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CASE REPORT
Fat Grafting to the Nose: Personal Experience with 36 Patients
Juan Monreal
Received: 13 July 2010 / Accepted: 11 February 2011
ÓSpringer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011
Abstract
Background Clinicians are facing an increasing trend
toward nonsurgical nose reshaping using synthetic injec-
tables, mainly for patients who refuse standard rhinopla-
sties. Autologous fat grafting is a safer and convenient
alternative to permanent or semipermanent injectables due
to better results as well as fewer and milder side effects.
The author reports his experience with fat grafting to the
nose using his personal technique for 36 consecutive
patients. The experience covers primary treatments of
noses not treated by surgery, treatment of post rhinoplasty
deformities, and combination fat grafting and rhinoplasties.
Methods The technique used by the author for fat grafting
to the nose does not differ significantly from that used for
other body or face areas. It is based in the atraumatic
extraction of fat fragments using a multi-orifice cannula
and injection of these fragments using 1.4- to 1.6-mm
cannulas or needles. In combining rhinoplasties with fat
grafting, fat grafts are used in the same location instead of a
prosthesis or cartilage grafts.
Results The initial analysis of postoperative results
showed a good to high level of patient satisfaction, par-
ticularly in primary cases, with virtually no complications
or severe side effects. Some easily corrected side effects
probably were learning curve dependent.
Conclusions Autologous fat grafting is an effective and
reliable technique for aesthetic and reconstructive nose
reshaping for patients who refuse surgical treatments.
Although optimal results can be achieved with this tech-
nique, they are not comparable with those obtained by
surgical rhinoplasties, and this is an important issue to
discuss with the prospective patient.
Keywords Fat grafting Lipofilling Lipoimplant
Lipostructure Nose
Recent years have found us facing an increasing number of
patients desiring aesthetic improvement of nasal shape
without having to undergo surgical rhinoplasty. Although
surgical rhinoplasty must be the primary indication for any
patient seeking aesthetic improvement of the nose, the
ability to smooth out irregularities or contour deformities
and asymmetries using an injectable material holds great
appeal due to the apparent simplicity of the correction. The
ability to fix a deformity with local or no anesthesia, less
financial expense, and no downtime is appealing. The great
majority of treatments I have witnessed involve the use of
permanent or semipermanent fillers injected in the dorsum,
tip, and columella.
Regarding semipermanent fillers, an acceptable degree
of safety depends on an even and complete resorption, but
some potential complications still must be faced [1,2]. The
patient must forego a permanent result unless he or she has
repeat injections on a regular basis, and if the patient finally
wishes to undergo a standard surgical rhinoplasty, we must
wait for the complete resorption of the implant until sur-
gical planning can be done with confidence. The use of
permanent fillers in the nose poses additional risks of
severe adverse reactions, skin necrosis, and extrusion in
J. Monreal (&)
Sociedad Espan
˜ola de Cirugı
´a Pla
´stica Reparadora y Este
´tica
(SECPRE) (Spanish Society of Plastic, Reconstructive and
Aesthetic Surgery), Asociacio
´n Espan
˜ola de Cirugı
´a Este
´tica
Pla
´stica (AECEP) (Spanish Association of Aesthetic Plastic
Surgery), International Society of Aesthetic Plastic Surgery
(ISAPS), Londres, #54–18D, 28850 Torrejo
´n de Ardoz,
Madrid, Spain
e-mail: drmonreal@drmonreal.info
123
Aesth Plast Surg
DOI 10.1007/s00266-011-9681-4
addition to the almost complete difficulty evacuating the
filler thoroughly and the obvious difficulties in eventual
surgical planning.
I discuss my experience in nonsurgical rhinoplasty using
autologous fat grafting instead of injectable fillers for
patients who refused primary or secondary surgical rhino-
plasties. The discussion also deals with the combination of
open or closed rhinoplasty with fat grafting to paranasal
regions to achieve equal or better results than with cartilage
grafts or solid prostheses in the same regions.
