Rhinoplasty and Hyaluronidase Administration Following Hyaluronic Acid Nose Filler
In the image on the side , when light is shone from the side of the nose of a patient scheduled for rhinoplasty, it becomes apparent that the nasal dorsum consists almost entirely of filler material; this indicates that a significant amount of graft material will be required for augmentation during the operation.
Crucially, dissolving the filler is not mandatory for every patient. Nevertheless, proceeding directly to surgery without knowing the type of filler used, the timing of the injection, and its current status within the nose may not be an appropriate approach. It should be noted that for fillers other than hyaluronic acid, there is no standard method for dissolution.
The following protocol is intended as a clinical framework for use in the practice of otolaryngology (ENT) and facial plastic surgery. Decisions must be made on a patient-specific basis, guided by clinical examination and, where necessary, diagnostic imaging findings.
Preoperative clinical evaluation
In patients who have previously received filler injections in the nose and are planning to undergo rhinoplasty, the following points must be considered:
A. Detailed history
If possible, records regarding the filler procedure and the product label should be requested from the patient.
- Filler material: Hyaluronic acid (HA), calcium hydroxylapatite (CaHA), polycaprolactone (PCL), permanent silicone, or other materials.
- Timing of the procedure: Date of the most recent filler injection and the number of previous sessions.
- Injection site: Radix, dorsum, supratip, nasal tip, or columella.
- Amount injected: Total volume (if known) and the brand of the product.
- History of complications: Redness, pain, skin discoloration, nodules, infection, prolonged edema, or previous attempts to dissolve the filler.
If the type of filler is unknown, it should not be assumed to be hyaluronic acid based solely on the patient’s description. A history of prior injections may influence the surgical approach.
B. Physical examination and photography
- Nasal skin thickness, edema, fibrosis, and subcutaneous nodules are evaluated.
- Contour irregularities in the dorsum, supratip, and nasal tip are examined.
- The skin is assessed for signs of erythema, tenderness, fluctuation, or inflammation.
- An intranasal examination is performed to evaluate the septum, nasal valves, and airway.
- Standardized photographs are taken, including frontal, right and left oblique, profile, and basal views. When necessary, high-frequency ultrasonography and Doppler examination can provide additional information regarding the location of the filler, any residual material, and the vascular anatomy. This can be particularly useful in cases where the type or distribution of the filler is uncertain.
2. Treatment algorithm based on filler type
Group 1 — Hyaluronic acid (HA) filler
Can be dissolved
Recommended approach: Dissolving the filler with hyaluronidase prior to elective rhinoplasty can facilitate the assessment of the underlying anatomical deformity.
1. Verify the history of the product used and the injection procedure.
2. Perform an initial examination and take photographs.
3. Evaluate the need for hyaluronidase based on the presence of residual filler, its distribution, and tissue findings.
4. In suitable patients—after considering potential allergies and other contraindications—administer hyaluronidase according to the clinical protocol.
5. Re-evaluate the nasal anatomy once edema and inflammation have subsided.
6. Update the surgical plan and proceed with the operation.
- In the literature, three approaches are described for noses containing HA filler:
- waiting for the filler to be resorbed naturally;
- administering hyaluronidase;
- performing surgery in selected cases without dissolving the filler beforehand.
Group 2 — Non-HA or permanent fillers
Special assessment
Materials such as CaHA, PCL, PMMA, and liquid silicone cannot be dissolved using hyaluronidase in the standard manner. In these patients:
- The identity of the product and its potential for permanence are investigated.
- Ultrasonography—and other imaging modalities, if necessary—are utilized for assessment.
- Any nodules, granulomas, chronic inflammation, or fibrosis are addressed individually.
- The surgical plan is determined based on the filler’s relationship with surrounding tissues and whether its removal is indicated.
It is not a valid generalization to assume that one should routinely inject a dissolving agent or necessarily aim to remove all filler material during surgery when dealing with permanent fillers.
Group 3 — Suspected filler-related complications
Prioritizing the management of complications
Elective rhinoplasty should be postponed in the presence of active infection, inflammatory nodules, skin ischemia, ulceration, or significant tenderness. The complication must first be diagnosed and treated. Furthermore, any intervention involving the filler itself must be planned with extreme caution if an active infection is present.
3. When should rhinoplasty be performed following the use of hyaluronidase?
There is no single, universally accepted waiting period in the medical literature.
