Injection rhinoplasty

What repeats

Five findings that hold across the literature.

It corrects by filling rather than by removing

The named uses repeat across the technique papers. Level a dorsal hump by adding volume above and below the convexity, fill concavities, correct asymmetries of the upper and middle thirds, raise an under-projected tip. The filler goes into the deep fatty layer, in small increments, undercorrected. The external nose between skin and bone holds four layers, and injecting into the deep fatty one is what keeps the gel away from the vessels.

Rests on: Saad and Stallworth, liquid rhinoplasty · Johnson and Kontis, nonsurgical rhinoplasty · Moon, injection rhinoplasty using filler · and the dorsal hump.

The volumes are small and the appointment is short

The Rino-4-Puntos series used a mean of 0.65 mL across four points, and a grid protocol in 61 patients had 97% calling the correction adequate at two weeks. In a 14-year series of 2130 cases the sites injected were the tip in 95%, the dorsum in 83%, the radix in 62%, the columella in 58%. Moon injects in the order radix, rhinion, tip, supratip, marking the midline first. A graft-based series of 70 patients had no complications and 2.8% asked for a retouch at 15 days.

Rests on: Silikovich and Kroumpouzos, four-point technique · Bertossi et al., nasal grid · Kassir et al., ascending technique · Moon · Segreto et al., graft-based technique.

The result is temporary and the reported span is under a year and a half

Hyaluronic acid is absorbed. A prospective study followed 29 patients past 12 months and found the correction still held in 96.6% at the final visit. Follow-up of high G-prime injections in 107 patients puts the effect at 8 to 12 months, and a review of 674 patients puts the span at 8 to 14 months, with 84.7% satisfied at 3 months and 96.4% at one year. The four-point series reports a median of 11 months, and a FACE-Q study of 83 patients found satisfaction still raised at 6 months.

Rests on: Liew et al., prospective long-term study · Bertossi et al., long-term follow-up · Radulesco et al., satisfaction review · Silikovich and Kroumpouzos · Lombardo et al., FACE-Q.

Satisfaction is high and the serious complication rate is low

A systematic review of 9657 patients reports satisfaction of 99.08% and a complication rate of 39.11%, most of it erythema and swelling at 27.95%. Arterial occlusion occurred in 0.27%. An earlier review of 1600 patients found 26 minor complications, no vascular events, and probable under-reporting. A review of 2488 procedures puts the adverse event rate at 7.6%, 0.20% serious. In the prospective series, 79.3% of patients were satisfied or very satisfied and 86.2% would recommend the treatment, with no serious adverse event.

Rests on: Song et al., updated systematic review · Williams et al., systematic review · Rivkin, safety review · Liew et al. · and filler complications in the nose.

The FDA has not approved any filler for the nose

Dermal fillers are approved as implants for adults aged 22 and over, for facial wrinkles and folds and for augmentation of 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 states that these uses are not approved. Nasal injection is off-label in the United States.

Rests on: FDA, Dermal Fillers (Soft Tissue Fillers) · Saad and Stallworth.

By what the patient brings to the appointment

The same syringe answers four different situations.

An unoperated nose with a small contour complaint

The commonest single indication in the largest series is the dorsal hump, at 44% of 5000 consecutive treatments. Swelling and redness settled on their own in about half of that cohort, with infection in two patients and localised skin necrosis in three.

Rests on: Harb and Brewster, 5000 treatments · and open versus closed rhinoplasty.

A nose already operated on, with a residual defect

A review of 2048 patients who had already had surgery found high satisfaction, few major complications, and a raised risk of skin necrosis. A 1122-patient series of secondary correction reports a complication rate of 2.8%, all minor and transient, and satisfaction of 92%. In the 2488 procedures, previously operated noses had an adverse event rate of 10.8% against 7.4%, odds ratio 1.51. In one practice, 85 of 800 rhinoplasty patients, 10.6%, had filler for a surface irregularity after surgery, at a mean volume of 0.2 mL; 11.8% of them were injected a second time and 3.5% a third, and no complications were reported. Rhinoplasty carries revision rates of up to 17%.