Patients and Methods
Since April 2007, I have analyzed 36 procedures for 33
patients, with a maximum follow-up period of 14 months
(mean, 7 months). For 18 patients, nasal lipoimplantations
were performed as the unique method of improving nasal
aesthetics whether surgery had been performed previously
or not (Figs. 1,2,3). The patients in these cases always
refused a standard rhinoplasty although they all were
informed and advised about the differences in final results,
limitations, and aesthetic improvements associated with
each technique. All the patients acknowledged the limita-
tions of lipoimplantation compared with surgical
rhinoplasty.
The remaining 15 patients underwent nasal lipoim-
plantation as a complement to surgical rhinoplasty (open or
closed) with the aim of reshaping the bony dorsum, radix,
glabella, or premaxillary region (Fig. 4). Traditionally,
patients presenting with short nasal bones, frontal reces-
sion, or premaxillary retrusion have been treated with
cartilage grafts or a solid prosthesis during rhinoplasties to
supplement deficient bone in this area. In this study, fat
grafts were used instead of cartilage or prosthesis to sup-
plement deficient bone so their efficacy could be assessed.
Nasal reshaping performed with lipoimplantation alone
was performed with the patient under local anesthesia
using 3–12 ml of fat harvested from the lower abdomen or
inner thighs. All lipoimplantations performed in combina-
tion with rhinoplasties were done with the patient under
general anesthesia using 6–12 ml of fat harvested from the
same areas. Due to severe postrhinoplasty deformities,
three patients needed an additional procedure to refine the
final result (Fig. 1).
Follow-up visits were scheduled at 7 days, 15 days,
3 months, 6 months, and 12 months, although unfortu-
nately, it was not easy to get patients back in the office after
postoperative month 6. Basic analysis including changes in
volume and shape, aesthetic improvement, and patient
satisfaction was performed by comparison with pre- and
postoperative control photographs.
Nasal Danger Zones
The arterial supply of the nose is derived from the oph-
thalmic and facial arteries (Fig. 5). The ophthalmic artery
arises from the internal carotid just as that vessel is
emerging from the cavernous sinus. The central retinal
artery is the first and one of the smaller branches of the
ophthalmic artery. The ophthalmic artery terminates in two
branches: the supratrochlear artery and the dorsal nasal
artery. The dorsal nasal artery emerges from the orbit
above the medial palpebral ligament and divides into two
branches. The first branch crosses the root of the nose and
anastomoses with the angular artery. The other branch runs
along the dorsum of the nose, supplying its outer surface in
its route toward the nasal tip, and anastomoses with its
fellow artery of the opposite side and with the lateral nasal
branch of the facial artery.
The lateral nasal artery is derived from the facial artery
as that vessel ascends along the side of the nose. It supplies
the ala and dorsum of the nose, anastomosing with its
Fig. 1 a, c Preoperative view of a patient after a previous rhinoplasty
performed by another surgeon. b, d Postoperative view at 6 months
showing nasal lipoimplantation and touch-up procedure to improve
dorsal and tip contours
Aesth Plast Surg
123
fellow, with the septal and alar branches, with the dorsal
nasal branch of the ophthalmic artery, and with the infra-
orbital branch of the internal maxillary. Finally, the colu-
mellar artery, a branch of the superior labial artery, runs up
the columella, ending and anastomosing in the tip with
branches of the lateral nasal artery.
From this anatomic review, we can obtain the main
conclusions. The proximal blood supply of the nose has
direct and short connections with the internal carotid and
retinal arteries. This means that embolization of this net-
work during injection in the area of the dorsum, radix, or
glabella can cause a variety of disastrous consequences
such as blindness or brain infraction [1,3]. The distal blood
supply, mainly at the tip and in alar regions, also can be
affected by embolization, causing a variety of ischemic
phenomena.
Fig. 2 Preoperative (a) and postoperative views 2 weeks (b),
6 months (c), and 14 months (d) after nasal lipoimplantation to
improve tip and dorsum contours
Fig. 3 Preoperative (a) and
postoperative views 5 months
(b) and 12 months (c) after
nasal lipoimplantation to correct
slight dorsal deviation and
pinching of the tip
Fig. 4 Preoperative and 12-month postoperative views of combined
open rhinoplasty and lipoimplantation to the premaxillary area for
improvement of facial profile and nasal base proportions
Aesth Plast Surg
123
Thus, it is of outmost importance to follow the same
strict principles in performing fat grafting to the nose as
would be followed for any other facial region if serious
complications are to be avoided. Use of blunt-tip cannulas
whenever possible reduces the chance of perforating the
arterial wall and thus cannulating the arterial lumen.
