Can I reshape my nose without surgery?

Asian noses are unique, bearing certain characteristics such as [1]:

• Having a bulbous tip 
• Flared nostril shape
• Wide base of the nose 
• Low nose bridge  

This is vastly different from what is considered the “ideal” nose, such as those of the Duchess of Cambridge and Scarlett Johansson.

Plastic surgeons have identified the ideal shape for a woman’s nose to have an optimum rotation of 106 degrees, measured from the lip up, in order to enhance a woman’s feature [2].

That said, many Asian women tend to feel inferior about their noses, and many resort to plastic surgery to try to enhance them. In South Korea, rhinoplasty, a surgical procedure meant to alter or reconstruct the nose, is one of the top 5 plastic surgery procedures done [3]. Injectables such as fillers and threads are also increasingly popular for creating refined features without resorting to surgery. 

Even more recently, there have been advancements that show energy devices may be used in the near future to reshape nose cartilage — a painless alternative to surgery without causing scars.

Invasive procedures: a botched surgery

Not everyone wants an invasive procedure due to the risk of complications, as well as the long downtime. In Guangzhou, a Chinese actress shared photos of her botched nose surgery which left her suicidal and losing some of her jobs [4]. Apart from that, she was also hospitalised for 61 days. 

Nose fillers and nose thread lifts are fantastic alternatives, as they are both minimally invasive, and can help to contour and reshape noses to your ideal shape. Furthermore, these can be done in under an hour with minimal downtime, earning them the title of “lunchtime nose jobs”. Are these completely safe and are they the only options available?

What are nose fillers?

Nose fillers contain gel-like substances and are injected under the skin. Most nose fillers contain hyaluronic acid (HA), a substance that naturally occurs in our body. More advanced fillers make use of semi-permanent materials such as calcium hydroxyapatite and polycaprolactone which are harder in viscosity and can mimic the bony parts of the nose and other facial areas. 

These help to create volume at the injection site (normally the nose bridge) just like a surgical implant without actually resorting to surgery. The added advantage of such injectables is the stimulation of collagen production in the skin, which can help for wrinkles on the nose and also pores, something which surgical nose implants do not provide. Nose fillers can also be used to enhance the nose tip, giving the nose a slimmer and sharper appearance. 

Can nose fillers cause blindness?

This may seem like a long stretch, but the truth is, nose fillers can cause blindness. A 13 year old girl in Vietnam has been left permanently blind in her right eye after visiting a spa for nose filler injections [5]. Her nose and forehead also showed signs of necrosis (tissue death). 

This is just one of many incidents where nose fillers have actually resulted in blindness. There has been an estimated number of 3 cases of blindness from filler injections in Singapore. While this number may seem low, the small risk of such a catastrophic event makes this an important consideration. 

The face contains many small blood vessels, some of which supply blood to the eyes [6]. Improper injection of fillers (e.g. injecting too fast) and accidental injection of fillers into blood vessels can cause blockage in these blood vessels that supply blood to the eyes. The blockage prevents oxygen from being supplied to the eyes, resulting in blindness. Depending on the severity of the blockage, vision loss could be partial or total. 

The nose area is considered a high-risk area to inject dermal fillers due to its proximity to our arteries that are linked to the retinal artery which supplies oxygen to the eyes [7]. Studies have also shown that once the retinal artery has been obstructed, there is a window of only 60 to 90 minutes before blindness is irreversible [8]. 

How can blindness occur from nose fillers?

The technique of the doctor performing the procedure plays a huge part in this, as they have to ensure that they do not accidentally inject the filler into blood vessels. There are very specific techniques to avoid this, and it is not simply a case of dumb luck when blindness happens — it is often poor skill and lack of experience.

For example, the injection plane is an important factor for safe and beautiful injections, and different needle types may be chosen for the different plane – this is something novice injectors may not understand and you may hear some say that blunt needles (also known as cannulas) are safest to avoid causing blindness. In actual fact, most cases of blindness from nose fillers were actually attributed to cannula use. 

Injections using a sharp needle in the hands of an experienced injector are definitely better than a blunt needle in the hands of a novice. I personally enjoy using both sharp and blunt needles in my nose jobs, depending on the results my patients wish to achieve. 

What are the chances of nose fillers causing blindness happening? 

The chances of nose fillers causing blindness can be said to be rare. Up to 2018, there have been over 100 cases of blindness caused by fillers [9]. It was stated that the nasal region accounted for about 25% of cases of blindness [10], which is the site with the second-highest percentage. 

However, it is still important for the doctor performing the procedure to be highly experienced and skilled in order to ensure that this rare occurrence does not happen. 

What are the other complications of nose fillers?

Apart from blindness, there are other side effects of nose fillers such as:

• Broadening of nose: Also known as ‘avatar nose’, HA that is injected can migrate or spread from the location that they were injected in, resulting in a broader nose bridge. This is most commonly due to the use of the wrong type of fillers. Poor technique also causes broadening of the nose. 
• Asymmetry and poor shape: Usually a result of poor judgment and technique. 
• Skin necrosis: This can happen due to the direct injection of the nose filler into a blood vessel, causing blockage in the blood vessel and resulting in necrosis [11]. Direct injection of nose fillers into a blood vessel is usually due to improper technique by the doctor.

