Aesth Plast Surg

https://doi.org/10.1007/s00266-019-01504-4

EDITOR’S INVITED COMMENTARY

Invited Discussion on: Concentrated Growth Factors Extracted

from Blood Plasma used to Repair Nasal Septal Mucosal Defect
After Rhinoplasty
Ronald P. Gruber1,2

Received: 16 September 2019 / Accepted: 22 September 2019

Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019

Level of Evidence V This journal requires that authors representative in that the wound was infected with
assign a level of evidence to each article. For a full Pseudomonas.
description of these Evidence-Based Medicine ratings, We can assume for the moment that there are wound
please refer to the Table of Contents or the online healing benefits of concentrated factors such as platelets,
Instructions to Authors www.springer.com/00266. fibrin, and hormones such as CGH. A few studies in plastic
surgery indicate that that there are measurable improve-
This study involves the use of concentrated growth
ments in wound healing by one or all of these factors [1–3].
hormone (CGH) to allegedly accelerate the healing of nasal
However, the immediate question is whether or not that
defects post-rhinoplasty. Ten patients were in the study
benefit can be convincingly demonstrated by this particular
who were followed up for 3–6 months. The patients
study.
received dorsal augmentation with alloplastic material and
Even if the total number of cases performed in this
some cartilage (costal or ear) for tip augmentation. Pre-
series was a few hundred, ten cases of septal wounds would
sumably, septal cartilage was not used. Patient progress
be a relatively high percentage in my experience. Septal
was assessed at 7–14 days post-rhinoplasty. Wounds of
wounds following rhinoplasty are uncommon these days in
various sizes were seen in the septum of these ten
part because an open approach is used which allows much
patients—mostly in the ‘anterior region,’ presumably
better visualization for dissection of the mucous membrane
where an entry incision was made for implant insertion.
off the cartilaginous septum. In this study, there did not
Wounds varied in size from 4 to 20 mm. If ‘conservative’
appear to be any actual septoplasty to harvest cartilage for
treatment (including antibiotics) failed, the author would
the tip augmentation. We are also not told what incisions
use CGH. The patient’s blood was spun down, and the
were made to insert the tip grafts. Therefore, the wounds
middle layer (rich in fibrin, platelets) was used to make
were presumably in the area of the entry incisions. It is
both liquid and gel for subsequent treatment. After
even more surprising that an entry incision should have
debriding the wound edges, the region surrounding it was
wound healing difficulties and one has to wonder if a better
injected with the liquid form and the gel was applied to the
location would have avoided the problem in the first place.
wound surface. This process would be repeated as many
For example, assuming one plans to use a closed approach
times as necessary until the wound is finally healed. All did
to insert a dorsal graft, the intercartilaginous incision would
heal although a few cases required implant removal. The
be a good choice. If one is using a marginal incision to
one case example is given as an example but it was not
access the tip region, dissection can be continued to make a
pocket in the dorsal region. There would appear to be no
& Ronald P. Gruber reason to involve the septum with its naturally thin tissues
ronaldpgruber@gmail.com and vulnerable to poor healing. Hopefully, the septal tis-
1 sues were hyperinfiltrated prior to making the pocket so
Departments of Plastic and Reconstructive Surgery, Stanford
University, Stanford, USA that dissection can be facilitated with the least trauma to
2 the tissues. Lastly, and most obviously, assuming one
University of California (SF), San Francisco, USA

123

intends to put alloplastic material in the nose, which I do
not personally prefer, the entry incision should not be near
the alloplastic itself. No doubt that is what led to the need
to remove implants in a few of these ten cases.
The next question is what is the best mode of therapy.
Personally, I do not routinely search for septal wounds
early post-op because they do not seem to be an issue in
septorhinoplasty. The exception to that is the patient who is
having secondary septoplasty for an obstructed airway in
which the tissues are friable and there is a risk to perfo-
ration. In general, however, I believe most rhinoplasty
surgeons do not expect these kinds of wounds that the
authors describe. Assuming such wounds did occur, the
preferred treatment for small wounds would be conserva-
tive with topical antibiotics because they tend to heal
spontaneously. Even large wounds such as a 2 9 2 cm
defect in the mucosa with intact septal cartilage would be
treated conservatively with a full expectation of healing,
such that the likelihood of grafting or more complicated
measures would be remote.
Assuming that for one reason or another, there is a large
wound of the septal mucosa that fails to heal would it be
advisable to utilize the author’s ‘CGH’ protocol? Frankly, I
am skeptical. The most important reason is that this study,
although well intended, does not employ a control group,
forbidding statistical analysis. It is possible sometimes to
perform a statistically significant analysis on limited data
involving retrospective data. So doing requires a non-
parametric analysis of the paired results and can be done
with as few as seven participants evaluated with a
Cochran–Q test, for example. This is occasionally done
when it is impossible to get a control group. However, in
this study the non-‘CGH’ group is expected to improve
anyway, making it impossible to statistically analyze the
author’s data. Conclusions are forbidden in this study,
unfortunately.
Assuming that this ‘pilot’ study was expanded and
improved to answer the fundamental question ‘should we
use CGH injections and CGH gel to accelerate wounds of
the septal mucosa?’ that we would face an even more
difficult challenge. The ‘CGH’ used by the author was
123
Aesth Plast Surg
taken from the middle layer of a spun down specimen of
blood. We do not know exactly what was in it or what
factors it contains, e.g. platelets, fibrin, actual CGH or
other hormonal factors. We would also have to control for
the difference between gel and injection. How much of the
improvement was simply due to wound care, the prophy-
lactic antibiotics given etc. There are numerous variables.
More than anything else this study serves as a good
illustration as to the difficulties all plastic surgeons face
when they try to evaluate the results of their suggested
alterations to the treatment of a given wound. That said I do
commend the authors for having the courage to make a stab
at it. We need more people like them to push the field
forward.
Compliance with Ethical Standards
Conflict of interest The author declares that he has no conflicts of
interest to disclose.
Human Participants or Animals This article does not contain any
studies with human participants or animals performed by any of the
authors.
Informed Consent For this type of study informed consent is not
required.
References
1. Scherer SS, Tobalem J, Vigato E, Heit Y, Modarressi A, Hinz B,
Pittet B, Pietramaggiori G (2012) Non-activated versus thrombin-
activated platelets on wound healing and fibroblast-to-myofibrob-
last differentiation in vivo and in vitro. Plast Reconstr Surg
129:46e
2. Eppley BL, Woodell JE, Higgins J (2004) Platelet quantification
and growth factor analysis from platelet-rich plasma: implications
for wound healing. Plast Reconstr Surg 114:1502
3. Lee L, Pu Q (2018) Fat grafting for facial rejuvenation and
contouring. A rationalized approach. Ann Plast Surg 81:S102–
S108
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