For nearly as long as fillers have existed, doctors have been injecting them into the nose—be it to veil blips from past surgeries or contour bumpy bridges without cutting. But only within the past decade has nonsurgical rhinoplasty gone mainstream, establishing itself as a bonafide procedure slash social media phenomenon. While the before-and-afters continue to pepper our feeds, some experts are forecasting a shift.
Meet the Expert
- Dr. Dara Liotta is a board-certified facial plastic surgeon in New York City.
- Dr. Richard G. Reish is a board-certified plastic surgeon in New York City.
- Dr. Sarmela Sunder is a board-certified facial plastic surgeon in Beverly Hills.
- Dr. Lara Devgan is a board-certified plastic surgeon in New York City.
- Dr. Christian Subbio is a board-certified plastic surgeon in Philadelphia.
"Nonsurgical rhinoplasty is over," asserts Dr. Dara Liotta, a board-certified facial plastic surgeon in New York City who treats noses almost exclusively. While she offers both surgical and injection rhinoplasty, she's seen most patients opting for the former over the past year and a half. "It's always bugged me that liquid rhinoplasty is touted as this super easy, fix-all magic," she says. "Patients are realizing that filler just doesn't fix everything—and that they should not be using it to 'try on' a surgery."
Last year's statistics support the dramatic rise in surgical rhinoplasties that Dr. Liotta and other face-focused surgeons have reported throughout COVID-19. WFH recovery opportunities, coupled with cash saved during lockdown, fueled a plastic surgery boom. Still, how the pandemic has allegedly furloughed the filler nose job in select practices hasn't been so widely discussed.
"I think the idea of nonsurgical rhinoplasty is a little less attractive after COVID," Dr. Liotta tells us. "Part of it is that, honestly, the mask pushes on the area where we put the filler—it can dent the gel and make it not look as good." For some folks, COVID-19 has also interfered with the upkeep involved with a filler-augmented nose, she adds, creating "more of a push for just fixing it." Zero judgment here, by the way. Your body, your call. If something is eroding your confidence or causing you to obsess, by all means, talk to a board-certified plastic surgeon about ways to enhance your look safely.
The nonsurgical nosedive predated the pandemic for Dr. Richard G. Reish, a board-certified plastic surgeon in New York City. "I've seen the rates of nonsurgical rhinoplasty and patients' overall sense of satisfaction [with it] dropping significantly over the past three or four years," he says. "Many patients are becoming disenchanted with the idea of making their nose larger by adding volume to it."
This is hardly a universal truth, however. Some of the surgeons we spoke to were somewhat shocked to hear anecdotes of waning interest in the liquid nose job. In Beverly Hills, board-certified facial plastic surgeon Dr. Sarmela Sunder says demand for the procedure has "been kind of insane" of late. And New York City board-certified plastic surgeon Dr. Lara Devgan shares that while her numbers are up for both surgical and filler nose jobs, "nonsurgical rhinoplasty has hugely increased in popularity" in recent months.
Other physicians, like Dr. Christian Subbio, a board-certified Philadelphia plastic surgeon, describes more of a plateauing of the procedure. He sees no sign of nonsurgical rhino dying out—but admits that he can understand why some surgeons might wish it so. "It is a trend that, like many others, has been exploited and pushed beyond the boundaries of its utility," he says.
However, this isn't him panning the procedure. "[Injection rhinoplasty] can do some amazing things," Dr. Subbio admits. "But it is a much more limited procedure than a surgical rhinoplasty, which is the only treatment that is going to definitively manipulate the architecture responsible for the true form of the nose." On the other hand, Dr. Subbio says the nonsurgical alternative is designed to camouflage and act as an optical illusion of sorts.
Where Nonsurgical Rhinoplasty Shines
Dr. Jason Bloom, a board-certified facial plastic surgeon and rhinoplasty authority tells us that nasal filler can temporarily help with three main issues: Masking a bump that's visible on profile; lifting the tip of the nose a tad; and veiling minor irregularities, most notably those resulting from surgery.
Doctors and studies reveal that the dorsal hump—the bump on the bridge of the nose, which is a birthright for many—is what drives the lion's share of patients to seek injection rhinoplasty. And, certainly, it is these magic-trick-like before and afters that most commonly fills our feeds. According to Dr. Sunder, social media only shows a limited scope of what's possible with the nonsurgical procedure.
