Given the advent of various injectable fillers along with their reported safety and efficacy, nonsurgical rhinoplasty has recently gained popularity for patients looking to alter the shape and/or appearance of the nose without incurring the risk, cost, and downtime typically associated with surgical rhinoplasty.
Despite these potential advantages, nonsurgical rhinoplasty remains a technically challenging procedure with significant associated risks (e.g., vascular occlusion). It thus should only be performed by those clinicians who possess a sound understanding of the relevant anatomy and safe injectable techniques.
Herein, we outline the principles of a successful nonsurgical rhinoplasty using injectable fillers with an emphasis on properly evaluating patients and executing a thorough, anatomic-based procedural plan.
First and foremost, a sound comprehension of the relevant anatomy is vital to performing a safe and successful nonsurgical rhinoplasty using filler.
Below are the layers of the nose encountered during nonsurgical rhinoplasty (listed from superficial to deep):
The vasculature of the nose encountered during nonsurgical rhinoplasty arises from both the internal and external carotid system via the ophthalmic and facial artery, respectively. While various branching patterns (particularly with the facial artery) and anastomoses exist between the two systems, the following categorization provides a basic description of the relatively constant vasculature encountered during nonsurgical rhinoplasty:
NOTE: For a useful and simplified schema of the superficial nasal blood supply, the reader is referred to the cadaveric study performed by Saban et al.
Emphasis is on injecting into the avascular deep fat or sub-SMAS plane to avoid vascular occlusion and its devastating sequelae, namely skin necrosis, and blindness.
Equally important to adhering to safe injection planes is comprehending pertinent rhinoplasty terms and definitions, several of which are characterized below:
Upon obtaining a thorough understanding of the relevant anatomy, only then can a comprehensive nasal analysis be performed. Such analysis should include not only classically recognized facial/nasal angles and proportions (some of which are detailed above) but also acknowledge cultural and/or ethnic preferences. Ultimately, however, the patient's personal aesthetic and desired outcome takes precedence over classical definitions of attractiveness when deciding how to reshape the nose.
Nonsurgical rhinoplasty is indicated for the correction of mild cosmetic deficits of the nose in patients either not medically able to undergo surgery or those patients looking to avoid the cost, downtime, and risks associated with traditional surgical rhinoplasty. From a logical standpoint, patients who benefit from nonsurgical rhinoplasty are similar to those patients who would benefit from specific cartilage grafts placed during surgical rhinoplasty (e.g., shield grafts, tip grafts, radix grafts, onlay grafts, rim grafts). With that in mind, nonsurgical rhinoplasty using fillers may be useful in addressing the following:
Of note, some propose that strategically placed filler may provide functional improvements as well (i.e., filler simulates spreader, butterfly, or batten grafts), though this remains controversial. 
NOTE: The patient should understand that while nonsurgical rhinoplasty has its appeal, there exists an equally safe, reliable, yet permanent alternative in a properly executed surgical rhinoplasty. Thus, all patients seeking nonsurgical rhinoplasty should receive an offer for surgical rhinoplasty as well.
Those who perform nonsurgical rhinoplasty must be able to determine which patients would be better served by surgical rhinoplasty. In general, results from nonsurgical rhinoplasty are typically limited in patients with a large hump, severe deviation, excessive tip rotation issues, or significant tip contour irregularities. Additionally, the surgeon should instead offer surgical correction to patients interested in undergoing a hump reduction, who have a superiorly positioned nasion. Also, patients should recognize that “nasal reduction” cannot be performed with filler. However, specific techniques (e.g., dorsal augmentation and tip projection) may give the illusion of a thinner or narrower nose. Likewise, realistic expectations require emphasis throughout the consultation process.
Contraindications to fillers, in general, include patients with a history of autoimmune disease, bleeding disorders, and hypersensitivity to one of the filler components (e.g., lidocaine). Patients with signs of inflammation or infection near the injection site, or who are pregnant, or breastfeeding should avoid receiving injectable fillers as well. NOTE: patients with a history of frequent herpes simplex virus outbreaks (e.g., several a year) should receive prophylactic antivirals.
Nonsurgical rhinoplasty should be avoided in patients who have had previous nonsurgical rhinoplasty with either silicon or unknown injection material.
