Use of Fat Transfer to Augment Rhinoplasty Results

Goals/Purpose: The goal of rhinoplasty is to create balance between the middle third of the face –including the nose and the malar area— and the upper and lower third. Structural and nanofat transfer to the nose and face can both improve the appearance of the nose itself and optimize nasal appearance within the context of the face as a whole. Technique for fat transfer to the face and nose to augment rhinoplasty results will be discussed.

Methods/Technique: Facial skeletal asymmetries affect the relative appearance of the nose and should be noted preoperatively and addressed with differential fat grafting. Differing pyriform projection and cephalad/caudad orientation affects how the alar base sit on the platform of the pyriform and should be addressed with preperiosteal structural fat. Skeletal asymmetries of the zygoma in terms of anterior projection and arch width can also be addressed with preperiosteal structural fat transfer. An underprojected and/or asymmetric mandible can affect perception of nasal size and projection, so should be managed with preperiosteal fat transfer to achieve the optimal anterior chin projection. By achieving proper facial relationships in the midface and lower third of the face, the nose can be appropriately altered to fit the new skeletal frame.

Shadowing in the nasolabial fold, tear trough, and malar areas can affect nasal appearance as well. The nasolabial fold should be addressed with deep and subcutaneous structural fat as well as subcutaneous subcision of the nasolabial fold with either the cannula or an 18 gauge needle to soften the crease. Preperiosteal structural fat grafting in the periorbital area can address infraorbital rim asymmetries contributing to the tear trough deformity, and the cannula can again be used for subcision of the orbitomalar ligament. Nanofat superficially placed in the lower eyelid can decrease visibility of the underlying orbicularis oculi muscle to further address lower eyelid shadowing that may otherwise detract from the rhinoplasty result. Malar fat pads and the prejowl sulcus should also be augmented with structural fat to optimize facial contours.

For the nasal dorsum/tip, 1-4 cc of fat transfer is typically done under local anesthesia either 3-4 months or 6-12 months postoperatively. If transferring fat preoperatively to thicken and soften the soft tissue on the dorsum/tip (e.g. before revision rhinoplasty), nanofat is typically used. Postoperatively, structural fat or a mixture of structural/nanofat can be used to soften the developing scar tissue and camouflage prominent cartilage grafts in thin skinned patients.

Results/Complications: Fat transfer is a safe technique to augment rhinoplasty results. When performed in complementary areas of the face at time of rhinoplasty, fat transfer addresses skeletal asymmetries, achieves optimal facial balance, and improves distracting contours and shadows. These changes remove variables that affect the relative appearance of the nose and allow the surgeon to tailor the nose to the optimal facial framework. In the senior authors’ experiences, fat grafting to the face at time of rhinoplasty and the nose itself pre- or postoperatively can be done safely with no fat transfer-specific complications in a combined 311 patients across three years. When fat grafting at time of rhinoplasty, increased swelling can be noted, but this is usually self-limiting, or can be addressed with 5-FU injection and massage if prolonged. Fat transfer to the nose before revision rhinoplasty facilitates nasal dissection by thickening the soft tissue envelope. Post-rhinoplasty fat grafting has demonstrated utility in thin-skinned or revision patients whose soft tissue envelope is adhering too closely to cartilage grafts creating visible contours.

Conclusion: Fat transfer to the nose can augment rhinoplasty results by directly facilitating dissection and improving nasal appearance after rhinoplasty. Indirectly, fat transfer can augment rhinoplasty results by creating overall facial balance through addressing skeletal asymmetries, bony and soft tissue deficiencies, and suboptimal facial contours and shadowing. Rhinoplasty surgeons can use these techniques to optimize their rhinoplasty practice.