It is reported in the medical literature that there is some incidence of blindness after dermal fillers have been used as an alternative to nose plastic surgery. One has to delve deep into the subject to understand how and why fillers can cause such a serious complication. Most temporary fillers that are used are comprised of hyaluronic acid. The entire volume of filler is injected at one time. Based on the consistency of the fillers and the volume required to make the cosmetic procedure successful, there is a potential for disruption of veins that traverse the nose. The cannula, or tube that is used to insert the dermal fillers, has to be of a certain diameter, and this increases the chance of interrupting the blood vessels. The material can enter into the venous system and then enter the circular system and move to a location deeper in the skull that could occlude the blood vessels that supply the eye. This is the most serious complication.
Issues such as the interruption of blood vessels, blindness, or tissue loss are nearly unheard of with the permanent non-surgical nose job. The reason is that the injection needle is very tiny and thus unlikely to penetrate a vessel; the technique of “micro-droplet” means the movement of the needle under the skin. Rather, multiple tiny injections are made. Most importantly, the permanent medical-grade liquid silicone filler, best known commercially as Silikon-1000, is injected over several sessions. It is less invasive, more precise, and less traumatic. It has 60+ years of great success and, for the patient, finality.
Is the non-surgical nose job over? Plastic surgeons weigh in.
When properly performed, a non-surgical nose job is still a valuable alternative to plastic surgery. For the right patients, employing the right indications, a liquid nose job makes sense. It is more economical and time efficient, and it houses less uncertainty than plastic surgery. The key question is why the popularity declined and, if so, is it related to the fact there is this complication of blindness or at least some loss of partial vision from the liquid rhinoplasty from the non-surgical rhinoplasty? There are so many variables in the equation that it seems unfair to demonize this very helpful procedure, but there is also a significant difference between the two classes of materials that are injected. The temporaries are the ones that have had the most publicity regarding the problem of blood vessels being occluded and vision suffering. The permanent non-surgical nose job using medical grade liquid silicone, marketed as Silicone-1000, has a much lower percentage of problems. So, it is not fair to blame the possible necrosis, or breakdown of skin, on all fillers. Also, of course, there is the issue of who is doing the filler injections; like all surgical treatments, experience, super specialization, and proper technique are factors in the success – or failure – of even a liquid rhinoplasty. If anything, the popularity of a non-surgical nose job should increase because of its overall success.
What is a non-surgical nose job, and what happens during the procedure?
A non-surgical nose job implies an office treatment whereby liquid dermal fillers are placed between the skin and the underlying bony and cartilage architecture to correct imperfections of the nose. These include dips, divots, depressions, potholes, and even asymmetries. This is why it is called a liquid nose job: it is a liquid that performs the plastic surgery, if you wish, upon the nose. Filler injections may be temporary or permanent filler. There are many more temporary fillers than permanent fillers. There are only two different brands of permanent fillers, Silicone-1000 and Adato Sil-Ol 5000. It is certainly within the ability of a plastic surgeon to master the technique of non-surgical rhinoplasty.
Are non-surgical nose jobs safe?
Non-surgical nose jobs are safe when performed for appropriate indications and by skilled practitioners. The injection of hyaluronic acid, one of many filler injections, has been conducted for many years. Temporary fillers such as Restylane® and Juvéderm® are degraded by the body within a certain period of time. The permanent fillers are not. The permanent variety of the liquid nose job is permanent. Once it is placed, nature seals up into the injection location, and there is no significant resorption. The practitioner must be skilled and understand the anatomy and potential risks and complications of a non-surgical rhinoplasty. One needs to know the location of blood vessels to avoid them. One needs to inject an appropriate amount to avoid serious complications or necrosis, meaning death of the skin. Plastic surgery always operates under the theme of “first do no harm.” Be conservative, be careful, and when in doubt, do less.
How to make patients aware of the risks
The patients are made aware of the risks by discussion between the physician or qualified injector of the conduct of the procedure and the results. Likewise, since dermal fillers have some potential for complications and problems, these need to be enumerated and explained. Filler injections can be easily understood by patients, particularly using anatomical drawings. Every plastic surgeon has those available to him or her. The key to liquid rhinoplasty, from the standpoint of the patient, is whether it can accomplish what they are not happy with. This is important because fillers are not automatically substitutes for surgery. Both surgery and fillers have their pluses and minuses, and these are the issues that should be discussed during consultation before any cosmetic procedure is agreed upon.
