Introduction

Since augmentation rhinoplasty is widely applied among Asian patients, contracture deformity, as one of the postoperative complications, could occur in a large number of patients. Nasal contracture deformity is commonly caused by four reasons: (1) Capsule contracture: After silicone prosthesis implantation, an abnormal fibrotic capsular contracture was formed [1] around the prosthesis. The contracture of the silicone capsule shortens the nose and increases the rotation of the nasal tip, which could result in nasal contracture. (2) Infection: Subclinical infection could cause local scar hyperplasia, which gradually leads to nasal contracture [2]. It is increased after nasal implantation of expanded polytetrafluorethylene. (3) Tissue necrosis: Skin and soft tissue necrosis after rhinoplasty result in nasal contracture due to tissue volume defect and scar formation. (4) Excessive resection of the nasal septum: The defect of the nasal septum caused the deformity of the nasal support structure, resulting in nasal contracture and collapse.

Nasal contracture caused by the above factors could lead to the protruding prosthesis, deviated prosthesis, and short nose deformity [3]. Based on the degree of skin hardness, color change, dislocation, and extrusion, researchers have classified the severity of contracture into three grades [3]. A revision surgery is essential for moderate and severe contractures.

Previous revision surgery showed that expansion of the constricted nasal envelope and re-establishment of the desired stable internal framework are the key factors for successful revision rhinoplasty [4]. Intraoperative expansion via wide dissection is not sufficient in many severe cases. In these cases, additional tissue with a softer texture is needed to cover the newly constructed nasal scaffold structure with less tension. Thus, to improve the nasal condition preoperatively, several adjuvant therapies were conducted. These adjuvant therapies mainly include (1) injection of autologous fat [5], SVF [6], and adipose-derived stem cells (ADSCs) [4], which aim at softening nasal envelop and (2) locally embedded expander [7], which aim at increasing additional soft tissue volume. Reportedly, these factors release the nasal soft tissue flap of patients with nasal contracture deformity to varying degrees and improve the revision conditions.

Is there a comprehensive adjuvant therapy that can further improve the soft tissue conditions of the nose and promote the effect of revision rhinoplasty? In this study, we creatively applied manual traction and autologous shuffling lipo-aspirated fat injection before the revision rhinoplasty for patients with severe nasal contractures. The performance of the patients was satisfactory, and the nasal three-dimensional measurement outcomes and incidence of complications in the group of manual traction and fat injection were compared between the fat injection and no adjuvant therapy groups.

Patients and Methods

In this retrospective study, we analyzed 24 patients with severe nasal contracture who agreed to undergo revision rhinoplasty between March 2016 and July 2020. The cohort comprised of females aged 29.2 ± 7.1 years. Severe nasal contracture is defined as the reduction of nasal length by > 5 mm with exposure of nostrils [6]. The implants used were silicon or e-PTFE, and the patients underwent about 2.4 ± 0.8 sessions of rhinoplasty revisions. The mean duration from the last surgical treatment was 20.3 ± 5.7 months. Among the above 24 patients, 8 underwent autologous shuffling lipo-aspirated fat injection combined with mechanical stretch, followed by revision rhinoplasty (comprehensive therapy group), 8 underwent mechanical stretch and then underwent revision rhinoplasty (stretch therapy group), and 8 underwent only revision rhinoplasty (control group).

Preoperative Adjuvant Autologous Shuffling Lipo-Aspirated Fat Combined with Mechanical Stretch Treatment

After obtaining written informed consent, 16 patients in the comprehensive therapy group and the stretch therapy group were required to manually pull the nasal tip according to education and guidance at least 4–6 times a day for at least 5–10 min each time. The traction therapy for stretch therapy group commonly lasted for 1–3 months. The preparation for surgical treatment can be started once the surgeon evaluates that the nasal envelop is sufficient for revision surgery.

In addition, 8 patients in the comprehensive therapy group received 1–3 sessions of intralesional shuffling fat therapy. Patients need to recover for 1–2 weeks after each session of fat injection to reduce swelling, otherwise the patient will feel obvious pain and discomfort during traction. Two weeks after injection, patients began traction treatment. According to our clinical experience, traction treatment for one month can ensure enough flap relaxation for the following injection. After 1–3 sessions of injection and traction treatment, the preparation for surgical treatment can be started once the surgeon evaluates that the nasal envelop is sufficient for revision surgery (Fig. 1).

