Journal Logo

Cosmetic: Original Articles

Nonsurgical Rhinoplasty: A Systematic Review of Technique, Outcomes, and Complications

Williams, Lauren C. B.A.; Kidwai, Sarah M. M.D.; Mehta, Karan M.D.; Kamel, George M.D.; Tepper, Oren M. M.D.; Rosenberg, Joshua D. M.D.

Author Information
Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 41-51
doi: 10.1097/PRS.0000000000006892

Abstract

Rhinoplasty is the third most common procedure performed by plastic surgeons in the United States.1 Slight imperfections or irregularities after rhinoplasty can often be corrected with nonsurgical rhinoplasty, especially in those patients that refuse a surgical revision.2 With the rise of minimally invasive procedures, nonsurgical rhinoplasty has also gained popularity as the primary option for changing nasal appearance. Nonsurgical rhinoplasty generally involves the use of either synthetic or autologous fillers into deficient areas of the nose with external molding to refine the position of the filler and shape of the nose. Hyaluronic acid and calcium hydroxyapatite tend to be the most commonly used materials; however, this procedure can also be performed using autologous fat or cartilage.2–4 Synthetic materials have the additional benefit of precluding the need for a donor site to harvest fat or cartilage.

Advantages of this procedure are the relative ease of the procedure, performance in an office setting, minimal recovery time and postoperative swelling, and a nearly immediate visualization of results. In contrast, the results are transient in nature, requiring repeated injections, which can be costly.5,6 In addition, minor complications such as local swelling, erythema, granuloma formation, and infection can occur, although these are usually temporary. More rare yet devastating complications include vascular compromise resulting in skin necrosis or blindness because of retinal artery occlusion or embolization.7 Although rhinoplasty remains the gold standard for changing nasal appearance, nonsurgical rhinoplasty can be used to correct deformities of the nasal sidewall, alter tip projection or rotation, augment the nasal dorsum, correct a deep radix, lengthen the nose, or alter the nasolabial angle.7

Despite nonsurgical rhinoplasty rapidly growing in popularity, there is no literature on the most common filler materials used, injection technique, and injection location. Much of the published literature consists of case reports and general discussion of technique.6,8–10 Therefore, we conducted a systematic review to identify common filler types, injection techniques and locations, and associated patient satisfaction and complications to further guide practitioners.

METHODS

Institutional review board approval was not required for this study, as it was a retrospective review of published literature. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.11 Keywords and Medical Subject Headings search terms were used to query four databases (i.e., Embase, SCOPUS, PubMed, and Cochrane) for studies relating to the use of injectable materials in the nose. A complete list of keywords and medical subject headings is reported. (See Table, Supplemental Digital Content 1, which shows the search syntax used in this study, http://links.lww.com/PRS/E101.) Resultant records were then imported into Covidence systematic review software (Veritas Health Innovation, Melbourne, Victoria, Australia) for removal of duplicates. Two independent reviewers (L.W. and S.K.) screened each study for relevance based on title and abstract. Conflicting studies were reviewed by a third reviewer (K.M.). The full text of each study was then reviewed by all reviewers to identify inclusion or exclusion. Any conflicts were resolved by discussion and consensus among the three reviewers.

Studies were included if they involved the use of injectable material to alter nasal appearance, were retrospective or prospective in design, included at least five total patients, and reported specific data on patient satisfaction. Studies were excluded from our review if they included patients who underwent simultaneous surgical rhinoplasty, failed to report specific objective or subjective outcomes, or were not available in English. Studies with less than five patients were also excluded from our review, meaning that case reports and reports of specific complications were not factored into analysis. In addition, the decision was made to exclude studies relating to autologous fat or cartilage grafting, as these require tissue harvesting, often under general anesthesia or sedation, and are not routinely performed in an office setting. Lastly, one study published in 1986 was excluded because the injection material used was silicone, which is currently not approved by the U.S. Food and Drug Administration for facial injections.12

Primary outcomes included complication rates and patient satisfaction. Because of the lack of a standardized satisfaction scale across the included studies, overall satisfaction was analyzed based on the total number of patients satisfied in each study. Secondary outcomes were mainly qualitative, including details on injection technique, including the type of injected material and injection instrument, location, plane, and volume. When applicable, proportions were compared using the n − 1 chi-square test. Statistical analysis was performed using IBM SPSS Version 22.0.0 (IBM Corp., Armonk, N.Y.).

RESULTS

The initial literature search based on search terms yielded 4632 distinct articles. After screening of title and abstract, 4323 studies were deemed irrelevant. Of these 309 studies, 23 met inclusion criteria after full-text screening (Fig. 1). Fourteen of the included studies were prospective cohort studies and nine were retrospective reviews of patients who underwent nonsurgical rhinoplasty. Details for each of these studies, including techniques and outcomes, are outlined in Table 1. A total of 1600 patients across 23 studies underwent injections to alter nasal appearance. In our review, 15 studies (n = 1078) reported patient sex. Of these patients, 855 (83.02 percent) were female patients, with a female-to-male ratio of 4.89. Thirteen studies (n = 781) reported patient age, with a mean age of 32.48 years across these studies. Of 19 studies that reported history of rhinoplasty, 1208 patients (52.9 percent) had previously undergone a surgical rhinoplasty and were receiving nasal injections for correction of persistent postsurgical deformities. Specialties of treating physicians in each study included plastic surgery [12 studies (52 percent)], otolaryngology/ear, nose, and throat [five studies (22 percent)], dermatology [four studies (17 percent)], and oral and maxillofacial surgery [two studies (9 percent)]. Specialty breakdown is provided in Table 11–78 and Figure 2.