What are the risks and dangers of non-surgical nose jobs?
Serious complications are very, very rare. In properly trained, experienced hands, these procedures are very successful in nearly every instance. However, it is important to commit to any intervention knowing the benefits but also the risks.
The main risks and dangers of non-surgical nose jobs are serious side effects secondary to improper technique. The liquid nose job, while not a “cut and sew” process, has a risk for some significant complications, despite the public’s – and some practitioners’ cavalier attitude and patient’s rather casual approach to a process that even has the potential, albeit very rare, for vision loss.
Generally, poorly trained and/or overly ambitious injectors, possibly registered nurses, physician’s assistants, or even some MDs, will not have the skill and judgment to avoid the complications and poor results that can be seen in the procedure.
There are two very serious complications of non-surgical rhinoplasty, but these have been reported when the nose filler used was one of the hyaluronic acid temporary fillers, such as Restylane® or Juvéderm®, or their variants. Extremely rare with the permanent filler, medical grade liquid silicone. The difference in rates of complications is reflective of the larger volume of the temporary fillers being performed by a huge army of practitioners, some of whom are less talented and risk-averse than others. Also, because the techniques of injection are very different, the results and complications are not parallel. The temporary filler session aims to completely correct all imperfections. The permanent filler is placed “sequentially,” i.e., micro-droplets are placed in small amounts over time. This lessens the risk of over-filling and is best at “fooling the body” that it now has a man-made, permanent inhabitant. While the temporary fillers are placed using a cannula, the permanent nose filler is injected via a very tiny, small bore needle to promote accuracy and lessen the risk of blood vessel injury.
Skin necrosis or breakdown is one complication, typically because of a volume of filler that is too large, usually the temporary variety. Excess pressure of the filler on the underside of the skin of the nose can compress or block the blood vessels that nourish the skin and cause some portion of the skin to die. It is more common with the “one full injection “of the hyaluronic acid temporary fillers than with the micro-droplet, gradually placed over time permanent filler, medical grade liquid silicone.
The even more feared complication is blindness because of entrance into the blood vessel system of the filler. Because of the small bore needle injection and the injectors’ ability to test whether or not the tip of the tiny needle has entered a blood vessel, such a complication is virtually unknown when Silikon-1000, the permanent filler, is used. However, when the coarser technique of temporary filler insertion is used, the risk is greater.
Inflammation
A key risk or danger of a non-surgical nose job is inflammation or infection. These should be very rare when proper technique is performed, beginning with cleansing the skin with an antibacterial agent. All dermal fillers must be done using standard sterilized syringes and needles. The technique must be done as carefully as plastic surgery.
Skin Necrosis Or Skin Death
The key to proper and responsible use of fillers is not causing skin death or skin necrosis by either injecting in the wrong area or injecting too large of IM, which would compress the blood vessels that sit under the skin that are superficial to the bone and cartilage. Skin necrosis, or death, can be avoided. There are early signs of incipient skin necrosis, and they can be encountered if discovered early by medications that dilate blood vessels and increase the blood supply to the area.
Another option available to those practicing the temporary non-surgical nose job is to use a particular injection that will basically dissolve the temporary filler. It will not work against the permanent filler, but permanent fillers are a variety of liquid rhinoplasties that are injected incrementally. That means over a period of time. Sessions are separated by six weeks to allow nature to deliberately incorporate and stabilize the permanent filler into the nose structure.
Can a non-surgical rhinoplasty cause blindness?
Yes, fillers, particularly an excess volume and poorly injected temporary filler, can cause blindness. Surgeons must be aware of the very first signs and have supplies available to try to reverse the complication of this particular non-surgical rhinoplasty. Hyaluronic acid is easily dissolved by an enzyme-caused hyaluronidase. Every practitioner should have that at hand. A cosmetic procedure always has the potential for complications, but the key to avoiding significant consequences is to be prepared to manage the untoward effect or potential serious complications. In the world of plastic surgery, the operative phrase is “be prepared.”
How can dermal fillers induce blindness?
Dermal fillers, particularly the hyaluronic brand, can induce blindness because an increased volume may compress the blood vessels, or the injection process through a large cannula may interrupt the integrity of the arteries and veins and, therefore, enter the circulatory system and be transported to the very arteries that nourish the eye.
Ptosis, visual loss, and ophthalmoplegia.
