artery and were propelled by the blood flow to the central retinal artery and the anterior and posterior long ciliary arteries, leading to her symptoms. Alternatively, there are several arterio-venous anastomotic channels in the nasal mucosa that aid heat exchange. These may have been the conduit for reflux of the filler into the arterial side of the regional circulation. Physicians must remain aware of serious complications during cosmetic injections to this region.
Article
Soft-tissue fillers have been applied throughout the face; however, the literature has largely ignored the injection of fillers into the nasal anatomy. This Special Topic article reviews proper filler choice and injection technique for the nose based on the senior author's (R.J.R.) experience. Discussion includes indications for soft-tissue filler injection into the nose as well as specific technical pearls based on filler material, anatomic area, and potential complications. The application of soft-tissue fillers to rhinoplasty has certainly broadened the nasal surgeon's armamentarium. While major structural changes of the nose are best accomplished through surgical alteration of the osseocartilaginous framework, soft-tissue fillers offer an excellent method to augment areas or refine irregularities. These often subtle alterations require precise preinjection nasal analysis.
Article
BackgroundIn a previous study we focused on gender specific nasal shapes. The aim of this study was to evaluate if preferences in nasal shape are also dependent on the gender of the observer.MethodsStratified on the basis of each photographed subject's (n = 311) own evaluation, female and male composite pictures of “average” (n = 128, each), “optimal” (n = 16, each) and “most unpleasant” (n = 8, each) noses were created in a previous study. These composites were assessed by 308 independent female and male judges using a visual analogue scale.ResultsOn average, female judges were found to accord significantly higher ratings of attractiveness as compared to male judges for the composite images independent of the gender of the person shown (p = 0.020). The difference was greatest when assessing most unpleasant male composites (p < 0.003) but was not apparent when assessing “optimal” female and “optimal” male noses. Despite this, women displayed the same preferences for “optimal” and “average” noses as compared to the “most unpleasant” noses. In assessing their own noses, women were significantly less satisfied with their appearance in general (p = 0.001) as compared to men.ConclusionsIn comparison to men, women are more critical in assessing the appearance of their own nose as opposed to the noses of other people. The implications of this for rhinoplasty, so far as considering the degree of influence of the gender of a person assessing a prospective patient's nose remains a matter of conjecture.
Article
Skin thickness can be a major factor affecting rhinoplasty outcomes. However, few studies have examined the impact of nasal skin thickness on rhinoplasty aesthetic results. The aim of this study is to determine the effect of nasal skin thickness on the tip surgery outcome objectively. Case series with chart review. Academic tertiary care medical center. The study involved 77 patients who were evaluated using preoperative computed tomography scans and underwent rhinoplasty including tip surgery. Surgical outcomes were classified as excellent, good, or poor. Nasal skin thickness was measured at nasion, rhinion, nasal tip, and columella using computed tomography scans and was analyzed according to surgical outcomes. The mean nasal skin thickness was 3.3 mm for nasion, 2.4 mm for rhinion, 2.9 mm for nasal tip, and 2.3 mm for columella. Postoperative outcomes were classified as excellent in 45, good in 17, and poor in 15 patients. The excellent outcome group had the thinnest nasal tip and columella nasal skin (2.8 mm and 2.2 mm), whereas the poor outcome group had the thickest skin in these regions (3.4 mm and 2.6 mm) (P < .0001 and P = 0.01, respectively). Nasal skin is thickest over the nasofrontal angle, thins over the rhinion, is thick again in the nasal tip, and thins out over the columella. Thick skin at the nasal tip and columella was associated with poor surgical outcomes. Regional skin thickness appears to be an important prognostic factor for tip surgery success.
Article
Permanent treatment for external nasal valve collapse (ENCV) is primarily surgical. In some situations, instead of a major operation, the placement of structural alar rim graft may be all that is needed. Alar rim graft placement is usually achieved through a marginal incision as a part of a rhinoplasty. We compared the aesthetic and functional outcomes of a simple technique in which the graft is placed via an external incision in the alar-facial groove with the outcomes of the more commonly used method. All patients who underwent ENCV repair in 2007 and 2008 were reviewed. Fifteen cases in which grafts were placed using the alar-facial stab technique were identified. Twenty cases with marginal incision graft placement in that time period were then randomly selected. All of the patients underwent concurrent additional procedures such as rhinoplasty/septorhinoplasty. The aesthetic and functional assessments of both techniques were explored by means of blinded observers rating the aesthetic outcome and patients rating their functional outcome through the use of questionnaires. A retrospective cohort study. A comparison between the patients' subjective results showed no difference between the outcomes of these two techniques (P > .05). The blinded surgeon evaluators could not differentiate between the different approaches utilized in the vast majority of cases studied. The alar-facial stab incision with alar rim grafting for treatment of ENCV is a very simple and effective technique that does not require significant rhinoplasty experience and may be performed in the office under local anesthesia.
