The Layered Anatomy of the Nose: An Ultrasound-Based Investigation

Abstract

Background An increasing number of soft tissue filler procedures in the nasal region has been reported. Concomitant with demand, the number of complications has risen due to the difficulty in administering filler in a region where soft tissue layering is complex. Objectives To describe the layered soft tissue arrangement of the nose as it relates to the underlying arterial vasculature and to define safer zones for nasal filler enhancement. Methods A total of 60 (28 males and 32 females) study participants were investigated with respect to their layered anatomy in the midline of the nose using ultrasound imaging. The presence and extent of the layered arrangement was examined as well as the depth of the arterial vasculature. Results In the mid-nasal dorsum, a 5-layer arrangement was observed in 100% (n= 60) of all investigated cases, whereas it was found to be absent in the nasal radix and tip. The 5-layer arrangement showed an average extent of 26.7% - 67.5% in relation to nasal length. The nasal arteries coursed superficially in 91.7% of all cases in the nasal radix, in 80% in the mid-nasal dorsum, and in 98.3% in the nasal tip. Conclusions Soft tissue filler administration in the nose carries the highest risk for irreversible vision loss compared to any other facial region. The safety of soft tissue filler rhinoplasty procedures is enhanced by knowledge of the layered anatomy of the nose, the location and depth of the major nasal vasculature, and employment of maneuvers to decrease the risk of blindness.

Displacement of Hyaluronic Acid Dermal Filler Mimicking a Cutaneous Tumor: A Case Report

“…6 It is a low-cost, convenient, non-invasive, portable and quick test that can be performed at the bedside during the dermatological consultation. 1,7,8 The doppler mode visualizes anatomical changes in the vessels; identifies the presence of vascular involvement; and provides a guided procedure, offering more safety during the application. 9 The patient described in this case had previously had hyaluronic acid injection in the nasal region, a three-dimensional and somewhat complex anatomical region.…”

“…This also varies according to different races, genders, and ethnicities. 7,10,11 The terms "liquid rhinoplasty" or "non-surgical rhinoplasty" are used to refer to the skin filling of the nasal region. 13 The procedure has been gaining space in the treatment of shape, correction of asymmetries, and nasal defects.…”

Vascular Safe Zones for Facial Soft Tissue Filler Injections

“…In most patients, the arterial vasculature courses superficially within the subcutaneous fatty layer of the nose at the radix, nasal dorsum, and nasal tip (Alfertshofer et al, 2021). With few exceptions, the supraperiosteal/supraperichondreal plane is considered an avascular plane (Alfertshofer et al, 2021).…”

“…Nasal injections are best performed in the deep (i.e., supraperiosteal/supraperichondreal) plane to avoid injuring the vasculature that travels more superficially. To ensure access to the deeper tissue planes of the nose, we recommend using a blunt tip cannula and selecting an entry point in the midline of the middle of the nose (Alfertshofer et al, 2021). Dermal access should not be attained at the tip of the nose, as this poses a risk for missing the deep tissue plane when advancing toward the nasal radix (i.e., the depression at the root of the nose) because the cannula may follow the oblique course of the procerus muscle toward a more superficial location cranially (Alfertshofer et al, 2021).…”

Applied anatomy of the layers and soft tissues of the forehead during minimally‐invasive aesthetic procedures

“…While for a long time anatomical knowledge has primarily been obtained by the dissection of cadaveric heads, ultrasound‐based imaging as a more recent method has proven to be useful for the analysis of facial anatomy in an in‐vivo setting. The universal availability, cost‐effectiveness and the ability to visualize the individual patient's topographical anatomy in real‐time and in a dynamic setting make it a useful tool in pre‐interventional planning (e.g., analyzing the individual anatomy of the patient), intra‐interventional execution (e.g., visualization of needle/cannula for product placement in the right layer) and post‐interventional control (e.g., complication management by guiding hyaluronidase injections) of minimally‐invasive facial procedures 13–17 . Without doubt, the implementation of ultrasound imaging in standardized treatment algorithms of minimally‐invasive aesthetic procedures has a substantial impact on the effectiveness and safety of these procedures.…”