PDO threads in the nose: indication, risks and evidence

The nose is one of the few aesthetic requests in which the patient wants a change in shape without surgery. Nonsurgical rhinoplasty with filler became known for that, and PDO threads appeared as another possibility: supporting the tip, adding a little projection to the dorsum and avoiding surgery. But the nose is also an area with little tolerance for error, and the use of threads there is one of the most controversial and least studied topics in orofacial harmonization (HOF, as the specialty is known in Brazil).

This guide is a review. It explains what is described, why the area is high-risk, what the evidence allows us to say and which alternatives exist. It does not include insertion technique, entry points, path or protocol, which are decisions for the qualified professional, according to the rules of their professional council. For thread types, see types of PDO threads, and for anatomy, nasal anatomy for injectables.

What is being attempted with threads in the nose?

Reports describe uses such as supporting and subtly lifting the nasal tip, supporting the columella, projecting the nasal dorsum and, in some cases, improving the contour in noses with a drooping tip. The idea is to use the support of the thread instead of adding volume. In noses with a low tip due to tissue laxity, the proposal seems attractive. But these uses rest on case reports and small series, with short follow-up and no comparison with other strategies.

Why is the nose a high-risk area?

Four reasons explain the caution. The first is vascularization: the dorsal nasal artery, the angular artery, the lateral nasal artery and the columellar artery form a network that connects with the circulation of the eye. Vascular injury or occlusion in this network can lead to skin necrosis and, in rare and serious cases, vision loss. See nasal vascular occlusion and amaurosis. The second is thin, tight skin, especially at the tip and dorsum, which reveals any thread or irregularity. The third is cartilage, with low vascularization and little ability to fight infection. The fourth is proximity to the nasal mucosa, which is colonized by bacteria.

What does the evidence allow us to state?

Very little with confidence. There are descriptions of techniques and reports of satisfaction, but comparative studies, long follow-up and standardized objective measures are lacking. In terms of levels of evidence in HOF, this is a low-evidence use. Safety data are even more limited, because rare and serious events only show up in large case series, which do not exist for this use. The absence of complication reports does not prove safety, and the prudent reading is that the risk in this area is less well known than in others.

To understand how to read this kind of literature critically, see how to read a clinical trial of injectables and publication bias in aesthetics.

What complications can happen?

Besides the general thread events (pain, swelling, bruising, asymmetry, infection, palpable thread, extrusion), the nose adds particular risks:

• Visible or palpable thread under the thin skin of the tip and dorsum;
• Extrusion through the skin or nasal mucosa, with a risk of infection;
• Deep infection and biofilm, which are hard to treat in a cartilaginous area;
• Deformity and irregularity of the dorsum or tip;
• Skin necrosis from vascular compromise, rare but serious;
• Visual change in the context of vascular occlusion, a rare and emergent event.

Management of each event is covered in complications with PDO threads, thread extrusion and visibility and infection and biofilm after filler.

Who should not have it done, or at least needs extra caution?

Some situations call for declining or for great caution: very thin or poor-quality nasal skin, previous nasal surgery (rhinoplasty, grafts), which alters the anatomy and vascularization, active infection on the face or in the nasal cavity, previous fillers of uncertain duration in the area, active autoimmune disease, heavy smoking, a history of poor healing and an expectation of structural change that only surgery delivers. In patients with previous surgery, the vascular risk is unpredictable, and many professionals avoid injectable procedures in the nose in these cases. See the safety context in safety and complications.

What are the alternatives?

For a drooping tip and a low dorsum, the patient can be told about more than one path. Nonsurgical rhinoplasty with hyaluronic acid adds volume and projection, is reversible with hyaluronidase, and has its own risks, described in hyaluronic acid in the nasal dorsum and hyaluronic acid in the columella and tip. Toxin at specific points can correct the tip dropping when smiling; see toxin in the nasal tip. And surgery (rhinoplasty) is the option for structural changes. The patient-oriented comparison is in nonsurgical rhinoplasty: hyaluronic acid or threads.

What should you tell the patient?

The nose is a subject loaded with expectation. An honest conversation separates what is possible from what is wished for, describes the rare, serious risk without dramatizing it and offers alternatives. In many cases, the most responsible answer is to recommend another route or to refer.

What about Harmy?

Harmy does not have a Nose point among the areas you can mark, and it does not simulate threads or changes in nasal projection. The app uses only the frontal photo, which does not show tip projection or the profile of the dorsum, exactly what is at stake in this concern. Do not use the app to promise a nasal result; it is meant for other areas of the face, with illustrative projection.

Summary

PDO threads in the nose have a described use, but with low evidence and a high specific risk, especially vascular. The indication is restricted, consent is specific, the anatomy must be mastered and the emergency plan prepared. When in doubt, prefer more predictable alternatives or refer.