Article
Nasal alar collapse is a common problem and difficult to assess and treat. In 10 healthy controls and 10 patients with alar collapse, the size of the external nasal valve was analyzed on standardized nasal base photographs during quiet breathing and forced inspiration. A novel internal nasal dilator (Nasanita, Siemens & Co, Germany) was employed to assess the effects of a therapeutic intervention. In addition, active anterior rhinomanometry was performed. During quiet breathing, the external nasal valves were significantly smaller in patients with alar collapse (0.3 +/- 0.08 cm2) than in controls (0.7 +/- 0.2 cm2; p < 0.001). In heal-thy controls, forced inspiration did not significantly alter the size of the external nasal valve (-1.8% +/- 27.5%; p = 0.84), whereas it significantly decreased the external valve area in patients with alar collapse (-42.1% +/- 26.4%; p = 0.001). The internal nasal dilator significantly increased external valve areas during quiet breathing and forced inspiration and completely abolished alar collapse. Nasal airflow at a transnasal pressure difference of 150 Pa was not correlated with external valve size. Nasal airflow increased significantly after inserting the internal nasal dilator to 1300 +/- 370 ml/s (p < 0.001) in controls and 1300 +/-300 ml/s (p < 0.01) in patients. A small sized external nasal valve appears to be a major causative factor of alar collapse. A novel internal nasal dilator effectively enlarged the external nasal valve, abolished alar collapse and improved nasal airflow.
Article
Assessing the external nose requires an understanding of the anatomic components that contribute to its normal topographic features. Structures that influence the external appearance include the skin, which varies in thickness, and the underlying bony/cartilaginous skeletal framework. The soft tissue covering of the nose, external blood supply, external sensory nerve supply, caudal third of the nose, internal anatomy of the nose, and the boney vault are described. The authors conclude that knowing the details of nasal anatomy is essential when undertaking rhinoplasty surgery. Careful study of these details makes for a more confident, prepared practitioner.
Article
Using soft tissue fillers to correct postrhinoplasty deformities in the nose is appealing. Fillers are minimally invasive and can potentially help patients who are concerned with the financial expense, anesthetic risk, or downtime generally associated with a surgical intervention. A variety of filler materials are currently available and have been used for facial soft tissue augmentation. Of these, hyaluronic acid (HA) derivatives, calcium hydroxylapatite gel (CaHA), and silicone have most frequently been used for treating nasal deformities. While effective, silicone is known to cause severe granulomatous reactions in some patients and should be avoided. HA and CaHA are likely safer, but still may occasionally lead to complications such as infection, thinning of the skin envelope, and necrosis. Nasal injection technique must include sub-SMAS placement to eliminate visible or palpable nodularity. Restricting the use of fillers to the nasal dorsum and sidewalls minimizes complications because more adverse events occur after injections to the nasal tip and alae. We believe that HA and CaHA are acceptable for the treatment of postrhinoplasty deformities in carefully selected patients; however, patients who are treated must be followed closely for complications. The use of any soft tissue filler in the nose should always be approached with great caution and with a thorough consideration of a patient's individual circumstances.
Article
There was great interest in the 19th and early 20th century in classifying human races as Caucasian, Asian African etc. according to nasal shape and size, and the nasal index was the most commonly used measurement to differentiate races. To determine if there is any clinical relevance of the shape and size of the nose in relation to physiology, pathology and surgery. Systematic review. A structured search of PubMed was performed from 1966 to 2008 for each section of the review focusing on the ethnic variations in nasal index, the effect of climate of nasal shape, ethic variations of nasal physiology and racial predilection for sinonasal pathology. Nasal proportions do vary between ethnic groups but the size and shape of the nose does not define Caucasian, Asian and African races respectively. Anthropologists agree that the nasal variations are due to man's adaptation to the environment. However, this theory remains to be proven. Published data on nasal physiology have not shown significant differences between the ethnic groups despite obvious differences in nasal proportions. There is no evidence of ethnic specific predilection to disease due to anatomical variation, physiological vulnerability or genetic susceptibility. Rhinology research is often confounded by classifying populations according to race, as racial characteristics are not based on any scientific principles and the nasal index may be a more reliable discriminator. The only area in which the size and shape of the nose is of relevance is in aesthetic and reconstruction surgery. Nasal proportions are important aesthetically but appear to have little relevance to the rhinologist.
