Management of internal nasal valve collapse after nasolabial fold augmentation with hyaluronic acid filler: A case report

Abstract

Hyaluronic acid dermal fillers for nasolabial fold correction are generally safe, but rare complications can occur. We present the first reported case of an internal nasal valve collapse following nasolabial fold augmentation with hyaluronic acid filler in a 50-year-old woman with mild septal deviation. The patient developed unilateral nasal obstruction and noisy breathing 3 days post-injection. Examination confirmed collapse of the left internal nasal valve during deep inspiration, which resolved with lateral cheek support. Conservative management, including warm compresses, firm downward massage, and intranasal corticosteroid spray, resolved symptoms by day 20 post-procedure without the need for hyaluronidase. The aesthetic result remained satisfactory. This case highlights the importance of thorough anatomical assessment before midface filler injections and prompt recognition of unexpected functional complications. Awareness of nasal valve dynamics and careful injection technique near the pyriform aperture can help prevent such events.

Introduction

Hyaluronic acid (HA) fillers are widely used for non-surgical correction of nasolabial folds and midface rejuvenation.¹ While generally safe, injectors must remain aware of rare but significant complications beyond commonly discussed vascular events.² This report describes what we believe is the first documented instance of internal nasal valve collapse following nasolabial fold augmentation with HA filler. The internal nasal valve is the narrowest segment of the nasal airway and can collapse dynamically if its support is compromised.³ This case illustrates how deep filler placement near the pyriform aperture, combined with mild pre-existing septal deviation, can precipitate this rare functional complication. We aim to alert aesthetic practitioners to this anatomical risk, outline conservative management, and reinforce careful anatomical assessment in midface injections.

Case report

Patient and setting

A 50-year-old healthy Scottish woman attended a training clinic session at Esteem Life Medical Group, Glasgow, seeking non-surgical treatment for deep nasolabial folds. She had no baseline nasal breathing problems but did have a mild leftward septal deviation noted on exam. Her medical history included well-controlled rheumatoid arthritis and a previous hysterectomy. She was not on regular medication except for occasional co-codamol. There were no known drug allergies and no history of previous nasolabial filler treatment.

Procedure

After standard clinical photography and written informed consent, nasolabial fold augmentation was performed using Teoxane® RHA3 hyaluronic acid filler. The treatment area was cleaned aseptically. Injection was performed with a 27-gauge needle delivering a 0.3 mL supraperiosteal bolus at the medial lower third adjacent to the pyriform aperture (avoiding the alar base), followed by 0.1 mL placed with a 25 G × 50 mm cannula as subcutaneous linear retrograde threads to finesse the fold. Aspiration was performed before deep placement and injections were slow (<0.05 mL/s). The total volume was 0.4 mL per side.⁴ This approach is consistent with MD Codes™ methodology for medial nasolabial fold support.⁴ The patient tolerated the procedure well with no immediate signs of vascular compromise, excessive bruising or discomfort. Post-treatment instructions included avoiding pressure and monitoring for late complications.

Development of complication

Three days post-injection, the patient noticed new-onset noisy nasal breathing on deep inspiration, mainly on the left side. She described mild nasal blockage during exercise but no pain or external swelling. Believing it might resolve naturally, she waited until her scheduled review 13 days post-procedure.

Assessment

At review, examination confirmed soft tissue support of the left internal nasal valve was compromised. The valve collapsed inward during deep inspiration but remained open with manual lateral cheek traction (positive Cottle manoeuvre).⁵ No signs of mucosal oedema or infection were seen on anterior rhinoscopy. A single dose of topical xylometazoline spray had no effect, suggesting a structural rather than mucosal cause. The likely mechanism was filler encroachment into the pyriform aperture, reducing the valve angle in a nose already narrowed by mild septal deviation. Point-of-care ultrasound can support vascular mapping or filler localization where clinically indicated; in this case it was not required because injection planes and small volumes were well documented, and there was no clinical suspicion of migration or vascular event.^6,7

Before-and-after clinical photographs were taken to document the aesthetic outcome (Figure 1). A short video clip was recorded demonstrating the valve collapse during inspiration and its resolution with the Cottle manoeuvre (Supplementary Video 1).