Table 1. - Overview of Included Studies
Reference Primary Specialty No. of Patients Prior Rhinoplasty (%) Filler Type (No., if multiple) Follow-Up* Patient Satisfaction (%) Complications (No.)
Alharethy, 201863 ENT 30 0.00 CaHA 14 days 90 Erythema (2)
Amore et al., 201568 Plastic surgery 212 44.34 HA 3 mo 90.57 None
Becker, 200818 Plastic surgery 24 62.50 CaHA 10 mo 92 None
Bertossi et al., 201969 OMFS 150 27.33 HA (with Vycross; Allergan, Inc., Dublin, Ireland) 14 days 96.67 Hematoma (2)
Braccini and Dohan Ehrenfest, 200858 ENT 85 62.35 HA (56), CaHA (11), botulinum toxin (12), other (6) 30 days 91.76 Infection (1)
Cassuto, 200915 Plastic surgery 14 14.29 Collagen (porcine) NR 100 None
Han et al., 201514 Plastic surgery 280 5.36 HA 30 days 93.21 None
Hedén, 201670 Plastic surgery 75 26.67 HA 6–8 wk 93 Telangiectasias/erythema (3)
Helmy, 201859 Plastic surgery 332 NR HA (163), CaHA (19), botulinum toxin (111), other (39) <6 mo 100 Infection (1)
Jacovella et al., 200655 Plastic surgery 5 NR CaHA 18 mo 100 None
Jacovella, 200871 Plastic surgery 25 0.00 CaHA NR 92 Ecchymosis/hematoma (3)
Kose et al., 201372 ENT 12 100.00 HA 30 days 100 None
Liew et al., 201673 Plastic surgery 29 0.00 HA 421 days 89.70 Filler displacement (2), injection site reaction (1)
Rauso et al., 201716 OMFS 52 5.77 HA 15 days 100 None
Rho et al., 201774 Dermatology 40 21.05 HA 14 days 100 None
Rivkin, 201417 Dermatology 19 0.00 Collagen (porcine, with PMMA) 12 mo 84.21 Nodule formation (3)
Rokhsar and Ciocon, 200875 Dermatology 14 0.00 CaHA 6 mo 100 None
Sahan and Tamer, 201776 Dermatology 35 6.52 HA <6 mo 100 None
Schuster, 201553 ENT 46 NR CaHA (26), HA (20; with Vycross in 4) <21 mo 84.79 Filler displacement (1), hematoma (1), nodule formation (1), infection (3), erythema (1)
Siclovan and Jomah, 200977 Plastic surgery 5 100.00 CaHA 6 mo 100 None
Solomon et al., 201257 ENT 26 0.00 Collagen (bovine) 3 mo 100 None
Tanaka, 201478 Plastic surgery 40 100.00 CaHA 7 days 95 None
Xue et al., 201254 Plastic surgery 50 0.00 HA NR 98 None
ENT, ear, nose, and throat; OMFS, oral and maxillofacial surgery; NR, not reported; HA, hyaluronic acid; CaHA, calcium hydroxyapatite; PMMA, polymethylmethacrylate.
*Follow-up refers to the length of time between injection and assessment of patient satisfaction.

Fig. 1.
Fig. 1.:
Study selection process.
Fig. 2.
Fig. 2.:
Injector specialty. ENT, otolaryngology/ear, nose, and throat; OMFS, oral and maxillofacial surgery.

Injection Types

Injection choice and injection technique for each study are recorded in Table 2. The most commonly used filler was hyaluronic acid, which was used in 1174 patients [n = 1600 (73.38 percent)]. One hundred ninety-nine patients (12.44 percent) received calcium hydroxyapatite injections, 123 (7.69 percent) received botulinum toxin injections, and 59 (3.69 percent) received either porcine or bovine collagen injections. Of the studies using hyaluronic acid filler, two studies (154 patients) reported the use of hyaluronic acid crosslinked with Vycross, a crosslinking technology that uses a combination of high- and low-molecular-weight hyaluronic acids.13 Lastly, 45 patients (2.81 percent) received injections with other materials, including tricalcium phosphate, l-polylactic acid, polyacrylamide gel, and polydioxanone threads for lifting. Volume of injected material varied throughout the studies; however, the majority reported using less that 1.0 ml in total per patient. Based on the 11 studies (n = 512) that specifically reported the mean volume used per patient, the average amount of injected filler was 0.54 ml.