Article
There is a lack in the understanding of the variation within the thickness of the soft tissue structures (muscle, skin and fat) overlying the cartilaginous skeleton of the nose and their relationship to the dorsum shape. We examined such relationships by dissecting noses of six adult female and six adult male cadavers, comparing the internal anatomical structures to the external nasal profile. We found that the soft tissue structures differ in thickness along the dorsum and that these differences are individualized. Specifically, continuous presence of subcutaneous fat from root to tip was found in half the sample, one nose had fat only on the tip, another one only on the root, the four others at both positions. The nasalis muscle was identifiable in nine of the 12 noses, transversing the nose in half the sample, and in the remaining three, only the lateral section of the muscle was identified. The superior border of the septal cartilage does not form a linear extension of the profile contour of the nasal bones but angles downwards. The actual profile contour of the dorsum does not follow the profile of the nasal bones or the septal cartilage. These results may influence the current use of nasal guidelines in forensic facial approximation.
Article
The human face influences and moulds one's personality and behaviour. The facial profile has become an important field of investigation by sculptors, artists, physiotherapists, orthodontists and maxillo-facial surgeons. The present study was conducted to understand the facial profile acceptance of 55 girls from silhouettee photographs judged by 3 orthodontists, 3 artists and 3 common men. To find out who appreciates the profile change the most, the chi-square test was applied to distribution of 3 professionally different groups for various occlusal categories. It was found that common bases for judging the profile do exist amongst the professionally different groups, however the public is more astute analyst of the face. Two profiles which got all acceptable votes were associated with malocclusion. Attempts were made to find out which areas on the facial outline alter the most between the acceptable and non-acceptable groups. It was concluded that the lip outline and the chin are chiefly responsible for profile acceptance while the nose alone, of its own, does not play important role. The only way by which the nose affects the facial profile is its relative position as compared to the position of the chin. Thus if the lip posture and the chin position can be corrected, a poor facial profile may be converted into a good and pleasing one.
Article
The nasal valve and nasal valve area are two entities which should not be confused. The nasal valve area is the narrowest portion of the nasal passage. It is bounded: medially by the septum; superiorly and laterally by the caudal margin of the upper lateral cartilage and its fibro-adipose attachment to the pyriform aperture ('empty triangle'); inferiorly by the floor of the pyriform aperture. The nasal valve, on the other hand, is the specific slit-like segment between the caudal margin of the upper lateral cartilage and the septum. From a physiological and surgical point of view, this distinction is fundamental. The nasal valve area is the site of the highest nasal resistance. Therefore, small deformities of the valve area may severely impair the dynamics of nasal air flow. Rhinomanometry and nasal endoscopy permit the best definition of valve pathophysiology. After having discussed the various surgical techniques reported in the literature, the authors present an original technique for the surgical correction of valvular deformities. It is completely performed through Cottle's hemitransfixion incision. The technique has several advantages: a) performance of only one incision, sufficient to visualize the entire nasal valve and cartilaginous vault, thus minimizing the risk of scar tissue formation; b) through the space thus created it is possible not only to correct the entire septum, but also to inspect and easily reach the structures constituting the nasal valve area; c) it is possible to use various types of grafts to support or reconstruct the valve area; d) it is possible to reach the key area as well as to do lateral osteotomies: all variations in shape and position of the nasal pyramid may be performed in order to normalize direction and pressures of nasal air flow: e) through the retrograde undermining of the lower lateral cartilages the resistance of the cul-de-sacs may be optimally adjusted; f) it is possible to change the shape, size and position of the nostrils as well as to properly correct the columella and naso-labial angle. The technique, therefore, permits maximum correction of valvular deformities with the concomitant functional modification of any abnormalities of the nasal pyramid.
Article
The nasal tip blood supply was studied through anatomic dissections and microangiography in 31 fresh cadaver specimens. The lateral nasal artery was present in all specimens, bilaterally in 30 (97 percent) and unilaterally in one (3 percent) and was located in the subdermal plexus 2 to 3 mm superior to the alar groove. The columellar branch of the superior labial artery was visualized bilaterally in 3 specimens (9 percent) and unilaterally in 21 (68 percent), and was absent in 7 (23 percent). Transcolumellar (external rhinoplasty) incisions were performed in 11 of these cadavers prior to dye injection. A consistent crossover flow (100 percent) was seen from the lateral nasal artery arcades to the distal aspect of the transected columellar branches. We conclude that nasal tip blood supply is derived primarily from the lateral nasal arteries, with a variable contribution from the columellar arteries. Collateral flow to the nasal tip may be provided by branches of the ophthalmic artery. The external rhinoplasty transcolumellar incision does not compromise nasal tip blood supply unless extensive tip defatting or extended alar base resections (above the alar groove) are performed.
