1. Non-surgical rhinoplasty
A new approach in aesthetic medicine
Non-surgical rhinoplasty is an aesthetic medical technique that improves the shape and contour of the nose by injecting dermal fillers into nasal tissue without using a surgical scalpel[1]. In the United States alone, over 2.7 million injection procedures were performed in 2019 (DeVictor 2021)[2], and demand has surged worldwide due to its low cost, minimal downtime, and immediate results[2]. This procedure is widely indicated for correcting nasal dorsal hump, raising nasal radix height, adjusting tip height and angle, and correcting subtle deformities after surgical rhinoplasty[3, 4].
Primary materials used
Injectable materials may include hyaluronic acid, calcium hydroxyapatite, autologous fat, or cartilage[1]. However, according to a systematic review, hyaluronic acid was used most frequently in 73.38% of all cases, followed by calcium hydroxyapatite at 12.44% (Williams 2020)[5]. Hyaluronic acid is a glycosaminoglycan component that naturally exists in the human body, composed of alternating monosaccharides of d-glucuronic acid and N-acetyl-d-glucosamine[6]. As a result, it is less likely to trigger allergic reactions and is characterized by high safety[6]. Additionally, it has the greatest advantage of being reversible using hyaluronidase enzyme, and due to its low adverse event rate, it is recommended as the first choice by many specialists[6, 7].
2. Efficacy and satisfaction in 5,000 cases (Harb 2020)
Background of the largest retrospective study
The efficacy of non-surgical rhinoplasty using hyaluronic acid has been reported in a retrospective study of 5,000 cases by a single specialist—the largest of its kind[8, 9]. This study covered treatments performed between March 2016 and January 2019[9]. The patient cohort included 4,702 women and 298 men, with a mean age of 27 years[9]. The most common age group was 25 to 34 years, accounting for 52% (Harb 2020) of the total[9].
Indications and specific treatment data
The most common indication for treatment was correction of nasal dorsal hump, accounting for 43.6% (approximately 44%) of all cases[8, 10]. This was followed by post-surgical deformity correction at 20.0%, nasal tip ptosis at 14.7%, loss of contour definition at 8.7%, frontal asymmetry at 7.0%, and bulbous nose at 6.0%[10]. The average procedure time was 12 minutes, ranging from as short as 5 minutes to as long as 25 minutes[11]. The average volume of hyaluronic acid injected per patient was 0.72 ml, with a range of 0.30 ml to 2.40 ml[11]. Additionally, pain scores reported by patients immediately after the procedure on a 10-point scale averaged 2 (Harb 2020), confirming minimal physical burden on patients[11].
Exceptionally high patient satisfaction
Among the 5,000 cases, only 3 patients (0.06%) expressed clear dissatisfaction with the treatment results[12]. Furthermore, when these 3 patients (Harb 2020) were offered hyaluronidase dissolution to revert the nose to its pre-treatment shape, all declined[12]. Additionally, in another systematic review of 1,600 cases, overall satisfaction was recorded at an exceptionally high rate of 94.94%[13]. In that study, short-term satisfaction within 6 months post-procedure was 95.19%, whereas long-term satisfaction beyond 6 months was 89.58%, showing a statistically significant difference (p = 0.017); nevertheless, approximately 90% (Williams 2020) of patients remained satisfied with results over the long term[13].
📊 Distribution of HA rhinoplasty indications by category (Harb 2020 / 5,000 cases)
Source: Harb et al. 2020 (single-surgeon, 5,000-case retrospective study)
3. Duration of effects
Characteristics of hyaluronic acid in the nasal region
In general,Hyaluronic acid injectionAlthough the effects of hyaluronic acid injection are temporary, injection into the nose tends to be absorbed more slowly compared to other facial areas, and the effects tend to be longer-lasting[14]. According to expert consensus, hyaluronic acid injected into specific areas of the nose may maintain its effects for up to 2 to 3 years (Trevidic 2022)[14]. Additionally, analysis from large-scale systematic reviews suggests that the typical duration for maintaining optimal aesthetic results is approximately 6 months to 1 year (Williams 2020)[15]. Surveys using patient self-reported assessment scales (such as FLO-11) demonstrate that good effects were maintained for 150 days (10.1097_DSS 2020) in over 50% of subjects (10.1097_DSS 2020), and it is concluded that notable cosmetic benefits generally persist for 4 months (10.1097_DSS 2020) to 6 months (10.1097_DSS 2020)[16, 17].
Long-term Follow-up Course and Retreatment
Clinical data from 5000 Before-after cases showed that patients were informed that the duration of effect was expected to be 9 to 12 months[18]. In actual outcomes, approximately 32% of patients returned for reassessment at the 12-month mark, and the majority underwent retreatment[18]. Furthermore, 5% of patients who returned at the 18-month mark underwent retreatment[18]. Notably, even at the 12-month mark after treatment, the nasal shape had not completely returned to its pre-treatment state, and soft contours were frequently observed to be maintained[19]. The product itself is a cross-linked hyaluronic acid designed for 12-month (Harb 2020) duration, but clinical effects are generally considered to persist long-term beyond this period, though gradually declining[19].