Patients with suspected or known body dysmorphic disorder (BDD) should receive a referral to psychiatry before considering nonsurgical rhinoplasty because they tend to have poor satisfaction following such procedures and show a higher rate of aggression and litigation toward those performing them. The prevalence of BDD may be prevalent in up to 43% of patients who present for a cosmetic rhinoplasty consultation.
Relative contraindications to undergoing nonsurgical rhinoplasty with fillers would include patients actively taking anticoagulants, antiplatelet agents, and nonsteroidal anti-inflammatory drugs for increased risk of bleeding and bruising. Similarly, patients taking herbal medications and supplements such as chondroitin, ephedra, echinacea, glucosamine, ginkgo biloba, goldenseal, milk thistle, ginseng, kava, and garlic should withhold these supplements for several days before and after treatment to minimize complications (e.g., bleeding and bruising). Additionally, caution is necessary for patients with a history of nasal implants or previous rhinoplasty for fear of increased complications, including infection and tissue ischemia. For this reason, some authors propose waiting up until 12 months after a rhinoplasty to perform injections.
The two main fillers used for nonsurgical rhinoplasty are hyaluronic acid (HA) and calcium hydroxyapatite (CaHa), with HA being the more widely used. While several product variations exist for both HA and CaHa, choosing the correct filler depends on a variety of characteristics, three of which will be highlighted here, including the filler’s reversibility, duration, and stiffness. For a complete discussion of the types of filler available for injectable rhinoplasty, the reader can read the review article by Friedman and Wang.
Without a doubt, the safest fillers to use are those that are not only biodegradable but also reversible, such as HA fillers, which can easily and rapidly dissolve with hyaluronidase. Not only does this reversibility provide some level of increased safety given the potential for vascular occlusion events, but also reversible products can be dissolved if overfilling or misplaced injections occur.
The duration of the filler should also be a consideration when choosing a product. In general, HA fillers last for 6 to 12 months, while CaHa fillers last up to 12 to 18 months (with potentially longer duration after repeated treatments due to collagen synthesis). Nevertheless, it remains important to counsel patients that repeated injections will be required to maintain the effects of the nonsurgical rhinoplasty, regardless of filler type.
Another filler characteristic to be considered includes the elastic coefficient, or G-prime, which represents a measure of the filler’s ability to resist flow (i.e., stiffness). Fillers with a high elasticity or G-prime, such as CaHa, are more resistant to deformation (i.e., remain more stable over time), tend to provide a more robust “filling” effect, and require less product to achieve a comparable result. On the downside, high G-prime fillers cause increased post-procedural edema and pain and may feel less “natural” than lower G-prime options, such as HA.
Permanent fillers (e.g., silicone and polymethylmethacrylate) are best avoided due to the risk of granulomas, uncorrectable irregularities, and irreversible complications (e.g., vascular injury).
In general, the ideal filler for nonsurgical rhinoplasty would be one that is reversible, easy to inject, and provides long-lasting support to the nose. Additionally, many surgeons advocate for non-inflammatory fillers that cause minimal native tissue distortion and thus are easily removed during surgical rhinoplasty. For these reasons, approximately 80% of nonsurgical rhinoplasty performed with HA. Nevertheless, some authors still endorse CaHa as the filler of choice due to its longer duration, improved moldability, and increased stiffness.
Cannula Versus Needle Injection Techniques
Theoretically speaking, using a small blunt cannula (e.g., 27-gauge) to perform nonsurgical rhinoplasty may decrease the risk of vascular occlusion; nevertheless, reports of tissue ischemia and blindness have been reported even with canula use. A technical advantage to using the cannula may be apparent when injecting large flat areas (e.g., for dorsal augmentation), which can help decrease local tissue trauma and increase efficiency by minimizing the number of injection points. Needle injection technique using a small caliber needle (e.g., 30-gauge), however, ensures pinpoint precision and accuracy.
NOTE: Regardless the technique used (cannula versus needle), emphasis must be placed on proper injection techniques including injecting into an avascular sub-SMAS plane, routinely aspirating to assess for intravascular needle/cannula placement, injecting slowly, and placing small aliquots of filler (no more than 0.1 mL) at each site.
Typical materials include disinfectant wipes (e.g., alcohol or chlorhexidine), topical anesthetic, a marking pen, gauze (for hemostasis), and a lubricant (for nasal molding).