Article
The blood supply to the nasal tip and columella was examined to determine whether it could be damaged as a result of transcolumellar incision during an external rhinoplasty approach in Asians. The blood vessels that supply the nasal tip were examined by dissecting 51 cadavers, and their corresponding 102 nasal sections were injected with red latex before dissection. The size and distribution of the vessels were measured with the unaided eye and the primary supply vessels were determined. The subdermal layer in which the vessels lie and the course of the vessels were also investigated. The main blood supply source of the nasal tip proved to be the lateral nasal artery in 78% (80/102) of the cases examined, while the remaining cases (22%) received their blood supply via the dorsal nasal artery. Columellar branches were narrow in diameter and varied in size and appearance, and were therefore appeared insufficient as a main blood supply. These arteries passed through the musculoaponeurotic layer, but they were also in close proximity to the main surgical plane in the dome of the lower lateral cartilage. The authors speculate that the nasal tip blood supply in Asians is primarily derived from the lateral nasal or dorsal nasal arteries, with a variable contribution from the columella arteries. Therefore, it is important to correctly determine the surgical plane below the musculoaponeurotic layer in order to prevent skin flap necrosis or nasal tip deformity that may occur from damage to the main vessel during an external rhinoplasty approach.
Article
To evaluate whether patients seeking reduction rhinoplasty hold a different concept of the ideal nose than does the general public, and to determine what features characterize the ideal nasal profile. Twenty-seven patients seeking reduction rhinoplasty and 15 randomly selected members of the public evaluated a series of computer-manipulated photographic profiles using a pictorial visual analogue scale to rate their preferences for several variables. Center-scale images were created from mesh-warped ("morphed") computer averaging of 12 white women. Differences between the rhinoplasty group and the public group were then compared, as was each group's deviation from the center of the scale. Both groups preferred narrowly distributed differences from the "average" profile to a high degree of significance. No statistically significant difference was found between the ideal nasal profiles selected by the rhinoplasty group and the public group. Reduction rhinoplasty patients do not appear to have a different concept of the ideal nose than does the public at large. The ideal nose, as it pertains to the ideal white female profile, has characteristics that differ from a mathematically averaged nasal profile.
Article
Aesthetic rhinoplasty is a complex surgical procedure that contains numerous components; when performed harmoniously, it should yield a successful, balanced result. The process begins with a comprehensive nasal analysis and surgical planning. Many surgeons concentrate on altering the nasal dorsum and nasal tip but may ignore potential contributions to overall appearance from the caudal nasal septum and nasal spine. One of the key parameters for evaluation and aesthetic treatment of the nose is the nasolabial angle. The nasal spine, caudal septum, and the medial crura of the lower lateral cartilages provide the framework for this area. Alteration of these structures, as well as nasal tip rotation and projection, may affect the resultant nasolabial angle, length of the upper lip, and overall harmony of the nose. Fullness at the nasolabial junction by a pushing philtrum may also result in an unbalanced appearance. The literature is replete with methods for categorizing the nasal tip and recommended surgical treatments. Treatment of the caudal septum and the nasal spine is often an afterthought that is left to the aesthetic judgment of the surgeon. A chart-with recommended treatment for the caudal septum and nasal spine following appropriate profile analysis-is included in the interest of a more systematic process. The chart takes account of the length of the nose, nasolabial angle, and possible presence of a pushing philtrum with suggested treatments to allow for proper tip placement and aesthetic balance to the nose. Adherence to this process provides a valuable tool for assuring a harmonious result in rhinoplasty.
Article
The nasal valve is a complex structure that can be weakened from effects of aging, surgery, and trauma. A variety of methods have been described to strengthen the nasal valve region and prevent or treat nasal obstruction, such as batten grafts, spreader grafts, butterfly grafts, flare sutures, and suspension sutures. They will be briefly discussed here, but the intent of this review is to highlight the new developments in the treatment nasal valve collapse that have appeared in the literature over the last few years. Various surgical techniques and approaches for addressing nasal valve collapse have been described in the literature. Still, new techniques continue to be developed and old techniques continue to be improved upon. More specifically, minimally invasive and endoscopic approaches are being developed and improvements are made on the use of graft materials. Finally, alternatives to surgery are explored for the treatment of nasal valve collapse. The aim of the new advances in the treatment of nasal valve collapse is to maximize the benefit from the surgical intervention while minimizing disruption of the normal anatomy and physiology of the nose. Another trend in the new advances explores the nonsurgical options for the treatment of nasal valve collapse.
Importance of the nasal-to-cervical relationship to the profile in rhinoplasty surgery
  • Greer
Avoiding and treating blindness from fillers
  • Beleznay
Vascular anatomy of the nose and the external rhinoplasty approach
  • Toriumi