Aesth Plast Surg

https://doi.org/10.1007/s00266-018-1279-7

ORIGINAL ARTICLE RHINOPLASTY

A Safer Non-surgical Filler Augmentation Rhinoplasty Based

on the Anatomy of the Nose
Gyu Sik Jung1 • Seung Gyun Chu1 • Jeong Woo Lee1 • Ho Yun Chung1 •
Jung Dug Yang1 • Byung Chae Cho1 • Ji Won Oh2,3 • Kang Young Choi1

Received: 29 July 2018 / Accepted: 18 November 2018

Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2018

Abstract Conclusions When performing filler augmentation rhino-

Background Filler augmentation rhinoplasty is a quick, plasty on the sellion area, direct percutaneous injection
non-surgical procedure that can produce outcomes com- from the glabella can allow more accurate injection into the
parable to open rhinoplasty surgery. However, the supraperiosteal level, which can reduce complications such
increased frequency of vascular complications has emerged as visual loss and skin necrosis due to vascular
as an important issue. The present study aimed to investi- compromise.
gate measures to overcome the vascular complications Level of Evidence IV This journal requires that authors
based on the anatomy of the nose. assign a level of evidence to each article. For a full
Methods A colored filler was injected into cadavers for description of these Evidence-Based Medicine ratings,
augmentation of the nasal dorsum using the retrograde please refer to the Table of Contents or the online
injection technique and direct percutaneous injection Instructions to Authors www.springer.com/00266.
technique. The concavity of the sellion area was measured
using lateral view cephalography X-ray images. Lastly, we Keywords Rhinoplasty
Nose
Filler
used ultrasonography to determine filler location in 20
Korean patients who had filler injected into the sellion area
by injection at the infratip lobule. Introduction
Results Filler was injected into the superficial layer by the
retrograde injection technique in three cadavers and into After the United States Food and Drug Administration’s
the deep layer by direct percutaneous injection technique in approval of a hyaluronic acid-based injectable filler in
another three cadavers. The average angle between the 2003, which has no side effects when injected into the
nasal dorsum skin and sellion was found to be 10.2 ± 2.8 body, there was a full-scale growth of the filler market.
degrees, while the minimum angle was 5.1 degrees. The Augmentation rhinoplasty using fillers has reached the
average distance between the needle tip and nasal bone was stage where it has overcome the limitations of it being a
1.9 ± 0.3 mm, while the minimum distance was 0.4 mm. non-surgical procedure and can produce results that are
comparable to those produced by open rhinoplasty surgery.
However, with the increasing use of injectable fillers, the
& Kang Young Choi associated vascular complications, such as skin necrosis
kychoi@knu.ac.kr and visual loss, and other limitations have become a fre-
1
Department of Plastic and Reconstructive Surgery, School
quent cause of concern. This has led to research into a new
of Medicine, Kyungpook National University, 130 procedure that can produce a more effective result with
Dongdeok-ro, Jung-gu, Daegu 41944, Republic of Korea regard to the intended outcome in the nasal region, with the
2
Department of Anatomy, School of Medicine, Kyungpook intended shape.
National University, Daegu, Republic of Korea The injectable method of correction of an under-pro-
3
Biomedical Research Institute, Kyungpook National jected dorsum using commonly used fillers involves
University Hospital, Daegu, Republic of Korea inserting a needle or cannula into the infratip lobule to

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augment the nasal dorsum from the sellion area using the
retrograding threading injection technique. However,
because the nasal bone is concave, this method can be a
major cause of vascular complications. In this report, we
discuss measures, which are based on the anatomy of the
nasal bone, to overcome the vascular complications of filler
augmentation rhinoplasty.