Ptosis is a droopy eyelid. Visual loss is when there is damage to the retina or “camera film” in the back of the eye. Ophthalmoplegia is when the nerves to the eye muscles may be impaired or the muscles themselves imperfect, such that double vision may occur. Typically, ptosis and ophthalmoplegia are not the consequences of a liquid rhinoplasty. The fillers used there are not apt to enter the course that would take them to compromise the function of the art of the nerves and blood vessels within the eye nor the controlling portions of the upper eyelid, which, when interrupted, would cause droopy eyelid. Imperfect BOTOX® injection is a more common consequence since it will temporarily paralyze the muscle that elevates the eyelid, causing a “sleepy” or “droopy” eye. Fillers cannot be indicted for that.
Current statistics for dermal filler blindness
Statistics may not be totally accurate because there is no absolute obligation for practitioners to report problems with fillers to a central registry. While liquid rhinoplasty may be a ubiquitous procedure, it is hard to know the exact volume of sessions performed. The manufacturers of the products had some ideas, but still, it is not accurate enough for the scientists who are studying this as an arm of plastic surgery to have more data. Filler injections are conducted in various locations by various practitioners, and while their skills and qualifications may vary, they have no obligation to file forms or submit data into a central registry. One relies on the integrity of the plastic surgeon and his staff to report complications, untoward events, and unanticipated consequences of the liquid nose job.
Devastating gaps in the system
One of the weaknesses in the current medical system is that there is inadequate oversight and control of unqualified practitioners performing cosmetic procedures, including non-surgical nose jobs. The Los Angeles Times, in a front-page story on April 13, 2024, highlighted that issue. The most common imperfection of the medical delivery system is that those without formal specialty training and being board-certified by an appropriate specialty board are performing cosmetic procedures well beyond their core training and specialty. Should internists, who have no training in the world of surgery, let alone cosmetic surgery, be performing filler injections or other cosmetic procedures? Of course not.
It is very hard for a given state’s medical licensure system to oversee all the activities of the thousands of practitioners it licenses.
Worse than MDs working outside their speciality sphere are non-MDs, even lay-people performing cosmetic procedures. Regulators are constantly wrestling with that problem.
Naturopath denies responsibility
There are nonphysician practitioners who may take it upon themselves to conduct liquid rhinoplasty. They often are not trained in the proper use of fillers. They are not educated enough to know the indications, understand the complications, and be prepared to deal with the complications. Skin necrosis and blood vessels being injured create an immediate emergency, and it is not likely that all practitioners are prepared properly. While the liquid nose job has great success generally, we hear of the exception to that whereby there have been significant problems, including visual loss. The people qualified to perform ejections using fillers in the nose, or liquid rhinoplasty are physicians, registered nurses, licensed nurse practitioners, and licensed physician’s assistants. There are certain fringe practitioners such as Naperpass who are not physicians and also chiropractors who may be anxious to provide services, including injection of fillers, but if they are licensed, that license does not include performing injections into the body. The consequences, which could visit the blood vessels and even cause skin necrosis, are serious and require proper education and training to avoid. (says he will continue later)
Who Is At Risk Of This Complication?
The most likely people to be at risk of this complication are those who probably had one or more surgical procedures on the nose. The risk, typically, of a liquid nose job or non-surgical nose job, is that interruption of the blood vessels may cause bleeding and, if so, some undue pressure on the skin. That, of course, is a significant side effect and possible major complication. Visual loss has been reported as a result of interruption of the blood vessels with some of the material traveling through the veins to the brain. Augmentation with temporary fillers is typically done such that the entire area that needs improvement, including the troughs, dips, divots, pits, etc., are filled at the same time, therefore requiring a more extensive field of the non-surgical rhinoplasty technique. Those who have had prior surgery have scar tissue, and it is always more difficult to plod through scar tissue since the normal layers of tissue have been distorted or may even fail to exist. Another risk of a temporary nose filler, whether performed by a board-certified plastic surgeon or any other specialist, including a dermatologist, facial cosmetic surgeon, et al., is the inconsistency of the filling and also perhaps some bruising and undue swelling, although the latter is expected to dissipate over time. But the most devastating consequence is blindness, and now we discussed that.
