Journal of Clinical and Aesthetic Dermatology

APR 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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38 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY April 2018 • Volume 11 • Number 4 R E V I E W Therefore, the female ideal nose is more raised than the male nose. We next measure the columellar-lobular angle, obtained through the intersection of a line parallel to the columella crossing a line drawn parallel to the lobe. This angle measures ideally 30 to 45 degrees. The smaller the angle, the more rectified, larger, and more rounded it will be, with a less natural appearance (Figure 7). The base of the nose and nasal wings should be compared to the tip of the lobe and the nasal pyramid. The columella must be evaluated with regard to the position of the median line, alignment, width, length, and position in relation to the nasal wings. Finally, the cephalic head view is used to evaluate the nasal pyramid. The angle of the nasal tip is calculated through the angle of the lobe toward the nasal wings. The smaller the angle, the narrower the nose; the larger the angle, the wider the nose. There is variation among angles between races: The nasal tip angle is generally 60 degrees in Caucasians, 90 degrees in Asians, and 120 degrees in people of African descent (Figure 8). These measures and angles should be established and applied individually to each patient to correlate with the main indications of nonsurgical nasal filling, namely elevation or rectification of the tip or the nasal dorsum as a complement to surgical rhinoplasty, correction of asymmetries, or correction to posttraumatic deformities and/or congenital hypodevelopment. Technique. After photographing with a three- dimensional digital device, the physicians should sterilize the area with 2% alcoholic chlorhexidine. A topical anesthetic with lidocaine spray 10% should then be applied. We prefer not to use a local anesthetic block, because this type of anesthesia can mask pain in the cases of vascular ischemia. The product we use is a high density hyaluronic acid (20mg/mL). With this technique, a puncture is made with a 22-gauge (G) needle in the central region of the nasal tip in order to introduce the 22G cannula (Figure 9). First, the introduction is made toward the nasal bone crest, passing the septum to reach the lower part of the columella. This aims the projection of the nasal tip. In our patients, the filler is applied with a bolus technique on the bony crest after a retroinjection into the tip. To reach the radix and rhinion, we insert the cannula through the same entry point in the nasal tip toward the radix and deposit a small bolus in this location (Figure 10). Then, a retroinjection is made along the dorsum, correcting dorsal humps or other asymmetries. If a correction in the higher part of the nose is required, an entry point can be made at the supratip for easier access. After the end of the procedure, a sterile dressing is placed over the entry point site. A micropore is placed along the dorsum and around the tip to protect and maintain the remodeling. It is removed after 24 hours by the patient. The use of a transparent dressing helps with the identification of early complications (e.g, livedo or ischemia). FIGURE 3. Ideal nose location when face is divided into thirds FIGURE 6. The nasal length is obtained through a transit line from the radix to the nasal tip FIGURE 7. The nasofrontal angle FIGURE 4. Ideal nose location when face is divided into fifths FIGURE 5. Proportions of nasal length and SM length in an ideal nose location FIGURE 8. The nasal tip angle

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