Rhinoplasty/management of filled noses

Rhinoplasty/management of filled noses | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Rhinoplasty/management of filled noses Semih AK This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7214246/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Facial plastic surgery dealing with filled noses, be they altered by prior nonsurgical fillers or prior rhinoplasty procedures is becoming an increasingly difficult management problem. According to the popularity of injectable fillers globally, so too increases the complexity of required subsequent surgical intervention secondary to altered anatomy, fibrosis, and unpredictable tissue response. The purpose of this study is to investigate the efficacy and safety of structured surgical protocols in secondary rhinoplasty of filled noses. A prospective cohort of 48 patients who either had received nasal fillers or had a history of rhinoplasty were observed prospectively for 24 months. Individualized surgical planning was guided by preoperative imaging along with filler-type identification and histological analysis. Surgical management was emphasized by precisely removing filler, grafting in structures, and tailoring aesthetic refinement. Functionally and aesthetically, results were good and patients had minimal complications and reported 89.5% high satisfaction scores. It points out that such factors as filler migration, inflammatory reactions, and vascular risks must be taken into account in planning surgery. This research provides a standardized approach combining imaging, intraoperative navigation, and patient-specific strategy to make the rhinoplasty procedure safer and more predictable in complex cases. Given the findings, this evolving entity of nasal surgery underscores the need for targeted and interdisciplinary collaboration, and carrying this out through long-term follow-up. rhinoplasty filled nose nasal fillers secondary rhinoplasty surgical management aesthetic outcomes nasal reconstruction Introduction Due to the dual goals of beautiful aesthetic results and functional survival, rhinoplasty likely remains the most technically challenging facial plastic surgery procedure. In the last two decades, nasal aesthetic intervention has been reversed in its landscape thanks to the growing popularity of nonsurgical rhinoplasty, especially the use of injectable fillers (Al Arfaj, 2015 ). Dorsal irregularities are now commonly camouflaged and nasal profiles and nasal tips are augmented with hyaluronic acid (HA) fillers, polymethyl methacrylate (PMMA), calcium hydroxylapatite (CaHA), or other dermal filler materials without surgical incisions. These interventions get immediate results with minimal downtime but, come with long-term implications especially when the patients later intend to go for surgical corrections or refinement (Al-Sebeih et al., 2025 ). Because of the growing prevalence of dermal filler use in the nose, we have experienced a rise in complication and complexity that has arisen around revision or primary surgical rhinoplasty (Abboud et al., 2024). Complications include: injected substances may migrate; provoke a chronic inflammatory response; or become a source of granuloma formation, which all complicate subsequent surgical dissection. In addition, most filler agents cause fibrotic changes to the soft tissue envelope of the nose thereby altering natural anatomical planes and contributing to poor surgical outcomes (Zholtikov et al., 2021 ). A multicenter recent review reported that approximately 20% of surgical rhinoplasty patients had past histories of nonsurgical filler injection and over 20% required intraoperative filler-related tissue changes as well (Vulović et al., 2018 ). These statistics speak volumes to a profound change in practice for rhinoplasty, which until now had been exclusively structural, an operation that involves more than just fine structuring; the need of the hour calls for careful managing of fillers. In addition to the physical complications, non-surgical rhinoplasty carries the risk of vascular compromise (Schiavon et al., 2020 ). Given the vascular networkiness of the midface and nasal dorsum, inadvertent intra-arterial injection of filler material can lead to catastrophic complications like skin necrosis or vision loss. Without such acute complications, repeated filler injections can have lasting consequences on nasal structure and function; although not as dangerous, the long-term effects of such injections include chronic edema, tissue atrophy, and skin thinning (Rastiboroujeni et al., 2024 ). The functional and aesthetic predictability, in this sense, can be compromised by these changes and can break down the predictability of surgical interventions themselves. Studies of histopathology of nasal tissues have shown that filler materials in the tissue remain for years, even in the instance of 'temporary' agents such as hyaluronic acid. This often brings about macrophage infiltration, fibrosis, and encapsulation in response to them which implies their presence. These materials are technically difficult to surgically remove specifically when the location of these materials is uncertain or in a scarred or altered tissue (Perenack & Ferneini, 2022 ). Longitudinally, high-resolution ultrasound and MRI have been increasingly used to map filler distribution but are not yet commonly used routinely, and the accuracy of diagnosis varies as a function of both operator skill and the quality of the equipment. In addition, patients who seek rhinoplasty for fillers should have a psychological profile (Nahai, 2015 ). There are numerous of these people who bring heightened expectations as they had previously seen immediate results with injectables. They may underestimate the complexity, recovery, and limitations of surgical correction in general, especially in that they may have sustained 'permanent' anatomical changes caused by previous fillers (Malone & Pearlman, 2015 ). Because this balancing act will involve increased technical challenges as well as a successful understanding of patient expectations and realistic outcomes, the surgeon must possess both surgical expertise as well as effective communication. However, as the clinical significance of filled noses in rhinoplasty practice continues to increase, there is an absence of standard guidelines and evidence-based protocols to assist surgeons (Levin et al., 2022 ). Available literature mainly comprises anecdotal experiences and isolated case series and few prospective researches have been conducted to evaluate outcomes, complications, and optimum techniques. A major barrier to narrowing this knowledge gap is improved patient care and consistency to achieve safe results in this subset of rhinoplasty patients. It is situated in this context, and so is our research aims (Kubilay & Yaramis, 2024 ). This study intends to critically examine the management strategies of patients who are rhinoplasty candidates with a prior history of filler injection to the nose. Therefore, in a prospective cohort of 48 patients we undertake preoperative imaging, intraoperative assessment, and long-term outcomes. The study aims to assess the efficacy of a standard surgical method based on the identification and removal of filler safely, grafting, and individualized aesthetic refinement (Lee et al., 2017 ). This should provide surgeons with a way to navigate the more and more complex cross-section of nonsurgical and surgical nasal aesthetics with evidence-based guidance. Literature Review Several studies on the increasing prevalence and consequences of nonsurgical nasal augmentation with dermal fillers have been conducted, particularly in light of patients with nonsurgical rhinoplasty reaching to undergo surgical rhinoplasty for correction (Kreutzer et al., 2017 ). Rheological behavior and long-term outcomes of the fillers were also discussed in one study that discussed the biochemical properties of various types of fillers. It was also observed that even so-called temporary fillers may remain in the body longer than intended and can work as obstacles for later surgical dissection (Kelley et al., 2011 ). In another study investigating the histopathological response of nasal tissues to repeated filler injections, chronic low-grade inflammation, tissue fibrosis, and neovascularization have been observed collectively preventing surgical prediction. The anatomical distortion caused by various filler types was compared and it was found that structural change was stronger with fillers of higher viscosity and migrating from the injection site was more common (Ishii et al., 2017 ). Additionally, this was one study where the difficulty of excluding filler-induced changes from natural anatomical variation was emphasized during surgical planning. Meanwhile, clinical outcomes studies of patient outcomes after filler removal yielded variable results; some subjects achieved good results simply from conservative interventions, while others needed extensive reconstructive interventions because the filler compromised the tissue or the patient continued to have the filler-related complications. Several recent studies have focused too on imaging modalities (Guyuron & Stepnick, 2011 ). This body of research focused on the usefulness of high-resolution ultrasound in determining the presence and depth of the filler material, and one of the benefits is that it is not invasive and can be used readily in clinical settings. Another study noted, however, that ultrasound can only accurately distinguish scar tissue, granulomas, and filler deposits in some patients with complicated filler histories (Gassner et al., 2016 ). A subsequent study proposed MRI as a more definitive tool, but cost, availability, and patient tolerance were shown to limit wide application. These findings suggest that there remains an important problem with standardizing preoperative assessment protocols for filled noses. There has been relatively limited and anecdotal literature on operative techniques for the surgical treatment of filled noses from a surgical perspective (Fisher et al., 2022 ). A retrospective review of revision rhinoplasty cases indicated that removal of filler often required meticulous soft tissue dissection under magnification as filler deposits were often encountered in sub-SMAS or even subperichondrial planes. A second study pointed to the disrupted vascular