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.
References:
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).
Conversations surrounding sexual health and wellness were, until recently, somewhat taboo topics. “Women have always dealt with incontinence, dryness and more, but they did not talk about it because there was not the medium to do so,” said triple board-certified cosmetic surgeon Daisy Ayim, MD (Houston, Texas). However, as society breaks barriers, the dialogue surrounding the look, feel and functionality of the vagina are healthy and inclusive discussions, leaving no woman to feel ashamed or alone.
The demand for treatments that rectify sexual health and wellness issues shows no signs of slowing down. According to data from researchandmarkets.com, the global sexual wellness market will reach $125 billion by 2026. From 2014 to 2019, vaginal rejuvenation treatments (surgical and nonsurgical) jumped 220%, with more than 25% of plastic surgeons offering these therapies.1
Energy-Based Treatments
Popular nonsurgical RF treatments to tighten the vagina include ThermiVa RF (Thermi) and the Viveve System (Viveve Medical). EMFEMME 360 from BTL Aesthetics (Boston, Mass.) goes one step further and tracks the tissue’s temperature for a uniform energy delivery. It is also fast – treatment clocks in at eight minutes. “With it, we can adjust the pelvic contractions’ timing, power and strength, and its ergonomic design makes it comfortable for patients,” Dr. Evans noted.
Injectables and Shots
Let’s Not Forget the Males
Into the Future
U.S. consumer demand for skincare products continues to grow, and aesthetic practices nationwide are looking for ways to position themselves as skincare experts by recommending products and counseling patients. Practices are using cosmeceuticals to optimize outcomes, and some are becoming product retailers.
According to Kim Nichols, MD, a board-certified dermatologist and the founder of NicholsMD of Greenwich, Conn., SkinLab by NicholsMD, and NicholsMD of Fairfield, skincare is an integral aspect of a dermatology practice, “…whether through a customized regimen or an individualized treatment plan. With skincare products, each initial consultation includes a suggested regimen based on patient’s skin type and concerns. I teach my staff to educate patients on the importance of at-home skincare as well. Half of the battle with any skin condition is maintaining [the] skin’s health in-between visits to the office,” Dr. Nichols shared.
Dr. Almukhtar uses skincare for medical dermatology and cosmetic patients and often combines skincare with prescription treatments. She asserted that all the products she recommends have clinical studies behind them that prove safety and positive outcomes.
Some Basics 
Physicians Taking Charge 
Top Practice Categories and Recommendations 
Combining Procedures and Skincare 
Michael H. Gold, MD, medical director of the Gold Skin Care Center and Tennessee Clinical Research Center in Nashville, Tenn., says Alastin’s Regenerating Skin Nectar with TriHex Technology (Carlsbad, Calif.) is the company’s hero product.
EMC Pharma’s (Maryland Heights, Mo.) products feature hypochlorous acid (HOCl), which has been shown to eradicate bacteria, reduce inflammation, reduce pruritus, break down biofilm and increase oxygenation. The company has several products in its skincare portfolio including Levicyn Dermal Spray, Levicyn Spray Gel, Celacyn Scar Gel, Acuicyn Eyelid and Eyelash Cleanser, Epicyn and Sebuderm.
“I tend to recommend hydroquinone-free products,” Dr. Almukthar stated. “There are a few on the market that are backed by evidence. The most common ingredients are tranexamic acid, kojic acid, niacinamide and cysteamine. Examples of products that are tested and will help with pigmentary issues are Lytera 2.0 by SkinMedica, which has tranexamic acid, resorcinol and niacinamide; Discoloration Defense by SkinCeuticals, which has tranexamic acid, niacinamide and Kojic acid; and Cyspera by Scientis, which includes cysteamine. Dr. Almukthar said she tends to use Lytera 2.0 or Discoloration Defense after a laser procedure targeting pigmentation. “Usually, it can be used immediately after the procedure, and patients can continue the treatment for a few weeks until I see them for follow-up.”
Advances in Skincare “Technology” 
Skincare or Cosmetic Procedure? 
Glen Frost