Fig. 1
figure 1

Diagram of the adjuvant therapy including autologous shuffling lipo-aspirated fat and manual mechanical stretch.

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We used shuffling fat for injection therapy. The “shuffling fat” is the fat which was processed through a three-way stopcock using two small-diameter syringes for a defined number of times (commonly 30 times) [8]. The “shuffling” procedure could provide mechanical refinement for fat lobules of larger size (i.e. macrofat, MF) to generate microfat (i.e. shuffling fat, SF). The prepared shuffling fat was harvested and processed according to a standardized procedure in our hospital. The abdominal region was infiltrated with the liposuction infiltrating fluid (30 mL of 2% lidocaine, 2 mL of 0.1% hydrochloride, 20 mL of 5% sodium bicarbonate in every 1000 mL of 0.9% saline) under intravenous anesthesia.

Hand-assisted liposuction was performed using a blunt three opening cannula (cannula diameter, 3 mm; hole diameter, 1 mm). The mixture of fat, swelling fluid and blood were filtered through a sterile stainless-steel filter (filter aperture, 0.8 mm) to harvest microfat. After that, the microfat was transferred to sterile cotton pads to absorb excess water, and filled into the 3cc syringe (opening diameter, 2 mm; area, 3.1 mm2; Germany). Then, this 3-cc syringe was connected with a three-way stopcock (diameter, 2 mm; area, 3.1 mm2; Germany) to another 3-cc syringe (Fig. 2). The fat was pushed and injected from one syringe to the other one (i.e., shuffling procedure) within 1 s (3 mL/s) for 30 times to harvest the shuffling fat. A video of shuffling fat is showed in supplemental material 1. The injection was processed in the subcutaneous layer and sub-SMAS layer of nasal tip, and the injection volume was 1.5–2.5mL.

Fig. 2
figure 2

Two 3-cc syringe was connected by a three-way stopcock to produce shuffling lipo.

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The control group was operated upon by revision rhinoplasty directly. In both adjuvant-treatment groups, the operations were conducted at 3–6 months after the first adjuvant treatment. The nasal injection site of shuffling fat during each session is shown in Fig. 3A.

Fig. 3
figure 3

A The injection sites of shuffling fat during each session, including the nasal tip and contracted nasal dorsum scar tissue, at the subcutaneous fat layer. B The structure diagram of secondary rhinoplasty. C Objective measurement index, including the nasal length, the nasal tip projection, nasofrontal angle, and nasolabial angle.

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Technique for Revision Contracted Nose

Secondary rhinoplasty was performed after completing the 3 sessions of pretreatment. The open incision of rhinoplasty was applied to separate the nasal flap from the lower and upper lateral cartilages and bone. Wild dissection was processed below the softened capsule. The tip position was exposed after releasing cartilages at the scroll, hinge, and membranous septum. The sixth or seventh rib cartilage was harvested. The spreader grafts (commonly 3 mm in width and length) were positioned along bilateral septum sides to extend the nasal tip, exceeding at least 5 mm from the septal angle. Columellar strut grafts were carved (3 mm × 5–7 mm × 25–30 mm) with a flared base notch to fix the septal caudal bottom as shown in Figure 3B. To achieve ideal tip projection, costal cartilage shield grafts were applied. The perichondrium was covered to avoid visibility. An I-shaped ePTFE alloplast (Shanghai Suokang Medical Implants Co., China) was carved and placed according to demand at a thickness of 2–6 mm.

Objective and Subjective Outcome Assessment

The morphology of the contracted nose before adjuvant therapy and at 6 months postoperatively was evaluated. Lateral photographs of each patient in these two time periods were collected, and four indicators were measured and recorded, including the nasal length (the length from the nasion to the tip-defining point), the nasal tip projection length (the length from the nasion-ala line to the tip-defining point), the nasofrontal angle, and nasolabial angle (Fig. 3C). In addition, the difference in nasal length and nasal tip projection from postoperative to pre-adjuvant-therapy was calculated. Also, patients were asked to report any side effects at 6 months, such as erythema, swelling, itching, petechiae, bruise, pain, lumping, bleeding, oozing, infection, and scarring.

The excess skin envelopes of one patient who underwent adjuvant therapy and another who received only rhinoplasty were harvested during revision rhinoplasty, respectively. H&E staining and Masson staining were processed to observe the difference of skin histology between patients treated with fat injection and patients not treated with fat injection.

