56.8.9 Patient Satisfaction

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56 Nonsurgical Rhinoplasty with Radiesse®

The most common adverse effects are local and transient. They include mild pain, erythema, ecchymoses, edema, pruritis, and hematoma [12, 19]. Other adverse effects include soreness, numbness, contour irregularities, tenderness, and irritation. Overall, Radiesse® rhinoplasty is typically well tolerated and patient satisfaction for nonsurgical nasal augmentation is high [8].

Removal of excess Radiesse® with an 18-gauge needle can lead to correction if Radiesse® is injected into the middermis [5] or in excess. Radiesse® has a 1:1 injection-to-augmentation ratio; thus it requires no additional posttreatment augmentation monitoring [29]. Additional touch-ups may be required after 2 weeks to 3 months. Patients are seen 2–3 weeks after injections to ensure that they are satisﬁed after most of the edema and ecchymosis has subsided.

633

Radiesse® has also been used to improve postrhinoplasty contour defects, such as dorsal nasal defects (cartilaginous and bony), nasal sidewall depressions, overly deep supratip breaks, and alar asymmetries [16]. Typical candidates include people with ethnic noses: Asians, Middle Easterners, African Americans, and Hispanics. This is because, in general, such people have thicker skin, lower nasal dorsums, and bulbous tips compared to Caucasian patients.

When performing a rhinoplasty on any patient population it is important to take cultural issues into consideration. While such patients seek correction of nasal defects, most patients also cherish subtleties and preservation of their ethnicity. Rhinoplasty should reﬁne facial features while maintaining ethnic identity. When they arise, also recognize language and cultural barriers

56.8.9 Patient Satisfaction	56.9.1 Asian

As with any aesthetic procedure, satisfaction depends	Augmentation rhinoplasty is a common procedure in
not only on surgical technique, but realistic expecta-
	the Asian community due to their generally lower
tions from patients, as well as proper prior communi-
	and more caudal nasal nasion compared to Caucasian
cation between surgeons and patients. Nonsurgical
	patients. A common misconception is that such rhi-
rhinoplasty with Radiesse® has a high rate of patient
	noplasty is done to look more “Western,” despite the
satisfaction in the literature [8, 12, 16, 19–23], as
	fact that high, narrow bridges are aesthetically pleas-
well as at our institute. Furthermore, one study found
	ing in many Asian cultures [31]. To achieve such
no correlation between patient satisfaction scores
	results, surgical augmentation			is	performed with
and demonstration of improvement by photographic
	autogenous or alloplastic material				placed	into the
analysis [8].
	nasal dorsum to make the nasion level higher and
In the rhinoplasty literature, the standard for mea-
	more cephalic. Over the years, there has					been a
suring patient satisfaction is through patient-reported
	debate over the more preferable material. To this end,
outcome measures. The most common instruments
	it has been found that surgeons performing augmen-
used to measure patient satisfaction after surgical rhi-
	tation rhinoplasty on Asian patients have had to rec-
noplasty are the Rhinoplasty Outcomes Evaluation, the
	ognize that	many	are unhappy with autogenous
Glasgow Beneﬁt Inventory, and the Facial Appearance
	implants and	prefer	alloplasts,	particularly		silicon,
Sorting Test [30]. For nonsurgical rhinoplasty with
	despite long-term side effects			[31]. Such		surgery,
Radiesse®, there is a need for the use of such instru-
	however, may produce conspicuous and unsatisfac-
ments to assess patient satisfaction.
	tory results [32], particularly due to exposure and

	extrusion of implants. Implant exposure can lead to
	scarring, which can be difﬁcult to treat with revision
56.9 Speciﬁc Types of Noses	surgery [33].
	As inhabitants of the largest continent, Asian’s

	noses vary depending on different geographical
At the nasal radix and dorsum, Radiesse® can be used	regions. Northern Asian noses can have dorsal humps
to augment height, to give a wider appearance, or cor-	and high nasions extending onto the glabella [31].
rect saddle deformities. By correcting retracted colu-	Filipinos and Polynesians typically have “ﬂat” noses
mellas, it can give a more prominent nasal tip.	which start off narrow at the bridge and gradually

634			G.J. Bitar et al.
become wide and blunt at the tip [31]. Despite differ-		c	d
ences, the goal of rhinoplasty in Asian patients can		c	d
ences, the goal of rhinoplasty in Asian patients can
generally be seen as similar to the goal of Occidental
rhinoplasty: a strong dorsum with a prominent origin
but not competing with the tip as the leading point of
the nasal proﬁle [31].
Nonsurgical rhinoplasty with Radiesse® in Asian
patients (Fig. 56.9) can increase tip projection, create
a higher dorsum, and improve tip contour [34].
Augmentation is also performed at the glabella in
response to deﬁciencies there, and the columella to
correct vertical deﬁciencies. Dorsal augmentation can
a1	b1

Fig. 56.9 (continued)

Fig. 56.9 Asian Radiesse® rhinoplasty. (a1, a2) pre-injection lateral and worm’s eye view respectively. (b1, b2) post-injection lateral and worm’s eye view respectively (c) Preprocedure Chinese woman. (d) Postprocedure following injections with Radiesse® to the dorsum and radix. (e) Preprocedure 26-year- old Philippino woman. (f) Postprocedure after injections with Radiesse® to the radix, bridge, and tip

also be used to create the appearance of a narrow bridge, a procedure also common in African-American noses [35]. In Asian populations, nonsurgical augmentation is also frequently done as part of revision or after removal of an implant.