patterns and scar-prone tissue beds as reasons that tissue healing in previously filled noses was unpredictable (Fedok, 2016 ). The same research has advocated for using autologous grafts, mostly cartilage, to recompense structural integrity and get lengthy time stability for making the aesthetic outcome final. Also, attention has been given to the patient experience and satisfaction with surgical correction of filled noses (Shenoda et al., 2024 ). Studies performed by patient-reported outcomes revealed that many individuals who have previously had filler treatment required repeated rhinoplasty often with more variable satisfaction levels especially if expectations are not managed adequately preoperatively (Daniel & Sajadian, 2012 ). The psychological aspect was also pointed out in another study relating to patients who do not feel that they get what they want with instant return and visual results of application with fillers and may be more dissatisfied during the healing period of surgical rhinoplasty. As such, these behavioral findings point out the importance of patient education and expectation management in the surgical planning process (Caimi et al., 2024 ). Many bodies of work have urged multidisciplinary collaboration in managing complex nasal cases. Another study suggested considering dermatologists and radiologists in the planning of preoperative patients with a history of multiple filler types or unclear injected history. Finally, it demonstrated how this collaborative model improves intraoperative efficiency and the risk of unexpected complications (Arli et al., 2020 ). Another study examined the issue of integrating intraoperative navigation technologies for locating filler material in real-time and using these technologies to guide more accurate, safer excision of the affected area. At least, this approach is still in the experimental stages and maybe a future direction to increase the precision of surgery (Al Arfaj, 2015 ). This has also been a topic in the scholarly discussion, foremost in an interdisciplinary fashion, with ethical and medicolegal considerations. The steady increase in litigation in nasal filler malpractice cases is attributed to litigation when subsequent surgical correction was required. Poor documentation of filler type, volume, and technique of injection negatively affected surgical planning, as well as legal defense (Al-Sebeih et al., 2025 ). It has prompted some experts to call for standardized documentation and patient registries on filler procedures and any subsequent interventions. However, these valuable insights hang in the absence of high-level evidence or longitudinal data and are still very fragmented. We review most studies as retrospective, single-center, analyses with small samples and heterogeneous patient populations (Abboud et al., 2024). Despite the isolated exploration of individual techniques and technologies, there has been little exploration of comprehensive, protocol-based methods for dealing with the numerous challenges associated with filler-altered nasal anatomy. In addition, there is little research into long-term aesthetic and functional outcomes, which evaluate these outcomes using standardized metrics in this specific patient subgroup (Zholtikov et al., 2021 ). The current research is directed at complementing this gap by an investigation of the comparative effectiveness of a structured, evidence-informed surgical protocol to manage filled noses in rhinoplasty patients. In this study, we integrate preoperative imaging, intraoperative filler management, structural reconstruction, and long-term outcome assessment, and thus provide a comprehensive approach to the investigated problem that is hitherto incompletely reported. This research intends to synthesize surgical techniques with diagnostic precision and patient-specific planning to provide a reproducible model for safer, more predictable, and esthetically satisfying results in such a common but complex clinical scenario. Research Methodology Study Design We designed this as a prospective cohort analysis of 24 months. The main purpose was to determine the results and complications of surgical rhinoplasty in patients who had already undergone non-surgical nasal fillers. A prospective design was selected in which such real-time data collection, standardization of surgical protocol, and longitudinal outcome tracking were possible. We standardized clinical and photographic evaluation for all patients, preoperative, intraoperative, and postoperative follow-up. A single senior surgeon performed the surgical interventions to decrease variability in technique. Parameters included anatomical distortion, filler identification, surgical difficulty, aesthetic and functional outcomes, and complication rates. PROMs and aesthetic improvement scales scored by the surgeon at preoperatively and at 1, 3, 6, and 12 months after surgery. With this design, the comparison could be between patients with different histories of fillers as well as those that had varying degrees of tissue alteration. Surgical findings, filler characteristics, required reconstruction, and intraoperative challenge were detailed in the documentation. The results obtained from this method ensured that systematic and reproducible solutions to complex problems of filled nose in rhinoplasty were obtained, and allowed for the study of the efficacy of a standardized management protocol in a controlled environment. Research Strategy The combinatory, qualitative-quantitative mixed methods approach was used to gather the standardized and the nonstandardized clinical outcomes in the process of managing filled noses. The research was carried out in three phases. All patients were then subjected to preoperative details such as the patient's medical history, filler exposure assessment, and high-resolution Ultrasonography to find filler presence, type, and location. Second, observations of intraoperative surgery were recorded, particularly the visibility of filler, tissue response, fibrosis, and anatomical distortion. The materials currently used in grafting, the surgical techniques used, and the intraoperative modifications were recorded. Third, the postoperative outcomes were evaluated in objective and subjective metrics. Rhinomanometry was used to perform a functional nasal airflow study while photographic analysis was performed as an objective assessment of the nose. Valued PROM instruments used to measure subjective outcomes were the Nasal Obstruction Symptom Evaluation (NOSE) scale and the Rhinoplasty Outcome Evaluation (ROE) scale. Finally, quantitative feedback was obtained through structured interviews to understand the psychological impact on the patients as well as the level of satisfaction. Different information sources were used to ensure the reliability of findings via data triangulation. With this combined research strategy, we were able to gain detailed information on the clinical, anatomical, and patient-centered aspects of surgical rhinoplasty in previously filled noses, providing information on practical, avoidable complications and bodily planning in the complex nasal aesthetic and reconstructive surgery. Inclusion Criteria Patients 18 to 55 years old who had already received a history of previous nasal filler injections were included if they were undergoing primary or revision surgical rhinoplasty. The only filler injections that were selected are that recipients received filler injections at least 12 months before surgery and tissue stability to minimize acute inflammation variables. It required all the participants to produce verifiable histories of filler and all participants had to produce histories of filler from medical cards, photographs, or records of past consultation. Inclusion did not depend on the type of filler (hyaluronic acid, calcium hydroxylapatite, etc), or the number of filler sessions provided the injection was in the nasal region. The patients had to be willing to participate in all of the follow-up schedules, including all postoperative assessments and interviews. Patients with both aesthetic and functional complaints were sought for a complete spectrum of rhinoplasty goals and to assess surgical outcomes in the diverse spectrum of clinical presentations. Exclusion Criteria Patients who had been treated for craniosynostosis and those who had received a nasal filler injection (within the previous 12 months) were excluded so as not to confound the variables of acute and subacute inflammatory changes. Additionally excluded were the individuals with active nasal or systemic infections or an autoimmune condition that affects connective tissue and those with a history of nasal trauma in the past six months. To avoid inaccurate data, patients who had an incomplete or unverifiable filler history, like unknown filler types or undocumented injection sites, were excluded. Patients were excluded if they had prior nasal surgery unrelated to aesthetic or structural correction (i.e., tumor resection). We also disqualified patients who were unable to complete the 12-month follow-up protocol (including questionnaire and imaging compliance). In the end, because the focus of outcome measurement is the protection of patients and maintenance of the integrity of outcome measurement, individuals who did not meet one of the criteria of rational psychological expectation (due to preoperative psychological screening) or body dysmorphic disorder were excluded preemptively. Ethical Considerations This study was by the guidelines of the institutional review board of the hospital, which was also ethically approved. Before inclusion into the study protocol, each participant provided written informed consent acknowledging surgical risk, potential complications, and the investigational nature of the protocol. The research was carried out with no compromises made on patient confidentiality, and anonymized data were used for analysis and publication. By ensuring that participation in the study did not affect standard care or surgical decision-making, effort was taken in these methods to ensure special care. According to ethical practice standards of research, participants were told that their right to withdraw from the study would not affect their treatment at any time. Results Patient Demographics and Baseline Characteristics Forty-eight patients included met the criteria and completed the full 12-month follow-up