Every clinician performing nonsurgical rhinoplasty with fillers should have a readily available emergency kit for vascular occlusion events containing: 2% nitroglycerin paste, sublingual nitroglycerin 0.6 mg, aspirin 325 mg, warm compresses, hyaluronidase, topical timolol 0.5%, systemic corticosteroids, and/or mannitol, and/or acetazolamide 500 mg.
An assistant is useful to help prepare the desired filler, disinfect the skin, and apply the topical anesthetic. An assistant may also be helpful to record the location and amount of product used and to provide distraction techniques (e.g., vibration, massage) to minimize patient discomfort during injections.
A history and examination are obtained with a focus on detecting any contraindications to nonsurgical rhinoplasty, as listed previously (SEE CONTRAINDICATIONS).
Preoperative photography using standard rhinoplasty views should be taken both before and 1 to 2 weeks after the procedure. Digital imaging software should be considered, as this helps to improve patient-clinician communication and provides a realistic expectation of the procedure results.
The skin should undergo meticulously disinfecting using chlorhexidine gluconate wipes.
Topical anesthetic (e.g., lidocaine) is applied 30 minutes before the procedure.
A marking pen may be useful to identify key nasal landmarks, including the midline, nasion, rhinion, and tip-defining points. The clinician may also find it helpful to outline any contour irregularities (e.g., concavities) or other areas needing attention.
Before detailing the technical nuances of nonsurgical rhinoplasty, it is worth reiterating that the clinician should always follow safe injection techniques when placing filler in the nose and include injecting into an avascular sub-SMAS plane (directly above the perichondrium or periosteum), staying midline when possible (also helps prevent asymmetries), aspirating to assess for intravascular needle/cannula placement, injecting slowly, placing small aliquots of filler at a time, and minimizing the number of injection sites. Lastly, the use of a blunt-tipped cannula may increase the safety of nonsurgical rhinoplasty by theoretically reducing the likelihood of intravascular injection. TIP: using two hands (one for injecting, the other for stabilizing, pinching, and/or molding) can help achieve safe, reproducible results.
The approach to nonsurgical rhinoplasty is relatively uncomplicated and relies on making incremental enhancements to the cartilage and bony framework of the nose. Nevertheless, multiple nonsurgical rhinoplasty techniques exist with variations on what type of filler to use, the order of injection, the specific injection technique employed (e.g., droplet, threading, need for subcision), location of filler, and the amount of filler required.
Regardless of the technique employed, reproducible, and satisfactory results are attainable if safe injection techniques and an anatomic-based treatment plan are executed. For those trained in surgical rhinoplasty, the graft-based technique (wherein the filler simulates the effects of a similarly positioned cartilage graft) represents the most intuitive approach.
Herein, we list several areas that can be addressed with nonsurgical rhinoplasty and describe key maneuvers required to produce safe and reliable results:
Radix/dorsal augmentation: First, the desired height of the radix and dorsum is determined, as well as the amount of supratip break (if any). The selected areas of the radix and/or dorsum are then filled with a 30-gauge needle using a series of droplets precisely placed in the midline with a 90-degree inclination. Alternatively, dorsal augmentation is achievable using a cannula introduced via the supratip and advanced in a sub-SMAS plane up to the height of the desired augmentation but not beyond the nasion. The cannula bevel should be faced down, and the filler injected in a retrograde fashion. In either approach (needle or cannula), the skin should be tented upwards to mitigate vascular occlusion. Some authors recommend placing a finger above the radix to prevent superior filler migration. Typically, 0.5 mL is an appropriate amount of filler for full dorsal augmentation. Immediate massage and molding will help to ensure smooth contour. NOTE: some authors advocate that dorsal augmentation with HA requires slight overcorrection to account for the immediate post-injection edema. If significant overcorrection occurs during the procedure, this can usually be addressed with molding and massage.
Dorsal convexity (hump) camouflage: the illusion of hump reduction is a relatively straightforward maneuver achieved by strategically augmenting the midline dorsum with a few precise needle injections placed cephalad and/or caudad to the existing dorsal convexity. An amount of 0.2 mL per injection site is typical. As with dorsal augmentation, radix height and supratip break must be determined before injecting.
