Nose Filler

What is nose filler?

Nose filler is the injection of a temporary filler into selected areas of the nose. In medical terms it is also called ‘non-surgical rhinoplasty’; the aim is to improve the appearance or function of the nose in people judged suitable, by adding volume to specific areas. The treatment areas are the angle between the root of the nose and the forehead, the bridge of the nose, the angle between the nose and the upper lip, and the columella. The columella is the small bridge of tissue that separates the two nostrils.

At its core, the treatment adds volume. No tissue is removed and no cartilage or bone is reshaped; what changes is how the added volume makes the nose look in profile. So what nose filler can and cannot do for you comes down to one question: is your concern the kind that could change if volume is added at one point?

The picture is clear when it comes to the material used. A review covering 30 studies and a total of 9,657 patients found that hyaluronic acid was used in the large majority of treatments, followed by calcium hydroxylapatite (CaHA), another type of filler. The recommended approach is to choose non-permanent fillers according to their properties and to work in small amounts. To avoid overfilling, irregularities and asymmetry, it is advised to under-correct rather than over-correct.

Which tissue layer is injected, how much filler is used and which technique is applied are decisions made by the doctor carrying out the treatment after assessing you. Detailed knowledge of the anatomy of the nose and spotting a developing problem early are considered among the conditions for a good result and a lower risk of complications.

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What does ‘non-surgical nose job’ mean?

‘Non-surgical nose job’ is really a search term; the medical term for it is nose filler. The words ‘nose job’ can give the impression that the same work as cosmetic nose surgery (rhinoplasty) is done without an operation. That is not the case: rhinoplasty changes the structure of the cartilage and bone, whereas filler only adds volume. Although their names are similar, the two treatments do not do the same job.

Research also shows this difference clearly. A review that brought together studies on this topic describes filler as a temporary alternative to traditional augmentation rhinoplasty (surgery that builds up the nose) for correcting the shape of the nose, and sees it as an option for people who want a temporary result or want to avoid general anaesthesia. The comparison here is with surgery that enlarges the nose, in other words surgery that also adds volume; filler is not the equivalent of surgery that makes the nose smaller.

Some people move on to surgery after filler. In one surgeon’s series of 162 patients, 8 later went on to have surgical rhinoplasty; the main reason reported was that they felt ready for a permanent result. These are data from a single practitioner and cannot be generalised; even so, they show that filler is seen as a temporary option, not a permanent solution.

There is also a regulatory detail. The US Food and Drug Administration (FDA) lists the nose among the unapproved uses of fillers; in other words, in the US, filler injections into the nose are an off-label use (outside the uses covered by the product’s approval). At the clinic, FDA approval is not the only criterion when a product is assessed; the assessment is based on the product’s CE marking, its registration and conformity status in Türkiye and the manufacturer’s intended purpose. This information only shows the scope; on its own, it is neither a safety certificate nor a ban.

RELATEDWhat Is Hyaluronic Acid?

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Nasal hump: it can be disguised, not removed

A hump on the bridge of the nose is one of the most common reasons for seeking nose filler. In one doctor’s series of 5,000 treatments, a nasal hump was reported as the most common reason, accounting for 44% of treatments. The hump is the part of the bridge that sticks out forwards when the nose is seen from the side; it is made of bone and cartilage.

Filler does not remove the hump. What it does is straighten the line of the bridge by adding volume to the areas above and below the hump. The hump stays where it is; because the dips around it are filled, the profile looks straighter. This is camouflage: the bone and cartilage that form the hump stay the same.

In practice, this means that while the profile line becomes straighter, volume is added to the nose, not taken away. Making a hump look less obvious is not the same as making the nose smaller; the second cannot be done with filler. If a decision is made without considering the size of the hump, the overall structure of the bridge and your expectations together, there is a risk that the result will not match what you expected.

The bridge of the nose is also an area that needs care in terms of risk. In a review of cases of vision loss after nose filler, among the cases where the injection site was known, the most common site was the bridge of the nose (reported as the nasal bridge or the nasal dorsum).

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Nose tip, columella and root of the nose

The nose tip is the second main target of filler. A tip that does not seem to project forward enough or turn up enough can be supported with filler. The columella and the angle between the nose and the upper lip are also among the areas treated with filler.

The third target is the root of the nose (radix), the dip between the eyes where the nose begins. The angle between the root of the nose and the forehead is also among the areas treated with filler. The root of the nose lies next to the area around the eyes, so the blood vessels in this area are especially important.

The blood vessels of the nose tip also need particular care. An anatomical study on 40 cadavers points out that, although the lower part of the nose has a rich blood supply, necrosis (tissue death) of the nose tip continues to be seen after filler. The study found that the vessels supplying the lower part of the nose form two loops joined like a figure of eight: the upper loop surrounds the nose tip and the nostrils, while the lower loop is the network of blood vessels in the upper lip and, according to the researchers, is the more important of the two.