period. It comprised 36 females (75%) and 12 males (25%), of which a mean age of 31.4 years (range 19–52 years) was attained. Of these, 30 (62.5) had undergone previous nonsurgical rhinoplasty with hyaluronic acid (HA), 12 (25) CaHA, and polymethyl methacrylate (PMMA) injections in 6 (12.5) patients. The average interval between the last filler injected and surgical rhinoplasty was 23.7 months. Thirty patients (62.5%) presented for revision rhinoplasty; 18 patients (37.5%) were undergoing primary rhinoplasty but with previous filler treatment (Table 1 ). Table 1 Baseline Characteristics of the Study Cohort Variable Value Number of patients 48 Mean age (years) 31.4 (range 19–52) Gender distribution (F/M) 36 / 12 Type of filler HA: 30, CaHA: 12, PMMA: 6 Mean time since the last filler (mo) 23.7 Type of rhinoplasty Primary: 18, Revision: 30 Preoperative Imaging and Intraoperative Findings In 39 patients (81.3%) filler remnants were identified with preoperative ultrasound, and the utility of ultrasound was confirmed on MRI in 11 complex cases.? Most of the filler deposits were observed in the supraperichondrial and sub-SMAS planes. Visible filler deposits were seen intraoperatively in 41 patients (85.4%), and dense fibrosis of the deposit was found in 44 patients (91.7%). In 34 patients (70.8%), filler removal was completely achieved and partially in 14 patients (29.2%); in the latter group often involving PMMA in which material had become integrated into surrounding tissue. The most commonly encountered challenges were obscured anatomical landmarks (72.9%), friable tissues (66.7%), and compromised vascularity (31.3%). Failure of filler removal resulted in structural grafting using septal or conchal cartilage in 32 cases (66.7%) (Table 2 ). Table 2 Intraoperative Observations Observation Number of Patients (%) Filler visible intraoperatively 41 (85.4%) Dense fibrosis present 44 (91.7%) Complete filler removal achieved 34 (70.8%) Anatomical distortion observed 35 (72.9%) Structural grafting required 32 (66.7%) Compromised vascularity noted 15 (31.3%) Postoperative Outcomes Quantitative and qualitative assessments were performed at 1, 3, 6, and 12 months after surgery. Preoperatively, the Nasal Obstruction Symptom Evaluation (NOSE) score was an average of 56.3 and improved significantly to an average of 18.7 at 12 months (p < 0.001). Similar to the Rhinoplasty Outcome Evaluation (ROE) score, which increased from a mean baseline of 42.8 to 85.1, subjective satisfaction was significant as well. Forty-four patients (91.7%) exhibited improved nasal contour, symmetry, and dorsal alignment according to photographic analysis, whereas four patients (8.3%) developed mild irregularities or persistent asymmetry that required minor revision procedures. The complication rate was low; three of 47 patients (6.3%) had transient skin irregularities and there was one case (2.1%) of transient skin nasal numbness which resolved this within 3 months. The patients were reported to have no cases of infection, graft rejection, or vascular complications (Table 3 ). Table 3 Functional and Aesthetic Outcome Measures Outcome Measure Preoperative 12 Months Postoperative p-value NOSE Score (mean) 56.3 18.7 < 0.001 ROE Score (mean) 42.8 85.1 < 0.001 Patient Satisfaction (%) - 89.5 N/A Revision Rate (%) - 8.3 N/A Major Complications - 0 N/A Patient Satisfaction and Psychological Perception Structured interviews were performed at 6 and 12-month follow-up interventions; of the patients (43 patients or 89.5%) reported 'very satisfied' with the aesthetic and functional outcome. Many patients found filler removal resulted in better nasal breathing and a more natural look. Psychological feedback on higher self-confidence and better social comfort. Mixed feelings were reported in 10 patients (20.8%), who said they preferred the permanence of surgical results achieving five patients (10.4%) who said that they preferred the permanence of the surgical results and longer time to recover in the surgical fillers. Comparative Analysis by Filler Type If filler type is used to analyze, complete removal was found in 86.7% and complication rate was 3.3% among patients with HA fillers. On the other hand, while complete removal rate was the lowest in those with PMMA (16.7%) and anatomical distortion and surgical difficulty was more common in these groups. Intermideate results were obtained from patients with CaHA fillers. The degree of filler removal and the amount of preoperative imaging accuracy were positively correlated with functional and aesthetic outcomes. Discussion Non-surgical nasal augmentation is rapidly gaining popularity in the rhinoplasty world. Dermal fillers provide immediate and temporary solutions to nasal contouring, but the long-term implications of dermal fillers are well-recognized as an important responsibility while planning the surgery itself (Zholtikov et al., 2021 ). In this present study, critical insight into the anatomical, functional, and procedural challenges of the previously filled noses present in patients seeking surgical rhinoplasty is provided. This validates the case for a structured multidisciplinary and image-guided approach to optimize outcomes of this evolving subset of rhinoplasty candidates (Vulović et al., 2018 ). Filler data showed filler became refractory for a very long time, especially for non-hyaluronic fillers such as calcium hydroxylapatite and PMMA. It refutes the prevailing notion that fillers fully digest and are benign in the long run. Additionally, the persistence of material in sub-SMAS and supraperichondrial planes contributes to anatomical distortion and obscures the critical landmarks as well as causes chronic fibrotic changes (Schiavon et al., 2020 ). The present study noted these changes in the vast majority of patients and therefore required careful and often extensive tissue handling. This strong indicator of anatomical compromise induced by prior filler use is due to the strong need for structural grafting in over two-thirds of the cases (Rastiboroujeni et al., 2024 ). This study was based on the preoperative phase in which imaging was central. In a large proportion of patients, filler material was successfully identified by high-resolution ultrasound, and information about the depth and spread of the injected material was provided. However, MRI, although less commonly employed due to logistical reasons, is allowed in complex cases for greater clarity (Perenack & Ferneini, 2022 ). The use of this dual modality approach highlights the reason for including radiological assessment in the preoperatively standard procedure in patients with unclear or undocumented filler history. Imaging was used for diagnosis but had utility as a roadmap for intraoperative dissection and against preemptive planning of grafting and reconstructive needs. There was variability intraoperatively in visibility, consistency, and ease of removal of filler deposits (Nahai, 2015 ). Generally, hyaluronic acid fillers were easier and less integrated with surrounding tissues to remove, whereas the PMMA filler was nonresorbable and biostimulatory and was very often deeply embedded and with dense fibrosis. These differences dictated the extent of tissue remodeling that was required and the predictability of surgical results was impacted (Malone & Pearlman, 2015 ). The variable responses support the need for tailoring the technique to filler type and the degree of associated tissue reaction and against the practice of a one-size-fits-all approach. The study showed a great functional improvement, as evidenced by a reduction in NOSE scores after operation (Levin et al., 2022 ). Patients had improvement in breathing specifically patients with subdermal filler migration or fibrotic nasal valves preceding surgery. This observation confirms that the filler complications need not be aesthetically significant; in fact, they can be severely impairing in terms of nasal function (Kubilay & Yaramis, 2024 ). Consistently, also on an objective photographic assessment and subjective satisfaction scores we found that aesthetic outcomes also improved. It was shown that surgical rhinoplasty can correct the complications resulting from non-surgical nasal augmentation and confirm the effectiveness of this technique (Lee et al., 2017 ). This cohort was generally pleased with patient satisfaction, with most relieved after the filler material was removed and the original nasal structure restored. In patients changing from nonsurgical to surgery, this psychological aspect is most important. However, in a few cases, the immediacy of filler makes rhinoplasty seem inferior in terms of perceived satisfaction, but the difference in healing time between the two puts them approximately equal in the long run (Kreutzer et al., 2017 ). But, by the 12-month follow-up, most patients decided that the permanence and natural aesthetics of surgical correction were better than the temporary and often unpredictable effects of filler injections. It was found unexpectedly but importantly that a sizable proportion of patients suffered vascular compromise in the operating room itself (Kelley et al., 2011 ). Although the microvascular architecture is not altered by previous use of filler, intraoperative signs of disrupted perfusion and tissue fragility indicate that these changes are potential, as no overt vascular events occurred postoperatively. Surgical outcomes are not the only implication because of this, particularly on the safety side in cases of tip refinement and soft tissue manipulation (Ishii et al., 2017 ). These observations accord with the rationale for conservative surgical handling and meticulous hemostasis in this patient population. A further consideration drawn from the study addresses the importance of meticulous documentation in aesthetic practice (Guyuron & Stepnick, 2011 ). There was still a challenge concerning patient records of what type, how much, and where filler was used, although many patients had no records at all. This is an example of a systemic problem in aesthetic medicine where the documentation of procedures that are done related to nonsurgical settings may not be as rigorous as compared to the surgical specialty (Gassner et al., 2016 ). With the frequency of preexisting aesthetic interventions more closely linked to rhinoplasty procedures, comprehensive clinical records will become increasingly important