Table 2. - Injection Techniques
Reference Filler Type Filler Brand Location Injected Total Volume Injected per Patient (ml) Injection Instrument Injection Plane
Alharethy, 201863 CaHA Radiesse (Merz Pharma GmbH & Co, Frankfurt, Germany) Dorsum, tip Mean, 1.0 22-gauge blunt cannula Supraperichondrial, supraperiosteal
Amore et al., 201568 HA Variable Tip Mean, 0.41 27-gauge needle Supraperichondrial, supraperiosteal
Becker, 200818 CaHA Radiesse Dorsum, tip, nasal sidewall, columella Range, 0.25–1.3 25-gauge needle NR
Bertossi et al., 201969 HA (with Vycross) NR Dorsum, tip, anterior nasal spine, columella, glabella, alar sidewall Range, 0.6–2.2 27-gauge needle Supraperichondrial, supraperiosteal, deep dermal (tip, glabella, ala)
Braccini and Dohan Ehrenfest, 200858 HA (56), CaHA (11), botulinum toxin (12), other (6) Variable Radix, anterior nasal spine NR 32-gauge needle Supraperichondrial, supraperiosteal, subcutaneous (anterior nasal spine)
Cassuto, 200915 Collagen (porcine) Dermicol-P35 (Ortho Dermatologics, Skillman, N.J.) NR Mean, 0.6; range, 0.2–1.0 27-gauge NR
Han et al., 201514 HA EME Dorsum, radix, tip, nasal sidewall, columella Range, 0.4–1.3 26-gauge needle, 23-gauge blunt cannula (in intramuscular and subcutaneous planes or if concern for vascular compromise) Supraperichondrial, supraperiosteal, intramuscular (dorsum), subcutaneous (dorsum)
Hedén, 201670 HA Variable Dorsum, tip, alar base Mean, 0.4 29-gauge needle Supraperichondrial, supraperiosteal, deep dermal (tip)
Helmy, 201859 HA (163), CaHA (19), botulinum toxin (111), other (39) Juvéderm Ultra 3 (Allergan) (HA), Radiesse (CaHA) Dorsum, radix, tip, anterior nasal spine, crura, columella NR 27-gauge needle Supraperichondrial, supraperiosteal (for saddle nose deformity only), deep dermal
Jacovella et al., 200655 CaHA Radiesse NR Range, 0.5–1.0 27-gauge needle Deep dermal
Jacovella, 200871 CaHA Radiesse Dorsum, radix, tip, anterior nasal spine Mean, 0.87 NR NR
Kose et al., 201372 HA Revanesse (Prollenium, Ontario, Quebec, Canada) Dorsum, supratip, nasal sidewall Range, 0.1–0.6 NR Supraperichondrial, supraperiosteal
Liew et al., 201673 HA Juvéderm Voluma Radix, anterior nasal spine, columella Up to 2.0 Needle (gauge NR) Supraperichondrial, supraperiosteal
Rauso et al., 201716 HA Juvéderm Voluma Dorsum, tip, anterior nasal spine, nasal sidewall, crura Mean, 0.8; range, 0.2–1.5 Needle (gauge NR) Supraperichondrial, supraperiosteal
Rho et al., 201774 HA YVOIRE Volume Plus (LG Life Sciences, Seoul, Republic of Korea) Dorsum, radix, tip, columella Mean, 0.69 27-gauge needle, 23-gauge blunt cannula NR
Rivkin, 201417 Collagen (porcine, with PMMA) Artefill (Suneva Medical, Inc., San Diego, Calif.) Dorsum, radix, tip, nasal sidewall Mean, 0.98 26-gauge needle Subdermal
Rokhsar and Ciocon, 200875 CaHA Radiesse Dorsum, radix, supratip, tip, alar sidewall Mean, 0.27 27-gauge needle Submuscular, subcutaneous
Sahan and Tamer, 201776 HA Juvéderm Volbella Dorsum, tip, columella Range, 0.5–0.9 22-gauge cannula Supraperichondrial, supraperiosteal
Schuster, 201553 CaHA (26), HA (20; with Vycross in 4) Juvéderm 4 (HA) Dorsum, radix, tip, sidewall, columella Range, 0.5–1.7 23-gauge needle (CaHA), 27- or 30-gauge needle (HA) Supraperichondrial, supraperiosteal
Siclovan and Jomah, 200977 CaHA Radiesse Dorsum Mean, 0.5 27-gauge needle Supraperichondrial, supraperiosteal
Solomon et al., 201257 Collagen (bovine) Artecoll Dorsum Mean, 0.2 NR NR
Tanaka, 201478 CaHA Radiesse Anterior nasal spine Range, 0.5–1.0 NR NR
Xue et al., 201254 HA Restylane-2 Dorsum, tip Range, 1.0–1.5 Needle (gauge NR) Supraperichondrial, supraperiosteal (dorsum), between greater alar cartilage (tip)
NR, not reported; HA, hyaluronic acid; CaHA, calcium hydroxyapatite; PMMA, polymethylmethacrylate.

Injection Technique

Injection technique was fairly consistent among the studies included in our review. The procedure was reportedly carried out by a physician in each study, with plastic surgery being the most common physician specialty. Technique generally involves application or injection of a local anesthetic followed by injection of small amounts of filler in serial droplets or by retrograde linear threading. Most physicians will use either a blunt- or needle-tip cannula ranging from 22- to 30-gauge. Han et al. describe using a 26-gauge needle, switching to a 23-gauge blunt cannula to minimize the risk of intravascular injection in cases where vascular compromise is a concern.14 Regarding the point of entry, some recommend entering the skin distal to the desired site to be injected, as local edema may distort the appearance of the area.8 The supraperiosteal or supraperichondrial plane was by far the most common level of filler deposition based on the studies included in this review. This ensures that the filler is placed below the plane of the superficial musculoaponeurotic system, which is rich in blood vessels.7 Still, however, there were several studies that endorsed injecting filler more superficially, into intramuscular, subcutaneous, or intradermal layers. This was typically done when augmenting the nasal tip and/or glabellar areas. The most common areas of filler augmentation were the nasal dorsum and the nasal tip. Still reported but less common were injections in the areas of the radix, nasal sidewall, columella, alar base, anterior nasal spine, and crura.

