Premaxillary and perialar depressions are commonly observed among Asians [1,2]. As these abnormal structures are quite close to the nose, their presence often causes to appear under-projected nose with a ptotic tip [3]. These conditions directly affect the cosmetic outcome of rhinoplasty; thus, rhinoplasty surgeons should be careful to avoid unnatural results.

We present an interesting case with a noteworthy outcome. The case involved a 36-year-old female with unnatural alar drooping and spindle-shaped nostrils, who sought treatment to improve her deep nasolabial folds using hyaluronic acid (HA) filler. Physical examination suggested she had premaxillary protrusion with perialar depression prior to her rhinoplasty, which did not include alar base resection.

The authors administered injections to correct the deep nasolabial folds and perialar depressions, and observed significant improvements in the previously unnatural contour.

Patient selection

A 36-year-old female who had undergone open rhinoplasty 2 years prior sought treatment to correct her deep nasolabial folds using HA filler. During the physical examination, her nasolabial folds were observed only when smiling. Additionally, she exhibited perialar depression, maxillary protrusion, a droopy alar, spindle-shaped nostrils, and difficulty breathing.

Procedure materials

In this study, we used a cross-linked high molecular weight HA filler (VOM volume with lidocaine’ CGbio Co, Ltd), with a molecular weight of 800 kDa.

Injection protocol

Entry sites were created on both sides of the central perialar regions using a sharp 18-gauge needle after administering local anesthesia with a 2.0% lidocaine solution.

A total of 9.5 ml of filler was injected into both regions (5.0 ml in the right and 4.5 ml in the left), including the entire length of the nasolabial folds, using a 23-gauge blunt cannula. The filler was first injected into the perialar region (2.0 ml in the right and 1.5 ml in the left) and then into the nasolabial folds using Kang’s sequential augmentation of filler injection (SAFI) method [4].

For the perialar augmentation, 60% of the total volume of the filler was injected into the nasal process of the maxillary bone, 30% into the deep fat layer, and 10% into the superficial fat layer. No filler was injected into the subdermal layer. For the nasolabial folds, the filler was sequentially injected into the lateral folded part, medial depressed part, and then the central crease. In each part, the filler was sequentially injected into the deep layer (60% volume), superficial fat layer (20%), and then the subdermal layer (10%) following the method of SAFI [4].

Results

The results of the filler injection into the perialar and nasolabial fold in the patient, who had experienced unnatural contour of the alar and nostril due to complications of a previous open rhinoplasty, are as follows:

1. The filler injection greatly improved perialar depression, providing volumetric support for the droopy alar, ultimately altering the contour of the alar and nostril (Fig. 1-3).

Figure 1. Frontal view, a 36-year-old female who had performed hyaluronic acid filler injection for improving her deep nasolabial folds. She had a history of open rhinoplasty using silicone implant 2 years ago. In physical examination, she might have perialar depressions with maxillary protrusion. Linear markings represent the deep nasolabial folds and perialar depression. In the preoperative view (A), the increased skin tension in the tip-defining region, the droopy alar with narrow base, the small and the spindle shaped of the nostrils were observed. In the postoperative view (B), the shortened and clockwise rotated vertical line (ab–a’b’) with the increased alar base width and the widened nostril sill were observed. The droopy and long appearance of the alar-facial groove (b–c) were changed to the lifted and rounded appearance (b’–c’) and the nostril size was enlarged. Two blue arrows mean entry sites. Superior-most alar groove (a), alar base (b), and upper most alar-facial groove (c).

Figure 2. Immediate improvement from the basal contour in the same patient from (A). Preoperative view (A), perialar depression with protrusion of Alveolar process of maxilla(premaxilla) and depressed transverse columella scar by previous open rhinoplasty are seen. The droopy alar base, a sharp and tightened tip, and the spindle-shaped nostril are seen. Postoperative view (B), the naris was remarkably changed from the spindle shape to the inferior-based triangular shape. The columella scar was more obviously observed due to reduced columella skin tension. The angle of nostril axis (c, c’) was decreased from 70.30°→62.50°, and interaxial angle (d, d’) was increased from 36.00° to 52.50°. The columellar height (a, a’) was decreased from 20.63 to 17.88 mm. The alar base width (b, b’) was increased from 46.75 to 50.19 mm. Two blue arrows mean entry sites.

Figure 3. Immediate improvement of lateral profile of the nasal alar in the same patient from (A). (A) Preoperative view, the alar drooping with relatively straight anterior alar border due to loss of supporting by perialar depression is seen. (B) Postoperative view, the vertical line (a and b) was shortened (a’ and b’) and observed as if it counterclockwise rotated. The contour of the anterior alar border (a white arrow) was changed from relatively straight shaped to the round shaped. (a) Superior-most alar groove, (b) alar base.