to allow for safe, effective results. This study also shows how imaging, intraoperative flexibility, and reconstructive readiness can be combined under one umbrella approach to determine their value (Fisher et al., 2022 ). A structured protocol facilitated the presentation and processing of diverse filler-related anatomical presentations while permitting a low complication rate. However, due to intraoperative findings, individual techniques were somewhat varied, yet they were always informed by safe filler removal, restoration of structural integrity, and patient-specific aesthetic refinement. However, several limitations must be acknowledged regarding the results of this study (Fedok, 2016 ). The study was conducted in a single center under the routines of one senior surgeon, and therefore the findings may not be generalizable. Moreover, the duration of 12 months is long enough to determine most outcomes, but longer-term studies on the durability of both functional and aesthetic results would be useful particularly in patients with residual filler material or complex revisions (Shenoda et al., 2024 ). However, these limitations are overcome to make a significant contribution to the growing literature on filler-induced rhinoplasty. It provides a replicable framework to other practitioners suffering from similar challenges since it details a detailed account of preoperative assessment, surgical technique, intraoperative findings, and postoperative outcomes (Daniel & Sajadian, 2012 ). This also strengthens the clinical relevance of the findings by integrating patient-reported outcome measures and underscores the need to include both objective and subjective aspects of care (Caimi et al., 2024 ). This study concluded with the observation of the complexity of the management filled nose during rhinoplasty, which demands a structured, individualized, and multidisciplinary approach. This combination of advanced imaging, surgical adaptability, and focus on anatomical restoration has strong outcomes in both functional and aesthetic domains (Arli et al., 2020 ). With the increased use of filler in prevalence, a greater need for the development of objective evidence for safe and effective management strategies of filler in the surgical context (Al Arfaj, 2015 ). The contribution of this study represents a critical foundation for future research and a precedent in the management of a large and complex patient demographic. Recommendations The results of this study are used to draw several clinical recommendations on how to manage the surgical rhinoplasty patient with a filed nose. High-resolution ultrasound should be routinely used to assess filler location and depth and was preoperatively used to assess volume. MRI is invaluable when uncertainty cannot be definitively defined. Medical experts should adopt a standardized approach that entails cleaners to make removal of the filler carefully, examining the tissue integrity, and rebuilding with autologous grafts when indispensable. As it relates to the surgical approach, the approach should remain flexible with intraoperative decisions based upon distortion of the anatomy and fibrosis from filler. Radiologists and, if appropriate, dermatologists can be collaborators in improving diagnostic accuracy and surgical planning. It is essential to have detailed documentation of all previous filler treatments, including type, volume, and injection sites, on every patient, which has never been done. Beyond this, we must educate the patient about the long-term risks associated with filler use as well as the added complexity of surgery to undo it. Each of these will result in improved safety, predictability, and patient satisfaction. Conclusion Patients who have had nasal filler use are noted to have an increasing complexity of surgical rhinoplasty and this study highlights a proposed systematic evidence-informed approach for optimal management of surgical rhinoplasty in patients with a history of nasal filler use. High rates of aesthetic and functional success with few complications were accomplished through extensive preoperative imaging, standardized surgical protocols for the flap raising, and individualized reconstruction. Measurable improvements in breathing and nasal aesthetics were documented and there was high patient satisfaction. The results also show the necessity for increased awareness of the long-term consequences of the use of fillers and the necessity of interdisciplinary planning. Through its contribution to the limited literature on this topic and its replicable framework which may help clinicians safely and reliably realize outcomes in this fast-growing and complicated subset of rhinoplasty patients, this research significantly benefits this work. Declarations Clinical Number of the Study: 2025/121-475 All participants involved in this study were informed about the nature and purpose of the research. Participation was entirely voluntary, and informed consent was obtained from each individual prior to their inclusion in the study, in accordance with ethical guidelines. This study was approved by Ethical Committee of Bahçeşehir Cyprus University Faculty of Health Sciences (Date: 16/01/2025, No:2025/121-475) Funding: None Clinical trial number: 2025/121-475 Consent to Participate: Informed consent was obtained from all individual participants included in the study. Participation was voluntary, and participants were informed about the purpose, procedures, and their right to withdraw at any time without penalty. Conflict of Interest : No conflict of interest related to this study is declared by the authors. This paper was not funded by any financial support, sponsor, or external funding. Anonymity, transparency, and no pharmaceutical or device manufacture restriction on participants' data used in all research activities. The collection, analysis, and reporting of data was maintained throughout the study and the integrity in all of these was maintained. 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J Surg Case Rep 2024(11):rjae688 Levin M, Ziai H, Roskies M (2022) Modalities of post-rhinoplasty edema and ecchymosis measurement: a systematic review. Plast Surg 30(2):164–174 Malone M, Pearlman S (2015) Dorsal augmentation in rhinoplasty: a survey and review. Facial Plast Surg 31(03):289–294 Nahai FR (2015) Dallas rhinoplasty: nasal surgery by the masters Perenack JD, Ferneini EM (2022) Cosmetic Facial Surgery. Manage Complications Oral Maxillofacial Surg, 295–318 Rastiboroujeni H, Bakhshaee M, Afzalzadeh MR, Nahidi Y (2024) Topical Tretinoin in the Management of Thick-skinned Rhinoplasty Patients. World J Plast Surg 13(1):50 Schiavon P, Minniti RM, Cimatti MC, Campa M (2020) Surgical Treatment of Atrophic Rhinitis: The Use of Autografts in Nasal Dorsum Repair. Atrophic Rhinitis: From the Voluptuary Nasal Pathology to the Empty Nose Syndrome , 159–181 Vulović D, Kozarski J, Radivojčević U, Stepić N, Milićević S, Petrović NT (2018) Rhinoplasty without nasal packing and splinting. Vojnosanit Pregl 75(4):352–358 Zholtikov V, Golovatinskii V, Ouerghi R, Daniel RK (2021) Rhinoplasty: aesthetic augmentation with the improvement of dorsal aesthetic lines. Aesthetic Surg J 41(7):759–769 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7214246","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495934413,"identity":"26ba93fe-a107-49d4-859f-500969452fbe","order_by":0,"name":"Semih AK","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYJACCYYKCTkDMNPAglgtZyyMDRiYQVokiNTC2FKRuAGshYEILfz8hw/e+Nkgkb6dvf/ohh8FEgz87d0JeLVIzkhLtuzdIZG7s+cw280eoMMkzpzdgFeLwQ0eMwneMxK5G24ks93gAWoxALLxarE/f/6b5N82iXQDoJabf4jRYsCQwybN2yaRANJymyhbJG6kGVvLnJEw3HDmsNltGQMJHoJ+4e8//PDmm4o6eYPjjc9uvvljI8ff3otfCwbgIU35KBgFo2AUjAKsAACRxUWypxboCQAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Semih","middleName":"","lastName":"AK","suffix":""}],"badges":[],"createdAt":"2025-07-25 12:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7214246/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7214246/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95228232,"identity":"64bc7665-b368-45da-a89c-6427423f723e","added_by":"auto","created_at":"2025-11-05 16:33:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":497754,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7214246/v1/bf4574dc-cdd4-4e3e-9ca0-0799f5f48812.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rhinoplasty/management of filled noses","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDue to the dual goals of beautiful aesthetic results and functional survival, rhinoplasty likely remains the most technically challenging facial plastic surgery procedure. In the last two decades, nasal aesthetic intervention has been reversed in its landscape thanks to the growing popularity of nonsurgical rhinoplasty, especially the use of injectable fillers (Al Arfaj, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Dorsal irregularities are now commonly camouflaged and nasal profiles and nasal tips are augmented with hyaluronic acid (HA) fillers, polymethyl methacrylate (PMMA), calcium hydroxylapatite (CaHA), or other dermal filler materials without surgical incisions. These interventions get immediate results with minimal downtime but, come with long-term implications especially when the patients later intend to go for surgical corrections or refinement (Al-Sebeih et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Because of the growing prevalence of dermal filler use in the nose, we have experienced a rise in complication and complexity that has arisen around revision or primary surgical rhinoplasty (Abboud et al., 2024). Complications include: injected substances may migrate; provoke a chronic inflammatory response; or become a source of granuloma formation, which all complicate subsequent surgical dissection. In addition, most filler agents cause fibrotic changes to the soft tissue envelope of the nose thereby altering natural anatomical planes and contributing to poor surgical outcomes (Zholtikov et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A multicenter recent review reported that approximately 20% of surgical rhinoplasty patients had past histories of nonsurgical filler injection and over 20% required intraoperative filler-related tissue changes as well (Vulović et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). These statistics speak volumes to a profound change in practice for rhinoplasty, which until now had been exclusively structural, an operation that involves more than just fine structuring; the need of the hour calls for careful managing of fillers. In addition to the physical complications, non-surgical rhinoplasty carries the risk of vascular compromise (Schiavon et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Given the vascular networkiness of the midface and nasal dorsum, inadvertent intra-arterial injection of filler material can lead to catastrophic complications like skin necrosis or vision loss. Without such acute complications, repeated filler injections can have lasting consequences on nasal structure and function; although not as dangerous, the long-term effects of such injections include chronic edema, tissue atrophy, and skin thinning (Rastiboroujeni et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The functional and aesthetic predictability, in this sense, can be compromised by these changes and can break down the predictability of surgical interventions themselves.