What are nose thread lifts — are they then the perfect solution?

Nose threadlifts were the answer for many doctors and patients who were worried of blindness from fillers. Nose thread lifts are threads made up of surgical suture material such as polydioxanone (PDO) or polycaprolactone (PCL), which are100% bioabsorbable materials. 

Nose thread lifts work by inserting threads of solid material horizontally up into the nose bridge, and vertically down into the nose tip to provide mechanical support in order to achieve a higher, more prominent nose bridge, and sharper nose tip. 

Because nose threads are solid, they don’t extrude into blood vessels and don’t result in blindness. But are they the answer and the solution for medical rhinoplasty? Definitely not. Nose threadlifts are NOT for everybody – certain nose shapes and skin types are unsuitable for this procedure, and this needs proper assessment before commitment to the procedures. If you’ve had nose threadlifts done and didn’t like the results, you were probably unsuitable. If done persistently as the only option, the results can be disfiguring. 

What are the side effects of getting these non-invasive nose procedures?

Some of the common side effects arising from non-invasive nose procedures such as nose fillers and nose thread lifts include:

• Pain or discomfort at injection site
• Bruising or swelling at injection site

Localised swelling and bruising are normal and usually go away by itself after a few days. 

What are the specific complications of nose thread lifts?

Some complications that may arise from nose thread lifts include:

• Infection: Infection may occur due to the thread lifts due to poor sterilisation techniques.
• Skin dimpling and visible appearance of threads: This happens only with poor technique and is a potentially disfiguring side effect. 
• Asymmetry and poor shape: Usually a result of poor judgement and technique.
• Extrusion and migration of threads: The threads can extrude and be seen from the surface of the skin due to breakage of threads. This can be due to inferior thread materials (persistent rejection by the body),  poor technique of the doctor or it may also happen from poor aftercare. 
• Scarring: Threads can be more invasive than fillers and the wrong choice can result in permanent scarring.

As such, even though nose threads may not carry any risk of blindness and do not result in broadening, you can see that they are not necessarily the perfect alternative to replace nose fillers.

I.e. They are not suitable for everyone and have their own set of disfiguring complications (potentially more) as well!

This was a junior injector who struggled with a nose threadlift case due to poor technique which resulted in the threads coming out three separate occasions, before he asked for advice on his technique.

The answer to the problem of side effects from fillers or threads is simple: find a doctor who:

• knows these side effects well
• are able to teach you ways to avoid such side effects apart from leaving it up to random luck
• have done enough to show you many cases of good work

Being limited to only doing threadlifts because they are “safer” is NOT TRUE, and NOT SAFE because it just shows that they are not as well-versed injectors. 

How about Botox for the nose?

Many patients and even doctors neglect the important role that Botulinum toxin (well known as Botox) has on the nose. It may surprise many that the nose tissues do have some muscles that control its shape and rotation. 

Toxin injections on the nose can help sculpt the nose further, thereby creating a slimming or lifting effects. This is especially so for the bulky tip that Asians dislike so much. Interestingly, threads and fillers also modulate muscle movement — so depending on where they are placed, they can also affect the shape and rotation of the nose. 

This shows you how much you can actually do with just injectables — it’s almost limitless.

Which procedure is more suitable for me, a nose filler or nose threadlift?

How do I know which procedure is best for me?

Both procedures have their own pros and cons. Choosing the right procedure for you typically depends on the feature of your nose that you are looking to improve.

Nose fillers are usually recommended to patients who want a higher, more defined nose bridge or correction of nasal bumps and humps. They can also help with nose tip and tip elevation in the hands of skilled injectors. My current favourite nose filler is Ellanse – it is not a reversible filler, so it needs to be done in only very experienced hands.

Nose thread lifts are usually recommended to patients who want a more defined or sharper nose bridge or nose tip. With the right amount of threads, they can also build a higher bridge or sculpt the nose. The highest number of threads I have used for a nose bridge was 28 threads! Nose thread lifts can also be done together with nose fillers to get the best of both worlds. 

Certain patients are more suitable for fillers, while others will benefit more from just using thread lifts. It really depends on a careful assessment  — so never sign up for promotional procedures even before a professional assessment. Nose threads aren’t your luxury handbags!

Botulinum toxin (Botox/Dysport) are useful adjuncts for medical rhinoplasty (basically nose shaping without surgery) and they can create gorgeous results when used properly. 

Ultimately, the most important factor is the skill and experience that your doctor has. It is important to ensure that your doctor is highly qualified and experienced in performing the procedure, in order to avoid any complications that may arise due to inexperience. 

Where should you go for your nose job? Can side effects like blindness be prevented?

Here’s what to look out for in your search for a minimally-invasive nose job (medical rhinoplasty):

• Find an injector well versed with all techniques – fillers, threads and even toxins. As described above, you want the best of all worlds when it comes to your facial features!

