Filler complications in the nose

What repeats

Five findings that hold across the literature.

The mechanism is filler entering an artery, not the filler itself

Filler pushed under pressure into a nasal artery can travel backwards into the circulation that supplies the eye and block it. That is the mechanism behind skin death, vision loss and stroke after nasal injection. The nasal arteries connect to the ophthalmic circulation directly and their course varies between people, so a midline landmark is not a guarantee of a safe plane. Dissection of 31 noses put the dorsal nasal artery 4.4 mm lateral to the midline at the intercanthal line, above the muscle layer over the nasal bone and below it over the cartilage.

Rests on: Caranti et al., complications review · Alfertshofer et al., dorsal nasal artery · Choi et al., dorsal nasal artery topography · and nasal anatomy.

Serious events are rare in the published series

In a systematic review of 9657 patients, arterial occlusion occurred in 0.27%. A review of 2488 procedures found an adverse event rate of 7.6% and 0.20% serious, five cases of ischaemia and necrosis. In 5000 consecutive treatments there were two infections and three cases of localised skin necrosis. In 2088 nonsurgical revisions, three patients had skin necrosis, 0.47%, all self-resolving. A review of 1600 patients recorded no vascular events and concluded they are under-reported.

Rests on: Song et al., systematic review · Rivkin, safety review · Harb and Brewster · Harb and Abdul-Razzak · Williams et al..

Vision loss is usually immediate and usually permanent

A review of the world literature collected 98 cases of vision change after filler anywhere in the face, with the nasal region the site in 25.5%. Its update added 48 further cases, and there the nasal region was the commonest site at 56.3%, hyaluronic acid the material in 81.3%. Vision came back completely in 20.8% of that group and partly in 16.7%. A systematic review limited to the nose screened 1498 articles and found 22 published cases. Mean age was 33.4 years and 90.9% were women, and hyaluronic acid was the filler in 50%. Vision loss began immediately after injection in 82% of cases. The bridge or dorsum was the site in 57% and the glabella in 29%. Full visual recovery occurred in 27% and took a mean of 5.3 months.

Rests on: Beleznay et al., world literature review · Beleznay et al., update · Pistone et al., vision loss review · Caranti et al..

A nose that has already been operated on carries more risk

In 2488 procedures, previously operated noses had an adverse event rate of 10.8% against 7.4%, an odds ratio of 1.51. A review of 2048 patients injected after surgery reports the same direction, a raised risk of skin necrosis. Scar tissue changes where the vessels run.

Rests on: Rivkin · Santamaria-Gadea et al. · and revision rhinoplasty.

The FDA lists the nose among the sites it advises against

Dermal fillers are approved for adults aged 22 and over, for wrinkles and folds and for the lips, cheeks, chin and back of the hand. The agency recommends against injecting the glabella, the nose, the area around the eyes, the forehead and the neck, and names unintended injection into a blood vessel as the most concerning risk of any filler, with necrosis, blindness, stroke and death among the reported outcomes.

Rests on: FDA, Dermal Fillers (Soft Tissue Fillers).

By what goes wrong

Four separate problems, with separate treatments.

Skin that loses its blood supply

Pain out of proportion to the injection, and skin that goes white then mottled, is the sequence to recognise. The FDA tells patients to seek immediate medical attention for unusual pain, vision changes, or white, grey or blue skin near the injection site, and tells injectors to stop the moment the skin blanches.

Rests on: FDA, Dermal Fillers (Soft Tissue Fillers) · Caranti et al..

The eye

Sudden ocular pain, a drooping lid, loss of eye movement and loss of vision, starting within minutes of the injection. The published series show that treatment started afterwards rarely restores sight, and both world-literature reviews report that no treatment has worked consistently.

Rests on: Pistone et al. · Beleznay et al. · Beleznay et al., update.

Lumps, migration and long-standing filler

Fibrosis, granuloma, surface irregularity and filler that migrates are the late problems. Where they persist the treatment is surgical: an open approach, selective removal of residual filler and reconstruction with the patient's own cartilage. High-frequency ultrasound finds residual filler and guides dissolving it before the operation.

Rests on: Wong and D'Souza, surgical management · Caranti et al. · and the pinched tip.

A result the patient does not want

Hyaluronic acid can be dissolved. In one series five patients had hyaluronidase and then rhinoplasty at intervals from 1 week to 6 months, with no filler residue found at operation. Materials that are not hyaluronic acid cannot be dissolved this way.

Rests on: Bektas et al., nasal filling practice · Rohrich et al. · FDA, FDA-Approved Dermal Fillers.

