Nonsurgical rhinoplasty can be extremely effective and simple to perform in experienced hands based on anatomical knowledge with surgical prioritizations, accurate injections, and artistic principles.
Medial injections avoid vessels. Following surgical principles, to achieve good tip support and rotation as the first step and then to correct dorsum.
- 1. Base support—Eiffel Tower strut: See video, Supplemental Digital Content 1, which displays nose anatomy, injections on cadaver, and safety. Showcase is on white, African, and Asian noses, http://links.lww.com/PRSGO/A306; See video, Supplemental Digital Content 2, which displays a blonde white patient being injected on the nasal spine, columella, tip, and dorsum, http://links.lww.com/PRSGO/A307; and See video, Supplemental Digital Content 3, which displays a brunette white patient being injected on the nasal spine, dorsum aesthetic lines, and supratip, http://links.lww.com/PRSGO/A308)
- (i) Step 1: deep preperiosteal nasal spine injection5 (0.5 to 0.8 mL) to open nasolabial angle (NLA) using a highly cross-linked hyaluronic acid gel4
- (ii) Step 2 (for Asian or African skull)3 (See video, http://links.lww.com/PRSGO/A306): premaxilla piriform fossa (0.5 to 1 mL)
- (iii) Step 3: bending the needle gently, form a midline columellar strut between the alar cartilages to achieve tip rotation (0.2 to 0.5 mL)
- *Stay strictly midline for safety to avoid vessels and anastomoses
- (iv) Step 4: one at times continues superiorly to inject between the 2 domes for tip enhancement/projection
- *NB: 1 to 4 steps, according to NLA
- 2. Profile complex: (See videos, http://links.lww.com/PRSGO/A306, http://links.lww.com/PRSGO/A307, and http://links.lww.com/PRSGO/A308)
- Dorsum is injected1 in a rectangular shape, creating ideal double aesthetic light reflex lines along the dorsum edges (0.5 to 1 mL severe saddle nose; step 5)
- Aim: to reproduce 2 parallel lines (described by Leonardo DaVinci) from an optimized point for the nasofrontal angle (NFA; 0.1 to 0.4 mL) superiorly and to blend to the projected tip while maintaining a subtle supratip break inferiorly
- *Tip: safer to inject those lines more superficially (compared with the dorsum and columella) subdermally (instead of deeply to periosteum and perichondrium), away from the major vessels (See video, http://links.lww.com/PRSGO/A308)
- 3. Tip support (step 6):
- (i) Heart-shape tip graft (0.1 to 0.3 ml) for a subtle refinement with a cohesive softer gel (See video, http://links.lww.com/PRSGO/A307)
- (ii) Alar batten grafts underlying the supraalar crease in the space between the internal and external valves if support to lateral wall is required (0.1 to 0.2 ml; See video, Supplemental Digital Content 4, which displays a secondary rhinoplasty patient injected on tip, nostril, and dorsum aesthetic lines, http://links.lww.com/PRSGO/A309)
- 4. Nostril refinement: See videos, http://links.lww.com/PRSGO/A306, http://links.lww.com/PRSGO/A307, http://links.lww.com/PRSGO/A308, and http://links.lww.com/PRSGO/A309)
- (i) Nostril rim graft using cohesive softer gel for correction of a retracted nostril or lowering (0.1 to 0.2 ml)
For results, See videos, http://links.lww.com/PRSGO/A306, http://links.lww.com/PRSGO/A307, http://links.lww.com/PRSGO/A308, and http://links.lww.com/PRSGO/A309). Duration: 10 to 18 months (according to NLA and gel rheology; See figure, Supplemental Digital Content 5, which shows results of patient from video 2 at 18 months. The patient has been injected with a hyaluronic acid following Eiffel Tower nose-lift steps 1,3,4,5 & 6, http://links.lww.com/PRSGO/A304; See figures, Supplemental Digital Content 6, which show results of patient from video 2 at 6, 12 and 18 months. The patient has been injected with a hyaluronic acid following Eiffel Tower nose-lift steps 1,3,4,5 & 6, http://links.lww.com/PRSGO/A305. See also, video, http://links.lww.com/PRSGO/A305.)
Reproduction is excellent to date within the author’s practice and judging from feedback from other physicians. Reproducibility is largely because of the fact the nose-lift follows surgical steps in a logical order and is broken into aesthetic units (described by Burget and Menick2).
To date none within the author’s practice of 15 years have had a severe adverse event.
Remaining medial assists in avoiding intravascular injection, as does the use of small aliquots.
Touch up is required in approximately 10% with a further 0.3 to 0.5 mL injected on average (most frequently on the nasal base/columellar strut top up if NLA <90 degrees, secondly tip projection for slight asymmetry).
- Large hump
- Nasofrontal angle large
- Tip excess
- Severe/complex deviation
For these, surgical rhinoplasty is required.
Injectors should progress step by step in learning curve from more simple to complex over time.
- (i) Level 1—basic: NLA simple improvement and/or NFA minor correction
- (ii) Level 2—experienced: NLA + columellate and slight dorsal correction (hump camouflage)
- (iii) Level 3—advanced: NLA + columella + premaxilla + interalar tip injection—slightly twisted nose
- (iv) Level 4—expert only (eg, surgeons/highly advanced physicians): tip refinement + nostril correction—secondary/traumatised nose—severe deviation
- (b) Remain medial within minimal vascular zones
- (c) Small aliquots
- (d) Very slow injection
Nose-lift performed with the Eiffel Tower concept is effective, safe, and versatile on white, African, and Asian noses.
1. Bray D, Hopkins C, Roberts DN. Injection rhinoplasty: non-surgical nasal augmentation and correction of post-rhinoplasty contour asymmetries with hyaluronic acid: how we do it. Clin Otolaryngol. 2010;35:227230.
2. Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. 1994, St. Louis, MO: Mosby; Year Book, Inc. page 78Chapter 1, fig.1-2, A- B.
3. Jung DH, Kim HJ, Koh KS, et al. Arterial supply of the nasal tip in Asians. Laryngoscope 2000;110(2 Pt 1):308311.
4. Raspaldo H. Volumizing effect of a new hyaluronic acid sub-dermal facial filler: a retrospective analysis based on 102 cases. J Cosmet Laser Ther. 2008;10:134142.
5. Tanaka Y, Matsuo K, Yuzuriha S. Westernization of the Asian nose by augmentation of the retropositioned anterior nasal spine with an injectable filler. Eplasty 2011;11:e7.