56 Nonsurgical Rhinoplasty with Radiesse®

635

56.9.2 African-American

A frequent complaint of African-American patients is a lack of a projection from the dorsum and the tip. In addition, African-American patients commonly complain of short columella, small nasolabial angle with the upper lip too close to the nasal tip, round nostrils, and excessively broad alae [31].

Augmentation to the dorsum is as routine in AfricanAmerican patients as hump removal is in Caucasian patients [31]. Approximately 50% of African-Americans are good candidates for augmentation [31]. AfricanAmerican patients with American Indian heritage frequently also have dorsal humps and high nasions that may extend on the glabella [31]. To this end, nonsurgical rhinoplasty with Radiesse® in African-American patients can increase the height of the dorsum, as well as convert saddle deformities into more linear forms (Fig. 56.10). Dorsal augmentation with Radiesse® is also advantageous because the caudal end of the nose tends to be mobile; therefore rigid implants are not routinely used [31]. In order to address wide-bridge appearances from frontal views, dorsal augmentation alone (without an osteotomy) can create the appearance of a narrower bridge [35].

In African-American patients, tip injections with Radiesse® can also give a more prominent appearance to an otherwise bulbous, ﬂattened tip. The nasal tip in African-American patients has also been described as ﬂeshy, ﬂat, wide, depressed, pendulous, or depressed, while the aim is to create a more sculpted tip [31]. Flared nares cannot be treated with Radiesse® rhinoplasty and need surgical correction.

56.9.3 Hispanic

Nasal surgery is one of the most commonly requested aesthetic surgeries requested by Hispanic Americans. A mestiso nose typically has a narrow and deﬁcient radix that may be augmented with Radiesse® to balance the cephalad aspect with the caudal aspect of the nose. Other common characteristics are insufﬁcient anterior project of the entire nose, wide alar bases, retracted columellas, acute nasolabial angles, and depressed piriformis areas [31].

The dorsum is typically wide, and the goal is to convert it into a straight or slightly concave shape (Fig. 56.11). This is difﬁcult to address with Radiesse®.

Fig. 56.10 African-

American Radiesse® rhinoplasty. (a) Pretreatment 42-year-old AfricanAmerican woman. (b) Posttreatment immediately after injections with Radiesse® to the radix, bridge, and tip. (c) One month postprocedure after initial swelling subsided

636		G.J. Bitar et al.
a1	b1	common features of Middle Eastern noses are: wide
a1	b1	nasal bones, slight alar ﬂaring, ill-deﬁned bulbous tips,
		nasal bones, slight alar ﬂaring, ill-deﬁned bulbous tips,
		bulky infratip lobules, overprojecting radix, high and
		wide dorsums, and acute columellar-labial angles [36].
		In addition, these patients commonly have thick, seba-
		ceous nasal skin – especially at the tip [36]. Middle
		Eastern noses can also have dorsal humps and high
		nasions extending onto the glabella [31]. Correction
		with Radiesse® should proceed with caution, since this
		population typically needs a “reduction” rhinoplasty as
		opposed to an augmentation rhinoplasty. Reduction
		typically involves a septorhinoplasty in response to a
		deviated septum, removal of a dorsum hump, correc-
		tion of a crooked tip, and/or reduction of a broad base
		[31]. Small improvements can be offered with Radiesse®
		rhinoplasty such as injections to the radix to augment it
		if it is deﬁcient, to the tip to offer more deﬁnition, as
		well as to the columella to create a more obtuse colu-
		mellar-labial angle. In women, this angle should be
		between 95º and 105º, while in men the angle should be
		approximately 90º [31]. From a lateral view, the colu-
a2	b2	mella should lie 2–3 mm below the alar rim [31].
a2	b2

Fig. 56.11 Hispanic Radiesse® rhinoplasty. (a1, a2) pre-injec- tion lateral and worm’s eye view respectively. (b1, b2) postinjection lateral and worm’s eye view respectively

The tip is ptotic and Radiesse® can provide a more prominent shape. Another problem site is the columella, which is often weak and found to lie above the alar rim. Radiesse® injection can increase the projection of the columella by adding structure. As with African-Americans, nostril ﬂaring may only be corrected surgically.

56.9.5 Aging

Facial aging is a complex process characterized by thinning of the epidermis, atrophy of subcutaneous fat layers, a degree of bone resorption, progressive loss of elastic ﬁbers and collagen organization, and weakening of underlying muscles [7]. In the nose, Radiesse® injection can be used to augment areas affected by the aging processes. For example, augmentation with radiesse to the base of the pyriform aperture can provide the columella with additional support. Nevertheless, it should be noted that Radiesse® can be used to smooth nasal wrinkles and depressions associated with aging in patients (Fig. 56.12). It is already used to improve aesthetic effects of aging on the forehead, cheeks, nasolabial folds, and labiomandibular lines.

56.9.4 Arabic (Middle Eastern)

56.9.6 Revision Rhinoplasty

While generalizations should be avoided, morphologically the Middle Eastern nose falls somewhere between African and Caucasian noses [36]. Some of the most

Contour irregularities after a rhinoplasty have to be assessed on an individual basis, and may be improved