Nanofat Injection in Empty Nose Syndrome: A Clinical Application for Inferior Turbinate Regeneration
Empty Nose Syndrome (ENS) is a complex clinical condition characterized by paradoxical nasal obstruction, cold and dry air sensation, burning, dyspnea, and significant loss of quality of life, often occurring after aggressive turbinate surgeries. The pathophysiology of ENS is not limited to mechanical volume loss; it involves multiple components such as mucosal atrophy, submucosal fibrosis, microvascular insufficiency, and neurosensory dysfunction. Therefore, structural filler approaches alone are often insufficient in treatment, and interest in regenerative therapies is increasing. We performed endoscopic turbinate nanofat injection procedures on a patient with symptoms of empty nose syndrome following previous turbinate procedures.
Here's the other link to my detailed article on "Microfat, Nanofat, SVF, and Microfragmented Fat in the Treatment of Empty Nose Syndrome" >> Regenerative Strategies in Empty Nose Syndrome: A Comparative Analysis of Microfat, Nanofat, SVF and Microfragmented Fat
Clinical Case and Application Summary
In a patient diagnosed with ENS, nanofat injection was performed under endoscopic control into both inferior turbinates. The right inferior turbinate showed significant volume loss, particularly in the middle and posterior (tail) sections. Additionally, the middle section of the right inferior turbinate was observed to be significantly fibrotic. The patient complained of a cold and dry sensation, especially on the right side. The patient's symptoms decreased when a cotton test was performed in this area. The procedure was performed under general anesthesia. Initially, the injection was administered via a cannula, but leakage of the injected nanofat was observed in the fibrotic middle section of the right inferior turbinate. Therefore, using a green syringe needle, intravenous injection control was maintained by retracting the plunger during the injection, and the procedure continued. Significant volume increase was observed in the tail section of the right inferior turbinate and in the middle and tail regions of the left inferior turbinate during the injection. All procedures were performed endoscopically and video recorded.
How is Nanofat Prepared?
Nanofat is a biological product obtained from the patient's own fat tissue, poor in adipocytes but rich in stromal and cellular components. In this case, nanofat was prepared from fat tissue aspirated from the patient's abdominal area. It requires longer filtration and injecting processes compared to microfat. Although preparation is somewhat more laborious, its regenerative properties are highlighted.
The preparation process includes the following steps:
- Obtaining fat tissue with low-pressure liposuction
- Mechanical emulsification of the fat (passing it back and forth between syringes)
- Reducing particle size through a long-term filtration process
- Removal of free lipids and observation of a noticeable whitening of the fluid
As a result of this process, large adipocytes are largely broken down; a suspension rich in stromal vascular fraction, mesenchymal stem cells, growth factors, and cytokines is obtained.
Biological Properties of Nanofat
The main characteristic of nanofat is its regenerative and biostimulatory effect, rather than its bulking properties. It contains:
- Adipose-derived mesenchymal stem cells
- Endothelial cells and pericytes
- Growth factors such as VEGF, HGF, and TGF-β
- Anti-inflammatory cytokines
This biological content can support angiogenesis, mucosal trophism, fibroblast activity, and extracellular matrix remodeling.
Benefits of Inferior Turbinate Nanofat Injection in ENS
The primary goal of inferior turbinate injections in ENS is not only to increase volume but also to improve mucosal quality and function. Nanofat offers several advantages in this regard:
- Support for mucosal trophism: Increased microvascular density reduces dryness and irritation
- Remodeling in fibrotic tissue: Increased tissue elasticity, especially in rigid and scarred areas
- Anti-inflammatory effect: Suppression of chronic mucosal irritation
- Autologous and biocompatible structure: Low risk of foreign body reaction
In this case, the limited volume retention, particularly in the fibrotic middle section of the right inferior turbinate, and the significant volume increase in less fibrotic areas, demonstrate the dependence of nanofat on the biological properties of the recipient bed.
Disadvantages and Limitations
Nanofat application in ENS also has some disadvantages:
- Low volume stability: May be insufficient on its own in cases requiring structural support.
- Difficulty in uptake in fibrotic tissue: Leakage may occur during injection in dense scar tissue.
- Risk of transient edema and symptom exacerbation: May cause short-term discomfort, especially in sensitive ENS patients.
- Limited literature: Data on long-term results are still insufficient.
Technical Challenges of the Procedure
Inferior turbinate injection in ENS patients is technically challenging. The irregular anatomy, degree of fibrosis, and vascular structure of the turbinate tissue directly affect injection success. While injections with a cannula may be ineffective in fibrotic areas, the risk of intravascular injection must be considered with needle injections. Therefore, aspiration control by retracting the piston is critically important.
Nanofat injection is a promising approach to biologically supporting the inferior turbinate mucosa in the treatment of ENS. In patients with predominantly mucosal atrophy, trophic insufficiency, and fibrosis, a regenerative effect may be targeted rather than structural fillers. However, it should be remembered that nanofat alone is not a curative method, and patient selection and combined treatment strategies are of great importance.