How To Avoid Causing Blindness With Dermal Fillers
There are two varieties of non-surgical nose fillers. One category is temporary, and the other is permanent. The temporary products are based on the hyaluronic acid “core” and include trade brands such as Juvéderm® and Restylane®. They are destined to dissolve. They are injected, and the filling mission is completed in one session. Another option that reduces the chance of blindness is using a permanent nose filler, and there is only one: Medical-grade liquid silicone. The most popular brand is sold under the name Silikon-1000. The medical-grade liquid silicone has been used for over 60 years and was approved by the FDA in the 1960s. It has never lost the confidence of the FDA. Because the injection technique uses the permanent silicone filler, this variety of non-surgical rhinoplasty is conducted differently with sequential visits six weeks apart. This sequential filling of small micro amounts is based on understanding nature’s need to build a wall around it, which takes time, and also to reduce the chance of over-filling, causing pressure on the blood vessels or tearing of the blood vessels, which, of course, leads to complications that are so feared, such as visual loss. The materials and techniques are different. The reason that would be the case is the difference in texture and maneuverability of the filler. By that, I mean that the temporary fillers can be somewhat massaged into place when the space is created for them. This is not the case for permanent non-surgical rhinoplasty. Remember, the blood vessels of the heart nourish all tissue. The skin of the nose, while endowed with a generous supply of blood vessels, is not immune to such trauma, which would compromise the structure and the integrity of the skin due to pressure upon the skin and, therefore, the complications which are much dreaded.
Can You Eliminate The Risk Of Vascular Occlusion?
Vascular occlusion as a consequence of a liquid nose job is the complication that is most commonly feared. It causes the lack of proper nourishment in the tissues and the risk of potential loss of tissue, which is a further complication that becomes a major burden upon the patient and surgeon. Typically, one of the techniques that is employed by highly specialized practitioners of plastic surgery is conservatism. An incremental or gradual filling is much less likely to apply pressure upon the blood vessels, causing their narrowing or blockage and, therefore, diminishing their ability to nourish the tissue. This is one of the features of the permanent liquid nose job. Sequential microdroplets in each area of imperfection make good sense.
What Do I Need To Do Before Getting A Non-surgical Nose Job?
Before getting a non-surgical nose job, one should have a very detailed consultation with someone who specializes in cosmetic surgery, who is ideally board certified, and has a very limited practice focusing on nose surgery, both surgical and non-surgical rhinoplasty. The consultation should include an examination of the interior and exterior of the nose to be certain that there are no infections present. It should include an evaluation of the strength of the support tissue of the nose. It is also helpful to reveal what the patient’s appearance was before surgery and if they had had prior plastic surgery on the nose. This is very important to have an understanding of why the appearance may be imperfect. Then there are patients who have never had surgery, and these patients often have very well-defined imperfections or points of dissatisfaction. For example, the bridge may be too low. The tip may be round and somewhat depressed, as it is related to the bridge. The columella has some irregularities, possibly due to previous surgery. The columella has some irregularities that would benefit from plumping or filling. One has to evaluate where an “addition” to the nose’s architecture makes sense. Permanent non-surgical rhinoplasty is relatively unknown in certain circles because it is not supported by an industry that sells and promotes absorbable temporary fillers. However, for patients who would benefit from an addition and whose nose imperfections would not benefit from subtraction, a non-surgical rhinoplasty is a good option. Computer imaging can be very helpful in demonstrating to the patient what the end result would be. Even more helpful is the Kotler saline demo, whereby sterile saline (salt water solution) is injected exactly as it would be for the permanent filler, and the patient can see in the mirror what the outcome would be. This is a “trial run” or “test drive,” which is incomparable in terms of clearly demonstrating the benefit available to the patient.
How Long Does A Non-surgical Nose Job Last?
The difference in the longevity of the nose filler depends on the material used. As many people have learned from studying social media, most people are aware only of the temporary fillers. They are indeed temporary and may last four months, six months, a year, or perhaps longer, but they are destined to be absorbed by the body. The common brands are Juvéderm® and Restylane®, as well as their successors. There is nothing wrong with the results from these, but the patient is faced with long-term, if not lifetime, needs to have them renewed. Somewhat parallel to the need to keep refilling your gas tank as long as you own an automobile. But there is another less well-known and yet venerable option, and that is permanent non-surgical rhinoplasty using medical grade liquid silicone. Silicone, this clear colorless liquid that injects quite handily, has been used for this purpose for over 50 years. Because it is not supported by massive advertising and marketing to influence physicians and other practitioners to use it, it is not well known, but it is extremely effective and popular because it is permanent. While there may be several sessions needed to achieve the ultimate result, and if the staggering or sequential process is one of the keys to its relative freedom from complications, it is a powerhouse. It does last. It is permanent.
