Journal of Cosmetic and Laser Therapy

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Specific complications associated with non-

surgical rhinoplasty

Tuyet A. Nguyen, Shivani Reddy & Nima Gharavi

To cite this article: Tuyet A. Nguyen, Shivani Reddy & Nima Gharavi (2020) Specific complications
associated with non-surgical rhinoplasty, Journal of Cosmetic and Laser Therapy, 22:4-5, 171-173,
DOI: 10.1080/14764172.2021.1898643

To link to this article: https://doi.org/10.1080/14764172.2021.1898643

Published online: 12 Mar 2021.

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JOURNAL OF COSMETIC AND LASER THERAPY
2020, VOL. 22, NOS. 4–5, 171–173
https://doi.org/10.1080/14764172.2021.1898643

Specific complications associated with non-surgical rhinoplasty

Tuyet A. Nguyena, Shivani Reddyb, and Nima Gharavic
a
Department of Dermatology, California Skin Institute Los Angeles, Los Angeles, CA, USA; bDepartment of Dermatology, Kaiser Permanente Los
Angeles Medical Center, Los Angeles, CA, USA; cDepartment of Dermatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA

ABSTRACT ARTICLE HISTORY

Non-surgical rhinoplasty is becoming an increasingly common procedure to alter the appearance and Received 14 December 2020
cosmesis of the nose. Although rare, complications with this procedure do exist, some of which can be Accepted 1 March 2021
devastating. Major complications include infection, vascular compromise, skin necrosis, and blindness. KEYWORDS
Here we discuss the nasal anatomy, complications associated with non-surgical rhinoplasty, and techni­ Filler; hyaluronic acid; non-
ques to prevent these complications. surgical rhinoplasty

Introduction glabella which is well known for complications of vascular occlu­

Surgical rhinoplasty is the fourth most common cosmetic
procedure performed by plastic surgeons in the United
States. Despite its popularity, the percentage of these pro­
cedures performed has decreased by 3% in the last year. In
contrast, the use of non-surgical rhinoplalsty, using soft
tissue fillers, has increased by ~1% over the same time
period (1). Non-surgical rhinoplasty, which involves aug­
mentation of the nasal contour using soft tissue fillers, has
become increasingly popular over the last several years.
This minimally invasive technique allows patients to have
excellent esthetic results without the high cost, anesthesia,
and post-operative recovery time associated with traditional
surgical rhinoplasty (2). However, the risk of complications
with non-surgical rhinoplasty still exists, particularly in
patients that have undergone surgical treatment or trauma
in the past. Major complications, although rare, include
vascular compromise, necrosis, and blindness. Knowledge
of nasal anatomy and injection technique is essential to
avoid these serious side effects.
Anatomy of the nose
The nose is a complex structure with a robust vascular supply
(Figure 1). The nose and surrounding structures are uniquely
supplied by both the internal and external carotid system
through anastomoses between the dorsal nasal artery and the
angular artery. The dorsal nasal artery arises from the supratro­
chlear artery and courses over the nasal root to form anasto­
moses with the angular artery (4). Because of the anastomoses
that occur in this area, there is an increased risk of complications
such as the retrograde flow of intravascular filler into vital
structures supplied by the internal carotid, including the
ophthalmic artery, as well as increased risk of intracranial infec­
tion. In addition, the nasal root, a common location for filler
placement for non-surgical rhinoplasty, lies just adjacent to the
sion and soft tissue necrosis.
Common complications
Reported complications of non-surgical rhinoplasty are few. In
a systematic review, Williams et al. described that the total
complication rate in a series of 1600 patients was 1.63% (5).
The most common side effects include erythema, local inflam­
mation and swelling, and bruising which occurred at compar­
able rates to filler placement in other anatomical sites. These
complications often resolve spontaneously without sequelae.
Subcutaneous nodules, Tyndall effect, and dislocation of filler
material were also noted (2,5,6). These complications are typi­
cally associated with provider error highlighting the impor­
tance of knowledge of facial anatomy as well as injection
technique.
Uncommon complications
Infection
Infection is an uncommon and usually mild complication of
non-surgical rhinoplasty. Few cases have been reported in the
literature (2,6,7). All cases reported were superficial bacterial
infections that responded to short courses of topical or oral
antibiotics without sequelae (7). However, other infectious
etiologies including Mycobacterium have been reported with
dermal fillers (8). Culture and appropriate treatment of an
infected wound is critical to prevent further complications.
Skin and soft tissue necrosis
Skin and soft tissue necrosis are rare but serious complications
of filler injection. It is thought that necrosis from filler injec­
tions can be caused by two mechanisms: 1) intravascular
embolization through direct injection into a vessel or 2) vas­
cular compromise from external pressure from the filler mate­
rial (8). The angular, dorsal nasal, and supratrochlear arteries