4. Complication Risk (SR + Meta-Analysis)
Overall Risk Based on Systematic Review
Nonsurgical nasal reshaping is considered to be safe; however, the risk of complications is not zero. In a comprehensive systematic review and meta-analysis involving 8604 Before-after cases, the overall adverse event (complication) rate was calculated to be 2.52%[20]. When case reports were excluded and limited to cohort studies only, the adverse event rate was 2.34% (DeVictor 2021)[21]. Additionally, in another review of 1600 Before-after cases, the complication rate within cohort studies remained at a low level of 1.63% (26 cases (Williams 2020))[22].
Details of Minor and Serious Complications
- Minor complications: The most common complications in the meta-analysis were minor in nature, with ecchymosis accounting for 1.58% (136 cases) and hematoma for 0.13% (11 cases (DeVictor 2021))[20, 23].
- Serious complications: Although extremely rare in frequency, serious complications have been reported. Vascular occlusion occurred in 0.35% (30 cases), vision loss in 0.09% (8 cases), skin necrosis in 0.08% (7 cases), and infection in 0.07% (6 cases)[20, 23]. Additionally, nodule formation was reported in 6 cases, asymmetry in 5 cases, granuloma in 2 cases, telangiectasia in 1 case, Ptosis in 1 case, and anaphylaxis in 1 case (DeVictor 2021)[23]. From extensive literature searches, a total of 65 serious vascular compromise cases have been identified, including 30 cases of skin necrosis and 33 cases of visual impairment (Williams 2020)[24].
Risk Comparison Between Formulations (Hyaluronic Acid vs. CaHA)
Meta-analysis reveals significant differences in complication risk depending on the type of filler used. The complication rate in 6385 Before-after cases using hyaluronic acid was 3.12% (199 cases)[25]. In contrast, in 63 Before-after cases using calcium hydroxyapatite (CaHA), the complication rate was markedly higher at 19.05% (12 cases (DeVictor 2021)), and many of the serious cases involving skin necrosis and permanent vision loss were associated with CaHA use[25, 26].
Safety Data from a Single Institution with 5000 Cases (Harb 2020)
In a single-institution study of 5000 Before-after cases, intraoperative bleeding was observed in 11.1% (559 patients) and immediate postoperative ecchymosis in 2% (100 patients)[27]. Signs of the most concerning arterial occlusion were confirmed in 0.48% (24 patients), with locations at the nasal tip in 16 patients, dorsum in 6 patients, and radix in 2 patients[27]. Of these, 14 patients recovered naturally through massage and warm compresses, and the remaining 10 patients underwent immediate injection of 1500 IU hyaluronidase and achieved complete recovery without sequelae[27]. Final skin necrosis was kept to 0.06% (3 patients) and infection to 0.04% (2 patients (Harb 2020)), demonstrating that rapid response strongly ensures safety[8, 28, 29].
5. Comparison with Surgery
Advantages and Risks of Surgical Rhinoplasty
Surgical rhinoplasty is the absolute gold standard for functional and aesthetic nasal reconstruction[3]. However, surgical approaches have drawbacks including high costs, the need for general anesthesia, and prolonged downtime[30, 31]. Furthermore, risks of prolonged post-operative swelling and bruising, iatrogenic deformities, and irreversible complications such as functional deficits from nasal valve destruction cannot be ignored[30].
Merits and Limitations of Non-Surgical Approaches
In contrast, non-surgical approaches using hyaluronic acid and similar substances offer significant advantages: minimal downtime and the ability to visually confirm results almost immediately after the procedure[4]. In particular, for patients refusing revision surgery, this represents an excellent option for correcting subtle asymmetries or over-resection following rhinoplasty[31]. Indeed, a study of 5,000 Before-after cases showed that 20.0% overall (Harb 2020) were revision procedures following surgical rhinoplasty[10].
However, non-surgical rhinoplasty has clear limitations. Since hyaluronic acid cannot alter the nasal skeleton itself, it is impossible to fundamentally correct severe deviated nose, extremely large dorsal humps, or pronounced bulbous nose tips[32]. Additionally, because results are temporary, regular re-injections are required every 1 to 2 years (Williams 2020) to maintain the effect[33]. Furthermore, when injecting into post-surgical noses, attention must be paid to the restricted injection space due to scar tissue from previous surgery and reduced skin elasticity, which increases the risk of vascular compromise[34, 35].
