Non-surgical rhinoplasty: liquid nose job injection safety advice

Non-surgical rhinoplasty, or injection rhinoplasty is also referred to as the ‘liquid nose job’. Many aesthetic clinicians have reservations about offering this procedure due its high-risk nature which makes it statistically more likely to result in severe complications.

In this blog, Dr Tim Pearce debates the techniques for injecting the nose and discusses the best dermal filler products to use for optimal results. He answers many frequently asked questions about non-surgical rhinoplasty to provide a comprehensive understanding of the procedure.

Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>

Are there any ‘no-go’ areas when performing a non-surgical rhinoplasty?

Dr Tim explains that he no longer thinks of the face in terms of ‘black and white’ answers, with an absolute yes or no when it comes to ‘no-go’ areas to treat – everything is risky, but there are degrees of risk and these guide your decision making.

He asks if he can justify the risk for the patient’s benefit. Is the individual injection likely to create a result that makes them so happy that he can offset the potential risk? Similarly, can the injection be conducted in such a way that it considers the risk, but allows for a safer approach towards completion, which may involve following additional steps to ensure increased safety, rather than a more gung-ho acceptance of the risk.

“I am trained in non-surgical rhinoplasty, but too scared to do the procedure.”

Often, it is the medical practitioners involved in facial aesthetics who are too scared to do it, despite their training. Dr Tim admits that he was one of those clinicians who held back due to the fear of complications and why he now produces so much educational content and training on managing medical aesthetic complications with the goal of helping people to get over the fear.

The way to approach complication anxiety, especially with non-surgical rhinoplasty, is not to wade in terrified, but to use that energy to think of ways to mitigate the risk and make the procedure safer. Consider the volume of injection, for example, add lesser amounts with each injection and validated that everything is fine between each time – check capillary refill, vision etc. Do not worry about how long it takes you, take your time to be safe.

Which are the best dermal filler products for non-surgical rhinoplasty?

Most non-surgical procedures using dermal fillers for the nose are aiming to emulate bone, says Dr Tim. To achieve this, he recommends using a stiff, high G-prime hyaluronic acid product. There are several to choose from, for example, Juvéderm Voluma.

You can also use non-reversible products which are similarly good at emulating bone, if you believe it is the best option for your patient, although Dr Tim does not personally like using them due to their irreversibility.

Can dermal fillers make the nose look bigger?

This is a common question asked by patients. The answer is indeed curious; because you are adding volume, technically it is bigger, but it is an optical illusion.

Most non-surgical rhinoplasties are simplifying the shape of the nose and often elevating the points of reference. Thus, if you think of a nose projecting from a face, and it is a large, curved nose, but you elevate the bridge, then the reference point that makes the nose look like it is projecting will be raised. Think of it like an island – if the water fills up around, the island looks smaller, because as the water rises it closes in and there is less of the island to project outwards.

Hence, with a nose, although you are adding volume, it tends to look smaller, if performed correctly by a good injector with an artistic eye.

Does aspiration with BD needles work?

Dr Tim evaluated this a few years ago – by filling the bevel of the needle and the syringe with multiple dermal fillers – and he can confirm that it does work. In fact, he found that the BD needles work slightly better than ‘normal’ needles, being slightly more sensitive to positive aspiration because they are short.

If you consider the physics of aspiration; the length of the needle is one of the things that is a positive predictor for positive reactions, thus a shorter needle is more sensitive than a longer needle, and a thicker needle is more sensitive than a thinner needle. Therefore, BD syringes perform quite well in terms of sensitivity with aspiration.

However, the caveat from Dr Tim is that you should test each filler with the needles that you use if you want to know if it is going to give you a positive because there are some fillers that no matter how long you wait, you will never get the filler to flow back out of the needle lumen, thus you never get a positive aspirate. Know your filler before you rely on aspirating.

Aspirating itself does not provide a hundred percent certainty of results, but it gives you a shot at detecting intravascular placement before you inject, approximately between 50 and 60 percent accuracy according to published papers.

What depth should you inject the nose?