Applying soft pressure to the plunger of the syringe helps
to deposit the smallest fat fragments possible and also to
reduce the chance of propelling the fat through the arterial
lumen in the event it is cannulated.
Unfortunately, at least in my experience, fat grafting to
the nose for some patients with previous surgery is more
challenging for two main reasons. First, the blood supply
architecture usually is distorted and the tissue planes less
identifiable. Second, fat grafting through blunt-tip cannulas
can be difficult due to severe soft tissue scarring and
adherence, particularly over the nasal dorsum. Only in this
case do I perform fat grafting with 18-gauge needles.
Technical Details
The fat grafting to the nose that I perform does not differ
much from the technique used for other body areas and
reported previously [4–6] including treatment of perinasal
areas such as the premaxillary region [6]. The technique
consists basically of atraumatic harvesting of fat fragments
with the patient under local anesthesia using a 3-mm multi-
orifice cannula (Fig. 6) attached to a 10-ml syringe. This
type of cannula allows harvesting of 2- to 3-mm fat frag-
ments with ease.
Usually, it is not necessary to obtain more than 12 ml of
fat ready for injection to treat the whole nose and perinasal
areas. This usually means that the clinician needs to harvest
at least 24 ml of lipoaspirate due to the loss of tissue during
the washing and decanting process. Harvested fat is washed
with Ringer lactate and allowed to decant for 20 min. Once
decanted, fat can be cautiously passed to smaller syringes
of 1 or 2.5 ml for easily handling.
Fat is injected routinely in a retrograde manner using
1.2- to 1.4-mm blunt-tip cannulas and applying very gentle
pressure on the plunger. I use conventional 18-gauge nee-
dles only when dealing with highly adherent or fibrous
tissues in the nasal dorsum of patients who have undergone
previous surgery. Conventional sharp needles need not be
used in primary cases. They pose an additional risk of
intravascular injection with disastrous consequences. In
any case, the clinician must have in mind all danger zones
and vascular territories of the nose to prevent an unwanted
intravascular injection. In dealing with the supratip and
glabellar region, special care must be taken in introducing a
cannula or needle from the tip because these approaches
pose the greatest risk.
The clinician can take advantage of two main tissue
planes when injecting fat in the nose. The submuscular
aponeurotic system (SMAS) plane is present along the
entire nasal dorsum and has continuity with the radix and
glabella. The subcutaneous plane also is useful in the
dorsum, and it is the only plane to be found over the tip and
lateral crura of the lower lateral cartilages. In secondary
cases, the clinician should be cautious because this plane
probably will not be found with ease, and different degrees
of fibrosis will impair cannula advancement and fat
placement. The clinician should always try to evaluate and
remember the vascular anatomy of the patient’s nose and
Fig. 5 Main arterial supply to the nose and danger zones regarding
fat injection (arrows). STA supratrochelar artery, DNA dorsal nasal
artery, AA angular artery, IOA infraorbital artery, LNA lateral nasal
artery. LA superior labial artery, FA facial artery
Fig. 6 Cannulas used by the author since 1998 to perform atraumatic
harvest of 2- to 3-mm fat fragments
Aesth Plast Surg
123
glabellar area to avoid severe complications such us
intravascular injection of fat.
Unlike other body and face areas, the soft tissues of the
nose do not allow the creation of a three-dimensional mesh.
For this reason, caution is needed in performing fat injec-
tion, both in the quantity and the location. Due to the rel-
atively small caliber of the cannulas and needles used in
nasal fat grafting, the clinician can choose whatever access
point is needed. However, it is preferable to avoid entering
the nasal skin directly or near the principal arterial trunks
of the nose. I usually perform fat grafting to the nose under
a regional block of the nose, avoiding direct infiltration of
nasal tissues to avoid any distortion of profile. Once the
procedure is completed, I routinely do not use any splint or
tape to immobilize nasal tissues.