Straightening the crooked nose: Just as surgically placed onlay grafts and/or asymmetric spreader grafts help to straighten a crooked nose, so too does carefully placed filler along the dorsum and nasal sidewall provide camouflage to contour irregularities of the mid to upper third of the nose. Of note, extra care should be taken when injecting laterally on the nose due to the vascular arcade (see ANATOMY above). In particular, direct injection in the region of the alar groove should be avoided to avoid intravascular injection of the lateral nasal artery. For this reason, some advocate adhering to midline injections while using massage and molding to lateralize the filler into the desired location.
Premaxillary deficiency: beside presenting as an obvious alar base discrepancy, asymmetry of the premaxilla can promote tip asymmetry as well as alar-columellar discrepancies (e.g., ipsilateral ala retraction). Like the premaxillary graft in surgical rhinoplasty, filler can be placed under the alar base to correct this asymmetry. Importantly, the filler should be injected deeply on the maxilla from a medial position to avoid vascular complications. Injection with a cannula is our preferred technique of injection in this region.
Tip projection: like the effects of various tip-projecting grafts in surgical rhinoplasty (e.g., tip graft, shield graft, caudal septal extension grafts, etc.), so too can filler be used to augment tip projection. Safe tip injection techniques include placing very small aliquots of filler in a location that will correspond to the desired tip defining point. Depending on the clinician’s experience, an infratip or supratip approach are both options. Regardless of the method used, filler should be injected at the depth of the perichondrium. Injection directly between the domes should be avoided to prevent splaying of the domes, which can result in inadvertent tip widening. If the infratip lobule warrants augmentation as well, and further injection can be placed to replicate a shield graft. Also, the supratip area is modifiable with careful filler placement depending on the desired supratip break. NOTE: supratip augmentation should always be performed after tip projection maneuvers to avoid the risk of iatrogenic Polly beak deformity.
Tip Rotation: increasing the tip rotation using fillers represents an advanced technique in nonsurgical rhinoplasty that is achievable in a variety of ways. Firstly, the illusion of increased rotation can be created by blunting the nasolabial angle with an injection placed deeply into the subnasale along the anterior nasal spine. Generally, approximately 0.5 mL of filler suffices. Secondly, filler can be deeply injected in the intercolumnar space between the medial crura footplates adjacent to the posterior septal angle (PSA). This deep intercolumnar space injection essentially acts as a columellar strut and lengthens the central leg of the tripod as described by Anderson, thus causing increased tip rotation (and projection). Of note, the injection along the PSA also promotes anterior displacement of the medial crural footplates, which can help correct a retracted columella but alternatively can exacerbate any existing columellar show. Usually, 0.2 to 0.3 mL of filler is necessary in the columellar space. NOTE: pinching the membranous septum while injecting the columella and nasal spine area can help keep the filler midline and prevent migration into the nasal cavity causing resultant nasal obstruction.
Alar rim contouring: similar to a rim graft’s effect on the contour of the ala, filler can be placed along the alar rim to correct slight alar retraction or asymmetry. Care is in order when injecting the alar rims in patients who have undergone previous rhinoplasty, as the blood supply post-operatively remains rather tenuous due to the previous marginal incision.
Functional applications: as mentioned previously, injectable fillers placed into the scroll, internal nasal valve, alar rims, and nasal sidewall have been used to address nasal valve insufficiency by simulating the effects of various functional grafts (e.g., spreaders, alar battens, butterfly grafts, strut grafts, alar rim grafts) or implants (e.g., poly-L-lactic acid). This application of fillers in nonsurgical rhinoplasty, however, remains controversial.
The patient should receive counseling that complications after rhinoplasty are generally mild and self-limited, though rare but serious complications certainly exist, some of which may not be reversible (e.g., blindness, stroke). Complications associated with nonsurgical rhinoplasty are outlined below and categorized as either early or late-appearing.
Early-onset (hours to days)
Delayed onset (weeks to years)
Despite these complications, the staff should reassure the patient that there exists a well-described body of literature supporting the overall effectiveness and safety of injectable fillers in nonsurgical rhinoplasty.