- First 48–72 hours: Assessing the final nasal contour can be misleading due to early post-injection edema and tissue reactions.
- 1–2 weeks: Some publications suggest that surgery may be performed within this timeframe, once the edema has subsided.
- 3–4 weeks: This is a commonly preferred waiting period among surgeons; it allows for a more accurate assessment of tissue changes. - Longer duration: Repeated filler injections may be necessary for patients with a history of significant fibrosis, inflammation, or complications.
A 2024 study reported that, in suitable patients receiving hyaluronic acid (HA) fillers, surgery may be possible within one week—once edema has subsided following the use of hyaluronidase. In contrast, a survey assessing the practices of surgeons indicated a waiting period of 3–4 weeks in most cases. These recommendations are based on varying levels of evidence; therefore, a blanket "7-day" or "4-week" rule should not be automatically applied to every patient.
How Is Hyaluronidase Injected? Protocol for Dissolving Nasal Fillers
Hyaluronidase injection is a procedure used to break down hyaluronic acid (HA)-based dermal fillers. It may be considered for patients who have previously received nasal fillers and are planning to undergo rhinoplasty, particularly if the filler complicates anatomical assessment or interferes with surgical planning. However, there is no universal, one-size-fits-all protocol that mandates the routine use of hyaluronidase for every patient with nasal fillers. The dosage to be administered varies based on the type and quantity of the filler, its cross-linking characteristics, the specific area of application, and the objective of the treatment.
Pre-procedure Assessment
The initial step involves obtaining a detailed history of the patient’s filler treatments, including the name and composition of the product used, the date of application, the volume injected, and whether any prior attempts to dissolve the filler have been made. It must be confirmed that the filler consists of hyaluronic acid; substances such as calcium hydroxylapatite, polycaprolactone, or permanent fillers cannot be dissolved using hyaluronidase. The nasal dorsum, radix, supratip, and nasal tip should be examined for signs of edema, nodules, fibrosis, asymmetry, or infection. In cases where the location of the filler is unclear or previous procedures have altered the anatomy, high-frequency ultrasonography can assist in identifying the target area for the injection.
Preparation of the Agent and Assessment of Allergy Risk
Hyaluronidase must be prepared in accordance with the manufacturer’s instructions for the specific product, using the recommended diluent. Since the concentrations and excipients of different preparations may vary, the reconstitution volume and the resulting enzyme concentration must be verified for each specific product. Product instructions should also be followed regarding the storage and shelf life of the prepared solution.
Prior to the procedure, it is essential to inquire whether the patient has previously experienced a reaction to hyaluronidase or has a history of severe allergies to bee or wasp stings. There are varying approaches in the literature regarding skin testing; it has not been demonstrated that routine skin testing for every patient reliably rules out an allergy. The decision to perform a test should be based on the characteristics of the specific preparation being used and the patient’s allergy history. The procedure must be performed in a clinical setting equipped to manage the potential development of anaphylaxis, with adrenaline and emergency intervention equipment readily available.
Administration of the Injection
The fundamental approach for the elective dissolution of dermal fillers involves the targeted administration of hyaluronidase into the area containing the filler, followed by a clinical assessment of the response. The injection site, depth, the choice of needle or cannula, and the total dose are determined by the physician based on the anatomical location of the filler and findings from ultrasonography. The nose is a unique area, given its complex vascular anatomy and the potential consequences of complications related to filler treatment. Therefore, the injection must be performed by an experienced physician who is well-versed in the regional anatomy and capable of managing potential complications.
There is no single standard value for determining the dose. The literature reports various doses and concentrations used for elective dissolution. The required amount may vary depending on the volume of the filler, its degree of cross-linking, and the product's susceptibility to hyaluronidase. Therefore, the procedure should be individualized in accordance with the instructions for the specific product used and current clinical guidelines. High-dose emergency treatment protocols—intended for cases of suspected vascular occlusion—should not be confused with the protocols used to dissolve fillers prior to elective rhinoplasty.
Post-Procedure Follow-up and Timing of Rhinoplasty
Following the procedure, the patient must be monitored for redness, edema, pain, itching, and allergic reactions. It may not always be possible to determine immediately whether the filler has completely dissolved; post-injection edema can also temporarily alter the nasal contour. For this reason, a follow-up examination should be scheduled to assess the clinical response, and if necessary, ultrasonography may be used to check for any residual filler. Some clinical guidelines recommend a re-evaluation approximately 48 hours after an elective dissolution procedure, with the option to consider further treatment if required.