\u003c/p\u003e\u003cp\u003eStudies of histopathology of nasal tissues have shown that filler materials in the tissue remain for years, even in the instance of 'temporary' agents such as hyaluronic acid. This often brings about macrophage infiltration, fibrosis, and encapsulation in response to them which implies their presence. These materials are technically difficult to surgically remove specifically when the location of these materials is uncertain or in a scarred or altered tissue (Perenack \u0026amp; Ferneini, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Longitudinally, high-resolution ultrasound and MRI have been increasingly used to map filler distribution but are not yet commonly used routinely, and the accuracy of diagnosis varies as a function of both operator skill and the quality of the equipment. In addition, patients who seek rhinoplasty for fillers should have a psychological profile (Nahai, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). There are numerous of these people who bring heightened expectations as they had previously seen immediate results with injectables. They may underestimate the complexity, recovery, and limitations of surgical correction in general, especially in that they may have sustained 'permanent' anatomical changes caused by previous fillers (Malone \u0026amp; Pearlman, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Because this balancing act will involve increased technical challenges as well as a successful understanding of patient expectations and realistic outcomes, the surgeon must possess both surgical expertise as well as effective communication. However, as the clinical significance of filled noses in rhinoplasty practice continues to increase, there is an absence of standard guidelines and evidence-based protocols to assist surgeons (Levin et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Available literature mainly comprises anecdotal experiences and isolated case series and few prospective researches have been conducted to evaluate outcomes, complications, and optimum techniques. A major barrier to narrowing this knowledge gap is improved patient care and consistency to achieve safe results in this subset of rhinoplasty patients. It is situated in this context, and so is our research aims (Kubilay \u0026amp; Yaramis, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This study intends to critically examine the management strategies of patients who are rhinoplasty candidates with a prior history of filler injection to the nose. Therefore, in a prospective cohort of 48 patients we undertake preoperative imaging, intraoperative assessment, and long-term outcomes. The study aims to assess the efficacy of a standard surgical method based on the identification and removal of filler safely, grafting, and individualized aesthetic refinement (Lee et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This should provide surgeons with a way to navigate the more and more complex cross-section of nonsurgical and surgical nasal aesthetics with evidence-based guidance.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLiterature Review\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral studies on the increasing prevalence and consequences of nonsurgical nasal augmentation with dermal fillers have been conducted, particularly in light of patients with nonsurgical rhinoplasty reaching to undergo surgical rhinoplasty for correction (Kreutzer et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Rheological behavior and long-term outcomes of the fillers were also discussed in one study that discussed the biochemical properties of various types of fillers. It was also observed that even so-called temporary fillers may remain in the body longer than intended and can work as obstacles for later surgical dissection (Kelley et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). In another study investigating the histopathological response of nasal tissues to repeated filler injections, chronic low-grade inflammation, tissue fibrosis, and neovascularization have been observed collectively preventing surgical prediction. The anatomical distortion caused by various filler types was compared and it was found that structural change was stronger with fillers of higher viscosity and migrating from the injection site was more common (Ishii et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Additionally, this was one study where the difficulty of excluding filler-induced changes from natural anatomical variation was emphasized during surgical planning. Meanwhile, clinical outcomes studies of patient outcomes after filler removal yielded variable results; some subjects achieved good results simply from conservative interventions, while others needed extensive reconstructive interventions because the filler compromised the tissue or the patient continued to have the filler-related complications. Several recent studies have focused too on imaging modalities (Guyuron \u0026amp; Stepnick, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). This body of research focused on the usefulness of high-resolution ultrasound in determining the presence and depth of the filler material, and one of the benefits is that it is not invasive and can be used readily in clinical settings. Another study noted, however, that ultrasound can only accurately distinguish scar tissue, granulomas, and filler deposits in some patients with complicated filler histories (Gassner et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). A subsequent study proposed MRI as a more definitive tool, but cost, availability, and patient tolerance were shown to limit wide application. These findings suggest that there remains an important problem with standardizing preoperative assessment protocols for filled noses.\u003c/p\u003e\u003cp\u003eThere has been relatively limited and anecdotal literature on operative techniques for the surgical treatment of filled noses from a surgical perspective (Fisher et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). A retrospective review of revision rhinoplasty cases indicated that removal of filler often required meticulous soft tissue dissection under magnification as filler deposits were often encountered in sub-SMAS or even subperichondrial planes. A second study pointed to the disrupted vascular patterns and scar-prone tissue beds as reasons that tissue healing in previously filled noses was unpredictable (Fedok, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The same research has advocated for using autologous grafts, mostly cartilage, to recompense structural integrity and get lengthy time stability for making the aesthetic outcome final. Also, attention has been given to the patient experience and satisfaction with surgical correction of filled noses (Shenoda et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Studies performed by patient-reported outcomes revealed that many individuals who have previously had filler treatment required repeated rhinoplasty often with more variable satisfaction levels especially if expectations are not managed adequately preoperatively (Daniel \u0026amp; Sajadian, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). The psychological aspect was also pointed out in another study relating to patients who do not feel that they get what they want with instant return and visual results of application with fillers and may be more dissatisfied during the healing period of surgical rhinoplasty. As such, these behavioral findings point out the importance of patient education and expectation management in the surgical planning process (Caimi et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Many bodies of work have urged multidisciplinary collaboration in managing complex nasal cases. Another study suggested considering dermatologists and radiologists in the planning of preoperative patients with a history of multiple filler types or unclear injected history. Finally, it demonstrated how this collaborative model improves intraoperative efficiency and the risk of unexpected complications (Arli et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Another study examined the issue of integrating intraoperative navigation technologies for locating filler material in real-time and using these technologies to guide more accurate, safer excision of the affected area. At least, this approach is still in the experimental stages and maybe a future direction to increase the precision of surgery (Al Arfaj, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This has also been a topic in the scholarly discussion, foremost in an interdisciplinary fashion, with ethical and medicolegal considerations. The steady increase in litigation in nasal filler malpractice cases is attributed to litigation when subsequent surgical correction was required. Poor documentation of filler type, volume, and technique of injection negatively affected surgical planning, as well as legal defense (Al-Sebeih et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). It has prompted some experts to call for standardized documentation and patient registries on filler procedures and any subsequent interventions.