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.[25]

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.[26][17] 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.[5][1][26][27][22][18][21][19][28]

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.[21]

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).[29] 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.[19]

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.[22][2][23]

Early-onset (hours to days)

• Asymmetry – can be avoided with proper injection techniques, including staying as midline as possible
• Injection site reaction – pain, edema, erythema, ecchymosis, itching
• Hypersensitivity reaction – pain, fever, itching, and fever; treated with corticosteroids and warm compresses
• Infection – abscess/cellulitis; mycobacterial infection; herpes simplex virus infection (can be mitigated with prophylactic antivirals in high-risk patients)
• Tyndall effect – occurs when the filler is injected too superficially and creates a blue hue underneath the skin
• Surface irregularities and nodules – secondary to improper placement of fillers (e.g., too superficial)
• Vascular occlusion – a rare but devastating complication that can present as A) local tissue ischemia (pain and pallor with subsequent edema, mottling, ulceration, and necrosis), and/or B) vascular occlusion with retrograde embolization leading to blindness and/or stroke. Vascular occlusion can occur either with HA or CaHa and with needle or cannula technique as well. Clinicians performing nonsurgical rhinoplasty with fillers should have a readily available emergency kit (See above EQUIPMENT) and emergency access to an ophthalmologist as well as a center with stroke expertise. NOTE: over injecting may cause tissue ischemia secondary to pressure occlusion of the adjacent nasal vasculature. 

Delayed onset (weeks to years)

• Scarring
• Dyschromia
• Foreign body granuloma – an immune response typically associated with permanent (e.g., silicone) injections; treatment is with corticosteroid injection and/or surgical removal
• Biofilms – may require excision and/or long-term antibiotics

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.[30]

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.[22] 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:

• Evaluation by a clinician experienced in selecting the appropriate patient for both surgical and nonsurgical rhinoplasty
• Assessment by a clinician familiar with the contraindications to nonsurgical rhinoplasty with fillers to ensure that the patient can safely undergo the procedure

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.[31]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).