Patient Satisfaction

In terms of satisfaction, patients were highly satisfied, with an overall satisfaction rate of 94.94 percent (n = 1600). The amount of time between injection and assessment of patient satisfaction was highly variable (reported for 20 studies, n = 1511), ranging from 14 days to 18 months. For the purposes of this review, studies were designated as having either “short-term” follow-up, meaning satisfaction was measured within 6 months of injection, or “long-term” follow-up, with satisfaction measured at 6 months or greater after injection. Based on this designation, the short-term satisfaction rate was 95.19 percent (14 studies, n = 1415) and the long-term satisfaction rate was 89.58 percent (six studies, n = 96). The difference between short- and long-term satisfaction rates was statistically significant (p = 0.017), with a 95 percent confidence interval of 0.77 to 13.43 percent. Three studies documented one or more patients requiring additional injections between 2 and 4 weeks after the initial injection for minor touch-ups because of persistent nasal contour deficiencies.15–17 In these studies, patient satisfaction improved after touch-up injections were performed and was measured after additional touch-up injections were administered. Becker followed patients for 26 months, noting that 11 of the 22 total patients required at least two treatments to maintain effects. The average period between initial injection and repeated injection ranged from 6 to 14 months. Only one of these patients, who underwent a second injection after 13 months, reported being dissatisfied because of poor treatment longevity. Two patients required three injections within a 24-month period; however, both continued to report satisfaction with treatment after the third injection.18

Complications

Complications were noted to be rare among these studies, with only 26 total reported complications, or 1.63 percent. Reported complications included hematoma or ecchymosis (seven patients), nasal skin erythema (six patients), subcutaneous nodule formation (four patients), infection (five patients), filler dislocation (three patients), and local injection-site reaction (one patient). Of note, the five patients who developed an infection had been treated with calcium hydroxyapatite filler. There were no reports of granuloma or nodule formation after injection with hyaluronic acid. Notably, there were also no reports of vascular compromise leading to visual complications or local tissue ischemia.

Further analysis was performed to compare complication rates and satisfaction between patients who received hyaluronic acid injections and those who received calcium hydroxyapatite injections. The complication rate in the calcium hydroxyapatite group was 7.04 percent, whereas the complication rate in the hyaluronic acid group was 0.77 percent. This difference was statistically significant, with a 95 percent confidence interval of 3.39 to 10.71 percent (p < 0.0001). Overall satisfaction was also slightly higher in the hyaluronic acid group, with 94.33 percent of these patients reporting satisfaction, versus 92.31 percent reporting satisfaction in the calcium hydroxyapatite group; however, this was not statistically significant (p = 0.34)

Lastly, of note, in our review we came across several case studies documenting complications related to vascular compromise. The majority of these reports were published in Asian countries such as the People’s Republic of China and the Republic of Korea, where nasal augmentation with facial fillers is more frequently performed. These studies were not included in our data analysis, as they included fewer than five patients. Two studies had more than five patients with vascular compromise after injections in the nose; however, these could not be included in analysis because the authors did not comment on the overall number of patients who were treated initially. In total, we identified 65 documented cases of vascular compromise following filler injection in the nose. Thirty of these involved necrosis of the nasal skin.19–30 Thirty-three of these involved visual or ocular complaints, including central retinal artery occlusion and blindness in the most severe instances.31–50 There were two cases in which patients developed both visual symptoms and nasal skin necrosis.51,52 Hyaluronidase was used in 19 patients with vascular complications after hyaluronic acid injection, and was effective in preventing permanent sequelae in 16 of these cases.

DISCUSSION

Nonsurgical rhinoplasty is an increasingly popular alternative to traditional rhinoplasty, with a high overall patient satisfaction rate. It is important to note, however, that the effects of these nasal injections are temporary. Only four of the studies in our review reported specific data on treatment longevity, with the majority providing an approximate effect of treatment duration.15,18,53,54 Based on our data, best results can be expected to last for 6 months to 1 year. There is some evidence suggesting that calcium hydroxyapatite injections may provide longer lasting results than injections with hyaluronic acid.18,55 The majority of studies included in this review measured satisfaction by surveying patients within 6 months of injection, during the period in which injected filler volume remains stable. This suggests that these are largely short-term satisfaction measures that do not take into account treatment longevity. Based on the several studies that surveyed patients beyond 6 months of injection, satisfaction did appear to decline slightly after 6 months, although it was still over 92 percent. This underscores the importance of preprocedural patient education, as patients may be quite happy with the initial results but will likely require repeated injections within 1 to 2 years to maintain results. This makes nonsurgical rhinoplasty less ideal compared with traditional rhinoplasty for patients seeking permanent aesthetic nasal corrections; however, it can be a helpful tool for aiding decision-making in patients considering rhinoplasty.

Several options exist when choosing a specific filler material. The earliest reports of injectable fillers in the nose describe using collagen or silicone to correct minor postrhinoplasty deformities.12 Today, semipermanent materials such as hyaluronic acid and calcium hydroxyapatite are more commonly used. An advantage to using hyaluronic acid is that it can be rapidly dissolved with hyaluronidase in the case of misinjection or vascular complication; however, this was not required in any of the studies included in our review.4 Although calcium hydroxyapatite may provide longer lasting results than hyaluronic acid, it appears to be associated with more complications based on our review. Schuster comments on this in his prospective study, in which the decision was made to use hyaluronic acid only after several patients experienced significant calcium hydroxyapatite–related complications.53 We observed a similar trend in our review, with the complication rate for calcium hydroxyapatite being almost 10 times higher than the complication rate for hyaluronic acid. There was, however, a significantly smaller sample size of patients receiving calcium hydroxyapatite injections. Interestingly, patient satisfaction did not differ significantly between these two filler groups. This may be because the majority of observed complications were minor; however, the risk of complications should still be weighed against desired treatment longevity when choosing a filler.