How Long Does the Effect of Endoscopic Nanofat Injection to Inferior Turbinates in Empty Nose Syndrome Last and When Should the Procedure Be Repeated?
There is no definitive literature on this subject. However, due to the properties of nanofat, I would like to provide the following information:
Early Effect (First weeks – 1 month)
In the first few days after injection:
- Submucosal edema
- Temporary feeling of fullness
- In some patients, a paradoxical increase in obstruction may be observed.
- This period is the phase where mechanical and inflammatory responses are prominent, not the true regenerative effect. These effects generally subside within 2–4 weeks.
Mid-Term Regenerative Effect (1–3 months)
The primary biological effect targeted by nanofat appears during this period:
- Increased angiogenesis
- Improved mucosal trophism
- Reduced dryness and "cold air" sensation
- Increased mucosal elasticity
In most ENS patients, subjective relief is noticeable after 4–8 weeks. According to clinical experience, this improvement may be progressive up to the 3rd month.
Long-Term Effect (6–12 months and beyond)
The lasting effect of nanofat is not volume increase, but the biological changes it creates:
- Strengthening of the microvascular network
- Improved epithelial and submucosal tissue quality
- Partial remodeling in fibrotic tissue
These effects can persist for 6–12 months, and even longer in some patients, with successful patient selection and a suitable recipient bed. However:
In cases of ENS with:
- Extensive fibrosis
- Advanced turbinate resection
- Severe neurosensory dysfunction
The duration of the effect may be shorter or limited.
Repeat Renewal Needs
Nanofat is a biological supportive treatment, not a curative one. Therefore:
The effect may decrease over time.
Some patients may require repeat injections after 6–12 months.
The duration of the effect can be extended with combined approaches (microfat, MFAT, PRP, etc.).
Clinical Summary (Practical Response)
Volume effect: Transient (weeks)
Onset of regenerative effect: 1–2 months
Continued clinical benefit: Average 6–12 months
In some patients: May be shorter or longer.
Endoscopic Nanofat Injection to Inferior Turbinates Cost
This procedure is performed in a hospital setting using specialized liposuction equipment and filters. The price may vary depending on the amount of fat aspirated and the total procedure time. The price can also vary depending on the hospital's facilities. Generally, in affordable hospitals, a half-day stay for inferior turbinate nanofat injection costs around 3500-4500 USD, while in luxury hospitals, this figure can be 5500 USD and above.
Endoscopic Nanofat Injection to Inferior Turbinates - Patient Information Form Procedure Description
Endoscopic Nanofat Injection to Inferior Turbinates is a procedure in which nanofat obtained from the patient's own fat tissue is injected endoscopically into the inferior turbinates (nasal conchae). This procedure is a regenerative treatment aimed at improving the biological quality of the nasal mucosa, reducing dryness and breathing-related complaints, especially in conditions such as Empty Nose Syndrome (ENS).
Nanofat aims not so much at adding volume, but rather at promoting tissue healing, increasing microcirculation, and supporting mucosal functions.
Anesthesia and Fasting Requirements
The procedure is performed under general anesthesia.
Eating and drinking should be stopped at least 8 hours before the procedure.
No water or food should be consumed for at least 4 hours after the procedure.
Unless your doctor specifies otherwise, your regular medications should be adjusted according to the recommendations of the anesthesia team.
Pre-Procedure Considerations
Blood-thinning medications (aspirin, clopidogrel, warfarin, NOAC group medications, etc.) should be discontinued at least 10 days before the procedure.
Discontinuation of these medications must be done in consultation with your doctor.
Inform your doctor if you have an upper respiratory tract infection, fever, or active nosebleeds.
Post-Procedure Procedures
At the end of the procedure, a compressed cotton swab is usually placed inside the nose.
This cotton is removed by the patient after a few hours.
After the cotton is removed:
Slight bleeding may occur as a drip from the front of the nose or the back of the throat.
This usually subsides spontaneously within a few days.
Expected Post-Procedure Findings
In the first few days:
Nasal congestion
Feeling of fullness
Mild pressure or discomfort
may be observed.
Nasal congestion may gradually increase over the next few days; this is usually temporary and part of the healing process.
Air Travel Warnings
Air travel is not recommended for the first few days after the procedure.
If air travel is necessary:
Nasal decongestant spray can be used only once,
Immediately before the flight,
After the descent announcement.
Avoid continuous or frequent use.
Things to Note
In the first few days:
Forceful nose blowing
Nose picking
Strong exercise
are not recommended.
Do not use sprays or solutions inside the nose unless recommended by your doctor.
If you experience severe bleeding, increased pain, fever, or any unexpected condition, consult your doctor immediately.
Information about the Effects of the Procedure
This procedure:
Is not a volume-increasing procedure,
It is a regenerative (biological healing) procedure.
Effects:
Generally appear within weeks
May last for months depending on the individual and tissue structure
Repeat injections may be planned in patients where deemed necessary.
This website contains articles prepared by Dr. Murat Enöz regarding Empty Nose Syndrome. [Link to search results] (You can also access other articles by clicking "more posts" below the link) >> https://www.ent-istanbul.com/search?q=empty+nose
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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