Figure 1.

(A) Pre-treatment view showing deep nasolabial folds. (B) Immediately after image showing aesthetic improvement. (C) Apparent post-treatment accentuation of septal deviation is influenced by head position and dynamic inspiratory collapse.

Management

The patient preferred to avoid hyaluronidase if possible to maintain the aesthetic outcome. Conservative measures were initiated: warm compresses, firm downward massage using a neutral lubricant (Hydromol®) to displace filler away from the nasal sill, plus beclomethasone nasal spray twice daily for 7 days to minimize any subtle mucosal inflammation. The patient was advised to repeat massage at home and use external nasal dilator strips if needed.

Outcome

At day 20 post-injection, nasal breathing had normalized. The collapse no longer occurred on inspiration. The aesthetic correction of the nasolabial folds remained satisfactory with minimal volume loss. Apparent accentuation of septal deviation in the immediate post-treatment photograph reflects slight head rotation and dynamic left alar wall collapse during inspiration; no structural change of the septum was identified on anterior rhinoscopy at review. The patient provided written consent for publication including images and video.

Discussion & conclusion

This report highlights a rare, functional complication following nasolabial fold augmentation with hyaluronic acid filler. To our knowledge, no previous case of internal nasal valve collapse due to filler placement has been published. The internal nasal valve is the narrowest part of the nasal airway, accounting for over half of total nasal airflow resistance.³ Minor changes to its structure or support can produce significant obstruction.³

In this case, filler placed near the pyriform aperture likely medialized soft tissue at the nasal sill and increased bulk adjacent to the caudal upper lateral cartilage, reducing the internal nasal valve angle (normally ∼10–15°) and predisposing the lateral wall to inspiratory collapse via Bernoulli effects.^8,9 Pre-existing mild septal deviation further narrowed the functional corridor, lowering the threshold for dynamic obstruction.⁹ The hydrophilic nature of HA filler may have temporarily increased local volume through water attraction, further contributing to transient narrowing of the valve angle and inspiratory collapse.²

Most complications after HA fillers are minor, transient injection-site reactions (pain, erythema, oedema, bruising) that resolve within 1–2 weeks.² Delayed inflammatory nodules/reactions are uncommon (∼0.02–4.0 %),¹⁰ and vascular occlusion is rare (∼0.01–0.05 % per injection; ∼1:10,000–1:2000).¹¹ Reported blindness events predominantly arise from injections in the nose, forehead, and glabella rather than from the nasolabial fold.¹² This case is therefore unusual in presenting a transient functional airway change. Conservative management—warm compresses, directional massage, and topical steroids—resolved the issue without the need for hyaluronidase, preserving the cosmetic benefit. Hyaluronidase remains an important option if conservative measures fail or symptoms worsen.²

Practical implications for medial nasolabial fold injections near the pyriform aperture:

• •Stage volumes (≤0.3–0.4 mL per side per session) and reassess nasal function before adding volume.
• •Counsel “complex patients” (prior septoplasty/rhinoplasty, midface deformity, baseline airflow symptoms) and perform a pre-procedure Cottle test; document baseline airflow symptoms.
• •Use slow injections with aspiration for any deep placement; avoid medial fanning.

In summary, injectors must balance aesthetic goals with anatomical awareness. Rare complications like nasal valve collapse should be recognized early and addressed appropriately to protect both functional and cosmetic outcomes.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images and videos.

Funding

No funding was received for this work.

Ethical approval

Not required.

Declaration of competing interest

None declared.

Appendix. Supplementary materials

Supplementary Video 1: Dynamic video showing left internal nasal valve collapse on deep inspiration and resolution with a positive Cottle manoeuvre.