Nonsurgical rhinoplasty represents a quick, safe, and reliable modality for patients looking to enhance the appearance of the nose while avoiding the cost, recovery, and complications associated with surgical rhinoplasty. Despite its rising popularity, however, nonsurgical rhinoplasty should be performed only on a case-by-case basis. It should always be compared to surgical rhinoplasty, which remains the gold standard for treating patients with cosmetic and/or functional deficits of the nose. When performing nonsurgical rhinoplasty with fillers, proper patient evaluation, and execution of a thorough, anatomic-based treatment plan can produce safe, reliable, and satisfactory outcomes.
It remains imperative to identify the risk factors and perform a thorough assessment of the patient before performing nonsurgical rhinoplasty. An interprofessional team approach is an ideal way to limit the complications of this procedure. Before surgery, the patient should have the following done:
An interprofessional team of an experienced injector and assistants should be involved during the nonsurgical rhinoplasty to maximize outcomes. Nursing staff can prepare the patient for the procedure, assist and monitor during the procedure, and provide post-procedural care. Close follow-up during the initial post-procedural period, either by the clinician and/or the plastic surgery specialty nurse experienced in post-procedural care of nonsurgical rhinoplasty, should evaluate the patient for possible complications, including tissue ischemia and blindness. It is also essential to educate the patient on properly caring for the nose after the procedure by avoiding extensive manipulation of the nose for the first 24 to 48 hours post-procedure to mitigate complications. [Level 5]
Pain is minimal after nonsurgical rhinoplasty and pain medication is typically not required. Bleeding can be easily controlled with pressure, and bruising is uncommon though self-limiting if it does occur. In order to minimize edema and complications, however, the patient should avoid excessive manipulation of the nose, sleep with the head elevated, and avoid rigorous activity for the first 2-3 days. Pre-procedural Arnica montana and/or Bromelain may help lessen bruising and swelling.Patients are asked to return to clinic at 1-2 weeks, at which time they may be given a repeated injection if warranted. Photographic documentation should occur at around 1-2 weeks after the procedure. Patients should be advised that results may last up to 9-18 months after surgery (depending mainly on the type of filler used), and that additional filler will eventually be required to maintain results.
Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in post-procedural care of nonsurgical rhinoplasty, should monitor the patient for possible complications including any signs of vascular occlusion (e.g., tissue ischemia, blindness).
|||Jasin ME, Nonsurgical rhinoplasty using dermal fillers. Facial plastic surgery clinics of North America. 2013 May; [PubMed PMID: 23731585]|
|||Bertossi D,Giampaoli G,Verner I,Pirayesh A,Nocini R,Nocini P, Complications and management after a nonsurgical rhinoplasty: A literature review. Dermatologic therapy. 2019 Jul; [PubMed PMID: 31152575]|
|||Pilsl U,Anderhuber F, The External Nose: The Nasal Arteries and Their Course in Relation to the Nasolabial Fold and Groove. Plastic and reconstructive surgery. 2016 Nov; [PubMed PMID: 27782991]|
|||Saban Y,Andretto Amodeo C,Bouaziz D,Polselli R, Nasal arterial vasculature: medical and surgical applications. Archives of facial plastic surgery. 2012 Nov; [PubMed PMID: 22710606]|
|||Moon HJ, Injection Rhinoplasty Using Filler. Facial plastic surgery clinics of North America. 2018 Aug; [PubMed PMID: 30005788]|
|||Raggio BS,Asaria J, Open Rhinoplasty 2019 Jan; [PubMed PMID: 31536235]|
