Letter to the Editor
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Filler Rhinoplasty: Evidence, Outcomes, and
Complications
Prateush Singh, MBBChir, MA, MRCS ;
Roshan Vijayan, MBBS, MRCS; and
Dariush Nikkhah, MBBS, FRCS (Plast)
Editorial Decision date: August 22, 2018; online publish-ahead-of-print September 28, 2018.
Rhinoplasty is one of the most popular facial aesthetic pro-
cedures but also one of the most technically challenging,
with revision rates after surgical rhinoplasty ranging from
5% to 20%.1 The popularity of nonsurgical alternatives
has been steadily increasing, especially that of injectable
filler rhinoplasty using hyaluronic acid (HA), which offers
reduced financial and anaesthetic impact, immediate aes-
thetic results, and rapid recovery.2 This is often demon-
strated on video posts on social media platforms, which
show immediate postprocedure results but often no fur-
ther follow-up.3 Although fillers are predominantly used
for aesthetic rhinoplasty, the technique has also been uti-
lized to address functional issues including internal valve
collapse.4
As the number of patients using injectable fillers
increases, so too does the likelihood of adverse events
such as skin necrosis and blindness. The chance of these
complications occurring increases in patients who have
had previous surgical rhinoplasty. This is due to unpre-
dictable vasculature increasing the risk of vessel can-
nulation, and subsequently vascular thrombosis and
ischaemia.1
There is no consensus on treatment algorithms for filler
rhinoplasty; no definitive inclusion or exclusion criteria;
no consensus on which brand of HA to use, how much
to use, which areas to inject, which to avoid, follow-up
duration for safety, or aesthetic outcomes. Specific target
areas to produce good results have been identified,5 such
as injecting the columella base to widen the nasolabial
angle and reshape the tip, and injecting the supratip and
radix to straighten the dorsum (Figure 1). However, these
are loose recommendations at best.
Aesthetic Surgery Journal
2018, 1–3
© 2018 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
journals.permissions@oup.com
DOI: 10.1093/asj/sjy223
www.aestheticsurgeryjournal.com
To minimize complications, precautions such as utiliz-
ing blunt, small-bore cannulae, aspirating before injection,
placing filler superficially, and using small quantities only
are beneficial. In addition, deep injections into the muscu-
loaponeurotic layers in the preperichondrial and preperios-
teal layers minimize vessel cannulation.2
An Ovid Medline search for “filler rhinoplasty” retrieved
only 7 retrospective studies, all of which presented mini-
mal complications. However, 8 case reports were retrieved
illustrating severe complications of filler rhinoplasty. We
have summarized these data (Tables 1-2), which show lim-
ited follow-up and the potential for serious complications
occurring. With the scarcity of long-term evidence and
strict management algorithms, further large-scale studies
need to be conducted. This will provide more robust sup-
port for filler rhinoplasty as an alternative to traditional
surgical rhinoplasty.
There is a place for filler rhinoplasty as a nonsurgical
alternative. Many key plastic surgery training texts and pro-
grams do not teach these techniques to plastic surgeons,
and they remain firmly in the realm of other specialties
that may have better training in this area.5
Mr Singh is a Surgical Trainee and Mr Vijayan is a Registrar,
Department of Plastic Surgery, Royal Free Hospital, London, UK.
Mr Nikkhah is a Clinical Fellow, Queen Victoria Hospital, East
Grinstead, UK.
Corresponding Author:
Mr Prateush Singh, Department of Plastic Surgery, Royal Free
Hospital, Hampstead, London, NW3 2QG.
E-mail: singh.prateush@gmail.com
2 Aesthetic Surgery Journal

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Figure 1.  Diagram illustrating recommended injection regions and anatomy on the nose of this 27-year-old man with no
previous rhinoplasty.

Table 1.  Summary of Filler Rhinoplasty Retrospective Studies

Study No. of patients Filler used Outcomes

Bravo et al; J Clin Aesthet Dermatol, 2018 44 HA 1 patient developed a fistula, which was excised

Bray et al; Clin Otolaryngol, 2010 18 HA 30 months. No complications reported.

Helmy; J Cosmet Laser Ther, 2018 364 182 HA; 162 CaH >12 months follow-up. 1 HA patient developed superficial infection treated
with oral antibiotics

Liew et al; Aesthet Surg J, 2016 29; all virgin noses HA 12 months follow-up. No “serious adverse events.” 28 achieved clinically
meaningful correction (≥1 grade improvement on the Assessment of
Aesthetic Improvement Scale) rated by a central physician.

Rauso et al; J Cutan Aesthet Surg, 2017 52; 3 who had had HA 6 months follow-up. No skin necrosis or vascular complications. All 52
previous surgical patients self-rated as “very satisfied”
rhinoplasty

Rivkin; Derm Surg, 2014 19 Polymethylmethacrylate 12 months follow-up. 1 patient had a nonvisible ectopic nodule

Schuster; Facial Plast Surg, 2015 46 20 HA; 26 CaH >12 months follow-up. 1 CaH patient with infection resolved with antibiot-
ics; 2 CaH patients developed skin necrosis

CaH, calcium hydroxyapatite; HA, hyaluronic acid.

Table 2.  Summary of Filler Rhinoplasty Case Reports

Study No. of patients Filler used Outcomes

Chen et al; Plast Reconstr Surg Glob Open, 2016 1 HA Skin necrosis

Cohen et al; BMC Ophthalmol, 2016 1 CaH Unilateral blindness

Fan et al; Plast Reconstr Surg Glob Open, 2016 2 HA 1 developed anaphylaxis; 1 skin necrosis

Kim et al; J Craniofac Surg, 2014 1 HA Unilateral blindness and cerebral infarction

Lee et al; Arch Plast Surg, 2017 1 HA Skin necrosis and oculomotor nerve palsy

Schelke et al; Ned Tijdschr Geneeskd, 2017 1 HA Permanent unilateral blindness

Sung et al; Ophthalmic Plast Reconstr Surg, 2010 1 HA Unilateral blindness and oculomotor nerve palsy

CaH, calcium hydroxyapatite; HA, hyaluronic acid.

Singh et al3
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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