LAUSR

Rhinoplasty is an important surgery with its effects on facial appearance and beauty [1]. However, changing reference points such as forehead, cheek and chin increases patient satisfaction in selected patients [2, 3]. The author’s article is very valuable in demonstrating the importance of these reference points and should be congratulated [4]. I learned about fat grafting from Dr. Oscar Ramirez in 2013 during his visit to Istanbul (Fig. 1). During my clinical practice, I performed forehead fat grafting solely or combined with rhinoplasty in 98 patients. All patients were women. The longest follow-up period was 7 years (Fig. 2a, b). In line with my experiences, while most of the fat grafts survived in some of my patients, I observed an almost complete loss of fat graft in some other cases. There are many factors affecting fat graft survival. Steps of fat grafting such as fat graft harvest, purification, transfer and patient age are crucial to achieving better surgical outcomes. Infiltration In the fat graft harvest step, there are studies reporting that the use of lidocaine is toxic to adipocytes [5]. For this reason, lidocaine should be preferred in terms of pain palliation in procedures performed under office conditions. On the other hand, it may be reasonable to use a tumescent solution without lidocaine in procedures performed under general anesthesia. Fat Harvesting The author used a 3 mm blunt cannula. However, hole size and the number of holes is not mentioned in the study model. I believe that the use of multihole cannula with 1, 5–2 mm hole diameter, which enables fat removal in small lobules, results with higher fat survival rates and homogenous distribution (Fig. 3) [6, 7]. The author used a 10 cc syringe to create low suction pressure in his study. As the author states, it is very important to take fat graft with low pressure to maintain adipocyte viability [8, 9]. Low pressure can be easily created by retracting the syringe plunger with the fingers. I think unnecessarily high pressure has been created by the syringe snapper locks. Fat Preparing Centrifuge, gravity separation, washing and filtrations can be used as a fat purification technique. The common purpose of these methods is to separate the oil layer, liquid layer and adipose layer [10]. Among these techniques, the centrifuge can be used as an effective and fast method for small volume fat injection. Although different centrifuge protocols are reported in the literature, I believe that the 1200 gr 3-min centrifuge protocol can be used effectively [11]. Forehead Preparing The transfer of the fat graft to the recipient area needs particular attention in the forehead area. Because the vascular network of this region is dense, the recipient area must be prepared meticulously for injection [12]. It may be beneficial to give lidocaine with & Barış Çakır [email protected]