Consensus Recommendations on the Use of Hyaluronic Acid–Based Fillers for Nonsurgical Nasal Augmentation in Asian Patients

Patrick Trevidic, M.D.; Hee-Jin Kim, D.D.S., Ph.D.; Ayad Harb, M.D.; Wilson W. S. Ho, M.B.B.S.; Steven Liew, M.B.B.S.

Disclosures

Plast Reconstr Surg. 2022;149(2):384-394. 

In This Article

Abstract and Introduction

Abstract

Background: Nonsurgical nasal augmentation using dermal fillers such as hyaluronic acid is increasing in popularity because of its less invasive nature and shorter downtime compared with traditional surgery. However, the complexity of the nasal vasculature makes it a high-risk procedure without proper training. Appropriate patient and product selection and safer standardized injection techniques are warranted to minimize complications and to achieve reproducible aesthetic results. In this article, recommendations for nonsurgical nasal augmentation using hyaluronic acid fillers are outlined, with focus on the dorsum, tip, and columella.

Methods: A consensus meeting was conducted to develop recommendations on nonsurgical nasal augmentation in Asian patients using hyaluronic acid–based fillers. Literature review was performed using PubMed and Google Scholar. Relevant studies were included to formulate recommendations. Consensus statements were graded using the criteria outlined by the Grading of Recommendations Assessment, Development and Evaluation Working Group.

Results: Nonsurgical nasal augmentation is an advanced procedure that warrants in-depth knowledge of the nasal anatomy. The panel recommends thorough preinjection assessment and counseling to fully align the patient's expectations with aesthetic goals. Injections must be deep and at the level of the periosteum or perichondrium to minimize risk of intravascular injection. Aliquots of hyaluronic acid must be introduced using slow, low-pressure, and low-volume injections. Optimal aesthetic effect is achieved with hyaluronic acid dermal fillers that are highly elastic, cohesive, and with good adaptability to their environment.

Conclusions: Hyaluronic acid injections are safe and effective in nonsurgical nasal augmentation. In-depth knowledge of vascular anatomy and proper injection techniques using suitable products are necessary to achieve aesthetic goals safely.

Clinical Question/Level Of Evidence: Therapeutic, V.

Introduction

The standards of beauty vary between ethnic groups and are constantly evolving. A recent review found that East Asian women prefer a smaller face, more obtuse nasofrontal angle, rounder nose tip, and smaller tip projection.[1] The nose is an important structure that defines facial aesthetics. Proportional projection and elongation of the nose helps create an illusion of facial narrowing. It must be noted that facial aesthetic treatments in Asia are not aimed at Westernization, but are instead geared toward the optimization of intrinsic Asian features or the correction of features that are perceived as deficiencies.[2]

Surgical rhinoplasty remains the gold standard in aesthetic and functional reshaping of the nose.[3,4] However, the use of dermal fillers in nonsurgical nasal augmentation ("rhinofilling")[5] is increasing in popularity, especially when correcting minor imperfections in dorsal contour, nasal crookedness, depressions, notching, or asymmetry.[6–8] It has also been considered as an alternative by patients who are hesitating to undergo surgery or have medical contraindications to surgery.[9] In addition, fillers have been used to retouch minor postsurgical defects following rhinoplasty.[10]

The two most used dermal fillers are calcium hydroxyapatite and hyaluronic acid.[11] The approved indications of these fillers vary across countries, and they are mostly used for the correction of facial wrinkles and folds.[12,13] The hyaluronic acid fillers are increasingly becoming the fillers of choice because of their efficacy in achieving aesthetic goals, the reversibility of their effect with hyaluronidase, and lower rates of adverse events.[14,15]

Hyaluronic acid is a glycosaminoglycan composed of alternating D-glucuronic acid and N-acetyl-D-glucosamine monosaccharides. It is naturally present in the human body, and hypersensitivity reactions to modern hyaluronic acid fillers are rare.[16] Although nonsurgical nasal augmentation using hyaluronic acid is generally considered safe when performed using proper techniques,[17] the complexity of the nasal vasculature makes it a high-risk procedure without proper training. Possible complications include vascular occlusion, skin necrosis, and blindness.[18–21] (See Table 1, Supplemental Digital Content 1, which presents a summary of anthropometric studies of the Asian nose; see Table 2, Supplemental Digital Content 1, which shows key studies investigating the vascular anatomy of the Asian nose; and see Table 3, Supplemental Digital Content 1, which shows complications associated with various dermal fillers in nonsurgical nasal augmentation, https://links.lww.com/PRS/E836.) In this article, we present recommendations on the use of hyaluronic acid–based fillers to optimize aesthetic results and improve safety, with focus on Asian patients.

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