One unsung role in which it shines is improving unfortunate surgical outcomes. "I think with revision rhinoplasty patients in general, there is more predictability with filler than with another surgery," she explains, since healing can breed unexpected changes—like a retracted alar, where the outer rim of the nostril draws up and back, adopting a notched appearance. "This is one of the hardest things we can fix surgically," she says. "It's not uncommon for these patients to have multiple revision procedures to try to get that nostril to come down a couple of millimeters. But, with filler, we're able to do it within minutes."
In the grand scheme, though, what resonates most with fans of liquid rhino is its nonsurgical nature. It's free of the trappings of surgery, including the general anesthesia, downtime, high cost, and even the possibility of repeat operating room visits. Dr. Devgan says this makes it enormously appealing to a variety of folks, like younger patients in the process of "figuring out who they are and what they want," more established individuals craving a quiet confidence boost, and people who may be reluctant to “wholly get rid of an aspect of ethnicity or a feature that’s familiar to their family."
Dr. Sunder agrees that for nose job-curious patients wanting to keep some character or "own their ethnicity," filler lets them soften whatever irks them about their nose while retaining their individuality—all without lasting repercussions. "The permanency of surgery scares a lot of people," she notes. "They say I'd never have surgery, but I want to tweak this about my nose. To them, fine-tuning their nose with filler is almost like trying a different haircut."
Test Driving A Nose Job
While these folks may never graduate to surgery, plenty of others do. According to renowned rhinoplasty expert and board-certified plastic surgeon Dr. Rod J. Rohrich, about 40% of his nasal filler patients eventually get a surgical rhinoplasty. In Dr. Sunder's office, it's approximately half. Dr. Devgan estimates her figure to be on the order of 10%, with "roughly 90% being happy to maintain the filler," she says. Studies generally report very high satisfaction rates for nonsurgical rhino.
While Dr. Liotta concedes nasal filler can be helpful when surgery isn't an option, she is passionately opposed to the idea of getting an injection rhinoplasty to trial a nose job. "I hate operating on people who've had fillers [in the nose]," she says. "It is tough to make a perfect [surgical] result in a patient who has had filler, even years ago." Yes, you can dissolve hyaluronic acid (HA) fillers, and she routinely does so before operating. However, it's not as simple as it sounds. "To dissolve filler, you need the hyaluronidase reversal agent to come into contact with each molecule of the HA—and there's no way to do that," she says. According to Dr. Liotta, the gel melts unevenly, and there's almost always some left hanging around (this is particularly true of the more resilient, highly crosslinked forms of HA).
In certain parts of the nose, like the tip, Dr. Liotta can physically remove it during dissection, but in others, like the radix, or topmost portion abutting the glabella, she can't access it. "You can't scoop it out when the filler is up that high," she explains. Filler and hyaluronidase also promote inflammation and leave the tissues exceedingly "friable," she notes, making surgery "bloody and difficult."
Other doctors interviewed haven't found previously filled noses to pose additional challenges during surgery. Dr. Jason Roostaeian, a board-certified plastic surgeon in Los Angeles, has similar stories of running into filler that was supposedly dissolved and discovering the tissues to be more swollen as a result. Still, he says he doesn't think it spoiled his outcomes. Dr. Sunder seconds these sentiments. While she acknowledges that other nonsurgical treatments, like threads and Ultherapy, have been known to complicate future facial surgeries (due to the scarring they promote), nose filler hasn't been a big obstacle for her.
Dr. Liotta, however, firmly believes that residual filler in the nose can undermine a pristine surgical result. "With time, when all of that filler eventually does dissolve, the [operated-on] nose is not going to look as perfect as it could," she says. And, realistically, that could be upwards of a decade after surgery. Because, according to Dr. Subbio, despite what filler manufacturers purport, no one knows how long different fillers last in human tissues. "The only good evidence we have currently shows that fillers last a lot longer than we think," Dr. Subbio explains. In a relatively immobile area like the nose, some types of filler may linger for years—not at their original quantities, but in measurable trace amounts.
How Injected Noses Wear Over Time
When nonsurgical patients come back in as bumps reemerge and tips begin to droop, a new gel is injected over the existing filler, which can spell trouble over time if top-offs aren't performed judiciously. "Injection rhinoplasty has been super popular for at least the past five years, and now we're seeing [people's noses] start to look weird," says Dr. Liotta. She finds that, after several treatments, filler added to the bridge of the nose tends to "settle to the side, making the area between the eyes look doughy."
Dr. Subbio sees this happening too, especially when injectors refill noses like clockwork, without allowing for the possibility that the gel-imparted "volume may still be there even though the definition is not," he says. "They're pumping filler into the nose without understanding what is truly happening to it."
