Patients need to be cautious and seek out an experienced injector. —Steven Dayan, MD
Explore This IssueApril 2020
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.”