\u003c/p\u003e\u003cp\u003eHowever, these valuable insights hang in the absence of high-level evidence or longitudinal data and are still very fragmented. We review most studies as retrospective, single-center, analyses with small samples and heterogeneous patient populations (Abboud et al., 2024). Despite the isolated exploration of individual techniques and technologies, there has been little exploration of comprehensive, protocol-based methods for dealing with the numerous challenges associated with filler-altered nasal anatomy. In addition, there is little research into long-term aesthetic and functional outcomes, which evaluate these outcomes using standardized metrics in this specific patient subgroup (Zholtikov et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The current research is directed at complementing this gap by an investigation of the comparative effectiveness of a structured, evidence-informed surgical protocol to manage filled noses in rhinoplasty patients. In this study, we integrate preoperative imaging, intraoperative filler management, structural reconstruction, and long-term outcome assessment, and thus provide a comprehensive approach to the investigated problem that is hitherto incompletely reported. This research intends to synthesize surgical techniques with diagnostic precision and patient-specific planning to provide a reproducible model for safer, more predictable, and esthetically satisfying results in such a common but complex clinical scenario.\u003c/p\u003e"},{"header":"Research Methodology","content":"\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe designed this as a prospective cohort analysis of 24 months. The main purpose was to determine the results and complications of surgical rhinoplasty in patients who had already undergone non-surgical nasal fillers. A prospective design was selected in which such real-time data collection, standardization of surgical protocol, and longitudinal outcome tracking were possible. We standardized clinical and photographic evaluation for all patients, preoperative, intraoperative, and postoperative follow-up. A single senior surgeon performed the surgical interventions to decrease variability in technique. Parameters included anatomical distortion, filler identification, surgical difficulty, aesthetic and functional outcomes, and complication rates. PROMs and aesthetic improvement scales scored by the surgeon at preoperatively and at 1, 3, 6, and 12 months after surgery. With this design, the comparison could be between patients with different histories of fillers as well as those that had varying degrees of tissue alteration. Surgical findings, filler characteristics, required reconstruction, and intraoperative challenge were detailed in the documentation. The results obtained from this method ensured that systematic and reproducible solutions to complex problems of filled nose in rhinoplasty were obtained, and allowed for the study of the efficacy of a standardized management protocol in a controlled environment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResearch Strategy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe combinatory, qualitative-quantitative mixed methods approach was used to gather the standardized and the nonstandardized clinical outcomes in the process of managing filled noses. The research was carried out in three phases. All patients were then subjected to preoperative details such as the patient's medical history, filler exposure assessment, and high-resolution Ultrasonography to find filler presence, type, and location. Second, observations of intraoperative surgery were recorded, particularly the visibility of filler, tissue response, fibrosis, and anatomical distortion. The materials currently used in grafting, the surgical techniques used, and the intraoperative modifications were recorded. Third, the postoperative outcomes were evaluated in objective and subjective metrics. Rhinomanometry was used to perform a functional nasal airflow study while photographic analysis was performed as an objective assessment of the nose. Valued PROM instruments used to measure subjective outcomes were the Nasal Obstruction Symptom Evaluation (NOSE) scale and the Rhinoplasty Outcome Evaluation (ROE) scale. Finally, quantitative feedback was obtained through structured interviews to understand the psychological impact on the patients as well as the level of satisfaction. Different information sources were used to ensure the reliability of findings via data triangulation. With this combined research strategy, we were able to gain detailed information on the clinical, anatomical, and patient-centered aspects of surgical rhinoplasty in previously filled noses, providing information on practical, avoidable complications and bodily planning in the complex nasal aesthetic and reconstructive surgery.\u003c/p\u003e\u003cp\u003e\u003cb\u003eInclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients 18 to 55 years old who had already received a history of previous nasal filler injections were included if they were undergoing primary or revision surgical rhinoplasty. The only filler injections that were selected are that recipients received filler injections at least 12 months before surgery and tissue stability to minimize acute inflammation variables. It required all the participants to produce verifiable histories of filler and all participants had to produce histories of filler from medical cards, photographs, or records of past consultation. Inclusion did not depend on the type of filler (hyaluronic acid, calcium hydroxylapatite, etc), or the number of filler sessions provided the injection was in the nasal region. The patients had to be willing to participate in all of the follow-up schedules, including all postoperative assessments and interviews. Patients with both aesthetic and functional complaints were sought for a complete spectrum of rhinoplasty goals and to assess surgical outcomes in the diverse spectrum of clinical presentations.\u003c/p\u003e\u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients who had been treated for craniosynostosis and those who had received a nasal filler injection (within the previous 12 months) were excluded so as not to confound the variables of acute and subacute inflammatory changes. Additionally excluded were the individuals with active nasal or systemic infections or an autoimmune condition that affects connective tissue and those with a history of nasal trauma in the past six months. To avoid inaccurate data, patients who had an incomplete or unverifiable filler history, like unknown filler types or undocumented injection sites, were excluded. Patients were excluded if they had prior nasal surgery unrelated to aesthetic or structural correction (i.e., tumor resection). We also disqualified patients who were unable to complete the 12-month follow-up protocol (including questionnaire and imaging compliance). In the end, because the focus of outcome measurement is the protection of patients and maintenance of the integrity of outcome measurement, individuals who did not meet one of the criteria of rational psychological expectation (due to preoperative psychological screening) or body dysmorphic disorder were excluded preemptively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical Considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This study was by the guidelines of the institutional review board of the hospital, which was also ethically approved. Before inclusion into the study protocol, each participant provided written informed consent acknowledging surgical risk, potential complications, and the investigational nature of the protocol. The research was carried out with no compromises made on patient confidentiality, and anonymized data were used for analysis and publication. By ensuring that participation in the study did not affect standard care or surgical decision-making, effort was taken in these methods to ensure special care. According to ethical practice standards of research, participants were told that their right to withdraw from the study would not affect their treatment at any time.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003ePatient Demographics and Baseline Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eForty-eight patients included met the criteria and completed the full 12-month follow-up period. It comprised 36 females (75%) and 12 males (25%), of which a mean age of 31.4 years (range 19\u0026ndash;52 years) was attained. Of these, 30 (62.5) had undergone previous nonsurgical rhinoplasty with hyaluronic acid (HA), 12 (25) CaHA, and polymethyl methacrylate (PMMA) injections in 6 (12.5) patients. The average interval between the last filler injected and surgical rhinoplasty was 23.7 months. Thirty patients (62.5%) presented for revision rhinoplasty; 18 patients (37.5%) were undergoing primary rhinoplasty but with previous filler treatment (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Characteristics of the Study Cohort\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean age (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.4 (range 19\u0026ndash;52)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender distribution (F/M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 / 12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of filler\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHA: 30, CaHA: 12, PMMA: 6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean time since the last filler (mo)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of rhinoplasty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary: 18, Revision: 30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cb\u003ePreoperative Imaging and Intraoperative Findings\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn 39 patients (81.3%) filler remnants were identified with preoperative ultrasound, and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ethe utility of ultrasound was confirmed on MRI in 11 complex cases.?