For the current series of patients, the nasal lipoimplan-
tations performed in combination with rhinoplasties fol-
lowed the principles described once the rhinoplasty was
finished and all the wounds were closed. The glabellar
region, the radix, and the premaxillary region were treated
individually if deficient to improve the final nasal profile.
The glabella and radix were approached from the middle
frontal region 1 cm above the eyebrows, and the premax-
illary region [6] was approached from the nasolabial fold
2 cm lateral to the nasal ala. In contrast to the technique
described by Ca
´rdenas and Carvajal [7], I do not place fat
parcels in the dorsal nasal skin of these patients, but only in
the radix, glabella, and piriform aperture, with the aim of
adding volume if deficient to further enhance nasal profile
and proportions. Final nasal dressings and splinting were
done as usual at the end of the rhinoplasty.
Results
The follow-up visits and control photographs were sched-
uled at 24 h, 7 days, 15 days, 3 months, and 12 months for
evaluation of improvement and stability of results. For the
nasal lipoimplantations performed in combination with
rhinoplasties, dorsal splints were removed at 7 days, and
follow-up visits were scheduled at the same intervals.
After 24 h, nasal swelling was mild, with nearly com-
plete absence of equimosis in primary cases. Patients were
happy to resume daily activities and daily work in a fairly
short time. Lipoimplantations performed for patients with
previous surgery showed a bit more swelling and equimosis
than in primary cases. When combined with rhinoplasties,
the degree of swelling and equimosis was equivalent to that
of cases managed without associated lipoimplantation
except in the glabellar area.
Grafted fat volume slowly decreased over the first
15 days after treatment and until the first month but
showed a high degree of stability thereafter. After
4–5 months, no patient showed changes in contour or
volume. The percentage of final graft take was difficult to
calculate due to the small volumes used, but based on
control photographs, it was estimated to be 60% in sec-
ondary cases and 75% in primary cases.
Patient satisfaction was good to high in 80% of cases,
particularly in cases of post rhinoplasty deformity. Only
two patients were disappointed, expecting more profound
changes from this technique. Only three patients presenting
with severe post rhinoplasty deformities needed a touch-up
procedure to add volume to an originally highly depressed
and adhered dorsal skin and to two under projected and
scarred tips that could not receive all the fat volume
required in the first procedure. Swelling improvement in
combined cases did not differ much from that in rhino-
plasty cases with no lipoimplantation.
Beside pure modeling capabilities, fat grafts offer pro-
ven biologic benefits in cases of scarred, pigmented, and
other skin disorders. It was not the purpose of this study to
evaluate the biologic improvements provided by fat graft-
ing to the nose. Nonetheless, I have witnessed improve-
ments in skin quality, particularly in pigmentations,
adherences, and texture, which were more evident after
treatment of secondary cases (Fig. 3). Specific studies are
needed for objective evaluation and measurement of these
findings.
The current series of patients experienced no compli-
cations or untoward results that required additional treat-
ment or surgical interventions. Only in one combined case
did minimal displacement of the grafted fat in the radix
occur, probably caused during the nasal splinting. This
complication was easily treated without major conse-
quences. None of the patients experienced significant
changes in body weight during the follow-up period, so the
impact of body weight changes in fat graft behavior could
not be evaluated. Patients who reported functional or
obstructive airway problems were informed about the
inefficacy of fat grafting to correct the symptoms. No new
symptoms of airway obstruction or worsening of previous
symptoms were noticed in any patient.
Discussion
The tendency of patients to seek minimally invasive cos-
metic treatments also reaches nasal aesthetics. Nonsurgical
rhinoplasty, also called medical rhinoplasty, has been
performed traditionally using permanent or semipermanent
injectable fillers [2]. With semipermanent fillers, the
patient must forego a permanent result unless he or she
repeats the injections on a regular basis. The use of per-
manent fillers makes it impossible or quite difficult to
remove the implant completely or to accomplish proper
Aesth Plast Surg
123
safe surgical planning in the event that the patient desires
an eventual surgical rhinoplasty. In either case, complica-
tions arising from the use of injectable fillers are already
known. Some disastrous complications reported in the lit-
erature include blindness and strokes [3]. Other local
complications are intolerance, granulomas, extrusion, and a
subtotal necrosis tip or nasal ala.
