Dr Raj Acquilla describes his eight-point technique for injection rhinoplasty, involving a combination of hyaluronic acid fillers and botulinum toxin
Noses come in all shapes and sizes, so how do we determine which are attractive and which aren’t? Some say beauty is subjective; in the eye of the beholder. But perhaps there is a structure and strategy behind beauty that we can follow to achieve optimum aesthetic outcomes.
There are snub noses; elegant, narrow noses; fleshy noses; hawk noses; Grecian noses and Roman noses to name a few. Despite their countless forms, we typically recognise what is pleasant and what’s not within 0.3 seconds.
The structure behind a beautiful nose has been studied, recorded and published. In terms of facial symmetry, beauty doesn’t just concern the midline symmetry; it’s also about the rule of vertical fifths in the face. With specific reference to the nose, the nasal width should equal the intercanthal distance and mirror the same width as each eye. Symmetry is not just about two halves.
When we look at people who are generically or exceptionally beautiful, we see that they display very high degrees of symmetry. Denzel Washington was voted one of the sexiest men in Hollywood and he also has one of the most symmetrical faces in Hollywood.
We all know about the golden ratio—the rule of five, the rule of thirds and the rule of one to 1.618. We can apply this to the face; for example, while the nasal width is one, the width from the alar to the tragus should be one to 1.618. Optimising the aesthetic appearance of our patients towards this ratio will give a better cosmetic outcome.
We can also study facial geometry. The naso-philtral angle should be between 90–105 degrees, the naso-facial angle should be 120 degrees, the naso-mental at 130 degrees and the naso-facial angle at 36 degrees. This doesn’t mean we should get a protractor out and measure the angles but if we did, we would arguably get a very good aesthetic outcome.
In ancient India, an Ayurvedic physician called Sushruta wrote the first compendium of medical and surgical procedures, specifically in plastic and cosmetic surgery—one of the first documented chronicles from 800BC.
With rhinoplasty, he was using a cheek flap transposing to the nose and securing with liquorice, sesame oil or castor oil. This was a very primitive use of nasal augmentation, but documented working towards an aesthetic ideal.
In later years, this compendium moved towards the Roman Empire, then Italy, followed by Greece—where they used different strategies and techniques. There is documentation on the primitive use of sutures, the use of the bicep muscle as a pedicel, using flaps from not just the cheek, but also the forehead, and securing with wax.
Eventually they were performing closed rhinoplasty using an intra-nasal technique resulting in no visible scarring, submucosal septal resection for septal deformities and deviations. Now, a popular form of surgery is open columella rhinoplasty—an incision is made in the columella itself to give direct visualisation of the cartilage and bone.
The evolution of injection rhinoplasty made perfect sense, as surgery in this area can be quite complex. It takes a high degree of precision and skill, and the aesthetic outcome is not always guaranteed.
Going back into the 1900s, liquid paraffin wax was used, which was very unstable and biologically harmful. Between the 1960s and 70s, silicone gel was used. Forms included small droplets but nevertheless, silicone proved to be a problem. It was hazardous with granuloma and ulceration, particularly in this vascularly friable part of the anatomy.
In 2002, the FDA approved Restylane for nasal contouring and the hyaluronic acid solution proved to be a safe, reversible option that could be moulded without producing the same kind of risk to the tissue.
Later on, injectables like Aquamid and Radiesse were recognised and the biggest study of its kind for injectable rhinoplasty, conducted by Alexander Rifkin from California on 385 cases, showed efficacy and safety.
Specific indications from superior to inferior, such as nasion depression, dorsal hump and tip depression, can be injected strategically to influence individual parts of tissue and give one overall, uniform aesthetic outcome.
All indications can be broken down into congenital versus acquired, but it is important to remember that some may be caused by trauma to the nose. Traumatic injury may produce asymmetry, which we can correct using injectables.
Typically the areas that we’ll treat are the nasium, the dorsal hump, the tip and the septal projection. Different injection sites will give different outcomes. When pinched at the glabella, the skin is quite loose with low pressure but very thick. You can expand the subcutaneous space and the skin will hold it in position, so it’s an ideal area for injection augmentation.