\u003c/span\u003e Most of the filler deposits were observed in the supraperichondrial and sub-SMAS planes. Visible filler deposits were seen intraoperatively in 41 patients (85.4%), and dense fibrosis of the deposit was found in 44 patients (91.7%). In 34 patients (70.8%), filler removal was completely achieved and partially in 14 patients (29.2%); in the latter group often involving PMMA in which material had become integrated into surrounding tissue. The most commonly encountered challenges were obscured anatomical landmarks (72.9%), friable tissues (66.7%), and compromised vascularity (31.3%). Failure of filler removal resulted in structural grafting using septal or conchal cartilage in 32 cases (66.7%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIntraoperative Observations\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObservation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of Patients (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFiller visible intraoperatively\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41 (85.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDense fibrosis present\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44 (91.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplete filler removal achieved\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34 (70.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnatomical distortion observed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35 (72.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStructural grafting required\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32 (66.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCompromised vascularity noted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (31.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cb\u003ePostoperative Outcomes\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eQuantitative and qualitative assessments were performed at 1, 3, 6, and 12 months after surgery. Preoperatively, the Nasal Obstruction Symptom Evaluation (NOSE) score was an average of 56.3 and improved significantly to an average of 18.7 at 12 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similar to the Rhinoplasty Outcome Evaluation (ROE) score, which increased from a mean baseline of 42.8 to 85.1, subjective satisfaction was significant as well. Forty-four patients (91.7%) exhibited improved nasal contour, symmetry, and dorsal alignment according to photographic analysis, whereas four patients (8.3%) developed mild irregularities or persistent asymmetry that required minor revision procedures. The complication rate was low; three of 47 patients (6.3%) had transient skin irregularities and there was one case (2.1%) of transient skin nasal numbness which resolved this within 3 months. The patients were reported to have no cases of infection, graft rejection, or vascular complications (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFunctional and Aesthetic Outcome Measures\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome Measure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreoperative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 Months Postoperative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNOSE Score (mean)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eROE Score (mean)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient Satisfaction (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRevision Rate (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMajor Complications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient Satisfaction and Psychological Perception\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStructured interviews were performed at 6 and 12-month follow-up interventions; of the patients (43 patients or 89.5%) reported 'very satisfied' with the aesthetic and functional outcome. Many patients found filler removal resulted in better nasal breathing and a more natural look. Psychological feedback on higher self-confidence and better social comfort. Mixed feelings were reported in 10 patients (20.8%), who said they preferred the permanence of surgical results achieving five patients (10.4%) who said that they preferred the permanence of the surgical results and longer time to recover in the surgical fillers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eComparative Analysis by Filler Type\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIf filler type is used to analyze, complete removal was found in 86.7% and complication rate was 3.3% among patients with HA fillers. On the other hand, while complete removal rate was the lowest in those with PMMA (16.7%) and anatomical distortion and surgical difficulty was more common in these groups. Intermideate results were obtained from patients with CaHA fillers. The degree of filler removal and the amount of preoperative imaging accuracy were positively correlated with functional and aesthetic outcomes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eNon-surgical nasal augmentation is rapidly gaining popularity in the rhinoplasty world. Dermal fillers provide immediate and temporary solutions to nasal contouring, but the long-term implications of dermal fillers are well-recognized as an important responsibility while planning the surgery itself (Zholtikov et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In this present study, critical insight into the anatomical, functional, and procedural challenges of the previously filled noses present in patients seeking surgical rhinoplasty is provided. This validates the case for a structured multidisciplinary and image-guided approach to optimize outcomes of this evolving subset of rhinoplasty candidates (Vulović et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Filler data showed filler became refractory for a very long time, especially for non-hyaluronic fillers such as calcium hydroxylapatite and PMMA. It refutes the prevailing notion that fillers fully digest and are benign in the long run. Additionally, the persistence of material in sub-SMAS and supraperichondrial planes contributes to anatomical distortion and obscures the critical landmarks as well as causes chronic fibrotic changes (Schiavon et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The present study noted these changes in the vast majority of patients and therefore required careful and often extensive tissue handling. This strong indicator of anatomical compromise induced by prior filler use is due to the strong need for structural grafting in over two-thirds of the cases (Rastiboroujeni et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This study was based on the preoperative phase in which imaging was central. In a large proportion of patients, filler material was successfully identified by high-resolution ultrasound, and information about the depth and spread of the injected material was provided. However, MRI, although less commonly employed due to logistical reasons, is allowed in complex cases for greater clarity (Perenack \u0026amp; Ferneini, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The use of this dual modality approach highlights the reason for including radiological assessment in the preoperatively standard procedure in patients with unclear or undocumented filler history. Imaging was used for diagnosis but had utility as a roadmap for intraoperative dissection and against preemptive planning of grafting and reconstructive needs.\u003c/p\u003e\u003cp\u003eThere was variability intraoperatively in visibility, consistency, and ease of removal of filler deposits (Nahai, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Generally, hyaluronic acid fillers were easier and less integrated with surrounding tissues to remove, whereas the PMMA filler was nonresorbable and biostimulatory and was very often deeply embedded and with dense fibrosis. These differences dictated the extent of tissue remodeling that was required and the predictability of surgical results was impacted (Malone \u0026amp; Pearlman, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The variable responses support the need for tailoring the technique to filler type and the degree of associated tissue reaction and against the practice of a one-size-fits-all approach. The study showed a great functional improvement, as evidenced by a reduction in NOSE scores after operation (Levin et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Patients had improvement in breathing specifically patients with subdermal filler migration or fibrotic nasal valves preceding surgery. This observation confirms that the filler complications need not be aesthetically significant; in fact, they can be severely impairing in terms of nasal function (Kubilay \u0026amp; Yaramis, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Consistently, also on an objective photographic assessment and subjective satisfaction scores we found that aesthetic outcomes also improved. It was shown that surgical rhinoplasty can correct the complications resulting from non-surgical nasal augmentation and confirm the effectiveness of this technique (Lee et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This cohort was generally pleased with patient satisfaction, with most relieved after the filler material was removed and the original nasal structure restored. In patients changing from nonsurgical to surgery, this psychological aspect is most important. However, in a few cases, the immediacy of filler makes rhinoplasty seem inferior in terms of perceived satisfaction, but the difference in healing time between the two puts them approximately equal in the long run (Kreutzer et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). But, by the 12-month follow-up, most patients decided that the permanence and natural aesthetics of surgical correction were better than the temporary and often unpredictable effects of filler injections. It was found unexpectedly but importantly that a sizable proportion of patients suffered vascular compromise in the operating room itself (Kelley et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Although the microvascular architecture is not altered by previous use of filler, intraoperative signs of disrupted perfusion and tissue fragility indicate that these changes are potential, as no overt vascular events occurred postoperatively. Surgical outcomes are not the only implication because of this, particularly on the safety side in cases of tip refinement and soft tissue manipulation (Ishii et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). These observations accord with the rationale for conservative surgical handling and meticulous hemostasis in this patient population.