Materials and Methods

Cadaver Study

We used six cadavers aged 47–73 years [mean 62.2 ± 10.1

(SD); 4 men, 2 women]. Augmentation rhinoplasty was
performed by injecting colored filler into the cadaver with a
Fig. 2 Direct percutaneous injection from the glabella was per-
23-gauge, 60-mm long needle (Korea Vaccine Co, Seoul, formed. Filler (pink) was injected into the deep layer. a Schematic
Republic of Korea). The colored filler was prepared by drawing. b Cadaver study (white line nasal bone)
mixing 0.2 cc of pink color stock solution (Montmartart,
Seoul, Republic of Korea) and 1 cc of filler (amalian 20 Cephalography Study
medium; S&V Technologies, Hennigsdorf, Germany). In
three cadavers, a long needle was inserted into the infratip To assess the concavity of the sellion area, we measured
lobule to augment the nasal dorsum from the sellion area the angle between the skin of the nasal dorsum and the
by the retrograde threading technique (Fig. 1). In the nasal bone of the sellion area using lateral cephalometric
remaining three cadavers, direct percutaneous injection radiographs (CX-90 SP; Asahiroentgen Co, Kyoto, Japan)
from the glabella was performed. To inject the filler as (Fig. 3). The images of patients who underwent maxillary
deeply as possible, the needle was inserted bevel-down and mandibular surgery and those with incompatible
once it touched the bone. Subsequently, we confirmed the occlusion were excluded. The angle was measured by
location of the layer of filler injection by performing a examining the lateral cephalograms obtained at the
dissection (Fig. 2). Department of Dentistry of Kyungpook National Univer-
sity Hospital between January 2013 and December 2017.
Angle measurements were taken in 92 patients aged

Fig. 1 A long needle was inserted through the infratip lobule to

augment the sellion area by the retrograde threading technique. Filler Fig. 3 To assess the concavity of the sellion area, we measured the
(pink) was injected into the superficial layer. a Schematic drawing. angle A° between the skin of the nasal dorsum and the nasal bone of
b Cadaver study (white line nasal bone) the sellion area by lateral cephalography

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19–69 years (mean 42.2 ± 20.4; 40 men, 42 women). Results

Statistical analysis was performed using the Kolmogorov–
Smirnov test for normality. All analyses were performed Cadaver Study
using SPSS software (IBM Corp., Armonk, NY).
In the three cadavers in whom nasal dorsum augmentation
Ultrasonography Study was performed by inserting a long needle into the infratip
lobule using the retrograde threading technique, we ini-
To augment the nasal dorsum from the sellion area by the tially confirmed filler injections in the superficial fatty and
retrograde threading technique, we inserted a 25-gauge and fibromuscular layers. In the other three cadavers, the filler
70-mm blunt cannula (Nanum Company, Seoul, Republic was injected by direct percutaneous injection from the
of Korea) into the infratip lobule of 20 Korean patients glabella. The filler was located in the deep fatty layer or the
aged 20–60 years (mean 41.3 ± 14.4; 5 men, 15 women) supraperiosteal layer, which is considered an avascular
(Fig. 4). The distance between the nasal bone and the layer.
cannula tip was measured using ultrasonography (M2540A
Envisor; Philips Ultrasound, Andover, MA) in 20 patients Cephalography Study
that consented to measurement. Sedation was not per-
formed. A nerve block was applied to the infratrochlear Based on the lateral cephalograms, the angle between the
nerve and internal nasal branch of the infraorbital nerve skin of the nasal dorsum and the nasal bone was on average
using 1% lidocaine with 1:200,000 epinephrine, and the 10.2 ± 2.8 degrees. The minimum angle was 5.1 degrees.
procedure was initiated 10 min later [1]. A cannula tip was The Kolmogorov–Smirnov test showed a normal
inserted parallel to the nasal dorsum, and the distance was distribution.
measured at the nearest possible point to the nasal bone.
The Kolmogorov–Smirnov test for normality test was used Ultrasonography Study
to analyze the results. All analyses were performed using
SPSS software (IBM Corp, Armonk, NY). Filler was injected into the superficial layer. The average
All procedures were in accordance with the ethical distance between the cannula tip and nasal bone was
standards of the institutional and/or national research 1.9 ± 0.3 mm, whereas the minimum distance was
committee and with the 1964 Declaration of Helsinki and 0.4 mm. Therefore, precise injection into the periosteal
its later amendments. layer was difficult with infratip lobule injection via the
linear threading technique. This was the anatomical result
of the angle between the nasal dorsum skin and the sellion.
The Kolmogorov–Smirnov test showed a normal
distribution.

Case Study

Augmentation rhinoplasty was performed in the sellion

area by direct percutaneous injection from the glabella
using a 25-gauge and 70-mm blunt cannula (Nanum
Company). The filler was injected into the area encom-
passing the sellion and the nasal tip using the retrograde
threading technique.