Statistical Analysis

After a normality test, the data from the three groups in the same period were analyzed using the one-way analysis of variance (ANOVA) and multiple comparisons. The preoperative and postoperative measurement outcomes of the same group were analyzed by paired t-test using IBM SPSS version 22 (IBM Co., Armonk, NY, USA). p < 0.01 indicated a statistically significant difference.

Results

Patient Information

The cohort of 24 patients underwent revision rhinoplasty in the three groups and was followed up at 6 months postoperatively. Among these patients, 19 of them used silicon implants, 4 of them used e-PTFE implants, and one used hydroxyapatite artificial bone dust in their previous rhinoplasty. The average injection volume of shuffling lipo-aspirated fat was 1.68 ± 0.27 mL per session. The differences in patient information among the comprehensive therapy group, stretch therapy group, and control group was insignificant (p > 0.01, respectively), as shown in Table 1. On the other hand, the differences in the measurement outcome of nasal tip projection, nasofrontal angle, and nasolabial angle among the three groups were insignificant (p > 0.01, respectively), while the nasal length among the three groups differed significantly (p < 0.01). Moreover, patients in the comprehensive therapy group had the shortest while patients in the control group had the longest nasal length.

Table 1 Patient demographics and baseline clinical characteristics
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Morphological Evaluation Outcomes

The evaluation outcomes of postoperative nasal length and nasal tip projection length are shown in Table 2. The nasal length was improved significantly in 1.0 ± 0.1 cm (p < 0.001), 0.6 ± 0.1 cm (p < 0.001), and 0.4 ± 0.1 cm (p < 0.001) in the comprehensive therapy, stretch, and control groups, respectively. In addition, nasal tip projection was improved significantly in comprehensive therapy group, stretch group, and control group (0.4 ± 0.0 cm (p < 0.001), 0.3 ± 0.1 cm (p < 0.001), and 0.3 ± 0.0 cm (p < 0.001), respectively). According to these two parameters, the improvement values of nasal length and nasal tip projection were significantly greater in the comprehensive therapy group than in the other two groups (p < 0.01 by ANOVA and multiple comparisons).

Table 2 Evaluation outcome among three groups using ANOVA test and multiple comparison
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The evaluation outcome of postoperative nasofrontal angle and nasolabial angle values are shown in Table 2. Briefly, these angles were significantly decreased (p < 0.001), while the nasolabial angle showed no significant difference postoperatively among the three groups (p > 0.05).

Histological Evaluation Outcome

The H&E staining and Masson staining outcome of patient who did not receive adjuvant therapy and patient who received adjuvant therapy are showed in Fig. 4. Without fat injection treatment, large fibroblasts were observed under the microscope, with disordered and disordered arrangement and dense and irregular collagen; after the adjuvant treatment, fibroblasts decreased, collagen arranged loose and regularly, and inflammatory cell infiltration decreased.

Fig. 4
figure 4

A The H&E staining outcome of patients who did not receive adjuvant therapy. B The H&E staining outcome of patients who received adjuvant therapy. C The Masson staining outcome of patients who did not receive adjuvant therapy. D The Masson staining outcome of patients who received adjuvant therapy.

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Course and Adverse Events

Side effects, such as oozing, hematoma, allergic reaction, infection, granuloma formation, or poor contracture, were not observed reported during the adjuvant therapy, including fat aspiration and injection. One case of wound infection was reported at the postoperative follow-up point in the mechanical stretch group, while two cases of wound infection were reported in the control group. Moreover, the defect of nasal columnar mucous was found in one case in the control group but none in the shuffling fat combined with mechanical stretch and comprehensive therapy groups. Other common side effects, including nasal tip contracture, pigmentation or dyspigmentation, cartilage absorption in the nasal tip, and septal deviation, were not observed. The typical cases of patients in three groups are summarized in Figs. 5, 6 and 7.

Fig. 5
figure 5

A typical contracted nose in a 25-year-old female patient who had underwent 3 unsatisfied revision rhinoplasties. In our study, she received the comprehensive therapy including 3 sessions of lipo injection and stretching, and the revision rhinoplasty. Clinical photographs were displayed at baseline in the frontal position (a), and raise mandible position (b), 45 degree left side (c), and 90 degree left side (d), and at 6 months after revision surgery at baseline in the frontal position (e), and raise mandible position (f), 45 degree left side (g), and 90 degree left side (h).

