COSMETIC

Nonsurgical Rhinoplasty: A Systematic Review

of Technique, Outcomes, and Complications
Lauren C. Williams, B.A.
Background: Nonsurgical rhinoplasty using filler injections has become a com-
Sarah M. Kidwai, M.D.
mon procedure in cosmetic practices. This is offered to patients that prefer a
Karan Mehta, M.D.
temporary outcome or would like to avoid general anesthesia. In addition, it
George Kamel, M.D.
Downloaded from https://journals.lww.com/plasreconsurg by zl3Fhsy9EaViocT2KUJxBCSZMSaUIdlPBWekTaEk5NfhhRSDUXKNYsDbHClE7C8rJcSHVRDF45u80qN2wpgyejdTxASi/1RRUVru9tyUnUebdTsu3K9A1ZEva/iPwbcH on 07/19/2020

can be used in postrhinoplasty patients to correct nasal deformities or irregu-

Oren M. Tepper, M.D.
Joshua D. Rosenberg, M.D.
New York and Bronx, N.Y.
larities. This systematic review highlights common filler types and injection
techniques, and associated patient satisfaction and complications to further
guide practitioners.
Methods: A systematic review was performed using keywords and Medical
Subject Headings search terms. PubMed, EmBase, the Cochrane Library, and
Scopus were searched using the appropriate search terms. Data collected from
each study included patient satisfaction and complications, in addition to injec-
tion material, location, and technique.
Results: Four thousand six hundred thirty-two studies were found based on
search criteria. After full-text screening for inclusion and exclusion criteria,
23 studies were included. A total of 1600 patients underwent nonsurgical rhi-
noplasty, most commonly with hyaluronic acid (73.38 percent), followed by
calcium hydroxyapatite (12.44 percent). Nearly 95 percent of patients were
satisfied with results, and there were only 26 relatively minor complications
reported. There were no reports of vascular complications such as skin necrosis
or visual compromise.
Conclusions: Based on the authors’ review of the literature, nonsurgical rhino-
plasty is an effective temporary alternative to traditional augmentation rhino-
plasty for corrections of nasal shape with a high degree of patient satisfaction.
Complications may be underreported, and thus further investigation is needed
to better understand the true incidence of major complications related to
vascular compromise.  (Plast. Reconstr. Surg. 146: 41, 2020.)

R
hinoplasty is the third most common pro-
cedure performed by plastic surgeons in
the United States.1 Slight imperfections or
irregularities after rhinoplasty can often be cor-
rected 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 popu-
larity as the primary option for changing nasal
From the Department of Otolaryngology–Head and Neck
Surgery, Icahn School of Medicine at Mount Sinai; and the
Department of Surgery, Division of Plastic and Reconstruc-
tive Surgery, Albert Einstein College of Medicine, Montefiore
Medical Center.
Received for publication July 7, 2019; accepted January 2,
2020.
Presented at the American Academy of Facial Plastic and Re-
constructive Surgery and Combined Otolaryngology Spring
Meetings, in Austin, Texas, May 1 through 5, 2019.
Copyright © 2020 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000006892
appearance. Nonsurgical rhinoplasty generally
involves the use of either synthetic or autologous
fillers into deficient areas of the nose with exter-
nal 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
Disclosure: The authors do not have any financial
conflicts of interest to disclose.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