Moving to the dorsum, the skin gets thinner. It’s the thinnest skin on the whole of the nose, but there is more pressure in this area. On the tip, we can hardly lift the skin at all, but it is thick and sebaceous.
So there are different qualities of skin and different pressures throughout the nose. The safest area to treat would be in the nasium; the least safe would be the tip. We use very small quantities in the tip to avoid any vascular complications.
The area below the skin on the nose and perinasal area is pretty much devoid of fat so there isn’t much room to bury material and safety margins are quite narrow.
The muscles in the nose are all fairly separate, but they sometimes act in cohesion with one another and produce complex movements. During an oral smile with nasal activation, we will see activation of the nasalis, the levator labii superioris, alaeque nasi, dilator naris and the depressor septi nasi muscles. We get “bunny” scrunch lines, alar widening, upper lip elevation and tip depression.
The snarl complex doesn’t involve the upper lip, so we just see “bunny” scrunch, alar elevation and tip depression. When we’re looking to treat certain indications, we can also use botulinum toxin to weaken specific muscles.
Nasal vasculature is derived from the facial artery, which tracks superior-medially from the anterior border of the masseter oral commissure. There is also a superior labial branch which gives a columella artery to the septum and the ascending angular artery, the marginal artery, with a medial branch—the dorsal artery—that supplies the external nose.
The tip of the nose is particularly prone to embolic problems, or vascular compromise, so we don’t want to inject too much in this area. Respecting the anatomy from a vascular point of view will minimise risks further, but it is a high risk area.
The innovation sensory part of the nose and the medial branches of the infra-orbital nerve are relevant in terms of blocks—we would hit those areas to block the nose—but generally, topical anaesthesia is sufficient.
Typically, we inject the midline of the nose, between the two crura in the inferior third of the nose, to give the best expansion. We also have the lowest risk of causing damage to cartilage, again which is very friable and sensitive to pressure. If we had a haematoma in the tissue, this could lead to cartilaginous degeneration which could cause volume loss.
There are many different factors which cause aesthetic changes in the nose and contribute towards ageing, such as glabella volume loss and cartilaginous laxity which can cause tip elongation and tip depression. Crural dehiscence causes the tip depression, the opening of the pyriform aperture and muscular components.
Eight point treatment
We have an eight point rhinomodulation technique, using fillers and toxins which is both dynamic and resting. The treatment can be carried out in one session, starting with hyaluronic acid injection, massage and moulding, followed by treatment with botulinum toxin so we don’t disrupt or migrate the toxin.
Position number one for hyaluronic acid is the alar fossa, up against the pyriform aperture, to lift the nostril forwards and begin the anterior lifting process. I then inject into the nasal spine, and/or the columella, to give a tip projection. We can treat the nasal tip itself if more refined local work is needed, but be aware this is very high risk.
Generally I don’t directly treat the midline, which has more vascular flexis, and instead treat either side. Next, I inject the nasium to elevate the naso-frontal angle and give a straighter appearance and a more uniform junction—a linear transition from frontal to the nasal area.
I then continue treatment with botulinum toxin, from superior to inferior. I first treat the nasalis into the transverse component, followed by the levator labii alaeque nasi. If the patient has nasal flare, I would treat the dilator naris next and it’s useful to assess that during their movements. Then I would inject the depressor septi nasi, which is a very easy technique.
I begin treatment by injecting to elevate the dome of the alar using deep injections with a 13mm, 27 gauge needle. I may or may not touch bone, depending on the facial fat of the patient. It is vital to aspirate the area because the facial artery, which then becomes the angular and marginal artery, is right under where the needle is going to be. The idea here is that the dome of the alar is elevated, starting the anterior projection process of the three-dimensional appearance of the nose.
In terms of volume, there is no definitive answer—you’re looking for the aesthetic result. Next I reposition, injecting right into the sulcus of the nostril, and then aiming a little more medially, and a little more inferiorly as well.
In doing this, I can start to push the patient’s left side of the nose towards the right side, and when that happens, I know that I’m generating anterior lift. It will change the configuration of the nostril slightly when you do this. But of course, now you have to lift at position number two, the nasal spine, and/or into the columella itself.
Cleaning has to be meticulous in this area because of the infection risk, so I use chlorhexidine or alcohol, and ensure this area is perfectly clean. In terms of blocking, I use EMLA cream. You can use a regional block as well, but it may distort the tissue.