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Fig. 6
figure 6

A typical contracted nose in a 28-year-old female patient who had underwent 2 unsatisfied revision rhinoplasties. In our study, she received the stretching therapy, and the revision rhinoplasty. Clinical photographs were displayed at baseline in the frontal position (a), and raise mandible position (b), 45 degree left side (c), and 90 degree left side (d), and at 6 months after revision surgery at baseline in the frontal position (e), and raise mandible position (f), 45 degree left side (g), and 90 degree left side (h).

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Fig. 7
figure 7

A typical contracted nose in a 23-year-old female patient who had underwent one unsatisfied revision rhinoplasty. In our study, she received only the revision rhinoplasty. Clinical photographs were displayed at baseline in the frontal position (a), and raise mandible position (b), 45 degree left side (c), and 90 degree left side (d), and at 6 months after revision surgery at baseline in the frontal position (e), and raise mandible position (f), 45 degree left side (g), and 90 degree left side (h).

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Discussion

In this study, all 24 patients underwent a successful revision rhinoplasty. Patients who underwent autologous shuffling lipo-aspirated fat injection combined with mechanical stretch did not present any postoperative wound infection and defect of the nasal column mucous. The comprehensive adjuvant therapy provides an optimal and clinically effective nasal flap foundation for the surgical treatment of nasal contracture deformity.

Patients who were recommended and were willing to receive comprehensive adjuvant therapy underwent several revision sessions but did not achieve satisfactory results. Their nasal condition was poor, which was reflected in the preoperative baseline measurement (a short nose). Based on the morphological measurement, the comprehensive treatment group (fat injection + mechanical traction) had the most significant improvement in nasal length and nasal tip projection, and the nasolabial angle was about 90°, which also proved that adjuvant treatment provided relaxed skin flap and sufficient soft tissue for nasal revision; this, in turn, provided more possibilities for optimizing nasal morphology.

To correct the severely contracted nose, a sufficient amount of soft tissue should be prepared to achieve tension-free redraping during revision rhinoplasty. Despite intraoperative expansion via wide dissection, the tight constricted nasal envelope does not expand adequately, which leads to insufficient blood supply and deformation of the internal framework. Hence, adjuvant treatment for expanding the nasal skin envelope is a breakthrough to improve the effect of revision rhinoplasty.

Mechanical stretch is a feasible approach to expand the nasal skin. Mechanical forces provide powerful assistance for skin replacement and scar modulation [9]. Studies have shown that the fibroblasts, keratinocytes, endothelial cells, and adipocytes are regulated by mechano-transduction with focal adhesion kinase (FAK) and integrin-mediated transforming growth factor β (TGF-β) [10, 11], which enhances angiogenesis and vessel remodeling [12, 13]; in the case of subcutaneous adipose tissue, optimal mechanical stimulation promotes adipogenic differentiation and endothelial differentiation of ADSCs [14].

In clinical practice, the mechanical force has been used for a long time. A soft tissue expander is widely applied in reconstruction. Nasal reconstruction with forehead tissue expander is a classic surgical method [15], but the method effectuates a large wound and notable scar, which is not suitable for aesthetic rhinoplasty. In some cases, an expander was embedded in the nasal dorsum before revision rhinoplasty of contracted nose. It offers the advantage of increasing the locally available tissue with identical color and appearances [7]. However, this technique requires multiple non-minimally invasive surgical treatments and sessions of water injections during expansion. Also, complications, such as infection, liquid leakage, and erosion of cartilaginous framework, cannot be neglected [16, 17]. Occasionally, the expanded skin does not meet the criteria for revision rhinoplasty as it is tight and thin, according to our experience, and patient acceptance is low.

External volume expansion (EVE) devices have also been developed to provide suction from outside. This tissue expansion form has achieved satisfactory results, and the mechanical forces applied to stimulate angiogenesis and the growth of adipose cells in soft tissues [18]. The EVE devices have been used after breast cancer surgery with a good effect on minimally invasive breast reconstruction combined with autologous fat grafting [19]. Patients wear these devices for 10 h a day preoperatively and apply cyclic suction over a 3-week period [9].

Similarly, in the current study, we utilized continuous manual traction in multiple sessions as an external volume expansion method to treat soft-tissue traction patients with nasal contracture deformity. However, in this process, the effect was limited due to severe scar contracture.

