Despite being plagued with many problems in its early years, filler-based rhinoplasty is steadily increasing in popularity. Over a century ago, Francis J. Quinlan, MD, tried injecting paraffin to fix deformities / improve the appearance of the nose. In the 1980s liquid silicone was a popular injectable for this procedure. However, these options failed due to disastrous granuloma formation.
In 1981, the FDA approved bovine collagen filler, which attracted many practitioners to begin performing improvements on the nose and around the face using this material. Unfortunately, the short-lived nature and the potential allergic reactions limited its use. Then came two other fillers: hyaluronic acid and hydroxyapatite.
I started to inject Restylane (Galderma Laboratories) for nose improvement in 2004. The technique I used began by injecting small boluses onto the nasal periosteum/perichondrium to improve the dorsum. I would also inject small boluses onto the surface of the domal cartilage or immediately at the tip of the subdermal layer to avoid vascular compromises. Nevertheless, these techniques did not prove to be trouble-free. From 2004 through 2015, I performed around 3,000 nasal filler injections. The results were mostly successful; however, vascular compromises unavoidably took place. A total of five complications were identified. Every time a vascular compromise occurred, I wished I could quit my job. The psychological burden of disfiguring people was simply unbearable. In addition, the use of hydroxyapatite was also problematic due to its prolonged recovery time and difficulty to inject.
There are six major blood vessels interconnecting in the tiny nasal tip region just under the skin, easily occluded with filler injections. As a result, it became apparent to me that, to avoid these vessels, I would have to utilize some other entry points or spaces in order to successfully inject filler for tip improvement.
A study published in the Plastic & Reconstructive Surgery Journal looked at the histology of the membranous septum, where they found only some scanty capillaries and an abundance of fibrous tissues.1 I used the concepts presented in this article and began injecting fillers into the septal space for tip improvement. I was able to master the techniques for elevating and elongating the nose tip with great efficiency.
For practitioners familiar with the nasal anatomy, the tip is very mobile. If one pulls on the columella, the tip range of motion could shift up to 1 cm upward (elevation) and up to 1 cm caudad (elongation). In the resting state, the columella hugs the caudal septum. However, as the columella is pulled upward or caudad, the membranous septum demonstrates great mobility like that of a “bounce house.” This concept of a “bounce house” is easily understandable because the membranous septum has columella in the front, caudal septal cartilage in the back, and an abundance of fibrous structures bind the two sides of the membranes.
Injection of filler boluses into this area could only lead to the mobile columella/tip structure moving away from the caudal septal cartilage due to the caudal septal cartilage being fixed and the membranes not expanding sideways. Consequently, the tip structure becomes propped up and can be lifted or elongated, as directed by the practitioner. The nose can be elongated up to 6 mm and the tip can be elevated up to 8 mm. These feats were never achievable with any of the techniques previously described.
Compared to the traditional tip injection technique, one of the most prominent features of the TipLyft protocol is the optimization of the infra-tip lobule to columella ratio, which was ignored for decades. Ideally, the lobule to columella ratio (L/C ratio) should be 1:2. However, with traditional tip injection techniques, the filler is simply piled onto the tip, causing a reversal of the lobule to columella ratio and further compressing the nostrils (Figure 1).
With the illustration of traditional filler injection results shown in Figure 1b, it is not a surprise that until now not a single practitioner has published any data or pictures depicting the changes in patients’ nostrils after their nose tip “improvement” from a worm’s eye view.
Nose tip elongation and elevation with TipLyft can be appreciated in Figures 2 and 3.
Many more benefits are observed with the unique TipLyft technique, as described in my original paper Nose Tip Elongation and Elevation: A Novel Filler Injection Technique.2 To date, I have performed more than two thousand TipLyft procedures, without a single vascular compromise. The injection into the septal space deposits the filler boluses far from the skin and columella so there is little risk for a vascular compromise to occur.
In conclusion, TipLyft using high G-prime hyaluronic acid gel is a revolutionary technique. It has disrupted many of the doctrines for filler nose injections. The protocol is safe, easy and extremely efficient. Furthermore, we know that nose tip elongation is hard to achieve, even with surgical maneuvers, but TipLyft easily accomplishes the job. My biggest objective is for this TipLyft technique to encourage more studies to follow, hopefully changing the way that plastic surgeons think about rhinoplasty surgeries.
About the Author
Arthur Yu, MD, PhD
Dr. Yu was trained in plastic surgery at Mayo Clinic (Rochester, Minn.); Asian cosmetic surgery with Robert Flowers, MD (Honolulu, Hawaii); head & neck surgery at MD Anderson (Houston, Texas); and general surgery at Brooklyn Hospital (Brooklyn, N.Y.). His main interests are Asian eyelid surgery, Asian rhinoplasty, facial and body contouring with high-definition liposculpturing and stem cell-enriched autologous fat grafting. He prefers minimally invasive approaches to achieve natural results.
1. Lee et al. (Lee MR, Menyoli M, Roostaeian J, Unger JG, Rohrich RJ.) Soft-tissue composition of the columella and potential relevance in rhinoplasty. Plast Reconstr Surg. 2014;134(4):621-625.)
2. Yu AY. Nose Tip Elongation and Elevation: A Novel Filler Injection Technique. Aesthet Surg J. 2022 May 18;42(6):660-676. doi: 10.1093/asj/sjac006).