www.PRSJournal.com 41
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

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 usu-
ally temporary. More rare yet devastating compli-
cations 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 dor-
sum, correct a deep radix, lengthen the nose, or
alter the nasolabial angle.7
Despite nonsurgical rhinoplasty rapidly grow-
ing in popularity, there is no literature on the most
common filler materials used, injection technique,
and injection location. Much of the published lit-
erature consists of case reports and general discus-
sion 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 Pre-
ferred 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 com-
plete list of keywords and medical subject head-
ings is reported. (See Table, Supplemental Digital
Content 1, which shows the search syntax used in
this study, http://links.lww.com/PRS/E101.) Resul-
tant records were then imported into Covidence
systematic review software (Veritas Health Innova-
tion, 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.
42
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • July 2020
Studies were included if they involved the
use of injectable material to alter nasal appear-
ance, 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 out-
comes, 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 car-
tilage 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 tech-
nique, including the type of injected material
and injection instrument, location, plane, and
volume. When applicable, proportions were com-
pared 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 screen-
ing 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 tech-
niques 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. Thir-
teen 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
 Volume 146, Number 1 • Nonsurgical Rhinoplasty
Fig. 1. Study selection process.
patients (52.9 percent) had previously undergone
a surgical rhinoplasty and were receiving nasal
injections for correction of persistent postsurgi-
cal deformities. Specialties of treating physicians
in each study included plastic surgery [12 stud-
ies (52 percent)], otolaryngology/ear, nose, and
throat [five studies (22 percent)], dermatology
[four studies (17 percent)], and oral and maxillo-
facial surgery [two studies (9 percent)]. Specialty
breakdown is provided in Table 11–78 and Figure 2.
Injection Types
Injection choice and injection technique for
each study are recorded in Table 2. The most com-
monly used filler was hyaluronic acid, which was
used in 1174 patients [n = 1600 (73.38 percent)].
One hundred ninety-nine patients (12.44 per-
cent) 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 stud-
ies using hyaluronic acid filler, two studies (154
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
patients) reported the use of hyaluronic acid cross-
linked 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.
Injection Technique
Injection technique was fairly consistent
among the studies included in our review. The
procedure was reportedly carried out by a physi-
cian in each study, with plastic surgery being the
most common physician specialty. Technique gen-
erally involves application or injection of a local
anesthetic followed by injection of small amounts
43
 Plastic and Reconstructive Surgery • July 2020

Table 1.  Overview of Included Studies

Prior Patient
Primary No. of Rhinoplasty Filler Type Follow- Satisfaction Complications
Reference Specialty Patients (%) (No., if multiple) Up* (%) (No.)
Alharethy, ENT 30 0.00 CaHA 14 days 90 Erythema (2)
201863
Amore et al., Plastic surgery 212 44.34 HA 3 mo 90.57 None
201568
Becker, 200818 Plastic surgery 24 62.50 CaHA 10 mo 92 None
Bertossi et al., OMFS 150 27.33 HA (with Vycross; 14 days 96.67 Hematoma (2)
201969 Allergan, Inc.,
Dublin, Ireland)
Braccini and ENT 85 62.35 HA (56), CaHA (11), 30 days 91.76 Infection (1)
Dohan botulinum
Ehrenfest, toxin (12),
200858 other (6)
Cassuto, 200915 Plastic surgery 14 14.29 Collagen (porcine) NR 100 None
Han et al., Plastic surgery 280 5.36 HA 30 days 93.21 None
201514
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), <6 mo 100 Infection (1)
botulinum
toxin (111),
other (39)
Jacovella et al., Plastic surgery 5 NR CaHA 18 mo 100 None
200655
Jacovella, Plastic surgery 25 0.00 CaHA NR 92 Ecchymosis/
200871 hematoma (3)
Kose et al., ENT 12 100.00 HA 30 days 100 None
201372
Liew et al., Plastic surgery 29 0.00 HA 421 days 89.70 Filler displacement (2),
201673 injection site
reaction (1)
Rauso et al., OMFS 52 5.77 HA 15 days 100 None
201716
Rho et al., Dermatology 40 21.05 HA 14 days 100 None
201774
Rivkin, 201417 Dermatology 19 0.00 Collagen (porcine, 12 mo 84.21 Nodule formation (3)
with PMMA)
Rokhsar and Dermatology 14 0.00 CaHA 6 mo 100 None
Ciocon,
200875
Sahan and Dermatology 35 6.52 HA <6 mo 100 None
Tamer, 201776
Schuster, 2015 ENT
53
46 NR CaHA (26), HA (20; <21 mo 84.79 Filler displacement (1),
with Vycross in 4) hematoma (1),
nodule formation (1),
infection (3),
erythema (1)
Siclovan and Plastic surgery 5 100.00 CaHA 6 mo 100 None
Jomah, 200977
Solomon et al., ENT 26 0.00 Collagen (bovine) 3 mo 100 None
201257
Tanaka, 201478 Plastic surgery 40 100.00 CaHA 7 days 95 None
Xue et al., Plastic surgery 50 0.00 HA NR 98 None
201254
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.

of filler in serial droplets or by retrograde lin-
ear 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 appear-
ance of the area.8 The supraperiosteal or suprap-
erichondrial 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 mus-
culoaponeurotic system, which is rich in blood