When carrying out a liquid nose job procedure, the aim is to emulate bone. The blood vessels in the nose tend to be in the middle layer of the tissue. However, the whole area of the nose that you must work within is very small. Most blood vessels in the face are found within the hypodermis, in the low end of the hypodermis. Remember, there is the dermis, the fatty layer, a blood vessel, and the muscle in a typical presentation. With little space in the nose, in means that in practice it is difficult to say exactly where the blood vessels are located. Yet, we can assume that they are less likely to be on the periosteum, but it could still be very risky. They are also less likely to be on the midline, but that is not a certainty.

Taking this into consideration, you cannot rely on anatomical knowledge, probability or aspirating in isolation, you must combine all these factors together to make it a safe procedure.

Technically, we can inject the nose more safely either superficially or deep, the mid depth is the riskiest place to inject. However, there is almost no space to discern so you are quite limited in terms of real depth, particularly at the bridge of the nose, compared to the tip. As we are aiming to emulate bone, being superficial will not change the shape of the nose from the base, and you risk leaving a visible lump of filler, so aiming deep is preferable.

How do you keep your needle steady during a non-surgical rhinoplasty procedure?

Steadiness starts with your feet, says Dr Tim, the most important thing is to stand in a stable position, without leaning. Stabilise your feet, then your pelvis, the arm that you are using to inject – usually at two points, the elbow or your forearm and another near your hand. The only moving parts of your body should be your fingers.

If you struggle and cannot use a stable structure like the bed or your patient’s shoulder, then Dr Tim suggests pulling your arm in to stabilise it against your torso.

Another great tip, especially if you are a male clinician treating female patients which engenders a sensitivity with leaning on the patient’s chest, ask your patient to cross their arms in a saintly position and then you get to lean on their arms and avoid their breasts.

How do you keep your needle steady during a non-surgical rhinoplasty procedure?

Steadiness starts with your feet, says Dr Tim, the most important thing is to stand in a stable position, without leaning. Stabilise your feet, then your pelvis, the arm that you are using to inject – usually at two points, the elbow or your forearm and another near your hand. The only moving parts of your body should be your fingers.

If you struggle and cannot use a stable structure like the bed or your patient’s shoulder, then Dr Tim suggests pulling your arm in to stabilise it against your torso.

Another great tip, especially if you are a male clinician treating female patients which engenders a sensitivity with leaning on the patient’s chest, ask your patient to cross their arms in a saintly position and then you get to lean on their arms and avoid their breasts.

If you have any questions or comments about non-surgical rhinoplasty, you can find Dr Tim Pearce on Instagram.

Is your worst nightmare causing a VO?

If you want to be a great injector then you need to get over your fear of complications. Register here for the next webinar to help you overcome your complications anxiety >>

Subscribe to our YouTube channel for really useful regular tips and advice.  

Aesthetics Mastery Show

Nose Filler Safety | Liquid Rhinoplasty Injection Safety Advice

In this episode, Dr Tim discusses  the safety of non-surgical rhinoplasty, a higher risk area more likely to result in severe complications. Dr. Tim outlines the key areas to avoid when injecting and discusses the best products to use for optimal results. Watch the full Aesthetics Mastery Show here.

The show has already recorded thousands of views and has generated comment and debate from practitioners, including Zara Pennvyn, who said:

“So why the heck are pharmacists , paramedics , beuaticians and nurses fresh out of training college taking on these kinds of procedures. It is completely outrageous that such untrained unprofessionals can think a few days of training entitles them to perform these procedures. UK training schools are exploiting this for financial gain. It is scandalous . The sheer number of filler injuries out there is now rapidly increasing. Necrosis passed of as ‘scabbing’ lips split by arterial damage and necrosis. In the UK measures from the Royal College of Surgeons are on the way to eliminate these dangerous practitioners.”

Dr Tim responded in person to day:

“Very unlikely. It’s been over 15 years, the UK is heading towards licensing everyone, non medics to surgeons all under one umbrella, following a commercial rather than a medical model.”

Read more questions and answers or join in the debate on our YouTube channel.

Filler Complications eLearning Courses

If you want to increase your confidence by learning how to handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• Botulinum Toxin Complications Mastery
• Dermal Filler Complications Mastery

Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.