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Page 2 of 8 Chu et al. Plast Aesthet Res 2020;7:73 I http://dx.doi.org/10.20517/2347-9264.2020.169

to obtain remarkable results with nonsurgical rhinoplasties. Nonetheless, the most important factor in
providing optimal treatment is patient selection.

Nasal reshaping with HA filler is often most helpful as a post rhinoplasty adjunct. However, many authors
have reported the use of HA filler in an unoperated nose. When treating the virgin nose, injectors must
be cognizant that the use of large amounts of HA filler to correct a deformity may lead to vascular
compromise, thus making liquid rhinoplasty a poor solution for significant nasal deformities. The most
appropriate candidates for nonsurgical rhinoplasty are often those with mild cosmetic defects. Patients who
tend to show the best results are those with a mildly deviated nose, mild dorsal hump, slight imbalances
[5,6]
from previous surgery, and high nasal tip with flat radix .Following a physical examination, the clinician
must determine whether a reasonable improvement in the defect can be achieved, and inform the patient
of alternatives such as surgical rhinoplasty as well as risks and benefits in order to improve patient
understanding and set reasonable expectations.

For some patients, there is a contraindication to using fillers. This group of patients includes individuals
with a history of bleeding disorders, autoimmune disorders, and hypersensitivity to filler composition.
Patients who are pregnant or are breastfeeding should avoid filler injections. In addition, patients who show
signs of inflammation or infection near injection sites should not receive the procedure. Extreme caution
should be taken with patients that have undergone a recent surgical rhinoplasty. Additionally, all patients
[6]
are advised to avoid substances that impair hemostasis for one week to prevent bruising and bleeding .
Further, it is suggested that patients with suspected body dysmorphic disorder (BDD) see a psychiatrist
before undergoing liquid rhinoplasty. This is done in an effort to avoid patient dissatisfaction, as there is an
[7]
increased occurrence of BDD in people seeking a rhinoplasty .
Successful application of filler also relies on choosing the appropriate product. Permanent fillers are
generally not used due to their irreversible nature and the risk of granuloma formation. Currently, HA filler
is the most common filler used in liquid rhinoplasty, with up to 80% of liquid rhinoplasty procedures using
[6]
HA .Many clinicians prefer HA because it is soft, provides a natural feel and can be reversed and quickly
[8]
dissolved with hyaluronidase . However, some clinicians opt for CaHa. While CaHa cannot be easily
reversed, it provides a longer lasting effect and is more durable over time. CaHa fillers usually last between
[9]
12 and 18 months, while HA fillers last between 6 and 12 months . Therefore, HA fillers may require more
repeated injections in order to maintain the desired form or shape. However, while CaHa requires less
[10]
product, more stiffness can cause increased discomfort after the procedure .

TECHNIQUE
Prior to injection, topical anesthetic ointment is applied 15-30 min before the procedure.

Fillers can be reconstituted with the addition of 1% lidocaine with epinephrine (1:100,000) to reduce
discomfort, viscosity, and ultimately result in less postprocedural ecchymosis. As the average injection
volume for nasal reshaping is 0.4 mL of HA per injection site, addition of 0.004 mL of lidocaine is
suggested .
[11]
Injections can be delivered with a needle or cannula. Previously, it has been shown that cannulas provide
improved patient comfort, with decreased side effects such as edema and ecchymosis, especially in highly
[12]
vascular regions . Additionally, Pavicic et al. demonstrated that filler placement with cannulas provides
[12]

improved precision. Nonetheless, injection technique is highly variable and often based on prior training
and comfort . Due to the reduced risk of vascular complications and bruising, the use of microcannulas
[13]
has become more popular [Figures 1 and 2].