44
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 146, Number 1 • Nonsurgical Rhinoplasty
Fig. 2. Injector specialty. ENT, otolaryngology/ear, nose, and
throat; OMFS, oral and maxillofacial surgery.
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 satisfac-
tion 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
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
satisfaction improved after touch-up injections
were performed and was measured after addi-
tional 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 dis-
satisfied 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 com-
plications, or 1.63 percent. Reported complica-
tions 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 devel-
oped 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 sat-
isfaction 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 hydroxyapa-
tite group; however, this was not statistically sig-
nificant (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.
45
 Plastic and Reconstructive Surgery • July 2020

Table 2.  Injection Techniques

Total
Volume
Filler Filler Location Injected per Injection Injection
Reference Type Brand Injected Patient (ml) Instrument Plane
Alharethy, CaHA Radiesse (Merz Dorsum, tip Mean, 1.0 22-gauge blunt Supraperichondrial,
201863 Pharma GmbH cannula supraperiosteal
& Co, Frank-
furt, Germany)
Amore et al., HA Variable Tip Mean, 27-gauge needle Supraperichondrial,
201568 0.41 supraperiosteal
Becker, CaHA Radiesse Dorsum, tip, Range, 25-gauge needle NR
200818 nasal sidewall, 0.25–1.3
columella
Bertossi et HA (with NR Dorsum, tip, Range, 27-gauge needle Supraperichondrial,
al., 201969 Vycross) anterior nasal 0.6–2.2 supraperiosteal,
spine, columella, deep dermal (tip,
glabella, alar glabella, ala)
sidewall
Braccini and HA (56), CaHA Variable Radix, anterior NR 32-gauge needle Supraperichondrial,
Dohan (11), botulinum nasal spine supraperiosteal,
Ehrenfest, toxin (12), subcutaneous
200858 other (6) (anterior nasal
spine)
Cassuto, Collagen Dermicol-P35 NR Mean, 0.6; 27-gauge NR
200915 (porcine) (Ortho range,
Dermatologics, 0.2–1.0
Skillman, N.J.)
Han et al., HA EME Dorsum, radix, tip, Range, 26-gauge needle, Supraperichondrial,
201514 nasal sidewall, 0.4–1.3 23-gauge blunt supraperiosteal,
columella cannula (in intra- intramuscular
muscular and (dorsum),
subcutaneous subcutaneous
planes or if con- (dorsum)
cern for vascular
compromise)
Hedén, HA Variable Dorsum, tip, alar Mean, 0.4 29-gauge needle Supraperichondrial,
201670 base supraperiosteal,
deep dermal (tip)
Helmy, HA (163), CaHA Juvéderm Ultra Dorsum, radix, tip, NR 27-gauge needle Supraperichondrial,
2018 59
(19), botulinum 3 (Allergan) anterior nasal supraperiosteal
toxin (111), (HA), Radiesse spine, crura, (for saddle nose
other (39) (CaHA) columella deformity only),
deep dermal
Jacovella et al., CaHA Radiesse NR Range, 27-gauge needle Deep dermal
2006 55
0.5–1.0
Jacovella, CaHA Radiesse Dorsum, radix, tip, Mean, NR NR
200871 anterior nasal 0.87
spine
Kose et al., HA Revanesse Dorsum, supratip, Range, NR Supraperichondrial,
2013 72
(Prollenium, nasal sidewall 0.1–0.6 supraperiosteal
Ontario, Que-
bec, Canada)
Liew et al., HA Juvéderm Radix, anterior nasal Up to 2.0 Needle (gauge Supraperichondrial,
2016 73
Voluma spine, columella NR) supraperiosteal
Rauso et al., HA Juvéderm Dorsum, tip, ante- Mean, 0.8; Needle (gauge Supraperichondrial,
201716 Voluma rior nasal spine, range, NR) supraperiosteal
nasal sidewall, 0.2–1.5
crura
Rho et al., HA YVOIRE Volume Dorsum, radix, tip, Mean, 27-gauge needle, NR
2017 74
Plus (LG Life columella 0.69 23-gauge blunt
Sciences, cannula
Seoul, Repub-
lic of Korea)
Rivkin, Collagen (por- Artefill (Suneva Dorsum, radix, tip, Mean, 26-gauge needle Subdermal
2014 17
cine, with Medical, Inc., nasal sidewall 0.98
PMMA) San Diego,
Calif.)
Rokhsar and CaHA Radiesse Dorsum, radix, Mean, 27-gauge needle Submuscular,
Ciocon, supratip, tip, alar 0.27 subcutaneous
2008 75
sidewall
(Continued)

46
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 146, Number 1 • Nonsurgical Rhinoplasty