While some see widening the top of the nose as an inevitable consequence of preserving nonsurgical rhino over the years, others argue that when small quantities of gel are placed in the appropriate layer of the nose, the filler should stay put and gradually dissipate with time.
One has to wonder, though, if this reported filler migration could be at least partly to blame for the unfortunate association that has formed between nonsurgical rhinoplasty and uncanny creatures, like avatars and Klingons, with broad noses originating from between their eyebrows. Proponents of the procedure dismiss any perceived similarity as bad work, vowing that this association is not representative of results on the whole. "This is a technical problem," Dr. Devgan says. "If you overbuild the nose, it can end up looking lionlike or bulky or give you that avatar feeling. But the avatar look should not be conflated with nonsurgical rhinoplasty." She avoids it by being very precise, meticulous, and conservative in her approach.
Skirting this odd aesthetic also means picking suitable patients for the procedure, especially when the goal is to blend away a bump on the bridge seamlessly, says Dr. Bloom. "To do that, we have to put filler above the bump [at the radix] and below it," he explains. But if the radix is naturally high, and you raise it further with filler, "the nose may look straighter, but its starting point will be strange," he says.
According to Dr. Reish, the growing prevalence of avatar noses may be what's turning some people off of liquid rhinoplasty. He blames injectors of questionable skill and training for injecting noses indiscriminately. He insists that "treating the wrong type of patient—one who has a high-set radix and a high hump—will blend the forehead into the nose, creating the avatar look."
Limitations Of Liquid Rhinoplasty
For this reason, Dr. Rohrich includes the high radix on his list of contraindications for nonsurgical rhinoplasty. "We must be super selective when doing this procedure," he stresses. Respecting its boundaries, he also refuses to inject broad noses, noses with excessive humps, and overly droopy noses. "There's only so much you can lift a tip—or create the impression of a lifted tip—with a nonsurgical rhinoplasty," adds Dr. Sunder. "There are some genuine limitations."
The procedure's handicaps are rooted mainly in the materials required for the job. For safety, hyaluronic acid fillers are the only substances that should be used in the nose. While these gels boast irrefutable selling points—their reversibility being chief among them—other characteristics of HA make it arguably ill-suited for contouring a defined, rigid structure like the nose. "Filler is a very smooshy gel, and we're asking it to look like bone and cartilage," notes Dr. Liotta. "Even the stiffest gels cannot push up into the skin like bone can," she says.
She explains that the immediate outcome tends to look crisp and sculptural because the HA hasn't settled. The result is being amplified by some degree of transient swelling. But by two weeks, "it doesn't look as good as when you first did it," she says. This is why injectors typically invite patients back two to four weeks post-shot to refine the result. The thing is, most injection rhinoplasty before and afters on Instagram are taken moments after the initial injection, at the peak of perfection. "That result is B.S.," says Dr. Liotta.
HA's smoosh factor makes liquid-rhino precision especially tricky to achieve on tough, sebaceous skin. "Many different ethnicities have thicker skin, particularly in the lower third of the nose, and we have to have a frank discussion with them about the limitations of filler rhinoplasty," says Dr. Subbio. Ultimately, how one's nose responds to filler—how a bridge elevates or a tip narrows—depends upon the flexibility of the tissues, he explains. If someone's tissues are firm, they can essentially overpower the filler. If an injector ignores this hindrance and forges ahead, "they're going to keep putting in more and more filler and chasing this impossible goal," says Dr. Subbio. "In tissues that are truly resistant, the gel is going to spread sideways and give you that widened avatar nose."
Despite being somewhat amorphous, HA is still substantive—it exists to impart volume—which means "your nose will be larger after filler," says Dr. Rohrich. (This seems intuitive, but many patients are surprised to hear it, he says.) And, so, it follows that filler is not a sensible solution for those with a prominent nose—anyone aiming "to deproject an over projected nose or shrink a very large nose or refine a boxy tip," clarifies Dr. Subbio. Only rhinoplasty surgery can truly downsize a nose, either by physically reducing its overall proportions or tailoring its finer aspects, like the nostrils and tip.
Ironically, on the flip side, "if someone has a tiny nose, it's hard to give that much more volume with filler—we're limited by the tension of the skin envelope," Dr. Sunder explains. Lastly, with apologies for perhaps stating the obvious, filler cannot fix functional problems with the nose, like a deviated septum and other structural quirks that make it hard to breathe.
