The medial crura should be expanded if the nostrils are flat. It should be teardrop shaped. A retracted columella can also be filled. Depending on the degree of retraction, soft-tissue expansion should be handled in more than one session. Expansion is undertaken with an injection into the membranous septum. Injecting into the
Fig. 5.23 The nasolabial angle filling enables the lifting of the tip of the nose. For women, this angle must be 100 or 110°. It produces a delicate appearance of the nose footplates of the medial crura may increase tip projection (Fig. 5.24).
Care should be taken not to erase the supratip break. Filling into this point may cause supratip deformation and consequent dropping of the nasal tip (Fig. 5.25). To enhance the supratip break, there must be a difference in height between the domes and the septal angle; a tiny injection into the tip of the dome may produce this effect.
To evaluate whether the filling of the tip was correctly performed, the final tip projection must equal the width of the alar base. An increase in tip rotation is conducted in patients with a reduced nasolabial angle. Increasing the nasal tip projection may be undertaken by direct injection into the domes (Fig. 5.26). When treating the tip, it must be established whether the patient needs augmentation of the domes and/or the middle crura. When only the domes need augmentation, injections must only be made into the upper portion of the tip. If the whole tip must be treated, upper and lower injections must be undertaken. This is a nice solution for patients with thin skin who present surface irregularities on the tip.
Care must be taken not to inject too much product as this may produce widening of the middle crura and a boxy tip aspect, which is undesirable. During the injection, pinching the tip may be helpful to avoid excessive filling. A delicate caudal injection into the tip may produce an increase in tip projection and a nice upwards tip rotation. When a major increase in tip projection is necessary, filling into the soft tissue of the pre-maxilla is advisable.
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