Having inherited a nose rich in character, boldly unbutton-like and angular in profile, I've taken a special interest in the rise of the nonsurgical nose job, or, as some call it, "liquid rhinoplasty" — that is, the injection of hyaluronic acid (HA) filler into the nose to temporarily tweak its shape. You've probably seen the before-and-afters online — some so shockingly transformative, one could easily mistake them for classic rhinoplasty results. Most transfixing are the images of noses that somehow, magically, appear smaller after being shot up with sugar gel. Like…how? This fix has sat atop my beauty bucket list for months now. I've preselected my plastic surgeon and mentally scripted my requests: Smooth the bumpy bridge, please, but don't flip the tip.
Scrolling through Instagram Stories the other night, however, a certain post about this procedure gave me pause. Shereene Idriss, a clinical instructor in dermatology at the Icahn School of Medicine at Mount Sinai, and a cosmetic dermatologist at Union Square Laser Dermatology in New York City, regularly answers her followers' skin-care questions during her #pillowtalkderm sessions (such the combination of brilliance and hilarity — check her out). When I tuned in, she was talking filler complications, and addressing the nonsurgical nose job, specifically, sharing that she refuses to offer it, because the risks can be catastrophic.
The Rise of the Nonsurgical Nose Job
"Liquid rhinoplasty, as seen on social media, appears to be this quick and easy thing — but it's not a treatment to be taken lightly," she says, with potential slip-ups precipitating skin death and blindness. "Complications can happen, and are actually increasing across the board as these procedures gain popularity, and injectors' qualifications become more and more questionable," she adds, alluding to the worldwide epidemic of untrained practitioners injecting without a medical license, board certification, or a fundamental understanding of human nasal anatomy. What's more, Idriss says, "the risks are often overlooked, which is a huge disservice to patients, and, frankly, just plain unethical."
Liquid rhinoplasty, as seen on social media, appears to be this quick and easy thing — but it's not a treatment to be taken lightly.
To further inform my own risk assessment, I reached out to some of the tippity-top plastic surgeons specializing in nose-specific plastic surgery, like Rod J. Rohrich, founding partner of the Dallas Plastic Surgery Institute, and professor in plastic surgery at UT Southwestern Medical Center.
"As a rhinoplasty surgeon, I do this nonsurgical rhinoplasty very frequently, but, of course, I know and respect the anatomy," he says. "It always disturbs me, though, when I see someone who's not a rhinoplasty surgeon willy-nilly injecting the nose, because it can be risky if you don't know what you're doing." While there are "no known numbers estimating the risks," Rohrich says he has met patients who've lost the tips or sides of their noses following misplaced needle pokes by other injectors.
Dara Liotta, a double board-certified facial plastic and reconstructive surgeon who performs upward of 30 liquid rhinoplasties a month in her New York City practice, says she wouldn't actually characterize the procedure as high-risk.
"When people talk about it being risky, they're referring to the complication of vascular compromise, which occurs when filler impedes the blood flow through a critical end artery, either by directly entering the artery itself and causing a blockage, or by compressing the artery from the outside, pinching it off, and stopping the flow of blood," she explains.
The Risks of Liquid Rhinoplasty
While Liotta calls the risk "remote," Rohrich argues that there exists "real potential for major complications" when injecting the nose.
An end artery, or terminal artery, is the sole supplier of oxygenated blood to a given area. The end arteries around the nose include those that feed each of the eye's retina — damming these would cause immediate blindness — and those that nourish the skin around the nasal tip and nostrils; a clog in these pipes could deprive the skin of nutrients and oxygen, causing it to decay and die over the course of several days.
The safest location to inject [filler] is along the bridge of the nose, away from the arteries.
Since the sides of the nose are essentially end-artery minefields, "the safest location to inject is along the bridge of the nose, away from the arteries," notes plastic surgeon Melissa Doft, a clinical assistant professor of surgery at Weill Cornell Medical College in New York City. Injecting deep down below the level of these vessels is another crucial safeguard, she says.
When a retinal artery is occluded, "blindness generally occurs right away — there's no turning back, there's no reliable way to fix it," Rohrich says. "With impending tissue loss, there will be pain, discoloration, and blanching of the skin, and when caught early, we can reverse it with hyaluronidase." (Hyaluronidase, an injectable enzyme that dissolves hyaluronic acid, only works on HA-based fillers, however; this is why permanent fillers should never be used.) Rohrich notes that doctors can also help recovery by giving aspirin to thin the blood and using hyperbaric oxygen for three to five days.
"For real, lasting skin damage to occur, the signs of vascular compromise, which typically present within 60 seconds of injection, would have to be totally ignored and left untreated for 12 hours or more," says Liotta. "These same exact risks — blindness or skin death — also exist when injecting filler into other parts of the face, including the tear troughs, the forehead, the nasolabial folds, and the lips."
A sobering fact, for sure — but one that, to us, doesn't underline the dangers of liquid rhinoplasty so much as underscore the vital importance of seeing a reputable, board-certified plastic surgeon or aesthetic dermatologist for your every cosmetic injection. (If you're targeting the very vascular nose, go with a rhinoplasty surgeon, and realize that even then, problems can arise.) Before treatment, discuss all of the risks with your doctor, and be sure she or he use only HA fillers, stocks hyaluronidase in the office at all times, and has admitting privileges to a nearby hospital should the procedure go sideways.
Personally, while I realize the risks may be pretty minuscule when you entrust your face to the right person, I'm choosing the path of self-acceptance for now, bumpy though it may be.
For more on rhinoplasty, check out the complete guide to the procedure in our Life in Plastic series.
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