Although not included in our review, several studies have also achieved good results with autologous tissue grafts using injectable fat or diced cartilage to reshape the nose.2,3,56 A drawback to using autologous tissue is that it necessitates an initial surgical procedure for tissue harvest. The use of bovine or porcine collagen circumvents this issue, which we saw in several of the included studies.15,17,57 Lastly, botulinum toxin can be used either alone or in combination with filler injection to alter nasal appearance.58–60 This is most effective in increasing nasal tip projection, as overactivity of the paired depressor nasi septi muscles is present in many patients seeking correction of nasal tip ptosis.61 Braccini and Dohan Ehrenfest noted that the effects of botulinum toxin injections wear off after approximately 4 months, versus the effects of filler, which last for 1 year or longer.58

The most commonly encountered adverse events related to nonsurgical rhinoplasty include transient edema, erythema, and bruising. These generally will resolve within 1 week after injection, but rarely can persist for longer periods. Nodule formation is also possible, which can be the result of superficial injection or granuloma formation. Risk of nodule formation may be higher with calcium hydroxyapatite than with hyaluronic acid, because of its higher viscoelasticity.5,62 There were four reports of nodule formation in our review, only one of which occurred following calcium hydroxyapatite injection. The other three cases occurred in patients receiving bovine collagen, which was injected subdermally, rather than into the supraperichondrial or supraperiosteal plane. Injection-site infection is another possible complication of nonsurgical rhinoplasty, and this was seen in five patients in our review. Notably, four of the five cases of infection occurred in patients treated with calcium hydroxyapatite. Each of these patients was treated with antibiotics, and infection resolved without permanent sequelae in all except for one patient who was lost to follow-up. None of the authors commented on function of the nose following nonsurgical rhinoplasty; however, Alharethy did find that sensation of the overlying nasal skin was not affected after calcium hydroxyapatite injection.63

Although facial filler injections are generally regarded as safe procedures with minimal risk, nonsurgical rhinoplasty carries the potential for serious complications if injection is not performed properly. The most feared complications of injections in the nose involve vascular compromise. This can be caused by intraarterial injection with filler emboli to the ophthalmic artery or by external vascular compression secondary to excessive volume injection or edema.10 In our review, we found over 50 instances of vascular complications leading to either visual compromise or necrosis of the nasal skin. Most of the published literature documenting cases of vascular compromise consist of case reports; however, Sun et al. report 15 cases of vascular compromise with impending skin necrosis following hyaluronic acid injections in the nose over a 7-year period.23 Thirteen patients were treated with hyaluronidase, and this treatment was effective in preventing the development of nasal skin necrosis in 11 of these patients. Among the studies documenting visual complications, hyaluronidase was used in two cases, after which both patients achieved complete resolution of visual symptoms.39,41 This suggests that early administration of local hyaluronidase may be an effective agent for treating vascular compromise following nasal injections with hyaluronic acid.

Interestingly, there was not a single case of vascular compromise across the 23 studies included in our review. This may represent a reporting bias, as our review includes only studies with five or more patients and thus is not representative of the entirety of physicians in practice. Although such complications are rare, the true incidence remains unknown. The risk of vascular compromise may be higher, however, in patients with prior surgical rhinoplasty, as the native vasculature has been altered and there may be decreased collateral circulation to certain areas.22,23 A thorough understanding of facial vascular anatomy is essential for preventing these complications, as blindness and skin necrosis have been reported following filler injection in other areas of the face as well. In a systematic review specifically evaluating blindness after soft-tissue filler use, Chatrath et al. identified 190 cases in total. Injections in the nose accounted for less than 25 percent of these cases, with the glabellar complex being the most common injection location.64 In addition, in a multinational survey, Goodman et al. found the frequency of intravascular injection with facial fillers to be equal in both the nose and the nasolabial folds.65 Thus, although nonsurgical rhinoplasty does carry the risk of vascular compromise after injection, this risk is similarly present when augmenting other areas of the face, such as the glabella and nasolabial folds.

Practitioners should take several factors into account when performing nonsurgical rhinoplasty to minimize the risk of vascular complications. As previously stated, thorough knowledge of vascular anatomy in the nose and forehead is critical. Although multiple studies in our review documented injections into the nasal sidewall without complication, it is generally advisable to limit injections to the midline of the nose to avoid the dorsal nasal arteries on either side. One should also avoid injecting large volumes of filler into the nasal tip, as this area may be especially at risk for vascular congestion. Given that the total volume injected per nose in our review was 0.54 ml on average, only small amounts of filler are necessary per injection site to produce noticeable changes. Other safety recommendations made by authors in the reviewed articles include the use of a topical vasoconstrictor before injection, aspiration before injection, and injecting in 0.1-ml increments at a time.24,66,67 Injections should be ceased immediately if patients develop any symptoms suggestive of vascular compromise, which include skin blanching, severe localized injection-site pain, eye or tooth pain, visual changes, and headache. Lastly, hyaluronic acid appears to be the safest choice of filler, as hyaluronidase can be used to degrade the product if too much volume is injected or if there is concern for intravascular injection.