Fat grafting to the nose must not be considered a risk-
free technique because potential complications can be
devastating. The use of fat grafting removes certain filler-
dependent side effects such as the need to repeat treatments
in the long term, intolerance or rejection of foreign mate-
rial, or difficulty planning in the event that a patient
eventually needs or wants a surgical rhinoplasty. Emboli-
zation of the arterial nasal network, a technique-dependent
complication that can occur with fat grafting and also with
other injectable fillers, has been well documented previ-
ously [3]. Therefore, to prevent its occurrence, every
plastic surgeon dealing with this technique must have a
thorough knowledge of the nasal arterial network and soft
tissue anatomy. In this sense, arterial embolization of the
angular or dorsal nasal artery in a cranial direction (via the
tip approach) will cause immediate pain, blindness, or
stroke, whereas arterial embolization of the dorsal nasal
artery or lateral nasal artery in a caudal direction (via the
glabellar, radix, or lateral alar approach) will cause
necrosis of soft tissues to a variable degree. Using a proper
technique that includes injection with blunt cannulas
whenever possible, very gentle pressure applied on the
syringe plunger, and placement of fat parcels in a retro-
grade manner is mandatory when nasal fat grafting is
performed.
It is essential to understand that true nasal modeling is
obtained through improving architectural elements of bone
and cartilage, leaving soft tissues to adapt to changes and
draw the final result. Autologous fat grafting applied to
nasal aesthetics works oppositely by altering only soft
tissues to mask architectural imbalances or irregularities
except when it is used in combination with rhinoplasty to
supplement deficient bone in the radix, glabella, and pre-
maxillary region. In these later cases, fat grafting has
worked with the same efficacy as cartilage grafts or solid
prostheses in the same locations. Obviously, we will face
patients with bone or cartilage architectures that cannot be
camouflaged by fat grafts, for example, patients with a
coarse boxy tip, an over projected tip, or a tension nose.
For these reasons autologous fat grafting to the nose is an
indication only for some selected nasal deformities of
patients who refuse rhinoplasty as the primary choice and
understand clearly the limitations in the final results.
Based on the biologic improvements I have observed in
secondary cases, fat grafting to the nose could be the first
choice for some selected cases in which a high degree of
scarring or adherence might jeopardize dissection or blood
supply during open or closed rhinoplasty. Fat grafts have
demonstrated the ability to release tightly adherent skin in
a way that provides better conditions and makes secondary
surgical rhinoplasty safer.
Some other authors have previously reported their per-
sonal experiences with fat grafting to the nose [7–10].
Ca
´rdenas and Carvajal [7] reported the use of lipoinjection
of the nasal dorsum in combination with open rhinoplasties
to obtain smooth dorsal contours with good results. Cole-
man [8] gave a thorough description of his nasal fat
grafting technique in his last book, and Duskova et al. [10]
reported their experience with cleft nose refinement.
Conclusions
Surgical rhinoplasty must be the primary approach for
patients seeking aesthetic improvement of the nose. Fillers or
fat grafts are no substitute for an adequate surgical technique
and will never provide better results. Nonetheless, autolo-
gous fat grafting also shows itself as a first-line nonsurgical
alternative to the modeling of nasal shape and profile in
primary and secondary cases of patients who refuse surgical
rhinoplasties and accept limitations in the results. The aes-
thetic nasal and paranasal units can be treated as a whole or as
aesthetic subunits individually as needed. It also is possible
to combine surgical rhinoplasty with lipoimplantation in the
dorsum, radix, glabella, or premaxillary area to improve
volume and shape in these areas without the need to use
cartilage grafts or solid prostheses.
The described approach to nasal remodeling uses an
easy, safe, and reliable procedure that lacks serious com-
plications, side effects, or untoward results if properly
performed. However, it is technically demanding if good
results are to be obtained and serious complications are to
be avoided. Unlike permanent injectable fillers, autologous
fat grafts do not pose any risk or difficulties in terms of
planning or performing an eventual rhinoplasty throughout
the patient’s lifetime.
Conflicts of interest The author declares that he has no conflicts of
interest to disclose.
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´nez-Alfaro I (1993) Middle
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