Nonsurgical rhinoplasty is a generally safe procedure, with most complications avoided through patient selection, product selection, and practicing the techniques mentioned above. Complication rates are low, but need to be thoroughly discussed with patients before injection (Table 1). The most severe, major complication of nonsurgical rhinoplasty is vascular compromise, which has the potential for dermal necrosis and blindness. The mechanism is categorized as extravascular, intravascular, or combined.

Extravascular compromise is due to filler producing a mass effect and vascular compression (specifically venous).

Intravascular compromise is secondary to injection of filler into the vessel lumen with subsequent direct obstruction, embolism, or endothelial damage.

During injection, the practitioner must be vigilant to watch for dermal blanching with or without complaints of severe, spreading pain. Local tissue ischemia progresses to geographic (vascular territory) edema, erythema, and necrosis. Furthermore, intra-arterial injection (especially under high pressure) carries the risk of retrograde arterial embolism to the ophthalmic and retinal artery with the potential of ocular issues and blindness. Early recognition and intervention are critical in the setting of vascular compromise. If any signs are noted, injections should be ceased and filler dissolved.

All clinics should have an Emergency Kit (Box 1) ready, to permit rapid intervention with massage, warm compresses, 2% nitroglycerin paste, hyaluronidase injection, and aspirin administration. High-dose hyaluronidase injection (200–300 U) should be performed to the entire area, with repeat injection hourly until clinical resolution is achieved or doses nearing 1500 U have been reached. Injections should then be performed daily until signs or symptoms are reversed. Adjunct procedures, such as oxygen administration or hyperbaric oxygen treatments, should be strongly considered. Some resources advocate for the injection of 10 mg of prostaglandin E1 daily for 5 days. After the initial time period, local wound care and antibiotic therapy may be indicated. Critical to any major, procedural complication is a solid rapport and open communication with the patient. Vision loss or changes indicate retrograde embolism affecting the retinal artery. In the event of central retinal artery occlusion, irreversible changes and blindness occur within 60 to 90 minutes.

All of the above measures should be performed with the addition of ocular massage (firm pressure to a closed eye for 5 seconds with a quick release), 1 drop of topical timolol 0.5%, sublingual nitroglycerin 0.6 mg, rebreathing into a paper bag, and rapid referral to an ophthalmology center, for possible retrobulbar injection of hyaluronidase, anterior chamber paracentesis, steroids, and mannitol. Early hyaluronidase administration (24 hours) injection efficacy is still a point of controversy anecdotally and in animal model studies (see Box 1).

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