What to ask before a nasal filler injection

Questions the evidence supports asking.

Is hyaluronidase in the building, and how much

Hyaluronidase is the only agent that removes hyaluronic acid filler once it is in. Ask whether the practice stocks it, how much, and who is trained to give it. Early treatment works best. For a blockage that threatens the skin, the published protocol is high-dose pulsed hyaluronidase, with injection directly into the facial, supratrochlear or superficial temporal artery as the more effective route. A consensus panel of injectors sets out the same steps and asks every clinic to keep the tools for them on hand.

Rests on: Fu et al., stepwise treatment protocol · Signorini et al., Global Aesthetics Consensus · Rohrich et al. · Hyaluronidase in StatPearls.

Needle or cannula, and which plane

Blunt cannulas lower the chance of entering a vessel. One protocol reaches the whole nose from a single midline entry point with a 5-cm, 25-gauge cannula, and a 511-treatment series places filler in the deep supraperiosteal and supraperichondrial layers through cannulas. The anatomy study adds one caveat: over a hump, a tip travelling in the deep layer rises towards the artery as it crosses the convexity.

Rests on: Radulesco et al., single entry point · Magacho-Vieira et al., deep columellar approach · Segreto et al., the 3P maneuver · Choi et al..

What is the plan if the skin blanches

Ask for the steps, in order, and where you would be transferred. The FDA tells providers to have a written plan before injecting and to train their staff to respond to a patient calling with these signs. The consensus statement puts most adverse reactions down to planning, product choice and technique, and asks the injector to be equipped to treat one before starting.

Rests on: FDA, Dermal Fillers (Soft Tissue Fillers) · Signorini et al. · Rohrich et al., safety in nasal augmentation.

The terms, defined

The words used about these complications.

• Vascular occlusion: filler blocking an artery, cutting the blood supply to the tissue that artery feeds. [39747417]
• Blanching: the skin turning white during or straight after injection. The first visible sign that a vessel has been blocked. [39747417]
• Necrosis: tissue death from lost blood supply, seen as a dark patch that later scabs and scars. [32097303]
• Ophthalmic artery occlusion: a blockage in the artery supplying the eye, presenting as sudden pain and vision loss. [42660550]
• Hyaluronidase: the enzyme that breaks down hyaluronic acid, used to dissolve filler and to treat a blocked vessel. [32778931]
• Cannula: a blunt-tipped tube used in place of a sharp needle to place filler. [35511074]
• Supraperiosteal plane: the layer directly on the bone, away from the vessels nearer the skin. [30560283]

Where else this is documented

Sources outside the journals, each one free to read.

The device regulator

The FDA regulates fillers as implanted medical devices and publishes the risks, the sites it advises against, and the warning signs. Two searchable databases carry the record behind each product.

• Dermal Fillers (Soft Tissue Fillers), the risks and what to do about them.
• FDA-Approved Dermal Fillers, the materials and which of them can be dissolved.
• MAUDE, the device adverse event database, searchable by product.
• Premarket Approval database, the safety and effectiveness summary filed for each approved filler.

The national guideline

The American Academy of Otolaryngology guideline on nasal form and function sets what a clinician should assess and document, with a plain language summary written for patients.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapter

Rhinoplasty Archive, the free online textbook edited by Daniel G. Becker, carries a chapter written for surgeons.

• Symptoms and treatment of necrosis of the nose after filler injection

The reference summary

Hyaluronidase in StatPearls, on the National Library of Medicine's Bookshelf, gives the drug, its dosing and its adverse effects at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.

The trials in progress

• Recombinant DNA-based Hyaluronidase to Dissolve Fixed Amounts of Filler, completed, 15 participants.
• Reducing and Removing Hyaluronic Acid Filler With Hyaluronidase, completed, 5 participants.

What is not settled

• The true incidence is unknown. Published rates run from no vascular event in 1600 patients to 0.27% in 9657, and the reviews say the difference is reporting. [32590640] [38862661]
• Vision loss is documented as 22 published cases in the nose and 98 plus 48 across the face, a count of what reached the literature, not a rate. [42660550] [26356847] [30805636]
• No trial compares needle with cannula, or one plane with another, for vascular events. The safety techniques rest on anatomy studies and single-operator series. [30560283] [35501057]
• Hyaluronidase dose and timing for a blocked vessel are not standardised, and the registered trials test dissolving filler rather than treating an occlusion. The stepwise protocol is drawn from case reports and consensus, not from trials. [42660550] [32983752] [37775575] [27219265]
• See also the journal archive on complications and injection rhinoplasty.