CONTACT Nima Gharavi nima.gharavi@cshs.org Dermatologic Surgery & Mohs Micrographic Surgery, Department of Dermatology, Cedars-Sinai Medical
Center, 99 N La Cienega Blvd #202, Beverly Hills, CA 90211.
© 2021 Taylor & Francis Group, LLC
172 T. A. NGUYEN ET AL.
Figure 1. Vascular patterns of the nose (3).
are particularly vulnerable to this complication, and are all
possible targets in the application of filler for non-surgical
rhinoplasty (9). The glabella is also a watershed area with
minimal collateral circulation and small caliber vessels making
it susceptible to external pressure and tamponade (10). Signs of
impending necrosis include severe pain, blanching, edema, and
violaceous discoloration (11–13). However, it is important to
distinguish arterial from venous occlusion. While arterial
occlusion is often immediately accompanied by pain and
blanching, venous occlusion may not present with significant
pain but demonstrates venous mottling or a livedo-like phe­
nomenon (13). It is important to recognize features of impend­
ing necrosis to allow for early intervention and prevention of
further complications.
Vision loss
Although rare, cases of vision loss secondary to filler injection
have been reported. Autologous fat injection is most com­
monly associated with this complication, likely due to the fact
that fat injection is often performed under general anesthesia
(at the time of liposuction), which prevents the patient from
reporting any discomfort. However, all commonly used fillers
have been associated with reports of embolic events (14). In
a literature review by Ozturk et al., the glabella was the most
common site associated with visual disturbances at 50%, fol­
lowed closely by the nose at 33.3% (9). Injection of filler for
non-surgical rhinoplasty poses a specific risk for this complica­
tion due to the course of the dorsal nasal artery over the nasal
root (15). The dorsal nasal artery is a distal branch of the
ophthalmic artery (4). Intravascular injection into the dorsal
nasal artery can cause embolization of filler material in
a retrograde manner causing occlusion of the ophthalmic
arteries and subsequent vision loss. Clinically, this is character­
ized by instantaneous vision loss and excruciating ocular pain
(14). Treatment and reversal of this complication are rarely
successful.
Other considerations
When performing facial fillers, it is important to under­
stand the variations in structure and vasculature from
patient to patient. However, some patients seeking non-
surgical rhinoplasty may have previously undergone trauma
or corrective surgery to the area. Previous history of surgi­
cal rhinoplasty or reconstruction can lead to distortion of
tissue and overlying vasculature (15,16). These patients may
be at higher risk for major complications with non-surgical
rhinoplasty.
Techniques to minimize risk of complications
Standard techniques to minimize complications with filler
injections regardless of anatomical location exist. Sterile
skin preparation to reduce the risk of infection and slow,
low-pressure injection techniques are crucial. In our experi­
ence, ideal antiseptics include hypochlorous acid and chlor­
hexidine wipes. Avoiding blood thinners, the use of firm
pressure, or ice packs can help alleviate more common
complications, such as erythema, ecchymoses, and swelling
(17). If no contraindications exist, discontinuing unneces­
sary anticoagulation 2 weeks prior to the procedure may
help prevent these complications. For nasal filler specifi­
cally, injections should be performed deep to the muscu­
loaponeurotic layer in the preperiosteal layer for the safest
approach (18,19). Larger caliber microcannula (27 gauge or
larger, in our experience) use may reduce the risk of injury
or intravascular injection of filler material (18). The gla­
bella, which is more susceptible to intravascular cannula­
tion and tamponade, can be treated with superficial dermal
injections with a serial puncture technique (19). Again, it is
crucial to understand the complex anatomy in this location
paying particular attention in post-surgical patients where
anatomy may be distorted.
Conclusion
Non-surgical rhinoplasty is becoming increasingly common
worldwide. It offers a fast, relatively safe, and effective option
for some patients seeking alternatives to traditional surgery.
Although rare, complications with this procedure do exist,
some of which can be devastating. Common complications
include edema, erythema, nodules, and granuloma formation.
Major complications include infection, vascular compromise,
skin necrosis, and blindness. Extensive knowledge of nasal
anatomy and vascular supply is essential to ensure patient
safety and prevent major complications.
Authors contributions
Made substantial contributions to conception and design of the study and
performed data analysis and interpretation: Nguyen TA, Reddy S, Gharavi N
Disclosure statement
All authors declared that there are no conflicts of interest.

Funding
The authors have no financial relationships relevant to this article to
disclose.
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