Liquid Rhinoplasty: How to Make Patients Aware of the Risks

The bride wanted her wedding day—and photos—to be perfect.

There was just one problem: her nose.

It was crooked. And because the big day was only a few weeks away, there wasn’t time for a surgical rhinoplasty.

“She’d always hated her nose and asked me, ‘Can you just fix my nose for the pictures?’” said Theda Kontis, MD, a Baltimore-based otolaryngologist who is board certified in both facial plastic and reconstructive surgery and otolaryngology–head and neck surgery.

The bride was the perfect candidate for liquid rhinoplasty, the injection of dermal fillers to reshape the nose. She had not had surgery on her nose previously, and she accepted and understood the risks, including possible blindness should the filler get into the blood vessels supplying the eye. Dr. Kontis, author of Cosmetic Injection Techniques, drew upon her years of experience and expertly sculpted the patient’s nose by injecting small amounts of dermal filler into strategic locations.

The bride’s nose was in perfect shape for her wedding.

Non-surgical rhinoplasty has been available for about 15 years; however, demand has increased in recent years (Plast Reconstr Surg Glob Open. 2016;4:e683). This trend may be fueled largely by social media posts that position liquid rhinoplasty as an “easy” way for individuals to get the nose of their dreams, Dr. Kontis said. At the same time, some clinicians, concerned about the risk of serious side effects, are shying away from the procedure.

“I’m conflicted regarding liquid rhinoplasty because I see quite a few problems surfacing, mostly from poor technique,” said Steven Dayan, MD, a Chicago-based facial plastic surgeon who is board certified by both the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology–Head and Neck Surgery. “The highest reported cases of blindness secondary to a filler complication come from injections in the nose, and every month, I get a phone call from someone who’s run into an unexpected vascular event, asking for help.”

Compounding the risk to patients is the fact that many physicians and non-physicians alike are not privy to the best practices and the latest in safe techniques for nasal filler injection. “The majority of people being trained today to perform this procedure are not board-certified otolaryngologists or the four core cosmetically trained physicians; they’re adjunct physicians and providers who may not have easy access to the latest in CME training or peer-reviewed resources,” Dr. Dayan said.

Dr. Kontis shares his concerns. “We doctors have always been very nervous about non-surgical rhinoplasty because of the risk of blindness and other complications, but as we start to see more paraprofessionals offering this procedure, we’ve become worried that we may see more complications,” she said.

Surgical vs. Non-Surgical Rhinoplasty

A surgical rhinoplasty typically costs thousands of dollars, and full healing of the nose and face post-procedure may take as long as six weeks. In contrast, a liquid rhinoplasty may cost $1,500 or less. Results are instantaneous, and patients can return to their usual activities immediately.

Liquid rhinoplasty cannot, however, minimize or substantially alter the nose. “Any time you are contouring the nose using fillers, you’re actually augmenting the nose or face,” said Sam P. Most, MD, professor and chief of the division of facial plastic and reconstructive surgery at Stanford University School of Medicine in Stanford, Calif.

And while it’s possible to minimize a dorsal hump by injecting fillers above and below, the aesthetic outcome isn’t always pleasing. “I’ve seen pictures on Instagram and elsewhere where the nose has been filled up until it’s almost even with the forehead,” Dr. Most said. “The hump is gone, but the nose is massive.”

Fortunately for those who undergo a less-than-ideal liquid rhinoplasty, the effects of a non-surgical rhinoplasty are temporary. If a patient is unhappy with the results, the physician can dissolve the filler and return the nose to its pre-procedure appearance.

In most cases, the results of a non-surgical rhinoplasty will last about a year, depending on the filler used. “Hyaluronic acid injectables, such as Restylane and Juvederm, last about six months to a year. The calcium-based ones last longer, about a year to a year-and-a-half,” Dr. Most said.

Liquid rhinoplasty can be repeated, but doing so raises the overall cost and increases the risk of complications. “If you keep doing it over and over again, it tends to have a detrimental effect on the skin,” Dr. Dayan said. If patients are pleased with the result of their non-surgical rhinoplasty, it may be in their best interest to book a surgical rhinoplasty sooner rather than later, so they can maintain the look they want without repeatedly subjecting themselves to the risks of liquid rhinoplasty.