\u003c/p\u003e\u003cp\u003eA further consideration drawn from the study addresses the importance of meticulous documentation in aesthetic practice (Guyuron \u0026amp; Stepnick, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). There was still a challenge concerning patient records of what type, how much, and where filler was used, although many patients had no records at all. This is an example of a systemic problem in aesthetic medicine where the documentation of procedures that are done related to nonsurgical settings may not be as rigorous as compared to the surgical specialty (Gassner et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). With the frequency of preexisting aesthetic interventions more closely linked to rhinoplasty procedures, comprehensive clinical records will become increasingly important to allow for safe, effective results. This study also shows how imaging, intraoperative flexibility, and reconstructive readiness can be combined under one umbrella approach to determine their value (Fisher et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). A structured protocol facilitated the presentation and processing of diverse filler-related anatomical presentations while permitting a low complication rate. However, due to intraoperative findings, individual techniques were somewhat varied, yet they were always informed by safe filler removal, restoration of structural integrity, and patient-specific aesthetic refinement. However, several limitations must be acknowledged regarding the results of this study (Fedok, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The study was conducted in a single center under the routines of one senior surgeon, and therefore the findings may not be generalizable. Moreover, the duration of 12 months is long enough to determine most outcomes, but longer-term studies on the durability of both functional and aesthetic results would be useful particularly in patients with residual filler material or complex revisions (Shenoda et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, these limitations are overcome to make a significant contribution to the growing literature on filler-induced rhinoplasty. It provides a replicable framework to other practitioners suffering from similar challenges since it details a detailed account of preoperative assessment, surgical technique, intraoperative findings, and postoperative outcomes (Daniel \u0026amp; Sajadian, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). This also strengthens the clinical relevance of the findings by integrating patient-reported outcome measures and underscores the need to include both objective and subjective aspects of care (Caimi et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This study concluded with the observation of the complexity of the management filled nose during rhinoplasty, which demands a structured, individualized, and multidisciplinary approach. This combination of advanced imaging, surgical adaptability, and focus on anatomical restoration has strong outcomes in both functional and aesthetic domains (Arli et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). With the increased use of filler in prevalence, a greater need for the development of objective evidence for safe and effective management strategies of filler in the surgical context (Al Arfaj, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The contribution of this study represents a critical foundation for future research and a precedent in the management of a large and complex patient demographic.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecommendations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe results of this study are used to draw several clinical recommendations on how to manage the surgical rhinoplasty patient with a filed nose. High-resolution ultrasound should be routinely used to assess filler location and depth and was preoperatively used to assess volume. MRI is invaluable when uncertainty cannot be definitively defined. Medical experts should adopt a standardized approach that entails cleaners to make removal of the filler carefully, examining the tissue integrity, and rebuilding with autologous grafts when indispensable. As it relates to the surgical approach, the approach should remain flexible with intraoperative decisions based upon distortion of the anatomy and fibrosis from filler. Radiologists and, if appropriate, dermatologists can be collaborators in improving diagnostic accuracy and surgical planning. It is essential to have detailed documentation of all previous filler treatments, including type, volume, and injection sites, on every patient, which has never been done. Beyond this, we must educate the patient about the long-term risks associated with filler use as well as the added complexity of surgery to undo it. Each of these will result in improved safety, predictability, and patient satisfaction.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePatients who have had nasal filler use are noted to have an increasing complexity of surgical rhinoplasty and this study highlights a proposed systematic evidence-informed approach for optimal management of surgical rhinoplasty in patients with a history of nasal filler use. High rates of aesthetic and functional success with few complications were accomplished through extensive preoperative imaging, standardized surgical protocols for the flap raising, and individualized reconstruction. Measurable improvements in breathing and nasal aesthetics were documented and there was high patient satisfaction. The results also show the necessity for increased awareness of the long-term consequences of the use of fillers and the necessity of interdisciplinary planning. Through its contribution to the limited literature on this topic and its replicable framework which may help clinicians safely and reliably realize outcomes in this fast-growing and complicated subset of rhinoplasty patients, this research significantly benefits this work.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eClinical Number of the Study: 2025/121-475\u003c/p\u003e\n\u003cp\u003eAll participants involved in this study were informed about the nature and purpose of the research. Participation was entirely voluntary, and informed consent was obtained from each individual prior to their inclusion in the study, in accordance with ethical guidelines.\u003c/p\u003e\n\u003cp\u003eThis study was approved by Ethical Committee of Bah\u0026ccedil;eşehir Cyprus University Faculty of Health Sciences (Date: 16/01/2025, No:2025/121-475)\u003c/p\u003e\n\u003cp\u003eFunding: None\u003c/p\u003e\n\u003cp\u003eClinical trial number: 2025/121-475\u003c/p\u003e\n\u003cp\u003eConsent to Participate: Informed consent was obtained from all individual participants included in the study. Participation was voluntary, and participants were informed about the purpose, procedures, and their right to withdraw at any time without penalty.\u003c/p\u003e\n\u003cp\u003eConflict of Interest : No conflict of interest related to this study is declared by the authors. This paper was not funded by any financial support, sponsor, or external funding. Anonymity, transparency, and no pharmaceutical or device manufacture restriction on participants\u0026apos; data used in all research activities. The collection, analysis, and reporting of data was maintained throughout the study and the integrity in all of these was maintained.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbboud L, Souissi A, Boucher F, Weill E, Mojallal A (2024, January) Surgical rhinoplasty after prior hyaluronic acid-based nose remodeling. Annales de Chirurgie Plastique Esth\u0026eacute;tique, vol 69. Elsevier Masson, pp 17\u0026ndash;26. 1\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Sebeih KH, Albazee E, Alsakka MA (2025) Safety of Using Tutoplast-Processed Fascia Lata in Rhinoplasty: A Systematic Review and Meta-Analysis. 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Aesthetic Surg J 41(7):759\u0026ndash;769\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"rhinoplasty, filled nose, nasal fillers, secondary rhinoplasty, surgical management, aesthetic outcomes, nasal reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-7214246/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7214246/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eFacial plastic surgery dealing with filled noses, be they altered by prior nonsurgical fillers or prior rhinoplasty procedures is becoming an increasingly difficult management problem. According to the popularity of injectable fillers globally, so too increases the complexity of required subsequent surgical intervention secondary to altered anatomy, fibrosis, and unpredictable tissue response. The purpose of this study is to investigate the efficacy and safety of structured surgical protocols in secondary rhinoplasty of filled noses. A prospective cohort of 48 patients who either had received nasal fillers or had a history of rhinoplasty were observed prospectively for 24 months. Individualized surgical planning was guided by preoperative imaging along with filler-type identification and histological analysis. Surgical management was emphasized by precisely removing filler, grafting in structures, and tailoring aesthetic refinement. Functionally and aesthetically, results were good and patients had minimal complications and reported 89.5% high satisfaction scores. It points out that such factors as filler migration, inflammatory reactions, and vascular risks must be taken into account in planning surgery. This research provides a standardized approach combining imaging, intraoperative navigation, and patient-specific strategy to make the rhinoplasty procedure safer and more predictable in complex cases. Given the findings, this evolving entity of nasal surgery underscores the need for targeted and interdisciplinary collaboration, and carrying this out through long-term follow-up.\u003c/p\u003e","manuscriptTitle":"Rhinoplasty/management of filled noses","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-07 09:50:13","doi":"10.21203/rs.3.rs-7214246/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1e05deab-6115-4434-872d-cb03d27a45ee","owner":[],"postedDate":"August 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T12:24:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-07 09:50:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7214246","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7214246","identity":"rs-7214246","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}