Rests on: Santamaria-Gadea et al., after rhinoplasty · Khan et al., postoperative fillers · Valente and Zanella, secondary liquid rhinoplasty · Rivkin · and revision rhinoplasty.

Someone deciding whether to have surgery at all

Filler gives a reversible preview of added volume, at lower cost and with no recovery time. Eye tracking of observers found the lateral view changes more after surgery than after injection, which is the size of the difference between the two.

Rests on: Rohrich et al., nonsurgical rhinoplasty · Kassir et al., eye tracking · and what rhinoplasty costs.

Someone who has had filler and now wants surgery

Surgeons do not agree on how to handle it. Among 165 rhinoplasty surgeons from 45 countries, 74% operate on patients with previous nasal filler and wait a median of 21 weeks, 44% dissolve the filler beforehand, 76% remove it during the operation, and 25% change their surgical steps.

Rests on: Vansteelant et al., cross-sectional survey · and rhinoplasty recovery.

What to ask about injection rhinoplasty

Questions the evidence supports asking.

What can filler not do for my nose

It cannot reduce. A large nose stays large, a wide nose stays wide, and a hump is hidden by adding volume around it. Ask the injector to mark on your own photograph where volume would go.

Rests on: Saad and Stallworth · Johnson and Kontis.

How long will it last and what happens when it goes

The published range is 8 to 14 months, and the one prospective study followed its patients past 12 months. Ask what the plan is at that point and what a top-up costs. Filler is absorbed gradually rather than all at once.

Rests on: Liew et al. · Radulesco et al. · Bertossi et al..

Who is injecting, and what happens if a vessel is blocked

The FDA advises choosing a licensed provider trained in dermatology or plastic surgery. Ask what the practice does if the skin blanches, whether hyaluronidase is in the room, and where you would go.

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

The terms, defined

The words used about this procedure.

• Injection rhinoplasty: reshaping the nose with injected filler instead of surgery. Also called nonsurgical rhinoplasty, liquid rhinoplasty and medical rhinoplasty. [35934437]
• Hyaluronic acid: a sugar present in skin and cartilage, used in gel form as a filler. The FDA puts the effect at about 6 to 12 months.
• Calcium hydroxylapatite: a mineral from teeth and bone, suspended in gel. The FDA puts the effect at about 18 months, and it shows on x-rays.
• G-prime: a measure of how stiff a gel is. High G-prime fillers hold a shape against the skin and are the ones chosen for the nose. [35158387]
• Off-label: a use the FDA has not reviewed for that product. Nasal filler injection is off-label. [35934437]
• Hyaluronidase: the enzyme that dissolves hyaluronic acid filler, used to reverse a result and to treat a blocked vessel. [34782136]

Where else this is documented

Sources outside the journals, each one free to read.

The device regulator

The FDA regulates dermal fillers as implanted medical devices. Two pages carry the approved uses, the unapproved sites, the risks, and the warning signs of a blocked vessel.

• Dermal Fillers (Soft Tissue Fillers)
• FDA-Approved Dermal Fillers, the materials and how long each one lasts.

The national guideline

The American Academy of Otolaryngology guideline on nasal form and function covers motivation, expectation and documentation, 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 on injection rhinoplasty written for surgeons.

• Injection rhinoplasty of the Asian nose

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy and the surgical alternative at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

• Effects of Restylane-L Filler Injection for Non-Surgical Rhinoplasty, completed, 10 participants.
• SkinPlus-HYAL Implant Lidocaine versus Restylane Lidocaine, status unknown, 100 participants.

What is not settled

• No randomised trial compares injection rhinoplasty with surgical rhinoplasty. The evidence is single-injector series and systematic reviews of those series. [37217605] [32590640]
• Complication rates disagree between reviews, from no vascular events in 1600 patients to arterial occlusion in 0.27% of 9657. Reporting, not risk, may be the difference. [32590640] [38862661]
• Duration is reported by the injectors and by patient recall, not by imaging. Whether previous filler makes a later operation worse rests on surgeon survey. [33660013] [39993423] [39060796] [37217605]
• See also the journal archive on complications and on outcomes and psychology.