Ear, Nose & Throat Journal2023, Vol. 102(9) 598–604© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/01455613211016902journals.sagepub.com/home/ear
Objective: This study was designed to analyze the clinical effect of autologous fat-granule transplantation in augmentation rhinoplasty and explore methods to improve the fat retention rate. Methods: A total of 70 enrolled patients were randomly divided into 2 groups: the platelet-rich fibrin (PRF) combined with high-density fat transplantation group (combined group) and the conventional fat-granule transplantation group (control group; n = 35 in each group). In the combined group, an appropriate amount of autologous fat was extracted and centrifuged, and the lower layer of high-density fat was taken and mixed with PRF isolated from whole blood for autotransplantation. In the control group, only fat was extracted and centrifuged for transplantation. The patients were followed up with for more than one year to observe the short- and long-term effects, complications, safety, and patient satisfaction. Results: Six months after the operation, the nasal shape was stable, the contour was higher and more stereoscopic than before, the average increase of nasal height was 3.0 mm in the combined group and 2.0 mm in the control group. No complications, such as fat embolism, infection, or necrosis occurred during the 1-year follow-up. The satisfaction rate between the 2 groups has statistical significance (P < .05). Conclusion: Overall, PRF combined with autologous high-density fat transplantation is simple to perform, has a significantly increased fat-retention rate than the control group, and has stable longterm effects without obvious adverse reactions. A sufficient amount of fat and PRF transplantation can achieve a good orthopedic effect. Thus, this method can be widely used in clinical augmentation rhinoplasty.
Keywordsfat granules, platelet-rich fibrin, transplantation, augmentation rhinoplasty, rhinoplasty
The primary concerns of autologous fat-granule transplantation in augmentation rhinoplasty are obtaining a better postoperative retention rate and improving the stability of the transplantation effect. In recent years, many scholars have found that platelet-rich fibrin (PRF) isolated from blood can stimulate the proliferation and differentiation of various cells. Its tissue repair function is mainly exerted through the regulation of cytokines and fibrin scaffolds.1,2 Since 2013, the author has performed augmentation rhinoplasty by PRF combined with autologous high-density fat transplantation and compared its effect with traditional fat transplantation. The process is reported and analyzed as follows.
All 70 enrolled outpatients were female, and their ages ranged from 18 to 60 years. The patients required natural improvement and hoped that the trauma would be minor and the recovery fast. The main manifestations were a low and flat nasal root and back. None of the patients smoked or drank alcohol. The patients who met the inclusion criteria were randomly divided into 2 groups: the combined group and the control group (n = 35 in each group). The study was conducted in accordance with the Declaration of Helsinki. The study was approved by the Ethics Committee of the Chenzhou First People’s Hospital, and informed consent was obtained from all patients.
Preoperative preparation. The base, back, and tip of the nose were marked with methylene blue. The height of the nasal root was measured carefully, and the amount of fat needed was estimated according to the patients’ requirements. The operation consent was signed, and preoperative photography was performed.
Preparation of fat granules. The first choice for the fat donor site was the lateral thigh. A total of 10 mL of 2% lidocaine þ 0.5 mL of 0.1% epinephrine þ 500 mL of 0.9% NaCl injection was used to prepare the tumescent anesthetic solution. A porous needle with a 1.4 mm diameter was used to inject the tumescent anesthetic solution into the fat donor area until the local skin was slightly swollen and white. After 20 minutes, a 10-mL disposable syringe was used to connect a dual-hole liposuction tube with a 2.5-mm diameter for fat extraction. The extracted fat mixture was left standing for approximately 5 minutes. Then, the tumescent anesthetic solution and blood in the lower layer were removed, and centrifugation was performed at 1500 rpm for 3 minutes. After centrifugation, the liquid components in the bottom layer and the liquefied fat oil droplets in the upper layer were discarded, leaving the concentrated granular fat for standby. In the combined group, the high-density fat in one-third of the lowest layer was taken for standby.
Preparation of PRF and high-density fat granule mixture. A total of 5 mL of blood was drawn from the median cubital vein into a sterile centrifuge tube and immediately centrifuged at 3000 rpm for 10 minutes. The blood samples were divided into 3 layers and left standing at 4° C for 5 minutes. The bottom layer was the red blood cell fragments, the light yellow clear liquid at the top layer was the platelet-poor plasma, and the pale yellow gel in the middle layer was the PRF gel. The sample was left standing for 20 minutes to let it contract naturally and release the serum in it. Then, the serum was absorbed with sterile gauze, and the remainder was prepared into PRF with a particular shape, elasticity, and toughness by molding. The PRF gel and high-density fat were mixed in sterile containers at a 1:3 ratio and packed into 1-mL thread syringes for standby.