There are several limitations present in our systematic review. A major factor limiting our ability to analyze outcomes was the lack of a common scale for measuring patient satisfaction. Although the majority of studies reported satisfaction in more specific terms than simply satisfied versus not satisfied, the scales used were highly variable. Studies also differed in the way they defined points on numerical satisfaction scales, making it impossible to standardize these data. We were also limited by the fact that very few of the studies reported satisfaction based on specific subgroups of treated patients. Because of this, we were unable to compare outcomes based on certain characteristics such as history of surgical rhinoplasty, age, or location of injection. Lastly, there are limited published data on long-term outcomes and the desire for repeated injections or eventual surgical rhinoplasty. Only three of the studies followed patients for 12 months or longer, making it difficult to accurately assess treatment longevity. Additional studies that follow patients receiving nonsurgical rhinoplasty over several years would be helpful to better understand the efficacy of this intervention.

CONCLUSIONS

This review provides new insight into the practice patterns, technique, longevity, patient satisfaction, and complications of nonsurgical rhinoplasty. The depth of our analysis was limited by the paucity of available data and the highly variable methods in which outcomes for nonsurgical rhinoplasty are reported in the literature. The literature demonstrates that nonsurgical rhinoplasty is an effective temporary alternative to traditional augmentation rhinoplasty for corrections of nasal shape, with a high degree of patient satisfaction. Complications may be underreported, and further investigation is needed to better understand patient selection, best practice techniques, and the true incidence of major complications related to vascular compromise (i.e., skin necrosis and blindness).

