Safety and Dermal Filler Injection to the Nose: A Case of Necrosis

What is the the best type of dermal filler to use for the nose?

That is debatable, and it depends on what is most important to the patient and the injector. In general, important features that injectors look for are: safety, lifting capability and longevity.

SAFETY

If safety is  the key, then a dissolvable dermal filler is at the top of the list. Safety should be the first and most important consideration, particularly when choosing a dermal filler for the nose, because it is at a higher risk for necrosis than other areas of the face.

LIFTING CAPABILITY

If lifting capability is your most important filler feature, then you will use something with the greatest capability to lift. This is definitely an issue with nose injecting as a filler with good lifting capability is an important requirement in this area.

LONGEVITY

If longevity is your most important filler feature, then a permanent dermal filler may be chosen. The most popular and reversible dermal fillers are not permanent but have excellent longevity in the nose, often lasting over 1 year. Permanent dermal fillers are less commonly used for the nose due to their higher risk of difficult to treat complications

CASE OF NOSE NECROSIS FROM INJECTION OF DERMAL FILLER

Some injectors argue that a reversible dermal filler in the nose is safer than biostimulator, R*******, a non-reversible but popular nose dermal filler. The reason this can be argued is that when complications occur, e.g. necrosis or infection, then the  H****** A***filler can be reversed, but R********  cannot be reversed

Here is a young asian patient who underwent dermal filler at another clinic with a biostimulator.

This patient had R******* injected into the nose and noticed symptoms of necrosis soon after. She was reviewed by the doctor the next day. The doctor tried to squeeze out the dermal filler product, which was very painful.

3 days later yellow “blister”-type lesions started to appear on the nose tip, but the nose wasn’t painful any more. Over the next week, the blisters turned into scabs. The scabs took 3 weeks to completely fall off and heal. There was no scarring, fortunately, but the patient said that her nose pores seemed much bigger after this event

Signs of necrosis: 12 hours after injection of dermal filler. Blue colour of nose tip. The nose was very painful to the touch. The patient describes a feeling of ” a lot of pressure in my nose”
24 hours after dermal filler to nose ? reticulated pattern on the nose skin
24 hours after injection to nose
Day 3 after injections, white/yellow raised lesions appear. Nose not painful at this stage

Here is my interview with the patient:

Dr N: Which areas of the nose were injected? Was it the bridge and the tip only?  How much product was used?

A full syringe was used to inject the bridge, the tip and also the dorsum. I wanted the bridge to be higher and the tip to be more projected and the doctor suggested that I also add some filler along the dorsum as well to achieve a more balanced look.

Dr N: At the time of injection, was there pain? If so was it mild/mod or severe? Particularly when the tip was being injected?

The pain was pretty bad when the tip was injected (I did shed a few tears) but the rest of the nose wasn’t too bad at all. I would say the pain in the tip was severe and the other areas were mild-mod.

Dr N: What was the first thing you noticed that you thought was not normal?

I had both R********* (reversible) and R******* (biostimulator) injected into my nose a few times before this incident occurred so I knew what to expect. I realised that something wasn’t normal around 1 hour after the injection. My nose felt very cold, very numb and it was paler than usual. I knew something was seriously wrong when the tip of my nose turned blue and purple the next morning (10 hours after the injection).

Dr N: At the 12 hour photo, there is a blue colour to the skin at the nose tip, can you remember when this started?

I first noticed it when I woke up the next morning which was around 10 hours after the injection but I think it must have happened sometimes while I was sleeping.

Dr N: Do you recall a white area on the skin at the time of injection?

I think there was a tiny white area in the tip of the nose.

Dr N: In the 12 hours after injection was there pain, if so, can you describe it? You did say there was pain when the Dr squeezed the product, but prior to you seeing the doctor at that time, was the area painful?

Yes, there was a lot of pain especially in the tip area. It was so tender and sensitive I couldn’t even touch it. The feeling was a bit like when you get a pimple inside your nose and you accidentally touch it. I could feel a lot of pressure in my nose as well.

Dr N: How was the wound was managed?

The doctor prescribed some antiseptic cream for me to put on the blistered area for 7 days and he also gave me some oral antibiotics to take for 7 days.

Dr N: Has this experience changed how you feel about cosmetic treatments? If so, how?

I knew that all treatments/procedures carry some risks so this experience did not change how I feel about cosmetic treatments. However, it has definitely made me more aware of how bad things can get even from a simple, 15 minute procedure!

Dr N: What would you like patients to know before going ahead with injection of dermal filler in the nose?

Do a lot of research and read as much as you can about pros and cons, side effects and long term effects of different types of dermal filler before making your decision. Make a list of questions to ask your doctor and do not rush into doing it. Always start with a dissolvable filler and see if you like the result it gives or not. Never go for permanent fillers such as A****** or Artefill! Even if you are lucky enough to not have any side effects from these permanent fillers, you might not like the results they give 10-20 years from now.

Dr N: What did you learn personally from this experience?

I’m a very cautious person and I always do a lot of research and ask a lot of questions before I decide to do anything to myself. However, I learned from this experience that things can go wrong no matter how careful you are and all treatments/procedures carry some risks. If you do decide to go ahead with a cosmetic treatment you have to be prepared for the worst as well. I guess the most important thing is to find a doctor that you can trust so that if something does go wrong you know that will be looked after.

DR N: Thanks so much for sharing your experience. That is very generous of you.

I’m really interested in this patient’s perspective, especially her thoughts about “you have to be prepared for the worst” and also “find a doctor that you can trust so that if something does go wrong, you know that you will be looked after”. This patient is perceptive and her ideas are so valuable for potential cosmetic patients. She is experienced and has learnt the hard way. I’m so delighted that I can share  this important message with others.

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