An Example Regarding the Debate on Inferior Turbinate and Cross-Linked vs. Unlinked HA Filler Injections!
We administered a non-cross-linked gel filler turbinate injection to a patient with symptoms of empty nose syndrome. Unlike classic cross-linked HA fillers, these products, packaged in 2ml sterile syringes, offer a greater volumizing effect with a single injection, except for the risk of rapid absorption and temporary relief. Classic cross-linked HA fillers are generally sold in 1ml sterile syringes. They are usually more expensive than non-cross-linked HA fillers and take approximately 10-12 months to decompose in the body.
While repeated injections might be more effective with this product, using cross-linked HA fillers seems more advantageous due to their longer duration of effect.
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| The images above and below show the left inferior turbinate before, after, and after injection of non-cross-linked HA filler (1ml and 2ml). Following the injection, the gap between the left inferior turbinate and the nasal septum was significantly closed. The patient reported feeling quite satisfied and well at this stage. Unfortunately, this effect almost completely disappeared after 1-2 weeks. |
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With the patient's permission and knowledge, we injected Kiara Reju, a non-cross-linked skin mesotherapy product containing Hyaluronic Acid (HA), (Salmon DNA), and Niacinamide (Vitamin B3), into the left inferior turbinate.
About the Product (source link: Kiara Reju skin booster):
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🧪 Main Ingredients
PDRN (Polydeoxyribonucleotide) – Typically ~5 mg/ml
→ Supports tissue renewal and cell proliferation; provides anti-aging effects.
Hyaluronic Acid (HA) – ~20 mg/ml
→ Provides strong moisture retention and plumping in the skin; increases elasticity.
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→ Exhibits anti-inflammatory properties, helps even out skin tone, and may reduce post-treatment irritation.
Besides the information I've shared here via the source link, what's important is our patient's satisfaction and the reduction or elimination of problems for our ENS patients.
In my patient's feedback, they stated that the effect decreased much faster after the injection, approximately 7-10 days, compared to the cross-linked HA filler, and that they were more satisfied with the cross-linked HA filler injection. We also administered a high-volume PRP injection (approximately 20ml) to the same patient, and they stated that even with the PRP injection, the effect lasted longer than with the non-cross-linked HA filler, although less than with the cross-linked HA filler.
Comprehensive scientific studies are needed on this subject, and stem cells, fat injections, and HA filler injections can be used as adjunktive products in treatment.
Comparison of Dissolving Times in HA Fillers
Uncross-linked HA: days → weeks
Lightly cross-linked HA: ~2-4 months
Standard cross-linked fillers: 6–12+ months
Short-Term Symptom Relief with Non-Cross-Linked HA Filler in ENS
Because turbinate tissue has high blood supply and circulation, the dissolving time may be shorter. This time can be further shortened, especially with increased circulation during exercise or heat exposure. Uncross-linked hyaluronic acid should not be considered a volumizing or structural filler. Its effects are temporary and biological, not mechanical. With repeated applications, due to its regenerative effect, it can improve mucosal health and reduce ENS symptoms.
Cross-Linked HA Fillers are More Advantageous in Turbinate Injections for ENS Patients!
The nasal mucosa naturally has higher hyaluronidase activity, which is responsible for the metabolism of hyaluronic acid. Therefore, the conversion of HA after injection is rapid. Airflow + moisture increases enzymatic access. This explains the faster HA absorption in ENS-related injections. Cross-linking extends the dissolution time of HA fillers by making the hyaluronic acid (HA) network mechanically stronger and enzymatically less accessible.
What does “cross-linking” mean in HA fillers?
Natural hyaluronic acid is a linear polysaccharide. Cross-linked HA fillers create a three-dimensional network by adding chemical bridges (most commonly BDDE – 1,4-butanediol diglycidyl ether) between the HA chains. This transforms hyaluronic acid from a freely soluble polymer into a viscoelastic gel.
Thus, in cross-linked HA fillers, the reduced hyaluronidase enzyme activity results in a longer dissolving time. Hyaluronidase breaks down β-1,4 glycosidic bonds along the HA chain. Cross-links sterically protect the cleavage sites. The physical access of hyaluronidase to these sensitive bonds is reduced. As a result, slower enzymatic degradation occurs.
Hyaluronidase activity is not homogeneous in the body. It is most abundant in tissues with rapid extracellular matrix turnover, high vascularization, and active cell migration. This enzyme activity is particularly high in mucosal surfaces, especially the nasal mucosa and turbinate. Therefore, the mechanical volume increase effect after injections of non-cross-linked HA fillers is very short-lived. However, with repeated injections, the regenerative effect may become more pronounced with the combined effect of salmon DNA and vitamin B3. More detailed results can be obtained after comprehensive scientific studies.
To read other articles about empty nose syndrome prepared by Dr. Murat Enoz and published on this website, you can click on the search result link (you can access other articles by clicking on "more posts" at the bottom of the opened link) >> https://www.ent-istanbul.com/search?q=empty+nose+syndrome
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
Private Office:
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
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Appointment Phone: +90 212 561 00 52
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