• An experienced injector may or may not participate actively in training other doctors for the procedure. There are some trainers who boast of their experience as educators to gain credibility – do your own background check and make sure that those training sessions actually happened! 

• Experienced doctors can also show many cases of good work to assure you of their good technique. Take note though:
  
  – The Singapore Ministry of Health does not allow before and after pictures to be shown to advertise a procedure. Thus, photos are often only shown during a consultation.
  
  – It is important that before and after photos are taken in the same lighting, angle and also expressive state. These may be difficult for a layman to take note of, but if you notice any discrepancies, don’t blindly accept such photographic evidence.
  

• There is more than one way to do nose threads or fillers! Experienced injectors have various techniques. If you hear that the “safest way to do the nose is using xxx only”, then you might want to stay away!

• Poor materials are a common mistake in doing nose threads or fillers. If you noticed that your thread lift or filler did not last for more than a few months, or if a particular influencer keeps returning to a certain clinic for her nose job many times a year, it may probably be a case of poor material choice for the procedure.

What are the costs of getting Nose fillers and Nose thread lifts in Singapore?

The cost of getting a nose filler usually varies from $800 up to $2000 in Singapore, depending on the materials and experience of the doctor.

The cost of getting a nose thread lift in Singapore is of a similar range, depending on the complexity of work and the number of threads used. Botox for the nose usually ranges from $200-700, depending on the treated areas. 

Both nose fillers and nose thread lifts are not Medisave-claimable as they are categorised under cosmetic treatments. 

Summary

In conclusion, non-invasive rhinoplasty such as nose fillers, nose thread lifts and even botox are significantly less invasive ways to improve your nose shape. Different nose shapes and different skin types may require different procedure types, or a specific combination of them – never trust someone who only gives you one or two limited options for your nose – it reflects a lack of experience with the various techniques and materials. 

Some doctors have sworn off from doing nose fillers because of risk of blindness, others swear off the thread lift because of excessive scarring in their own experience. Proper assessment is of paramount importance to ensure safe and beautiful results, so don’t choose your own procedure before you get assessed by a real professional! 

References:

1. Moon, K.-C. and Han, S.-K. (2018). Surgical Anatomy of the Asian Nose. Facial Plastic Surgery Clinics of North America, 26(3), pp.259–268.
2. Hope, J. (2014). Plastic surgeons say Scarlett Johansson has the ideal nose. [online] Mail Online. Available at: https://www.dailymail.co.uk/sciencetech/article-2671205/Plastic-surgeons-say-Scarlett-Johansson-ideal-nose.html [Accessed 13 Feb. 2021].
3. WOMANLY LIVE. (2020). The Top 5 Most Popular Plastic Surgery Procedures Done In South Korea. [online] Available at: https://womanlylive.com/the-top-5-most-popular-plastic-surgery-procedures-done-in-south-korea/ [Accessed 13 Feb. 2021].
4. The Straits Times. (2021). Chinese actress shares photos of her botched nose surgery. [online] Available at: https://www.straitstimes.com/life/entertainment/chinese-actress-shares-photos-of-her-botched-nose-surgery [Accessed 13 Feb. 2021].
5. Lim, K.A. (2019). Nose job gone wrong leaves 13-year-old Vietnamese girl blind in right eye. [online] AsiaOne. Available at: https://www.asiaone.com/asia/nose-job-gone-wrong-leaves-13-year-old-vietnamese-girl-blind-right-eye [Accessed 24 Feb. 2021].
6. Odunze, M. (2019). Facial Injections Are Mostly Safe but There’s Complications to Consider. [online] Verywell Health. Available at: https://www.verywellhealth.com/permanent-blindness-after-cosmetic-facial-injections-2710232 [Accessed 24 Feb. 2021].
7. Cityskin Cosmetic Clinic. (2018). Blindness after nose dermal filler | A case in Sydney that we all need to learn from. [online] Available at: https://cityskin.com.au/education/blindness-nose-dermal-filler-sydney/ [Accessed 24 Feb. 2021].
8. Walker, L. and King, M. (2018). This month’s guideline: Visual Loss Secondary to Cosmetic Filler Injection. The Journal of Clinical and Aesthetic Dermatology, [online] 11(5), pp.E53–E55. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5955635/#:~:text=TREATMENT%20OF%20BLINDNESS%20AFTER%20FACIAL [Accessed 24 Feb. 2021].
9. Beleznay, K., Carruthers, J.D.A., Humphrey, S., Carruthers, A. and Jones, D. (2019). Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature. Aesthetic Surgery Journal, 39(6), pp.662–674.
10. Beleznay, K., Carruthers, J.D.A., Humphrey, S. and Jones, D. (2015). Avoiding and Treating Blindness From Fillers. Dermatologic Surgery, 41(10), pp.1097–1117.
11. Robati, R.M., Moeineddin, F. and Almasi-Nasrabadi, M. (2018). The Risk of Skin Necrosis Following Hyaluronic Acid Filler Injection in Patients With a History of Cosmetic Rhinoplasty. Aesthetic Surgery Journal, 38(8), pp.883–888.