When performing nonsurgical rhinoplasty, one should think in terms of cartilage grafts, rather than simply contour. On the dorsum, filler placement is an alternative to surgical diced cartilage placement. Patients with a low dorsum, most typically those of Asian or African descent, often desire a taller, narrower-appearing dorsum. These patients often have a shorter quadrangular cartilage, and ear or rib cartilage may be needed, even in primary rhinoplasty. Even with meticulous surgical technique, dorsal diced cartilage grafts may result in minor contour irregularities as the skin and soft tissue envelope shrinks back down. The smoothness and ease of dorsal filler placement may make this an attractive alternative. In patients with a lower dorsum, it is important to consider the natural nasal starting point, typically at in line with the pupils. Computer simulation can be helpful to determine whether the patient is seeking this lower starting point or one which sits at the level of the superior lid crease.
To fill the dorsum, one may use a cannula, introduced in the supratip. The bevel is placed downward toward the perichondrium or periosteum. If the cannula is in the proper plane, it should glide easily. There have been cases of blindness reported in the literature with injections in and around the radix/glabella.11 For this reason, it is recommended to tent the skin/soft tissue envelope up while keeping one’s fingers along the nasal sidewalls. This technique also keeps the product in the midline. The cannula tip should be kept below the level of the nasion. The product can be massaged upwards easily after injection, if desired. In most patients, 0.4 to 0.6 mL of filler is enough to provide enough dorsal height, depending on the native height and the desired effect. A dorsal hump can be created with filler. Increased tip projection may be advisable when augmenting the dorsum, to avoid a hooked-appearing profile.