Case 1

Filler injection was performed in the nose of a 22-year-old

female patient by injecting filler (amalian 20 medium,
amalian 24 SF advanced; S&V Technologies, Hennigsdorf,
Germany). The overall nasal area was properly raised in
both front and side views (Fig. 5).

Fig. 4 The distance between the nasal bone and the needle tip was
measured by the retrograde threading technique

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Fig. 6 A 32-year-old patient was injected with filler (amalian 20

medium, amalian 24 SF advanced; S&V Technologies, Hennigsdorf,
Germany). The procedure was performed in the radix and dorsum and
resulted in a well-elevated sharp nasal tip. a Preoperative photograph.
b Immediate postoperative photograph

side effects, such as curving of the nose and thinning and/or

sharpening of the nasal tip due to contracture, highlights
the safety of this procedure. In Asia, where the demand for
rhinoplasty is significantly higher than that in other regions
of the world, most nasal augmentation procedures can be
performed with fillers without a surgical intervention [3, 4].
Fig. 5 A 22-year-old female patient was injected with filler (amalian
20 medium, amalian 24 SF advanced; S&V Technologies, Hennigs-
A successful filler augmentation rhinoplasty can only be
dorf, Germany). a Preoperative photograph of front view. b Immediate based on an accurate anatomical understanding of the nose.
postoperative photograph of front view. c Preoperative photograph of The nose is a three-dimensional facial structure that has
side view. d Immediate postoperative photograph of side view. The considerable variations in external appearance and
overall nasal area was raised in both front and side views
anatomical structure based on each individual and ethnic
group. Further, a correct understanding of the anatomy of
Case 2
the nose and the characteristics of each filler is essential
because filler augmentation is based on insertion of the
Injection of filler (amalian 20 medium, amalian 24 SF
needle into an invisible cavity under the skin to reshape the
advanced; S&V Technologies, Hennigsdorf, Germany) was
nose. This is crucial for preventing disastrous complica-
carried out in a 32-year-old female patient. The procedure
tions and achieving a good aesthetic result [4, 5].
was performed in the radix and dorsum and resulted in a
For rhinoplasty surgery in Caucasians, the initial starting
well-elevated sharp nasal tip without excessive bulkiness
point of the implant should be at the double eyelid; how-
(Fig. 6).
ever, Asian patients require an implant that starts at the
eyelashes or the upper margin of the pupil for a more
natural look [5]. It is generally accepted that the sellion in
Discussion
Asians is reshaped to be lower than the average sellion in
Caucasians. Whereas it creates a more natural looking
Being centrally located on the face, the nose has a signif-
outcome to the use of the lower end of the double eyelid as
icant influence on the balance of the adjacent facial fea-
the saddle point in women, it is more aesthetically desir-
tures such as the eyes and the mouth and plays an important
able to set the saddle point slightly higher [6]. In the case of
role aesthetically [2]. Due to the fact that filler injected into
filler augmentation, the same standards should be used to
the nose gradually disappears over a certain period of time,
set the starting point of the augmentation in the sellion.
the procedure needs to be repeated. However, the relative
In Asians, the sellion point is typically located deeper
lack of bruising or swelling compared with surgery means
and lower in the nose than in Caucasians [7]. The ethnic
that the patient can carry on his or her daily life without
characteristics of the midface can be determined by the
any discomfort or inconvenience. In addition, the lack of
appearance of the connection between the midface and the