The date for rhinoplasty should not be determined solely by the number of days that have elapsed since the hyaluronidase application. It is essential that edema has subsided, signs of inflammation are absent, and the true nasal anatomy can be accurately re-evaluated. In patients who have undergone multiple prior filler injections, developed fibrosis, or received fillers of an unknown type, additional assessment and a longer observation period may be necessary.
Risks and Potential Side Effects of Hyaluronidase Injection
Hyaluronidase is an enzyme that breaks down hyaluronic acid (HA)-based fillers; it may be used to remove filler material in patients who have previously undergone non-surgical rhinoplasty (nose filler treatment) before they proceed with a surgical rhinoplasty. While it generally has an acceptable safety profile, as with any injection procedure, certain undesirable effects may occur. These risks can vary depending on the characteristics of the specific product used, the dosage administered, the injection site, and the individual patient's sensitivity.
The most common side effects are local reactions. Temporary redness, swelling, tenderness, a burning sensation, itching, and bruising may occur at the injection site. These symptoms are typically mild and transient; however, in areas such as the nose where subcutaneous tissues and contours are aesthetically critical post-injection edema (swelling) can temporarily make it difficult to accurately assess the shape of the nose. For this reason, in patients scheduled for rhinoplasty, it is important to allow the tissues to settle after the filler has been dissolved so that the nasal anatomy can be re-evaluated.
Although rare, allergic reactions are clinically significant. In addition to local itching, redness, and swelling, more severe—though less common—reactions such as widespread urticaria (hives), angioedema, and anaphylaxis can occur. The fact that some hyaluronidase preparations are derived from animal sources is a relevant factor regarding the potential for hypersensitivity. Particular caution should be exercised in patients with a history of severe allergic reactions to bee or wasp stings. While this history may not constitute an absolute contraindication for every preparation, a risk assessment should be conducted based on the specific characteristics of the product in question.
Another significant effect of hyaluronidase is the partial or complete reversal of the desired filler outcome. By breaking down the hyaluronic acid filler in the treated area, the enzyme can cause a loss of volume. This may lead to the reappearance of irregularities on the nasal dorsum, asymmetries, or pre-existing contour deformities that had previously been camouflaged by the filler. Patients should be informed in advance that, following the dissolution of the filler, the appearance of their nose may differ from what they had initially expected. Furthermore, hyaluronidase may temporarily affect not only the injected filler but also the surrounding natural hyaluronic acid; however, it should not be assumed that this effect results in permanent tissue damage.
Caution must also be exercised regarding infection and inflammation. An injection can facilitate the spread of an existing infection. In patients presenting with an active infection, inflammatory nodules, or granulomatous reactions around the filler, the treatment approach should not be limited solely to dissolving the filler. Instead, the underlying condition must first be evaluated, and an appropriate treatment plan developed. Although the use of hyaluronidase can be beneficial for certain inflammatory reactions, it is not a sufficient standalone treatment for every nodule or infection.
When planning the use of hyaluronidase prior to rhinoplasty, the patient’s medical and allergic history must be obtained, it must be verified that the filler used indeed contains hyaluronic acid, and the procedure must be performed under appropriate clinical conditions. Given the risk of anaphylaxis, emergency intervention equipment and adrenaline must be readily available. The development of shortness of breath, a sensation of throat swelling, widespread hives, or fainting following an injection requires emergency medical intervention. In the context of elective rhinoplasty, the resolution of edema and a re-evaluation of the nasal anatomy help in determining the timing of the surgery.
Sources: Guideline for the Safe Use of Hyaluronidase in Aesthetic Medicine, Including Modified High-dose Protocol - PMC / Hyaluronidase for Dermal Filler Complications: Review of Applications and Dosage Recommendations - PMC / Allergic Complications of Hyaluronidase Injection: Risk Factors, Treatment Strategies, and Recommendations for Management - PubMed / Management of Patients Seeking Surgical Rhinoplasty with Previous Nasal Injections of Hyaluronic Acid - PubMed / Surgical rhinoplasty after prior hyaluronic acid based nose remodeling - ScienceDirect / Italian Online Survey Regarding the Use of Hyaluronidase in Previously Hyaluronic Acid-Injected Noses Looking for Surgical Rhinoplasty | Aesthetic Surgery Journal Open Forum | Oxford Academic /
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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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