I then inject directly into the midline, again using a 13mm, 27 gauge needle with Juvederm Ultra 4 and I look to achieve a degree of tip elevation—perhaps no more than 1–2mm—but in this part of the face, it can be a lot.
I use deep aspiration again in this area because of the columella artery, the vertical branch of the superior labial artery and a slow injection technique behind the base of the septum, to observe and appreciate an anterior lift of the tip.
The columella will widen slightly and I pinch it with my fingers to make sure that it’s located very tightly in position. I push upwards, and pinch it directly, moulding it into position and squeezing the product to give more vertical lift in the septum. Once the tip has started to elevate, I begin the process after two injection points.
I could use a needle at the tip, and then go up to the nasion separately. Instead, I use a 1.5–2”, 27 gauge cannula. I run this from the nasal tip up to the glabella, so I can treat in one linear passage. This way, with a blunt tipped device, I won’t cause any shearing or damage to vessels and will reduce haematoma risk.
It is important to be aware that the haematoma risk at the nasium can be increased.
I inject into the supra tip—not directly into the tip itself—using a 27 gauge needle with a 27 gauge cannula. You can use a larger needle, but this can cause more trauma.
The technique must be subcutaneous, not intra-dermal. You very slowly dissect the tissue in between the two crura, so you’re in the midline and up against the nasal bones. It takes a little pressure to get past into the glabella.
The tip of the cannula should be up in the naso-frontal angle, and should be kept there as it directs the kind of aesthetic outcome I will achieve, because if I leave product in that linear plane, I will get a good result.
Once I’m satisfied with the position, I then pinch the glabella so I know that the product will be moulded to conform to my index finger and thumb, and it will be retained in the nasal bridge. If you don’t do this, the product can escape laterally and give you an asymmetry.
I correct with more volume at the top and less going down. Then at the nasal tip, I may inject more to create a leaf curl effect depending if the patient wants it.
Sometimes when I do volumetric work in the nose, I can make it look smaller by making it appear sharper, despite the fact that from a volumetric point of view, we’re actually increasing volume.
Following injection at point numbers one, two, three and four, I achieve a linear correction across the nasal bridge. If I want to finish by achieving a little more tip elevation, I inject directly into the columella, and you can bend the needle to achieve more anterior injection, if you wish, and then pinch into place.
Next I move onto the toxins and mark four points, from superior to inferior—the nasalis, levator labii superioris alaeque nasi, dilator naris and depressor septi nasi muscle.
Interestingly, patients will often complain of more pain with the toxin injections in this area than they do with the filler, because there’s no aesthetic component in the product. In the depressor sept nasi muscle I use an 8mm, 30 gauge needle, and push it hard to get to the nasal spine insertion. Ideally, use a 15ml needle to get all of the way.
Risks and complications
We have to counsel our patients very carefully about having this procedure because there are risks involved. Redness, swelling, bruising are common, but we don’t want haematoma because it can compress the cartilage. Infection and abscesses can occur so meticulous disinfectants like chlorhexidine and alcohol washes before you inject are essential.
The four Ps are the biggest nightmare; if we see pallor, purport, if there’s pain, and if there are pustules, we’re looking at impending necrosis. You can rescue with hyalase warmth, glyceryl trinitrate (GTN) and patient management.
Visual acuity compromise is also a risk. Complications can happen, because of the close proximity of the dorsal artery, the angular or marginal artery, and its direct anastomosis with the ophthalmic artery which feeds into the central retinal artery. Good technique, aspiration if you’re using a needle and the avoidance of large volumes are all vital.
Nodules and granuloma are more of a volume and produce-related issue. If you’re using a hyaluronic acid filler with a non-particular, low molecular weight, there should be no problem.
The osteo-cartilaginous junction between the septum and the upper lateral cartilages is an interesting structure. On inspiration, there is no resistance, but on expiration, there is. If you put more pressure in there, you can definitely obstruct air flow so be aware of that.
Dr Raj Acquilla is a cosmetic physician who runs private clinics in Cheshire, London and Ibiza and has his own facial aesthetic academy where he is a recognised masterclass trainer