Clinical data point in the same direction. In one doctor’s series of 2,488 treatments spread over ten years, the areas with the highest adverse event rate were reported to be the nose tip and the side wall of the nose. These are data from a single practitioner; even so, they show that the nose tip is not simply a matter of volume.

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Irregularities after rhinoplasty

Filler is also used to hide irregularities that remain in people who have had cosmetic nose surgery (rhinoplasty). In a review that brought together studies on this topic, the most commonly used filler was hyaluronic acid, and the most common reason was irregularities in the shape of the middle third of the nose.

However, this use is not free of complications: an increased risk of skin necrosis has been observed in noses that have had surgery. One possible anatomical reason is that surgery can move blood vessels in unpredictable ways and can leave the blood supply of the nose more fragile. In a series of seven patients who developed skin necrosis after hyaluronic acid filler, all of the patients were reported to have had rhinoplasty more than three years earlier.

A larger series also shows a difference. In one doctor’s series of 2,488 treatments, the adverse event rate was 10.8% in patients who had had nose surgery before and 7.4% in patients who had not; the researchers noted that this difference may be due to the changes that surgery makes to the anatomy. A review of safety measures also treats extra care in a nose that has had surgery as a separate topic.

This does not mean that filler cannot be used in a nose that has had surgery; this use has been described in research. But your previous surgery is one of the first things you will be asked about at the consultation, and it changes the risk assessment. When the surgery was done, which technique was used and whether any other treatment was done afterwards are also part of this assessment.

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A crooked-looking nose and breathing

When a nose looks crooked, filler does not correct the curve; it aims to make the nose look straighter by filling the dips along its line. In a case series of five patients with a mildly to moderately crooked nose, filler was reported to camouflage the curve. However, it is also stated that this approach has limited value for structural problems such as a deviated septum, that the result is temporary and that the treatment has to be repeated to maintain it.

The septum is the wall of cartilage and bone that divides the nasal cavity in two. When it is deviated, the bend is inside the nose and can affect breathing; volume added to the profile from the outside does not change the position of this wall. The cause of complaints such as a blocked nose or difficulty breathing through one side is identified through a separate assessment.

There are also small studies looking at injecting hyaluronic acid into the valve area inside the nose (the part where the airway inside the nose narrows) to widen this area. In a series of 16 patients, a significant reduction in nasal resistance was reported after one month; however, it was reported that patients’ symptom scores tended to return to baseline levels by 12 months. This is a functional treatment, separate from cosmetic nose filler; it is also a small series with no comparison group.

In short, the honest answer to the question ‘does filler improve breathing?’ is this: cosmetic nose filler is not done for this purpose; in someone with breathing complaints, the cause of the complaint is identified first.

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Limits of this treatment

Nose filler adds volume; it does not take volume away. Almost all of its limits come from this fact. The described uses are filling around a hump, filling visible dips, disguising asymmetry in the upper and middle parts of the nose and supporting the nose tip. Even when it is compared with surgery, the benchmark is surgery that enlarges or supports the nose; there is no filler equivalent of surgery that makes the nose smaller.

In concrete terms:

• The nose is not made smaller and the hump is not removed; the hump can only be disguised by adding volume around it.
• Wide nostrils or a wide nasal base are not narrowed.
• Structural problems such as a deviated septum are not corrected; breathing complaints are assessed separately.
• Hyaluronic acid fillers are not permanent; they break down in the body over time.

Research is not consistent on how long the effect lasts. In a review of 16 studies on how long hyaluronic acid nose filler lasts, six authors reported that the effect lasted 8–12 months, while others reported longer periods; the longest reported duration was 8 years. The review concludes that it is extremely complex to determine longevity with certainty. For this reason, it would not be right to give you a specific duration.

Nose filler is not a substitute for surgical rhinoplasty. Which route makes sense for you (filler, a surgical option or neither) is decided through the assessment at your consultation and by your own decision. Having no treatment at all is also a valid decision.

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Blood vessels of the nose: why it is considered a high-risk area

Among the areas of the face treated with filler, the nose is one of those considered high-risk. According to a review on safety, many doctors still regard this treatment as high-risk because of serious complications that may not be reversible, especially vascular occlusion. Most safety recommendations are based on expert opinion and anatomical knowledge; the scientific evidence on this is limited. Vascular occlusion, tissue necrosis and blindness are listed as the complications that make the nose a difficult area for filler.

The anatomical reason for the risk is that the blood vessels of the nose are connected to the vessels that lead to the eye. Anatomy references describe the dorsal nasal artery, which supplies the bridge of the nose, as a branch of the artery that supplies the eye (the ophthalmic artery). After leaving the eye socket, this artery joins the part of the facial artery at the corner of the eye and also connects with branches on the other side. Measures to reduce the risk of injected material travelling along this route into the ophthalmic artery are also based on this knowledge of the connections.

The course of this artery varies from person to person. In a study on 60 cadavers, 53.3% of faces had a dorsal nasal artery on both sides, 38.3% had a network of small arteries, and five had a single dominant artery. The study found that the artery can arise from four different sources and that its source affects its course; the most common source, at 56.8%, was the branch from the ophthalmic artery. The researchers note that a dominant artery running close to the midline can reduce the effect of the precaution of pressing on the sides during treatment.

