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Chu et al. Plast Aesthet Res 2020;7:73 I http://dx.doi.org/10.20517/2347-9264.2020.169 Page 7 of 8

arteries at risk of vascular complications in the nose are the lateral nasal artery, which predominately
supplies the nasal tip, and the dorsal nasal artery, which supplies the upper dorsum of the nose. There are
several anastomoses in the nasal region between the external and internal carotid systems, whose blood
flow can be reversed with injections, creating a potential retrograde embolization and subsequent stroke
[24]
or blindness . To diminish the risk of vascular complications, injectors should aspirate before injection,
inject slowly with minimal pressure, use products with vasoconstrictors, and use blunt, large microcannulas
[25]
in the avascular deep plane below the level of the SMAS .
In addition to complications and safety concerns, novel research has shown that liquid rhinoplasty can have
an insufficient effect in some patient populations. A 2016 study notes that 10% of 250 patients reported that
the filler injection lasted only a short duration of less than 6 months or did not achieve the desired aesthetic
result . This requires patients to receive repeat injections, which increases the risk of complications and
[20]
may cause potential financial burden.

Novel treatments of complications
Recent literature highlights the treatment for the complications explained above. Immediate adverse effects
of HA, such as ischemia, can be corrected in a variety of ways. Hyaluronidase is the standard treatment,
and there are several supplemental treatments available to help spread the hyaluronidase effectively.
These supplemental treatments include topical nitropaste, oral acetylsalicylic acid, warm compresses,
and massage. Nitropaste and warm compresses promote vasodilation, which promotes spread of the
hyaluronidase through tissues. The pressure caused by massage helps to distribute the hyaluronidase
rapidly, and acetylsalicylic acid provides an anti-clotting effect .
[26]
Additionally, a 2019 study elucidates a procedural strategy to reduce complications. In the study, researchers
injected a colored filler into the dorsum of a cadaver. In three of six cadavers, the filler was injected into
the superficial layer and in the other three cadavers, the filler was injected by direct percutaneous injection
into the deep, avascular layer. Injection through the glabella into the deep layer allowed for more accurate
injection. This can decrease the chance of vascular injury, which can reduce the risk of necrosis and vision
[27]
loss .

CONCLUSION
Liquid rhinoplasty with HA fillers is a safe procedure with positive aesthetic results when performed by a
trained professional. Post procedure, many patients will have self-limiting side effect such as mild erythema
and swelling. Very rarely, some patients will suffer infections and local tissue necrosis. Using correct
injection technique such as filling only in the deep fatty later and staying in the midline can help reduce the
chance of adverse effects. Further, having a targeted plan on the location and order of injections can help
achieve the desired aesthetic result with safety, consistency, and reproducibility.

DECLARATIONS
Authors’ contributions
All contributed equally to the research, writing, and editing of the manuscript: Chu Y, Bacos J, Becker S

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.