Multiple sessions of shuffling fat injection could effectively dilate and release the nasal envelope and reduce the postoperative complications caused by insufficient flap volume. The injected fat also provides part of the soft tissue volume, and various cells and factors in the adipose would be useful in adjuvant therapy. Fat injection in nasal tip required precise volume control and contour refinement. The shuffling procedure of fat could prevent uncontrolled, excessive fat injection into the recipient site which occurs when large fat or fibrous tissue blocks the fat injection needle and excessive injection pressure was processed [8]. This could bring better controlled fat application rather than macro fat injection. Most importantly, micro-fragmented fat (including shuffling fat and nano-fat) was reported to show capability to repair, regenerate, and rejuvenate surrounding tissue [20]. The application of shuffling fat in this study is very suitable and promotive for the traction treatment of nasal envelop in the aspect of promoting regeneration and increasing volume.

The main cause of scar formation is fibroblast proliferation. Inhibiting fibroblast proliferation and promoting vascularization is an effective direction to improve scar and relieve contracture [21, 22]. The fat particles contain all the active constituents of SVF and are rich in adipocytes, ADSCs, preadipocytes, macrophages, and endotheliocytes [23]. Recent researches also proved that the process of shuffling did not the microscopic structure of the lipo-aspirated fat. No difference in cell viability nor the ratio of cell composition was found between shuffling fat and macro fat [8].

Among these cell compositions, SVF can organize the vascular components and extracellular matrix [24–26], reduce dermal fibrosis of normal skin and stimulate the production of vascular components [27]. ADSCs were also applied in other therapies owing to their regenerative properties [28–30] and can increase angiogenesis [31], collagen synthesis, and the number of fibroblasts [32]. Hence, fat graft inhibits fiber proliferation and promotes vascularization and regeneration, thereby improving the skin texture, dermal thickness, and microcirculation of the defective areas [31]. These characteristics make fat graft suitable and offer promising therapies for softening the nasal envelope.

Several clinical studies, such as that of Ahn et al. [6] performed revision septorhinoplasty after multiple sessions of SVF injection, while Oh et al. [4] chose ADSCs as the adjuvant therapy with satisfactory surgical outcomes.

Autologous fat is also used for scar treatment and skin quality improvement in the recent decade [33, 34]. Chen [23] administered autologous chyle fat injection in patients with hypertrophic scars. Reportedly, the hypertrophic scar tissue tended toward normalization, and the patient was satisfied. Regarding the application in nasal contracture, Shen [5] reported 9 patients with a mild and moderate contracted nose who were treated with autologous fat grafting with no revision rhinoplasty; the outcome was satisfactory.

Taken together, in this study, we pioneered the combination of shuffling lipo-injection with mechanical traction to improve nasal texture and soft tissue volume. Shuffling lipo-aspirated fat could promote smoothness during fat injection, minimize the fat graft lobule size, and reduce the risk of bolus injection and consequently, the complication rate [8, 35, 36]. It also shows the same cellular component activity, tissue viability, and microscopic structure compared to regular aspirated fat [37]. Considering the limited space at the nasal tip, shuffling lipo-injection is a reasonable choice.

In recent years, adipose-derived stem cell exosomes (ADSCs-EXOs) have been proved to promote angiogenesis, accelerate the proliferation of skin cells, regulate collagen remodeling, which inhibits scar hyperplasia, and enhance the effect of fat-grafting [38, 39, 40]. In future applications, ADSCs-EXOs may also be used in the adjuvant treatment of contracture nasal deformity.

Nevertheless, the limitation of this study is that the adjuvant treatment of contracture nasal deformity is still in the early stage of application, and the sample size is small. In addition, as a retrospective analysis, the observation time points of the results are limited. Thus, we will continue to improve the prospective cohort study in the future to explore the preoperative adjuvant treatment of nasal contracture deformity.

Conclusion

The present study introduced preoperative adjuvant therapy, including multiple autologous shuffling lipo-aspirated fat sessions combined with daily manual mechanical stretch for nasal contracture revision rhinoplasty. Clinical observation and objective evaluation showed that this novel adjuvant therapy improves the surgical outcome and decreases the postoperative complications of revision rhinoplasty for severe nasal contractures. It also brings relaxed skin flap and sufficient soft tissue for nasal revision, increasing the possibility of optimizing the nasal morphology.