REFERENCES

1. American Society of Plastic Surgeons. 2018 national plastic surgery statistics report. Available at: https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Accessed January 10, 2018.
2. Baptista C, Nguyen PS, Desouches C, Magalon G, Bardot J, Casanova D. Correction of sequelae of rhinoplasty by lipofilling. J Plast Reconstr Aesthet Surg. 2013;66:805–811.
3. Erol OO. Injection of compressed diced cartilage in the correction of secondary and primary rhinoplasty: A new technique with 12 years’ experience. Plast Reconstr Surg. 2017;140:673e–685e.
4. Kontis TC. Nonsurgical rhinoplasty. JAMA Facial Plast Surg. 2017;19:430–431.
5. Humphrey CD, Arkins JP, Dayan SH. Soft tissue fillers in the nose. Aesthet Surg J. 2009;29:477–484.
6. Thomas WW, Bucky L, Friedman O. Injectables in the nose: Facts and controversies. Facial Plast Surg Clin North Am. 2016;24:379–389.
7. Johnson ON III, Kontis TC. Nonsurgical rhinoplasty. Facial Plast Surg. 2016;32:500–506.
8. Jasin ME. Nonsurgical rhinoplasty using dermal fillers. Facial Plast Surg Clin North Am. 2013;21:241–252.
9. Mai JP, Haring CT, Hopping S, Chaboki H. “Nonsurgical rhinoplasty”: Achieving nasal contour through the use of neuromodulators and tissue fillers. Am J Cosmet Surg. 2016;33:133–139.
10. Moon HJ. Use of fillers in rhinoplasty. Clin Plast Surg. 2016;43:307–317.
11. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med. 2009;151:264–269, W64.
12. Webster RC, Hamdan US, Gaunt JM, Fuleihan NS, Smith RC. Rhinoplastic revisions with injectable silicone. Arch Otolaryngol Head Neck Surg. 1986;112:269–276.
13. Goodman GJ, Swift A, Remington BK. Current concepts in the use of Voluma, Volift, and Volbella. Plast Reconstr Surg. 2015;136(Suppl):139S–148S.
14. Han X, Hu J, Cheng L, Li F. Multiplane hyaluronic acid (EME) in female Chinese rhinoplasty using blunt and sharp needle technique. J Plast Reconstr Aesthet Surg. 2015;68:1504–1509.
15. Cassuto D. The use of Dermicol-P35 dermal filler for nonsurgical rhinoplasty. Aesthet Surg J. 2009;29(Suppl):S22–S24.
16. Rauso R, Colella G, Zerbinati N, Salti G. Safety and early satisfaction assessment of patients seeking nonsurgical rhinoplasty with filler. J Cutan Aesthet Surg. 2017;10:207–214.
17. Rivkin A. A prospective study of non-surgical primary rhinoplasty using a polymethylmethacrylate injectable implant. Dermatol Surg. 2014;40:305–313.
18. Becker H. Nasal augmentation with calcium hydroxylapatite in a carrier-based gel. Plast Reconstr Surg. 2008;121:2142–2147.
19. Chen Q, Liu Y, Fan D. Serious vascular complications after nonsurgical rhinoplasty: A case report. Plast Reconstr Surg Glob Open 2016;4:e683.
20. Grunebaum LD, Bogdan Allemann I, Dayan S, Mandy S, Baumann L. The risk of alar necrosis associated with dermal filler injection. Dermatol Surg. 2009;35(Suppl 2):1635–1640.
21. Kim SK, Kim JH, Hwang K. Skin necrosis of the nose after injection of ribose cross-linked porcine atelocollagen. J Craniofac Surg. 2015;26:2211–2212.
22. Robati RM, Moeineddin F, Almasi-Nasrabadi M. The risk of skin necrosis following hyaluronic acid filler injection in patients with a history of cosmetic rhinoplasty. Aesthet Surg J. 2018;38:883–888.
23. Sun ZS, Zhu GZ, Wang HB, et al. Clinical outcomes of impending nasal skin necrosis related to nose and nasolabial fold augmentation with hyaluronic acid fillers. Plast Reconstr Surg. 2015;136:434e–441e.
24. Beleznay K, Humphrey S, Carruthers JD, Carruthers A. Vascular compromise from soft tissue augmentation: Experience with 12 cases and recommendations for optimal outcomes. J Clin Aesthet Dermatol. 2014;7:37–43.
25. Fan X, Dong M, Li T, Ma Q, Yin Y. Two cases of adverse reactions of hyaluronic acid-based filler injections. Plast Reconstr Surg Glob Open 2016;4:e1112.
26. Kim SG, Kim YJ, Lee SI, Lee CJ. Salvage of nasal skin in a case of venous compromise after hyaluronic acid filler injection using prostaglandin E. Dermatol Surg. 2011;37:1817–1819.
27. Kim DW, Yoon ES, Ji YH, Park SH, Lee BI, Dhong ES. Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management. J Plast Reconstr Aesthet Surg. 2011;64:1590–1595.
28. Xiaoling F, Yi C, Zhang Y, et al. Analysis of the complications induced by polyacrylamide hydrogel injection. Plast Reconstr Surg. 2004;114:261–262.
29. Hsien-Li Peng P, Peng JH. Delayed paleness after hyaluronic acid filler injection: A warning sign of vascular compromise. Dermatol Surg. 2018;44:590–592.
30. Honart JF, Duron JB, Mazouz Dorval S, Rausky J, Revol M. A case of nasal tip necrosis after hyaluronic acid injection (in French). Ann Chir Plast Esthet. 2013;58:676–679.
31. Chou CC, Chen HH, Tsai YY, Li YL, Lin HJ. Choroid vascular occlusion and ischemic optic neuropathy after facial calcium hydroxyapatite injection: A case report. BMC Surg. 2015;15:21.
32. Cohen E, Yatziv Y, Leibovitch I, et al. A case report of ophthalmic artery emboli secondary to calcium hydroxylapatite filler injection for nose augmentation: Long-term outcome. BMC Ophthalmol. 2016;16:98.
33. Marumo Y, Hiraoka M, Hashimoto M, Ohguro H. Visual impairment by multiple vascular embolization with hydroxyapatite particles. Orbit 2018;37:165–170.
34. Kim YJ, Kim SS, Song WK, Lee SY, Yoon JS. Ocular ischemia with hypotony after injection of hyaluronic acid gel. Ophthalmic Plast Reconstr Surg. 2011;27:e152–e155.
35. Kim SN, Byun DS, Park JH, et al. Panophthalmoplegia and vision loss after cosmetic nasal dorsum injection. J Clin Neurosci. 2014;21:678–680.
36. Kim EG, Eom TK, Kang SJ. Severe visual loss and cerebral infarction after injection of hyaluronic acid gel. J Craniofac Surg. 2014;25:684–686.
37. Hsieh YH, Lin CW, Huang JS, Yeh PT. Severe ocular complications following facial calcium hydroxylapatite injections: Two case reports. Taiwan J Ophthalmol. 2015;5:36–39.
38. Kim YJ, Choi KS. Bilateral blindness after filler injection. Plast Reconstr Surg. 2013;131:298e–299e.
39. Sharudin SN, Ismail MF, Mohamad NF, Vasudevan SK. Complete recovery of filler-induced visual loss following subcutaneous hyaluronidase injection. Neuroophthalmology 2019;43:102–106.
40. Xing L, Almeida DR, Belliveau MJ, et al. Ophthalmic artery occlusion secondary to fat emboli after cosmetic nasal injection of autologous fat. Retina 2012;32:2175–2176.
41. Bae IH, Kim MS, Choi H, Na CH, Shin BS. Ischemic oculomotor nerve palsy due to hyaluronic acid filler injection. J Cosmet Dermatol. 2018;17:1016–1018.