Table 2.  Continued

Total
Volume
Filler Filler Location Injected per Injection Injection
Reference Type Brand Injected Patient (ml) Instrument Plane
Sahan and HA Juvéderm Dorsum, tip, Range, 22-gauge cannula Supraperichondrial,
Tamer, Volbella columella 0.5–0.9 supraperiosteal
201776
Schuster, CaHA (26), Juvéderm 4 Dorsum, radix, Range, 23-gauge needle Supraperichondrial,
201553 HA (20; with (HA) tip, sidewall, 0.5–1.7 (CaHA), 27- or supraperiosteal
Vycross in 4) columella 30-gauge
needle (HA)
Siclovan and CaHA Radiesse Dorsum Mean, 0.5 27-gauge needle Supraperichondrial,
Jomah, supraperiosteal
200977
Solomon et Collagen Artecoll Dorsum Mean, 0.2 NR NR
al., 201257 (bovine)
Tanaka, CaHA Radiesse Anterior nasal Range, NR NR
201478 spine 0.5–1.0
Xue et al., HA Restylane-2 Dorsum, tip Range, Needle (gauge Supraperichondrial,
201254 1.0–1.5 NR) supraperiosteal
(dorsum), between
greater alar
cartilage (tip)
NR, not reported; HA, hyaluronic acid; CaHA, calcium hydroxyapatite; PMMA, polymethylmethacrylate.

These studies were not included in our data analy-
sis, 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 vas-
cular 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 hyal-
uronic acid injection, and was effective in prevent-
ing 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 impor-
tant 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 approxi-
mate 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 aes-
thetic nasal corrections; however, it can be a help-
ful tool for aiding decision-making in patients
considering rhinoplasty.
Several options exist when choosing a specific
filler material. The earliest reports of injectable fill-
ers 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 complica-
tion; 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.

47
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

Schuster comments on this in his prospective study,
in which the decision was made to use hyaluronic
acid only after several patients experienced sig-
nificant calcium hydroxyapatite–related complica-
tions.53 We observed a similar trend in our review,
with the complication rate for calcium hydroxyapa-
tite being almost 10 times higher than the complica-
tion rate for hyaluronic acid. There was, however, a
significantly smaller sample size of patients receiv-
ing calcium hydroxyapatite injections. Interest-
ingly, 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 autol-
ogous 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 cal-
cium 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 com-
plication 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
48
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • July 2020
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 gener-
ally regarded as safe procedures with minimal
risk, nonsurgical rhinoplasty carries the potential
for serious complications if injection is not per-
formed properly. The most feared complications
of injections in the nose involve vascular compro-
mise. This can be caused by intraarterial injection
with filler emboli to the ophthalmic artery or by
external vascular compression secondary to exces-
sive 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 litera-
ture documenting cases of vascular compromise
consist of case reports; however, Sun et al. report
15 cases of vascular compromise with impend-
ing skin necrosis following hyaluronic acid injec-
tions in the nose over a 7-year period.23 Thirteen
patients were treated with hyaluronidase, and this
treatment was effective in preventing the develop-
ment of nasal skin necrosis in 11 of these patients.
Among the studies documenting visual complica-
tions, 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 vas-
cular 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 compro-
mise may be higher, however, in patients with
prior surgical rhinoplasty, as the native vascula-
ture has been altered and there may be decreased
collateral circulation to certain areas.22,23 A thor-
ough 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 evaluat-
ing blindness after soft-tissue filler use, Chatrath
et al. identified 190 cases in total. Injections in the
 Volume 146, Number 1 • Nonsurgical Rhinoplasty
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 naso-
labial folds.65 Thus, although nonsurgical rhino-
plasty 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 rhino-
plasty to minimize the risk of vascular complica-
tions. 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, aspi-
ration before injection, and injecting in 0.1-ml
increments at a time.24,66,67 Injections should be
ceased immediately if patients develop any symp-
toms 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 abil-
ity 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 vari-
able. 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
Copyright © 2020 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
characteristics such as history of surgical rhino-
plasty, 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 fol-
lowed 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 prac-
tice patterns, technique, longevity, patient satisfac-
tion, 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 demon-
strates 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 com-
promise (i.e., skin necrosis and blindness).
Sarah M. Kidwai, M.D.
Department of Otolaryngology
Annenberg 10th Floor
Icahn School of Medicine at Mount Sinai
1 Gustave L. Levy Place
New York, N.Y. 10029
sarah.kidwai@mountsinai.org
Instagram: @sarahkidwaimd
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51