Non-surgical rhinoplasty is often used to tweak the results of surgical rhinoplasty. “There’s always some little thing that’s not 100% right with rhinoplasty, a little indentation or whatever. Fillers allow you to make it perfect without going back to surgery,” Dr. Kontis said. “Why do a whole rhinoplasty over again when you can put just a little touch of filler in there and make them totally happy?” Of course, to maintain the effect, the patient would need to get injections regularly.

Patients need to be cautious and seek out an experienced injector. —Steven Dayan, MD

Liquid rhinoplasty is also a good option for patients who “think they have a dorsal hump but actually do not,” Dr. Most said.

“These patients do really well because they don’t need to have their nose cut down; they need to have augmentation of the radix to make it look straight,” he said.

Informed Consent Is Essential

The risks of liquid rhinoplasty are significant; possible complications include infection, skin necrosis, and blindness. Many patients, however, think non-surgical rhinoplasty is safer than surgical rhinoplasty because they perceive dermal fillers as low risk.

“The public perceives Botox and neurotoxins [as] dangerous and scary because they’re ‘toxins,’” Dr. Kontis said. Yet the worst-case scenario for neurotoxin injection is paralysis of the wrong muscle, an effect that will be reversed over time as the effect of the neurotoxin wanes. In contrast, the public has little fear of fillers, even though “fillers are much more dangerous because if you accidentally inject it into a blood vessel, you will embolize that blood vessel and knock off blood supply to a certain area of the face,” Dr. Kontis said, which may cause skin necrosis or blindness.

Unfortunately, social media posts about liquid rhinoplasty rarely mention the risks involved, and some unscrupulous injectors don’t mention potential harms either. “I’ve had people who got injection rhinoplasties elsewhere come to me, and when I tell them there’s a risk of blindness, they say, ‘Well, the last person didn’t tell me that,’” Dr. Kontis said.

It’s difficult to quantify the risks associated with dermal fillers. A 2019 literature review and meta-analysis of vascular complications after facial filler injection looked at 93 cases globally, and found that five patients (5.4% of the population) experienced blindness and skin necrosis simultaneously. Eight patients (8.6%) reported pain or erythema, which resolved completely (J Clin Aesthet Dermatol. 2019;12:E65–E72). This study did not focus exclusively on non-surgical rhinoplasty.

“It’s really important to carefully discuss the risks and benefits with your patients,” Dr. Most said. In his experience, some patients will opt for surgical rhinoplasty after learning that blindness is a risk of liquid rhinoplasty.

Minimizing the Risks of Liquid Rhinoplasty

Non-surgical rhinoplasty should always be performed by a qualified medical professional—ideally, a physician who is board-certified in plastic surgery, dermatology, or facial plastics, according to the surgeons interviewed for this article. The physician should intimately understand the anatomy of the vasculature of the nose, they said. For the best results, patients should select a provider who appreciates nasal aesthetics.

“Injectors who don’t understand nasal aesthetics don’t know where to put the filler,” Dr. Kontis said, recalling a patient who came to her after undergoing injection rhinoplasty with a dermatologist. “She needed more projection,” Dr. Kontis said. “A provider who can tell you if your nose is under-projected or over-rotated will be able to give you a much better result.”

An emergency kit containing hyaluronidase, an enzyme that can be used to dissolve hyaluronic acid (the filler most often used during non-surgical rhinoplasties) should be available throughout the procedure. Providers should also have on hand the phone number of an ophthalmologist they can call and refer patients to in case of visual complications.

Physicians may be able to decrease the risk of vascular embolization, blindness, and necrosis by using a cannula instead of a needle to inject the dermal filler, Dr. Dayan said. “I believe a cannula is much safer. A large bore, 22-gauge cannula, in particular, takes a lot more effort to penetrate a vessel than a needle.” Available research suggests that a 22-gauge may indeed be a bit safer than a needle. According to a 2019 article in Plastic and Reconstructive Surgery, it takes significantly more force for a 22-guage cannula to penetrate a vessel than it does for 25 or 27-gauge cannulas. A 27-guage cannula offers little to no benefit because it penetrates a vessel as easily as a 27-gauge needle (Plast Reconstr Surg. 2019;143:504e-512e).

Otolaryngologists can help educate patients about the risks and realities of liquid rhinoplasty.

“The cheapest place isn’t necessarily the best place to get a non-surgical rhinoplasty,” Dr. Dayan said. “Patients need to be cautious and seek out an experienced injector.”

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Jennifer Fink is a freelance medical writer based in Wisconsin.