Autologous transplantation in the combined group and control group. In the combined group, 35 patients received autologous transplantation with the PRF and high-density fat mixture. In the control group, 35 patients underwent transplantation with conventional fat after centrifugation without adding PRF; only 0.9% NaCl was added. Local infiltration anesthesia of the fat donor area was performed with 2% lidocaine before waiting 15 minutes for the anesthesia to take effect. A 1-mm miniincision was made in the middle of the distal end of the nose. A single-hole blunt-tip fat-injection needle with a diameter of 1.2 mm was used. The fat was injected into the nasal root, the back of the nose, and the nose tip layer by layer from the periosteum upper layer to the muscle layer to the subcutaneous layer by injecting and then withdrawing. The average injection volume was 3 mL. After the fat injection, the incision was sutured with 8-0 nylon threads. The operation area was immediately iced. The recipient area could not be massaged, and no pressure bandaging was required.
Postoperative measures. In the perioperative period, prophylactic use of antibiotics could be given. A cold compress was intermittently provided within 48 hours after the operation. For 2 weeks after the operation, the patients had to consume liquid food and control their facial expressions, and, for 2 weeks after the operation, pressing for shaping could not be performed.
All patients were followed up with for 3 to 12 months after the treatment, and the curative effects and complications of all patients were observed. Photos taken with the same background before and after the operation were compared, and the status of the autologous fat absorption was systematically evaluated. The patients’ satisfaction was divided into 3 levels: satisfied, relatively satisfied, and dissatisfied. Satisfaction rate = (the number of satisfied cases þ the number of relatively satisfied cases)/the number of total cases × 100%.
Statistical processing. The statistical analysis was conducted using statistical software SPSS 16.0. The total effective rate was compared among the groups using the w2 test. A P value <.05 was considered statistically significant.
Immediately after the operation, local swelling was observed, and no obvious erythema was found. Two to 3 days after the operation, the swelling was noticeable, but 7 to 10days after the operation, most of the swelling had disappeared. Six months after the operation, the shape of the nose was stable. In the combined group, 34 patients were operated on once, and only 1 patient was operated on twice. The effective rate of 1-stop transplantation was 97.1%. In the control group, 29 patients were operated on once, and 6 patients were operated on twice; the operation interval was 6 months. The effective rate of 1-stop transplantation was 82.9%. All patients were followed up for 12 months, and the results revealed that in all patients, the nasal root height was higher than before, the silhouette was more apparent, and no complications such as fat embolism, infection, or necrosis occurred in any patient. The patients’ nasal shape improved more significantly in the combined group (with an average of 3 mm) than in the control group (with an average of 2 mm). The satisfaction rate of patients in the combined group was 97.1%, which was higher than the control group at 82.9%; χ2 tests showed a significant difference between the 2 groups (χ2 = 3.968, P = .046; P < .05). Photos of typical cases are presented in Figures 1 to 6. The instructions of typical cases are shown in Table 1.
Augmentation rhinoplasty is one of the most common plastic surgeries in Asia. There are 3 main substances used for heightening. The first is a prosthesis of silicone rubber and an expanded body. The second is autologous tissue,3,4 such as autologous dermal fat, autologous cartilage, and costal cartilage. The third is fillers, such as hyaluronic acid, collagen, and hydroxyapatite. Each material has its advantages and disadvantages. For the beauty seekers who want to achieve the safest and longest-lasting effect in the simplest way, augmentation rhinoplasty with injection is undoubtedly the most attractive method. Experts have researched augmentation rhinoplasty by injection, and autologous fat transplantation is the most advantageous method.5,6
Autologous fat has become the ideal soft-tissue-filling material for plastic surgery experts due to its advantages of having an abundant source, no rejection reaction, ability to be used by injection, simple and effective operation, and has a natural shape after the procedure. However, a study revealed that the survival rate of transplanted fat in a recipient area with less fat is lower.7 As the main areas of bone and cartilage are covered by skin, the nasal root and dorsal part of the nose have a relatively low survival rate of fat transplantation than other parts of the face. The high absorption rate limits the application of autologous fat transplantation in augmentation rhinoplasty. Therefore, many experts seldom use it. As such, improving the survival rate of fat after transplantation is the key to promoting this technology.