Where Non-surgical Rhinoplasty Shines
Non-surgical rhinoplasty shines particularly for patients who have had one, two, four, or five or even more unsuccessful surgical rhinoplasties. This very impressive and expensive sojourn becomes a major psychological burden for the patient. They have been in search of a satisfactory appearance to their nose and have not achieved it despite many efforts. For many of these people, a non-surgical nose job is a boon. The challenge for the patient who is unhappy is knowing about the permanent alternative to the temporary fillers. Medical-grade liquid silicone, the only recognized permanent filler, can be a gem when properly employed. There are probably no more happy patients among the pool of satisfied patients than those who have finally been able to “close the book” or “end the play” of their unhappy history of surgical rhinoplasties.
Trying Out A Nose Job
“Trying out a nose job” is an interesting concept. What it implies is that one could see as a “test drive” or “preview” what the end result would be. There are several means of doing this. The most practical is when one is considering a permanent, non-surgical, or liquid nose job. Using the Kotler Saline Demo, which is an injection of sterile saline, one can see exactly what this technique can accomplish. That is the most effective and accurate predictor of the end result. If the patient likes what he or she sees in the mirror, then it increases their happiness with permanent non-surgical or liquid rhinoplasty. Right behind, in terms of practicality, is computer imaging, which is used to see on a computer screen what the predictive result would be of either surgery on the nose or treatments using filler injections. One should be confident about the result before embarking on either classic surgical rhinoplasty or non-surgical or liquid rhinoplasty.
How Injected Noses Wear Over Time
Injected noses may or may not wear over time, depending upon the material used. If temporary fillers, such as Restylane® and Juvéderm®, are used, there will be an absorption over a period of months or a year or so, and this calls for reinjection. This is not necessarily harmful to the nose when conducted properly but tends to be a burden upon the patient’s time and wallet. Alternatively, the permanent non-surgical or liquid rhinoplasty is, indeed, permanent since medical-grade liquid silicone is employed. It does not wear out over time. It stays with the patient throughout their lifetime. Due to the differential in cost for a lifetime versus cost for several sessions, this permanent option offers economy, among other important features, such as a lesser incidence of complications.
Limitations Of Liquid Rhinoplasty
Liquid rhinoplasty limitations are based on the patient’s anatomy. One should not have it injected if you are not contemplating having some addition to your nose. If your nose is large already, even though it can be used to conceal humps, lumps, bumps, and divots, in the end, you are undergoing a process of “addition,” which makes the nose larger. The choice is up to the patient, of course, but that is not a limitation, per se; it is a poor indication of it. The limitations of the procedure, as such, tend to be anatomical, such as there is too much scar tissue in the nose to be able to properly inflate those areas, which feature the divots, depressions, asymmetries, prominent edges, etc. Also, know that the non-surgical option, whether temporary or permanent, has no effect on breathing. It is not an operation that can improve the position of a deviated nasal septum or enlarged turbinates, which are the principal offenders causing nasal obstruction and often difficulty sleeping, etc. So, the limitations are based on the anatomy and the history of whether or not one has had surgery. It also depends on the patient’s perception of what bothers them. Some people are bothered by certain minor imperfections that others would not consider significant, but the sole arbiter of what he or she thinks they would like to have their nose be is the patient.
Is It Worth Getting A Non-surgical Nose Job?
There is no question that patients who have a non-surgical nose job, particularly those who have had permanent non-surgical rhinoplasty, also known as liquid rhinoplasty or non-surgical rhinoplasty, are extremely happy, particularly if they suffered a lack of success for one or more surgical rhinoplasties. It is an enormous bargain for them to be able to finally achieve a satisfactory nose for a fraction of the cost of yet another surgical rhinoplasty, which, in fact, may not be successful at any cost. The value of the permanent filler unquestionably exceeds the value of the temporary filler since temporary fillers require lifetime renewal.
Why People Get Liquid Rhinoplasty
People get liquid rhinoplasty because it appears to be a far better option in terms of time, cost, and predictability than either primary or revision rhinoplasty. Some people choose to have a liquid rhinoplasty because they just have an inbred anxiety about surgery or anesthesia, and that is perfectly legitimate to have. In those cases, liquid rhinoplasty may or may not be the optimal solution to correcting their own anatomic perfections, but they can make that decision once they get a better sense of what can be done. So, the popularity of a liquid rhinoplasty rests on the economy, less time off work, and no recovery. It also rests on the fact that the patient is allowed to participate while the process is ongoing with the doctor to decide “how much should be done” and “where it should be done.”