42. Chen W, Wu L, Jian XL, et al. Retinal branch artery embolization following hyaluronic acid injection: A case report. Aesthet Surg J. 2016;36:NP219–NP224.
43. Vu PQ, Grob SR, Tao JP. Light perception vision recovery after treatment for calcium hydroxylapatite cosmetic filler-induced blindness. Ophthalmic Plast Reconstr Surg. 2018;34:e189–e192.
44. Thanasarnaksorn W, Cotofana S, Rudolph C, Kraisak P, Chanasumon N, Suwanchinda A. Severe vision loss caused by cosmetic filler augmentation: Case series with review of cause and therapy. J Cosmet Dermatol. 2018;17:712–718.
45. Schelke LW, Fick M, van Rijn LJ, Decates T, Velthuis PJ, Niessen F. Unilateral blindness following a non-surgical rhinoplasty with filler (in Dutch). Ned Tijdschr Geneeskd. 2017;161:D1246.
46. Lin YC, Chen WC, Liao WC, Hsia TC. Central retinal artery occlusion and brain infarctions after nasal filler injection. QJM 2015;108:731–732.
47. Hu XZ, Chen SQ, Zhang Q, Wu PS, Lu W. Clinical analysis of visual loss caused by facial cosmetic fillers injection (in Chinese). Zhonghua Yan Ke Za Zhi 2017;53:594–598.
48. Chen Y, Wang W, Li J, Yu Y, Li L, Lu N. Fundus artery occlusion caused by cosmetic facial injections. Chin Med J (Engl.) 2014;127:1434–1437.
49. Chang TY, Pan SC, Huang YH, Hsueh YY. Blindness after calcium hydroxylapatite injection at nose. J Plast Reconstr Aesthet Surg. 2014;67:1755–1757.
50. Luchi T. A case report: Blindness following cosmetic injections of the nose. Jap J Plast Surg. 2015;58:958–961.
51. Lee JI, Kang SJ, Sun H. Skin necrosis with oculomotor nerve palsy due to a hyaluronic acid filler injection. Arch Plast Surg. 2017;44:340–343.
52. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and ischemic oculomotor nerve palsy after vascular embolization of injectable calcium hydroxylapatite filler. Ophthalmic Plast Reconstr Surg. 2010;26:289–291.
53. Schuster B. Injection rhinoplasty with hyaluronic acid and calcium hydroxyapatite: A retrospective survey investigating outcome and complication rates. Facial Plast Surg. 2015;31:301–307.
54. Xue K, Chiang CA, Liu K, Gu B, Li Q. Multiplane hyaluronic acid rhinoplasty. Plast Reconstr Surg. 2012;129:371e–372e.
55. Jacovella PF, Peiretti CB, Cunille D, Salzamendi M, Schechtel SA. Long-lasting results with hydroxylapatite (Radiesse) facial filler. Plast Reconstr Surg. 2006;118(Suppl):15S–21S.
56. Monreal J. Fat grafting to the nose: Personal experience with 36 patients. Aesthetic Plast Surg. 2011;35:916–922.
57. Solomon P, Sklar M, Zener R. Facial soft tissue augmentation with Artecoll: A review of eight years of clinical experience in 153 patients. Can J Plast Surg. 2012;20:28–32.
58. Braccini F, Dohan Ehrenfest DM. Medical rhinoplasty: Rationale for atraumatic nasal modelling using botulinum toxin and fillers (in French). Rev Laryngol Otol Rhinol (Bord.) 2008;129:233–238.
59. Helmy Y. Non-surgical rhinoplasty using filler, Botox, and thread remodeling: Retro analysis of 332 cases. J Cosmet Laser Ther. 2018;20:293–300.
60. Redaelli A. Medical rhinoplasty with hyaluronic acid and botulinum toxin A: A very simple and quite effective technique. J Cosmet Dermatol. 2008;7:210–220.
61. Dayan SH, Greene RM, Chambers AA. Long-lasting injectable implant for correcting cosmetic nasal deformities. Ear Nose Throat J. 2007;86:25–26.
62. Rho NK, Chang YY, Chao YY, et al. Consensus recommendations for optimal augmentation of the Asian face with hyaluronic acid and calcium hydroxylapatite fillers. Plast Reconstr Surg. 2015;136:940–956.
63. Alharethy S. Alterations in nasal sensibility following calcium hydroxyapatite dorsal augmentation. J Craniofac Surg. 2018;29:e104–e106.
64. Chatrath V, Banerjee PS, Goodman GJ, Rahman E. Soft-tissue filler-associated blindness: A systematic review of case reports and case series. Plast Reconstr Surg Glob Open 2019;7:e2173.
65. Goodman GJ, Roberts S, Callan P. Experience and management of intravascular injection with facial fillers: Results of a multinational survey of experienced injectors. Aesthetic Plast Surg. 2016;40:549–555.
66. Carruthers J, Rzany B, Sattler G, Carruthers A. Anatomic guidelines for augmentation of the cheek and infraorbital hollow. Dermatol Surg. 2012;38:1223–1233.
67. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S. Blindness following cosmetic injections of the face. Plast Reconstr Surg. 2012;129:995–1012.
68. Amore R, Donnamaria D, Marini F, Amuso D, Leonardi V, Di Vito Francesco M. Nonsurgical rhinoplasty with injectable fillers: Italian technique for reshaping the tip of the nose. Am J Cosmet Surg. 2015;32:172–177.
69. Bertossi D, Lanaro L, Dorelan S, Johanssen K, Nocini P. Nonsurgical rhinoplasty: Nasal grid analysis and nasal injecting protocol. Plast Reconstr Surg. 2019;143:428–439.
70. Hedén P. Nasal reshaping with hyaluronic acid: An alternative or complement to surgery. Plast Reconstr Surg Glob Open 2016;4:e1120.
71. Jacovella PF. Aesthetic nasal corrections with hydroxylapatite facial filler. Plast Reconstr Surg. 2008;121:338e–339e.
72. Kose R, Erdivanli OC, Coskun ZO. Use of hyaluronic acid in the correction of contour asymmetries following rhinoplasty. Eur J Plast Surg. 2013;36:295–300.
73. Liew S, Scamp T, de Maio M, et al. Efficacy and safety of a hyaluronic acid filler to correct aesthetically detracting or deficient features of the Asian nose: A prospective, open-label, long-term study. Aesthet Surg J. 2016;36:760–772.
74. Rho NK, Park JY, Youn CS, Lee SK, Kim HS. Early changes in facial profile following structured filler rhinoplasty: An anthropometric analysis using a 3-dimensional imaging system. Dermatol Surg. 2017;43:255–263.
75. Rokhsar C, Ciocon DH. Nonsurgical rhinoplasty: An evaluation of injectable calcium hydroxylapatite filler for nasal contouring. Dermatol Surg. 2008;34:944–946.
76. Sahan A, Tamer F. Non-surgical minimally invasive rhinoplasty: Tips and tricks from the perspective of a dermatologist. Acta Dermatovenerol Alp Pannonica Adriat. 2017;26:101–103.
77. Siclovan HR, Jomah JA. Injectable calcium hydroxylapatite for correction of nasal bridge deformities. Aesthetic Plast Surg. 2009;33:544–548.
78. Tanaka Y. Oriental nose occidentalization and perinasal shaping by augmentation of the underdeveloped anterior nasal spine. Plast Reconstr Surg Glob Open 2014;2:e197.

Supplemental Digital Content

Copyright © 2020 by the American Society of Plastic Surgeons