New Case Submission - Location: Nose
Submitter Credentials: MD
Case Variables:
Location: Nose
Product: HA Filler
Sign: Tissue Necrosis
Onset: Delayed
Tx: Hyaluronidase (Tissue Flooding), Aspirin / Anticoagulants
Outcome: Full Resolution
History & Presentation:
A 30-year-old healthy Italian female presented for aesthetic rhinofiller treatment of a slightly convex nasal curvature (c+) with sub-projection (p-) on lateral plane. Total of 1.2 mL high-visco-elastic crosslinked HA with lidocaine was administered via 27-gauge needle in bolus technique with gentle aspiration before each injection: 0.8 mL at the root of the nasal bones and 0.4 mL on the periosteal plane at the columellar-nose angle. No cannula was used. Patient was observed for 1 hour post-procedure with no signs or symptoms reported, and was discharged home.
Two to three days post-procedure, the patient began experiencing constant rhinorrhoea and a peculiar sensation of cold air entering the nose — both subtle symptoms easily mistakable for a common cold (hence the article's title "An out-of-season cold"). At the 2-week follow-up, the patient reported initial aesthetic satisfaction but described the persistent symptoms above. Suspecting filler complication, rhinoscopy was performed and revealed full-thickness necrosis of the anterior wall of the nasal septum.
The proposed pathomechanism is compression or embolization of the septal branch of the superior labial artery (the columellar artery) following injection at the nasolabial/columellar-nose angle. This vessel is a minor anastomotic component of Kiesselbach's plexus (Little's area), which supplies the anterior cartilaginous nasal septum. In anatomical variants where this branch contributes substantially to septal perfusion (rather than the dominant anterior ethmoidal, greater palatine, or sphenopalatine arteries), its occlusion can cause septal necrosis since collateral supply is insufficient. The "cold air" symptom is explained by loss of mucosal function — the nasal mucosa normally warms incoming air, and ischemic mucosa loses this capacity.
SOURCE REFERENCE: Zengarini C, Sapigni C, Benati M, D'Agostino G, Piraccini BM, Melandri D, Russo A. An out-of-season cold. Filler-induced vascular occlusion of the columellar artery causing necrosis of the cartilaginous anterior nasal septum: case report and a literature review. Dermatology Reports. 2025;17:10061. DOI: https://doi.org/10.4081/dr.2024.10061
Management Protocol:
Initial procedure (Day 0): 1.2 mL HA filler injection via 27G needle with gentle aspiration. 1-hour observation, no immediate symptoms. Discharged.
Days 2–3: Onset of constant rhinorrhoea and unusual cold-air sensation. Patient did not seek immediate evaluation as symptoms appeared to mimic common cold.
Week 2 (follow-up visit): Patient reports persistent symptoms. Rhinoscopy reveals full-thickness necrosis of anterior nasal septum (Kiesselbach area). Treatment initiated: Hyaluronidase 1,200 IU bolus: 600 IU (½ vial) at columellar injection site, 600 IU (½ vial) infiltrated around the lesion at the level of the septal mucosa Aspirin 100 mg PO daily Topical mupirocin to the ulceration
Week 4 (4 weeks post-injection / 2 weeks post-treatment): Complete resolution of ulcer and symptoms confirmed on follow-up rhinoscopy.
Key teaching points from the authors:
Columellar artery occlusion is rare and likely underreported; only one similar prior case identified (Souza et al. 2021)
Subtle, delayed-onset symptoms (rhinorrhoea, "cold air") can mimic common viral illness and delay diagnosis
Clinicians should consider vascular complications even weeks after filler injection, and even in the absence of overt dermatologic findings
Anatomic variation in Kiesselbach's plexus contribution determines whether septal branch occlusion produces necrosis
Despite delayed treatment (>2 weeks), conservative management with hyaluronidase, aspirin, and topical antibiotic produced full resolution — reassuring for similar presentations