The Question Of Safety
The nose’s intricate and sometimes variable anatomy makes both surgical and nonsurgical refinements less than breezy.If you follow more than a handful of injectors on social, you've probably seen horrifying images of tissue necrosis—blackened skin that's been robbed of blood supply by a clot of filler and is dying—resulting from a poorly executed nonsurgical rhinoplasty. But we don't hear much about what could potentially go wrong with rhinoplasty surgery.
"The only major risks with rhinoplasty are those of an anesthetic reaction or severe hemorrhage leading to death—these are exceedingly rare and happen much less frequently than necrosis with filler," says Dr. Sunder. More run-of-the-mill surgical complications include prolonged swelling, sensory changes, bruising, and unsatisfactory outcomes. "There is a significant rate of dissatisfaction," she adds.
The unpredictability of post-op healing, not to mention the inherent challenges involved with remodeling the notoriously unforgiving nose, give rhinoplasty "the highest revision rate of any facial plastic surgery procedure," Dr. Bloom tells us. Numbers published in medical journals vary wildly, adds Dr. Rohrich, so the precise figure is a bit of a mystery. But experts agree that seeing a rhinoplasty master—someone who operates on noses every day—guarantees the very best chance of a successful one-and-done procedure.
While nonsurgical rhinoplasty obviates concerns related to dissection and anesthesia, we can’t overlook the fact that the nose is a major danger zone for filler—so much so that many esteemed physicians refuse to perform nonsurgical nose jobs. Accidentally injecting into an artery can cause necrosis and even permanent vision loss (the vessels of the nose share connections with those feeding the eyes, and blocking them can lead to blindness). Post-surgical noses, whose blood supply has been tampered with, have a higher rate of vascular occlusion, Dr. Bloom adds.
"I think necrosis and blindness are way more significant than any risk with surgical rhino," notes Dr. Sunder. However, if an injector has loads of experience injecting the nose and knows how to spot and manage complications, the odds of anything going awry should be slim. One study found the risk of vascular occlusion associated with nonsurgical nose jobs to be 0.48%—that’s 24 instances in 5000 cases. A separate review of 2488 procedures noted five occlusions. A third study looking at 1600 patients saw zero. That said, it’s critically important, our experts say, to use an easy-to-dissolve HA, like Restylane, in the nose, in case of emergency.
The other risk with injection rhinoplasty, is distorting the shape of the nose by filling it too much or too often. Since returning clients are building on a foundation of preexisting gel, injectors should be "putting less product into the face to achieve the same result," notes Dr. Devgan. While the touch-up timetable is slightly different for everyone, Dr. Sunder usually has patients plan for a maintenance session at nine or 12 months. "That doesn't mean all, or even most, of the filler will be gone," she says. "If we were to do an MRI or ultrasound, there would be filler in there. But that's the point at which you're going to start noticing that things are changing back."
How long a liquid nose lasts also hinges on what the gel is being asked to do for a given individual, points out Dr. Liotta. "If you're using filler to camouflage a big bump, you're going to feel like your bump is back after four or five months." Again, you haven't necessarily burned through your filler, but "enough may have dissolved that the overall effect is that you have your bump back," she says. If the gel is being used for a more passive purpose, like filling a tiny indent from a previous rhinoplasty, Dr. Liotta says it may last you three years.
The Bottom Line
As you've likely gleaned, nonsurgical rhinoplasty is a divisive topic on which thoughtful surgeons voice strong and sometimes opposing opinions, informed by their own unique experiences.
The beauty of nonsurgical rhinoplasty, per Dr. Devgan, is that "it allows us to make small adjustments without completely altering facial identity or taking away parts of the face." This makes it an invaluable option for countless patients who perhaps "have one little thing they'd like to change about their nose but don't want to change it to the extent that they're willing to take on the risks and recovery of surgery," she says.
On the other hand, surgical rhinoplasty is primarily regarded as the gold-standard fix for the nose. It can correct myriad aspects of the anatomy—related to both form and function—in a lasting way. "We're far from the very reductive and destructive rhinoplasty of yesterday," Dr. Roostaeian adds. While he understands patients' desire to get the nose they want noninvasively, he still advocates for surgical rhinoplasty. "It makes more sense to get a one-time surgical procedure, given how low the risks are and the consistency of the results we're now able to obtain." (Again, these perks are surgeon-dependant, so choose wisely.) The recovery is easier than ever.
Despite surgery's stronghold, the nonsurgical nose job's future seems relatively secure. While it has fallen from favor in certain practices, it otherwise remains a reliable tool for temporarily enhancing noses that can withstand the slight size increase that comes with filler. "There will always be a place for a less invasive version of rhinoplasty," says Dr. Subbio.
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