Stepwise Filler Reshaping Associated With High Satisfaction in Pilot Rhinoplasty Study

A staged, personalized protocol for reshaping the nose with hyaluronic acid fillers was associated with high patient satisfaction and mostly mild, self-limiting side effects in a retrospective pilot study of 137 patients treated at a single private clinic. At the three-month assessment, 126 of 130 patients who returned for follow-up, or 96.9%, said they were satisfied or very satisfied with the aesthetic result. The investigators observed no major vascular complications, but cautioned that the cohort was too small to determine whether rare but serious events could occur.

The approach, called R-Evolution, or Rhinofiller Evolution, divides nonsurgical rhinoplasty into three planned treatment-and-assessment sessions spaced approximately 20 days apart. The first session provides the primary correction. At the second and third visits, the clinician reassesses nasal proportions, residual asymmetry, tissue response and whether further filler is clinically indicated; no additional product is injected if the result is already considered satisfactory. The staged schedule was intended to allow post-treatment edema to subside and the initial result to stabilize before further volume was considered, supporting conservative volume titration and limiting the potential for overcorrection.

Patients in the cohort were treated between 2022 and 2024. Their mean age was 29.6 years, and 89.8% were women. The investigators excluded people with severe nasal deviations, marked dorsal humps requiring surgical correction, severe structural deformities, significant functional nasal obstruction or aesthetic concerns considered better suited to conventional rhinoplasty. Other exclusion criteria included previous nasal surgery or filler treatment, pregnancy or breastfeeding, connective tissue disorders, bleeding disorders, allergy to lidocaine or hyaluronic acid, and a diagnosis or suspicion of body dysmorphic disorder. All procedures were performed by one plastic surgeon with 10 years of experience in facial injectable treatments, including nonsurgical rhinoplasty. Because the study took place in one private practice and involved a single experienced operator, its findings may not generalize to clinicians with different training or experience.

R-Evolution uses two crosslinked hyaluronic acid fillers, ART FILLER Universal and ART FILLER Volume, each containing 25 mg/mL hyaluronic acid and 0.3% lidocaine. ART FILLER Universal has a moderate elastic modulus, or G′, and was selected for smoothing and contouring, while ART FILLER Volume has a higher G′ and was selected for stronger structural support and projection. The authors also describe tan delta as the ratio of viscous to elastic behavior, with lower values indicating a more elastic gel associated with shape retention and structural support. The two products were used to combine contour refinement with support. The protocol did not introduce new injection sites; instead, it combined established anatomical targets with progressive reassessment, individualized volume distribution and the selective use of fillers suited to either contouring or structural support.

The injection sequence ran from superior to inferior through the nasion, nasal dorsum, columellar base, nasal tip and selected areas of septal deviation. A 30-gauge needle was used for contouring injections, while a 27-gauge needle was used for volumetric support. The nasion received 0.2 to 0.4 mL in avascular connective tissue; deep supraperiosteal injections addressed sagittal defects along the dorsum; no more than 0.2 mL was placed at the columellar base to enhance tip projection; and the nasal tip was treated at the midpoint between the domes. Deep injections over cartilage or bone could be used for septal deviations. The maximum cumulative injected volume per patient was 1.2 mL. Up to 0.8 mL could be administered during the first session, with a maximum additional 0.4 mL distributed across the second and third sessions if clinically indicated.

To reduce the chance of compromising blood flow, the operator injected slowly in tiny aliquots, used low extrusion pressure and intermittently released pressure after each push. Slight needle repositioning between aliquots was intended to avoid a large bolus in one location, while injections remained in deep planes where appropriate. Hyaluronidase was always available at the clinic, and patients were monitored for early signs of vascular compromise. If vascular occlusion was suspected, the protocol called for interruption of treatment and immediate management under established emergency procedures. The nasal region nevertheless has complex vascular anatomy and connections to the ophthalmic circulation. The discussion notes that severe complications including skin necrosis and blindness have been reported with filler injections, even though no major vascular complications occurred in this cohort. The reported absence of such events therefore applies only to the 137-person sample, the protocol used, the operator and the monitoring methods.

Among the 130 patients who completed the minimum three-month follow-up, 92, or 70.8%, were very satisfied and 34, or 26.2%, were satisfied with the aesthetic outcome. Four patients, representing 3.1% of the follow-up cohort, reported dissatisfaction and subsequently underwent treatment with hyaluronidase. None of those reversals was performed because of suspected vascular compromise. Seven of the original 137 patients did not attend the scheduled three-month assessment and were considered lost to follow-up; their reasons for nonattendance were not documented. The staged treatment pattern varied: 42 patients, or 32.3%, received no additional filler after the initial treatment, 32, or 24.6%, received additional filler during the second session only, and 56, or 43.1%, received additional filler during both the second and third sessions. The investigators classified these later injections as planned refinements within the protocol rather than retreatments for complications.

Adverse events were assessed immediately after each treatment session, during the second and third scheduled treatment-and-assessment visits, at the three-month follow-up and at any later available follow-up. Patients were told to contact the clinic and attend an unscheduled assessment if concerning symptoms developed between scheduled visits. Events were identified through clinical examination and patient reporting and were recorded in medical records. Monitoring covered edema, erythema, bruising, pain, tenderness, nodules, infection, asymmetry requiring correction and signs of vascular compromise, including blanching, livedoid discoloration, delayed capillary refill, skin necrosis and visual symptoms. Mild, self-limiting edema occurred in 41 patients, while 11 experienced minor bruising that resolved with conservative management. Four patients had moderate adverse events: one case of localized folliculitis and three episodes of delayed edema during systemic infections. All were successfully treated with medical therapy. No major vascular complications were observed, but the study was not large enough to characterize rare vascular emergencies.

Longer follow-up was available for a subset of the cohort: 96 patients reached 12 months, 41 reached 18 months and 18 reached 24 months. The researchers noted that satisfactory aesthetic results were often maintained beyond a year among patients for whom longer follow-up was available. However, follow-up duration was heterogeneous, and no objective measurements of durability were performed, so the study cannot establish how long the effects reliably persist. Other important limitations included the retrospective, single-center design, the absence of a control group, satisfaction ratings obtained retrospectively from routine records, and the lack of blinded or independent aesthetic evaluation. Although the operator considered the naso-frontal, naso-labial and naso-facial angles during planning, no formal angular measurements or digital analysis were performed. Standardized frontal and lateral photographs were obtained with the same smartphone under consistent lighting and positioning, but background conditions were not fully controlled. The results are preliminary and specific to the selected cohort, treatment protocol and experienced operator; prospective, controlled, multicenter studies with standardized photography, objective anthropometric measurements, validated patient-reported outcomes and blinded independent evaluators are needed to assess the approach more reliably.

Subject of Research: Evaluation of a staged hyaluronic acid filler protocol for nonsurgical rhinoplasty

Article Title: The “R-evolution” technique: a pilot observational study of a stepwise nonsurgical rhinoplasty approach using hyaluronic acid fillers

Article References: Castellaneta, F., Bianco, N., Lombardi, M., & D’Antonio, S. (2026). The “R-evolution” technique: a pilot observational study of a stepwise nonsurgical rhinoplasty approach using hyaluronic acid fillers. BMC Plastic and Reconstructive Surgery, 2(1), 29. https://doi.org/10.1186/s44452-026-00042-8

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00042-8

Keywords: nonsurgical rhinoplasty, hyaluronic acid fillers, R-Evolution technique, aesthetic medicine, patient satisfaction, observational study, filler complications, nasal reshaping, retrospective cohort, R-evolution, technique, pilot