According to a review of filler complications that led to permanent damage, the injected volume is not the only deciding factor; the anatomical area injected, incorrect technique and whether the filler is permanent are the main factors. At the clinic, the doctor chooses a needle or a cannula (a fine tube with a blunt tip) for each person individually, according to the treatment area and the anatomy. The aim of this information is not to put you off; it is to show clearly why the nose needs particular care.

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Vascular occlusion, skin necrosis and vision loss

The most serious known complication of nose filler is vascular occlusion (a blocked blood vessel), which happens when filler enters a blood vessel. Reported consequences include poor blood supply to the skin and necrosis, vision loss and stroke. These events are rarely reported; but being rarely reported does not mean they can be ignored, and they must be explained to you before treatment.

A research group that regularly reviews cases of filler-related vision loss examined 365 new cases published between September 2018 and March 2023. The highest-risk areas were reported to be the nose (40.6%), the forehead (27.7%) and the area between the brows (19.0%). In 68.2% of the cases where the visual outcome was reported, vision did not improve at all; none of the treatments used was significantly associated with improvement in vision.

According to a review of vision loss caused by hyaluronic acid fillers, in almost all cases the loss affects one eye and symptoms start immediately after the injection; the areas most often involved are the nose, the area between the brows and the forehead. Even volumes as small as 0.2 ml were found to be capable of causing permanent and complete vision loss. In a review of cases after nose filler only, vision fully returned in only 27% of 22 cases.

In a series of 20 patients monitored for threatened necrosis of the nasal skin after filler in the nose or the nose-to-mouth lines (nasolabial folds), 7 patients developed full skin necrosis and 13 recovered completely. Of the patients who developed full necrosis, 85% had sought help late and had not received combined treatment with hyaluronidase (an enzyme that dissolves hyaluronic acid) within two days of their symptoms starting. The FDA says you should get medical help immediately if you notice unusual pain, changes in your vision, or white, grey or bluish discolouration of the skin after filler. How you contact the clinic in such a situation is set by the doctor’s own protocol; you can ask your doctor about this before treatment.

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Known risks

The most commonly reported effects after nose filler are mild and temporary. In the review covering 9,657 patients, the most common were redness and swelling, and most complications were reported to be mild. In one doctor’s series of 5,000 treatments, swelling and redness occurred in about half of patients and went away on their own; the same series reported infection in two patients and limited skin necrosis in three patients.

The possible complications of hyaluronic acid nose filler are listed as follows: in the early period, asymmetry, injection-site reactions and hypersensitivity reactions; in addition, infection, bluish discolouration under the skin (Tyndall effect), nodules (small firm lumps you can feel under the skin), granuloma, scarring and biofilm. Biofilm is a layer of bacteria that forms around the filler. The most serious risk is vascular occlusion.

There are figures on how often these events occur, but they should be read with care. A review and meta-analysis (an analysis that combines data from many studies) covering 8,604 patients reported vascular occlusion in 0.35%, skin necrosis in 0.08% and vision loss in 0.09%. These rates are pooled from published series; they are not a personal risk calculation and they are not data from this clinic.

The differences between reported rates also tell us something. A review covering 23 studies states that no vascular complications were reported in the studies it examined, but it also notes that complications may be under-reported and that more research is needed to understand how often they really occur. According to another review, the shortage of high-level evidence may also point to under-reporting.

RELATEDWhat to Expect After a Treatment

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Reversibility: hyaluronidase and permanent fillers

Hyaluronic acid fillers can be dissolved with an enzyme called hyaluronidase. The fact that this enzyme can reverse complications of hyaluronic acid fillers is seen as an important reason why these treatments have become widespread. In emergencies such as vascular occlusion and vision loss, it is stressed that treatment must be given without delay and at a high dose. When nose filler is done with hyaluronic acid, having hyaluronidase immediately available is considered important. Hyaluronidase is kept at the clinic.

However, reversibility is not a guarantee. According to a consensus statement prepared by experts, when necrosis is threatened, rapid diagnosis and treatment started without delay are decisive. Another publication on necrosis of the nasal skin states that there is no single accepted standard treatment protocol for this condition. In vision loss, too, none of the treatments used has been shown to be significantly associated with improvement in vision.

Hyaluronidase dissolves only hyaluronic acid. According to the review of complications that led to permanent damage, hyaluronic acid fillers remain a preferable option because they can be reversed, whereas permanent fillers increase the risk of long-term complications. The FDA also states that fillers not made from substances such as hyaluronic acid, especially permanent fillers, can be difficult or impossible to remove.

If you have had nose filler somewhere else before, you will first be asked what type of filler it was, when it was done and which area was treated; fillers of unknown type, or fillers that cannot be confirmed to be hyaluronic acid, are not dissolved straight away. You can find out what filler dissolving involves and what its limits are on the Filler Dissolving page.

RELATEDFiller Dissolving

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