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upper face in the area of the sellion point. The silhouette recent remarkable growth in the popularity of the cosmetic
line from the medial eyebrow to the nasal dorsum is also filler market has caused a dramatic increase in the number
very important in the evaluation of facial aesthetics of cases of blindness. Blindness caused by filler injection is
because, in basic facial proportions, the length of the nose a disastrous complication for both the patient and the
is one-third the length of the face [8]. Thus, the sellion physician. While various interventions can be attempted in
point is very important. cases of blindness, recovery is very difficult [13]. Thus,
The soft tissue of the nose consists of: (1) skin, (2) a ongoing and persistent research efforts are crucial to min-
superficial fatty layer, (3) a fibromuscular layer, (4) a deep imize the risk of filler injection-associated blindness.
fatty layer, and (5) periosteum or perichondrium. It is If filler has to be injected into the side of the nasal
known that the main arteries of the dorsum of the nose are dorsum, for example, for correction of a deviated nose, the
located at the level of the superficial or deep fatty layers. In needle should never move in parallel with the direction of
the lower part of the dorsum, the dorsal nasal arteries are the blood vessel. After inserting the needle into the mid-
adjacent to the fibromuscular and deep fatty layers; how- line, the needle tip should move to the side to prevent
ever, in the upper part of the dorsum, the dorsal nasal injection of the filler into the blood vessel, although there
arteries are located at the superficial fatty layer, immedi- may be some bleeding due to vessel injury [14]. While the
ately above the fibromuscular layer [2, 9]. Therefore, the dorsal nasal artery is generally known to take a more lateral
dorsal arteries are generally found at a deeper level than the than central position, as the dorsal nasal artery originates
fibromuscular layer [10]. However, they take a more from the ophthalmic artery on both sides, there are bran-
superficial position going toward the radix. According to ches that intersect and connect at the midline. Specifically,
recent studies, a branch of the dorsal nasal arteries is it should be noted that in certain cases, a branch originating
located in the superficial part of the deep fatty layer, from the artery on the opposite side crosses the nasal
immediately below and parallel to the fibromuscular layer dorsum and spreads out [10].
[11]. Therefore, the filler must be injected into a layer During the cadaver studies, we believed that the colored
deeper than the fibromuscular layer to prevent injecting filler was injected into the supraperiosteal layer. However,
into the blood vessels [2]. the cadaver dissection revealed that the filler was in the
Superficial filler injection increases the possibility of superficial, deep fatty, or fibromuscular layers. Further
blood vessel compression of the thin vascular network in cadaver studies are required to ensure precise filler injec-
the superficial layer, which is surrounded by dense and tions into the target layer.
tough tissue. However, filler injection into the deep layer This study has some limitations. First, the cadaver (6
minimizes this possibility since the blood vessels are cadavers), cephalography (92 cases), and ultrasonography
thicker and stronger, while the surrounding tissue is rela- (20 cases) studies’ sample sizes were all small. Second, as
tively soft and flexible compared to the superficial layer. the study samples only included Koreans, ethnic differ-
Therefore, while a superficial filler injection results in a ences were not considered. In particular, the nose may
more effective augmentation, it is safer to inject the filler differ between Asians and Caucasians. Subsequent studies
into the deep layer [10]. It has been reported that the skin of should investigate ethnic differences and include a larger
the nose and the tissue underneath the skin are thicker in study population.
Asians in comparison with Caucasians. This suggests that
while the unevenness and/or asymmetry observed post-
augmentation can be concealed to a certain degree, the Conclusions
thicker tissue under the nasal skin in Asians requires more
caution during filler augmentation [2]. The periosteum or perichondrium is known to lack both
Generally, the measures to minimize vascular compli- fibrous septae and blood vessels. The injection plane of the
cations include avoidance of large-bore needles; using filler should be at the level of the supraperiosteal or
blunt cannulas or small-bore needles; injecting epinephrine supraperichondrial layers, which is the deepest level of the
with the filler to reduce the size of the vessels; using deep fatty layer. Thus, precise filler injection into the
smaller syringes; always withdrawing before injecting; supraperiosteal or supraperichondrial layers, which are
injecting slowly, gently, and in small aliquots; never avascular, can significantly reduce the risk of vascular
injecting in a previously traumatized area; knowing the complications. When a filler is injected into the sellion
anatomical plane and depth for each injection; and ceasing area, it should be injected more directly than the infratip
injection immediately if the subject complains of pain or lobule approach, and the needle should be inserted bevel-
vision issues. Blindness after the facial injection of par- down into the nasal tip.
ticulate materials was first reported in 1963 [12]. The

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Conflict of interest All authors declare that they have no conflict of evaluation of Asian–Chinese profiles from a white perspective.
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8. Mizumoto Y, Deguchi T Sr, Fong KW (2009) Assessment of
facial golden proportions among young Japanese women. Am J
Orthod Dentofacial Orthop 136:168–174
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