2. The deep nasolabial fold also showed significant improvement (Fig. 1).

3. The droopy alar exhibited notable improvement, evidenced by measurements showing a decrease in both the columellar height and the angle of the nostril axis. Conversely, there was an increase in both the alar base width and the interaxial angle (Fig. 1B, 2B, 3B).

4. The spindle-shaped nostril transformed into a triangular-shaped nostril with a widened nostril sill, ultimately leading to improvement in the patient’s nasal obstruction symptoms (Fig. 2).

In the preoperative view, increased skin tension in the tip-defining region, along with a droopy alar featuring a narrow base and small, spindle-shaped nostrils, were observed. Additionally, deep nasolabial folds were greatly present (Fig. 1A).

In the postoperative view, a shortened and clockwise rotated vertical line (ab–a’b’) with an increased alar base width and widened nostril sill were observed. The previously droopy and elongated appearance of the alar-facial groove (b-c) transformed into a lifted and rounded appearance (b’–c’), accompanied by enlarged nostrils. Two blue arrows indicate the entry sites: (a) the superior-most alar groove, (b) alar base, and (c) upper most alar-facial groove (Fig. 1B).

In the preoperative view, perialar depression with protrusion of the Alveolar process of the maxilla(premaxilla) and a depressed transverse columella scar from a previous open rhinoplasty are evident. Additionally, a droopy alar base, a sharp and tightened tip, and spindle-shaped nostrils are observed (Fig. 2A). In the postoperative view, the naris underwent remarkably transformation from a spindle shape to an inferior-based triangular shape. The columella scar became more apparent due to reduced tension in the columella skin. Measurements showed a decrease in the angle of the nostril axis (c, c’) from 70.3° to 62.5°, while the interaxial angle (d, d’) increased from 36.0° to 52.5°. Furthermore, the columellar height (a, a’) decreased from 20.63 to 17.88 mm, while the alar base width (b, b’) increased from 46.75 to 50.19 mm. Two blue arrows indicate the entry sites (Fig. 2B).

In the preoperative view, alar drooping with a relatively straight anterior alar border, caused by the loss of support due to perialar depression, is observed (Fig. 3A). In the postoperative view, the vertical line (a and b) was shortened (a’ and b’) and appeared to have counterclockwise rotation. The contour of the anterior alar border (indicated by a white arrow) changed from a relatively straight shaped to a round shaped denoted by (a) superior-most alar groove and (b) alar base (Fig. 3B).

The occurrence of unnatural contours following rhinoplasty, such as droopy tip deformities, including asymmetric alar and nostril shapes, has been frequently observed [5]. These are expected complications, particularly in patients with nasal structural deformities arising from the nasal septum, lateral cartilages, and thick nasal skin [6], as well as non-nasal structural deformities such as maxillary concavity, especially in the perialar or premaxillary region [3,7].

To treat and prevent these complications, most surgical procedures have primarily focused on modifying nasal structures, including techniques such as the alar lift technique [8], arrow tip technique [9], and alar base resection. Additionally, paranasal augmentation using autograft or allograft implants have been used to correct maxillary concavity. However, there has been no report demonstrating significant improvement in droopy alar and unnatural-shaped nostrils through paranasal augmentation.

In this case, it is suggested that the rhinoplasty surgeon overlooked the risk of complications stemming from preoperative maxillary depression. However, this study demonstrates significant improvement in droopy alar and changes in nostril shape solely through filler injection, as depicted in Fig. 1, 2, and 3. It is noteworthy that the filler, traditionally utilized to restore insufficient soft tissue volume, surprisingly altered the shape of the nasal tip and nostril due to its fluidity.

This study focused on the innovative approach of not only placing the filer at the soft tissue layer but also attaching it to the perialar depression in the maxillary bone [10]. This technique resulted in anterior protrusion of the bone, pushing the alar base forward and ultimately contributing to a dramatic change in the overall contour of the nasal tip, alar, and nostril.

Generally, despite achieving immediate perfection in tip rhinoplasty outcomes, nasal droopy deformities tend to gradually develop postoperatively. This concern becomes particularly significant in cases where maxillary concavity exists preoperatively. Therefore, drawing an analogy to building construction, it is imperative to ensure a stable base ground before created the building to prevent complications such as tip drooping deformity.

Based on the aforementioned results, it can be concluded that filler injections can serve as a non-invasive tool both preoperatively and postoperatively in rhinoplasty. The fillers can help maintain results, prevent side effects, and treat complications, albeit not as a permanent solution.

The authors have nothing to disclose.