|||Lessard ML,Daniel RK, Surgical anatomy of septorhinoplasty. Archives of otolaryngology (Chicago, Ill. : 1960). 1985 Jan; [PubMed PMID: 3966894]|
|||Lam SM,Williams EF 3rd, Anatomic considerations in aesthetic rhinoplasty. Facial plastic surgery : FPS. 2002 Nov; [PubMed PMID: 12524592]|
|||Goodman WS,Gilbert RW, The anatomy of external rhinoplasty. Otolaryngologic clinics of North America. 1987 Nov; [PubMed PMID: 3320862]|
|||Lane AP, Nasal anatomy and physiology. Facial plastic surgery clinics of North America. 2004 Nov; [PubMed PMID: 15337106]|
|||Chait LA,Widgerow AD, In search of the ideal nose. Plastic and reconstructive surgery. 2000 Jun; [PubMed PMID: 10845313]|
|||Leong SC,Eccles R, Race and ethnicity in nasal plastic surgery: a need for science. Facial plastic surgery : FPS. 2010 May; [PubMed PMID: 20446199]|
|||Azizzadeh B,Mashkevich G, Middle Eastern rhinoplasty. Facial plastic surgery clinics of North America. 2010 Feb; [PubMed PMID: 20206101]|
|||Harris MO, Rhinoplasty in the patient of African descent. Facial plastic surgery clinics of North America. 2010 Feb; [PubMed PMID: 20206100]|
|||Mehta N,Srivastava RK, The Indian nose: An anthropometric analysis. Journal of plastic, reconstructive [PubMed PMID: 28729079]|
|||Kontis TC, The Art of Camouflage: When Can a Revision Rhinoplasty Be Nonsurgical? Facial plastic surgery : FPS. 2018 Jun; [PubMed PMID: 29857337]|
|||Kontis TC, Nonsurgical Rhinoplasty. JAMA facial plastic surgery. 2017 Sep 1; [PubMed PMID: 28492936]|
|||Johnson ON 3rd,Kontis TC, Nonsurgical Rhinoplasty. Facial plastic surgery : FPS. 2016 Oct; [PubMed PMID: 27680521]|
|||Mehta U,Fridirici Z, Advanced Techniques in Nonsurgical Rhinoplasty. Facial plastic surgery clinics of North America. 2019 Aug; [PubMed PMID: 31280849]|
|||Picavet VA,Prokopakis EP,Gabriëls L,Jorissen M,Hellings PW, High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty. Plastic and reconstructive surgery. 2011 Aug; [PubMed PMID: 21788842]|
|||Segreto F,Marangi GF,Cerbone V,Alessandri-Bonetti M,Caldaria E,Persichetti P, Nonsurgical Rhinoplasty: A Graft-based Technique. Plastic and reconstructive surgery. Global open. 2019 Jun; [PubMed PMID: 31624669]|
|||Wang LL,Friedman O, Update on injectables in the nose. Current opinion in otolaryngology [PubMed PMID: 28509672]|
|||DeLorenzi C, Complications of injectable fillers, part 2: vascular complications. Aesthetic surgery journal. 2014 May 1; [PubMed PMID: 24692598]|
|||Urdiales-Gálvez F,Delgado NE,Figueiredo V,Lajo-Plaza JV,Mira M,Moreno A,Ortíz-Martí F,Del Rio-Reyes R,Romero-Álvarez N,Del Cueto SR,Segurado MA,Rebenaque CV, Treatment of Soft Tissue Filler Complications: Expert Consensus Recommendations. Aesthetic plastic surgery. 2018 Apr; [PubMed PMID: 29305643]|
|||Swamy RS,Sykes JM,Most SP, Principles of photography in rhinoplasty for the digital photographer. Clinics in plastic surgery. 2010 Apr; [PubMed PMID: 20206739]|
|||Singh S, Practical Tips and Techniques for Injection Rhinoplasty. Journal of cutaneous and aesthetic surgery. 2019 Jan-Mar; [PubMed PMID: 31057272]|
|||Thomas WW,Bucky L,Friedman O, Injectables in the Nose: Facts and Controversies. Facial plastic surgery clinics of North America. 2016 Aug; [PubMed PMID: 27400851]|
|||Bertossi D,Lanaro L,Dorelan S,Johanssen K,Nocini P, Nonsurgical Rhinoplasty: Nasal Grid Analysis and Nasal Injecting Protocol. Plastic and reconstructive surgery. 2019 Feb; [PubMed PMID: 30531619]|
|||Anderson JR, A reasoned approach to nasal base surgery. Archives of otolaryngology (Chicago, Ill. : 1960). 1984 Jun; [PubMed PMID: 6721774]|
|||Schuster B, Injection Rhinoplasty with Hyaluronic Acid and Calcium Hydroxyapatite: A Retrospective Survey Investigating Outcome and Complication Rates. Facial plastic surgery : FPS. 2015 Jun; [PubMed PMID: 26126227]|
|||Laliberté F,Bloom I,Alexander AJ, The Critical Role of Nutrition in Facial Plastic Surgery. Facial plastic surgery clinics of North America. 2019 Aug; [PubMed PMID: 31280854]|