Shot of Courage
Nonsurgical rhinoplasty guru Dr. Alexander Rivkin shares the ins and outs of nose filler—and the reason his peers think he's "out of [his] f*cking mind."
The nonsurgical nose job strikes fear into the hearts of some injectors—tales of blindness and necrosis haunt the field—yet the procedure seems more popular than ever. Its appeal? In skilled hands, a few carefully placed drops of filler can smooth a bump, perk up a tip, even fix flaws from surgeries past—all in about 10 minutes.
The demand for nose filler isn’t new. In fact, it predates the advent of conventional hyaluronic acid gels. Since the late 1800s, doctors have aimed to shape noses with all manner of materials—paraffin, mineral oil, beeswax, silicone, fat—and in most cases, “it didn’t turn out terribly well,” says Alexander Rivkin, MD, an LA-based cosmetic surgeon and assistant clinical professor at UCLA’s David Geffen School of Medicine. For decades, liquid rhinoplasty “was a procedure waiting for a technology,” he tells me. It arrived in 2003, in the form of Restylane, the first FDA-approved hyaluronic acid filler. Since then, Dr. Rivkin has injected some 20,000 noses.
Personally, I find this procedure both mesmerizing and terrifying. My own nose could certainly benefit from some subtle finessing, but the risk of vision loss—so rare! I know!—stops me every time.
Dr. Rivkin is made of far steelier stuff. In addition to his signature HA nose job, he performs a permanent nonsurgical rhinoplasty with Bellafill—that’s polymethyl methacrylate (PMMA) beads suspended in collagen. Talk about upping the ante on an already controversial procedure! For the record, I’m not endorsing either treatment; I’m merely illuminating the options.
One day, not long ago, Dr. Rivkin subscribed to my newsletter. When I reached out to thank him, we got to talking about filler, misinformation, transparency around complications—something I admire him for—and we agreed that a formal Q&A was in order. So, here’s the intrepid doctor talking all things liquid rhino—from risks and rewards to leech therapy (you heard me) and critical colleagues.
The nose that started it all
At the time, I had this little, tiny practice on the second floor of a hair salon. The woman in charge of the salon was a friend of mine—she's Armenian—and her nose had a curve to it on profile. I realized even then that if I could make her nose straight with filler, I could make it look smaller, even though I'd be adding to it, because it would blend into the rest of her face. And so we did it—and right away I knew it was something special. I could save people an operation. This was 2005 and I hadn't heard of anyone talking about filler as an actual alternative to surgery. Nonsurgical rhinoplasty didn’t really penetrate [culturally] until social media hit years later.
Syringe > scalpel
From the beginning, I saw nonsurgical rhinoplasty as undoubtedly more precise and reliable than surgery, even though it’s temporary. I mean, clearly there are limitations. It's not a reductive procedure. Not everyone's a candidate. But for those who are, this could spare them pain, downtime, surgical risk, and expense.
As a surgeon, I know what people go through after surgery—what they really go through. On Instagram, you see the before, you see the after, and you’re like, Oh, wow! But in between, I know what happens. I know the uncertainty in the healing process. I know the uncertainty in the results. Even in the best hands, surgery is a little bit unpredictable in terms of how things heal. And so I saw, in these fillers, an opportunity, because they offered a way to make aesthetic changes that were, in my opinion, more precise and predictable than surgery, for the right patient.
The optical illusion of it all
This procedure is not going to work for somebody who needs a physical reduction. If their nose is proportionally too large for their face, they need a surgical reduction. But it's interesting, because proportions, when you measure them, are one thing. But perception is something entirely different. Oftentimes, patients feel that their nose is big when it’s actually not. It's just that they have a bump and a droopy tip that draw attention to the nose, making it appear bigger in relation to the rest of the face. This warping of perception is something I can work with—this is the bread-and-butter of my practice. I camouflage the bump, I lift the tip, and the nose looks straighter. It’s technically bigger, but it looks considerably smaller, and the problem is solved.
Where filler falls short
There are things you just can't fix with filler. If you have a bump, but the radix at the top of the nose is too high, I can't add to it [to blend the bump], or you’ll wind up looking like an Avatar. If your tip is super-low and droopy, filler isn’t going to work. Fillers can lift the tip, but only slightly. If somebody comes in with a bulbous tip and wants it refined and dainty—that's not happening. Fillers, even the robust ones, are still relatively soft; they can define a tip only so much. A nose that's really twisted—that requires surgery. Narrowing a wide nostril base is not really possible. In fact, that’s hard to do surgically, as well. And the last thing, of course, is unrealistic expectations: The person who thinks filler is going to solve everything and give them a perfect nose. I won’t inject them.
Avoiding the carbon-copy “influencer” nose
Not everyone wants a Tinkerbell nose. A lot of my patients are Gen X or older millennials who like a natural look. They don't want the influencer nose.
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