6. Choosing Safe Treatments
Anatomical Knowledge and Characteristics of Asian Noses
Non-surgical rhinoplasty is a high-risk procedure that can lead to devastating complications such as blindness or tissue necrosis if done incorrectly[36]. Therefore, selecting an experienced physician well-versed in the complex vascular anatomy of the nose is an absolute requirement[37]. The nose consists of 5 layers (DeVictor 2021): skin, superficial adipose layer, fibromuscular layer (SMAS), deep adipose layer, and periosteum or perichondrium[38]. Blood supply is derived from branches of the external carotid artery (facial artery) and internal carotid artery (dorsal nasal artery), and technique to avoid misdirected injection into these vascular networks is essential[39]. Additionally, Asian noses are classified as mesorrhine, intermediate between Caucasian (narrow) and African (broad) noses[40]. Selecting a physician who understands anatomical characteristics such as low and flat nasal root and dorsum, and thick dermis and subcutaneous tissue at the nasal tip, directly contributes to aesthetic success[40, 41].
Recommended Injection Techniques and Device Selection
The following technical points are recommended as procedure standards to maximize safety:
- Injection depth: Since the majority of major vessels run superficially, minimizing vascular injury risk requires injection into the deepest layer—directly above the periosteum or perichondrium (deep plane)[42].
- Low-pressure, micro-volume injection: To prevent bolus injection into vessels, injection is recommended at extremely slow speed and low pressure, in minute droplets of 0.1 ml or less per injection (in some locations less than 0.02 ml (Harb 2020) to 0.05 ml (Trevidic 2022))[43, 44].
- Needle selection: Since vascular occlusion has been reported even with blunt needles (cannulas), experts recommend using extremely fine sharp needles such as 27-gauge or 30-gauge (Trevidic 2022) for precise, low-pressure injection into the correct plane[45, 46].
Pre-procedure Assessment and Emergency Management (Hyaluronidase)
Before any treatment, assessment using a "pinch test" to pinch the nasal skin is absolutely necessary[32]. If the skin is firm and cannot be lifted away from the bone or cartilage, access to the correct injection layer is difficult, and forceful injection carries a high risk of vascular complications due to pressure, so treatment should be deferred[32, 47]. Furthermore, the pre-injection syringe aspiration test for intravascular confirmation functions with only approximately 53% probability (Trevidic 2022) even in animal studies and is not a completely reliable technique[48]. Therefore, it is essential to choose a clinic that keeps hyaluronidase (an enzyme that can immediately dissolve hyaluronic acid) on hand in case signs of vascular occlusion such as skin blanching appear[7]. Animal studies have shown that administering hyaluronidase within 4 hours (DeVictor 2021) of vascular complications may prevent skin necrosis, and this reversibility is the primary safety reason for choosing hyaluronic acid[7, 49].
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7. Summary
Non-surgical nasal contouring using hyaluronic acid is an excellent aesthetic medical treatment that effectively improves the contour and height of the nose while avoiding the downtime and risks associated with surgical procedures[1, 50]. Analysis of case data involving thousands of cases shows that overall patient satisfaction reaches approximately 95% (Williams 2020), proving that many patients remain satisfied with the results long-term[13]. The overall complication rate is also relatively low at 2.52% (DeVictor 2021), and risks can be minimized by using the correct formulation (hyaluronic acid)[20, 25].
However, despite its convenience, if serious complications such as vascular occlusion occur, it carries a high-risk aspect that can lead to irreversible consequences such as skin necrosis or blindness[36]. Therefore, to ensure this treatment is performed safely and successfully, it is most important to choose an experienced specialist who deeply understands the anatomical structure of the nose unique to Asian populations and possesses advanced technical skills to inject minute amounts of hyaluronic acid at low pressure into the appropriate deep layers[37, 40, 42]. Additionally, whether the medical facility is equipped to respond quickly using hyaluronidase in case of emergency is also an essential condition for choosing a safe clinic[7].
References
- Williams L, Kidwai S, Mehta K, et al. Nonsurgical Rhinoplasty: A Systematic Review of Technique, Outcomes, and Complications. Plastic & Reconstructive Surgery. 2020 DOI
- Harb A, Brewster C. The Nonsurgical Rhinoplasty: A Retrospective Review of 5000 Treatments. Plastic & Reconstructive Surgery. 2020 DOI
- Trevidic P, Kim H, Harb A, et al. Consensus Recommendations on the Use of Hyaluronic Acid–Based Fillers for Nonsurgical Nasal Augmentation in Asian Patients. Plastic & Reconstructive Surgery. 2022 DOI
- DeVictor S, Ong A, Sherris D. Complications Secondary to Nonsurgical Rhinoplasty: A Systematic Review and Meta‐analysis. Otolaryngology–Head and Neck Surgery. 2021 DOI
Author of this article
Hiromi NakamuraPhysician
Zetith Beauty Clinic Ginza / Osaka / Fukuoka
Has a track record of research presentations at domestic and international conferences, and is involved in technical instruction and education across all of Zetith Beauty Clinic. Specializing in precision aesthetic medicine based on anatomical evidence, pursuing natural results tailored to each individual's skeletal structure and tissues.