In recent years, there have been many studies on PRF in animal experiments and clinical applications. The results suggest that PRF is a second-generation platelet extract superior to platelet-rich plasma.8,9 When activated in vivo, platelets gradually release platelet-derived growth factor, fibroblast growth factor, epidermal growth factor, transforming growth factor, insulin-like growth factor, and vascular endothelial growth factor as well as fibronectin, cellulose, and hyaluronic adhesin. These factors play essential roles in promoting the proliferation, differentiation, and tissue formation of stem cells.10-14 Therefore, several scholars have studied the role of PRF in augmentation rhinoplasty,15,16 and some have mixed injectable PRF with cartilage tissue and applied it for this procedure, revealing that this method could effectively improve the surgical effect.17,18
The concept of high-density fat was first proposed by Allen et al19 in 2013. Extracted adipose tissue is centrifuged at 1200 rpm for 3 minutes; then, the tissue can be roughly divided into upper, middle, and lower layers. Adipocytes with fewer lipid droplets have a higher density and are in the lowest layer after centrifugation, that is, high-density fat. Caggiati et al revealed that20,21 compared with the other 2 layers, this part of the fat contains more adipose stem cells and vascular-related growth factors and has a high tissue survival rate after clinical application.
In this study, high-density fat combined with PRF was used for transplantation to improve the curative effect of fat transplantation in nasal dorsum augmentation. Autologous blood was extracted from the patients, and jelly-like PRF was obtained by a 1-step centrifugal method, mixed with autologous high-density fat particles at a ratio of 1:3 to form an injectable fat particle mixture (Figure 7), and then divided into a 1-mL screw syringe, using a blunt liposuction tube with an inner diameter of 1.2 mm to perform the nasal injection. The results revealed that compared with the control group, there was no significant difference in the recovery process and time, but the fat survival rate and patients’ 1-operation satisfaction rate were higher. No fat embolism, infectious induration, or other complications occurred. This result is indicative of accurate control of the fat volume and a better soft-tissue-filling effect.
The earliest angiogenesis of transplanted fat began at 48 hours after surgery, and nutrition was mainly obtained through surrounding tissue fluid at the early stage. Therefore, adequate tissue fluid infiltration and vascularization are the keys to the survival of transplanted fat. The improvement of grafting techniques around the benefit of fat vascularization is also an important factor for the high-fat survival rate of nose lifting. (1) Before injection of the mixture of PRF and fat particles, we used water injection needles to separate the recipient area by multi-tunnel between subcutaneous tissues, which not only expanded the contact surface between the graft and the recipient area, making it easier to obtain nutrition and survive but also made the exudated tissue fluid provide more nutrition for the survival of the transplanted cells. (2) Adopt zonal stratified transplantation, 3-dimensional crossover, drop needle micro slow injection. The main injection sites of the nose were the subcutaneous depth of the nasal dorsum and root, the upper periosteum, and the nasal injection were only in the subcutaneous layer. This injection layer allows the transplanted fat to be evenly distributed across the recipient area, maximizing close contact with surrounding tissue, promoting neovascularization, and better controlling the risk of fat embolism. Usually, a 1-mL syringe is used to push 1/10 of each.
Furthermore, after years of observation, the fat volume remained stable 6 months after transplantation in the combined group, and no patients presented with overgrowth. In addition, it may be that PRF with a unique 3-dimensional structure collected numerous white blood cells, which plays an essential role in reducing postoperative infection. In this study, no infection complications occurred.
From the case analysis in this study, patients with the following indications are suitable for and can achieve high satisfaction through PRF combined with high-density fat transplantation for augmentation rhinoplasty. (1) The nasal root and back of the nose are low and flat; the height of the nasal root is over 5 mm, the nose base is good, and the nose shape is natural and not too high. (2) Although the height of the nasal root is greater than 9 mm, the back of the nose lacks a sense of contour. (3) The nasal root, back of the nose, and nose tip reach the ideal height, but they are thin, partially deflected, or depressed and need local shaping.
In conclusion, PRF combined with autologous high-density fatgranule transplantation for augmentation rhinoplasty achieved a good and stable long-term effect. No apparent adverse reaction was found, and a sufficient amount of transplantation could achieve a good orthopedic and cosmetic effect. In addition, this method did not require prosthesis and incision or leave. Moreover, the nose achieved a natural appearance after a week of recovery. Thus, this method is expected to attain clinical popularization and clinical practice application.
Dan Yan and Shuai-Hua Li contributed equally to this study.
The authors are particularly grateful to all the people who have given us help on our article.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is supported by Hunan Health Committee (202104100629). The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.
Ze-Chun Huang https://orcid.org/0000-0001-7334-6967
1 Department of Plastic and Cosmetic Surgery, Chenzhou First People’s Hospital, Hunan, China
Received: December 31, 2020; revised: April 21, 2021; accepted: April 22, 2021
Corresponding Author:Ze-Chun Huang, BD, Department of Plastic and Cosmetic Surgery, Chenzhou First People’s Hospital, No. 102 Luojiajing Street, Beihu District, Chenzhou 423000, Hunan, China.Email: huangzc_dr@163.com
