Non-Surgical Touch-Up with Hyaluronic Acid Fillers Following Facial Reconstructive Surgery

Round 1

Reviewer 1 Report

Your work is relevant and well done. I just have a few questions and suggestions to make.

Abstract - Please, make corrections on the spaces among the words.

Matherial and Methods - Please, what was de HA used? Brand, density, cross link. What factors determined the amount to be used? Please, if possible, insert the photographic registers of all patients' applications.

Conclusion - Addresses a summary of the results presented. Please, I suggest that you make reference about the need for randomized clinical trials, considering the type of HA that would be more suitable for these performed treatments 

Author Response

Dear Reviewers

 

We would thank you for your feedback on our manuscript.

The points presented in your letter have been copied below, and the responses are indicated beneath each item (in blue type).

The newest content revisions to the manuscript text appear in red type in the files.

 

Review Report 1
=====================

 

English language and style

 

( ) Extensive editing of English language and style required
( ) Moderate English changes required
( ) English language and style are fine/minor spell check required

(x) I don't feel qualified to judge about the English language and style

 

 

 

 

                                                  Yes           Can be improved      Must be improved        Not Applicable                   

 

Does the introduction                   (x)                   ( )                              ( )                              ( )

provide sufficient

background and include

 all relevant references?

 

Is the research                               ()                      ( )                             ( )                              ( x)

 design appropriate?

 

Are the methods                            (x)                    ( )                             ()                                    ( )

adequately described?

 

Are the results                                ( x)          ( )                                   ( )                                 ( )

 clearly presented? 

 

Are the conclusions                        (x )       ()                               ( )                                         ( )

supported by the results?

 

 

 

 

 

 

 

 

 

 

 

 

Comments and Suggestions for Authors

 

Your work is relevant and well done. I just have a few questions and suggestions to make.

Abstract - Please, make corrections on the spaces among the words.

Matherial and Methods - Please, what was de HA used? Brand, density, cross link. What factors determined the amount to be used? Please, if possible, insert the photographic registers of all patients' applications.

Conclusion - Addresses a summary of the results presented. Please, I suggest that you make reference about the need for randomized clinical trials, considering the type of HA that would be more suitable for these performed treatments 

 

 

 

 

Response to Reviewer 1 Comments

 

We would thank you for your precious comments.

In abstract section, we have made corrections on the spaces among the words, as you kindly suggested to us.

In Material and Methods section, we have provided to underline the HA filler used, specify in details brand, density, cross link, as you recommended.

 

Moreover, in order to underline the determination of the amount to be used, we have discussed the rheological and physiochemical features of each filler used, according to our approach for every specific case. As best as we could, we have improved photographic registers of patients' applications where it was possible.

 

In conclusion section, we have addressed a summary of the results presented, as you kindly suggested. Furthermore, we have made reference about the need for randomized clinical trials according to the type of HA gel that would be more suitable for the performed treatments. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Again, we are grateful for the feedback and we are really thankful for all your recommendations. These have been precious to improve the quality of our work.

 

We look forward to your comments on the revised version.

Kind Regards,

 

 

Fabrizio Chirico MD

 

Author Response File: Author Response.docx

Reviewer 2 Report

First of all, congratulations to the authors for their apparent interest in minimally invasive aesthetic procedures. I agree that we are witnessing a change in paradigm regarding botulinum toxin and hyaluronic acid as means for aesthetic reconstructive surgery. Nevertheless, the paper has, in my opinion, some issues that must be corrected before publication: - the number of included cases is way too low. I believe 24 months to be a long enough interval for retrieving a more significant number of patients in the study. - the article presents a retrospective study with a follow-up period of nine weeks, which is also way too low. The authors mention assessing the results at more extended periods in some patients, but a questionnaire of patient satisfaction after only nine weeks is unacceptable. - are hyaluronic acid fillers readily available at the authors' institution? If the answer is yes, then congrats on using them in reconstructive cases as well. If the answer is no, how was the study financed? - although I have no doubt the cited papers are excellent, the number of self-citations is unusually high. - finally, the authors' goal is to demonstrate that fillers are at least as valuable as fat grafting - which is considered the gold standard, especially for volume replacement and contour improvement. The way to do so is with facts, not opinions. I am afraid I have to disagree with two statements presenting personal opinions as facts: "Even if its benefits are simplicity and minimal donor site morbidity, this procedure requires a harvest procedure, additional operative time, relevant downtime, patient postoperative discomfort and an unpredictable longevity of the results." "Compared to a fatty tissue transfer, HA injections achieve excelent aesthetical results, perfectly natural and symmetrical, without the necessity of surgical procedure or anesthesia and without visible or palpable irregularities due to the rheological features of the filler." Both downtime and patient postoperative discomfort are practically the same with facial fat grafting and filler; the longevity of the results for fat grafting is well known; fillers can produce visible or palpable irregularities depending on the area and injection technique; filler results, no matter how beautiful, are still temporary; the use of filler instead of fat, especially for young patients, might add higher total costs long-term. I suggest the authors change the article's proposed title slightly and reconfigure the paper as a limited sequence of successfully solved cases. In my opinion, hyaluronic acid fillers might replace fat as the gold standard in the distant future, and only after the discovery of the ideal temporary filler.

Author Response

Dear Reviewers

We would thank you for your feedback on our manuscript.

The points presented in your letter have been copied below, and the responses are indicated beneath each item (in blue type).

The newest content revisions to the manuscript text appear in red type in the files.

Review Report 2
=====================

 

English language and style

( ) Extensive editing of English language and style required
(x ) Moderate English changes required
( ) English language and style are fine/minor spell check required

( ) I don't feel qualified to judge about the English language and style

 

                                                  Yes           Can be improved      Must be improved        Not Applicable                   

 

Does the introduction                   ()                     ( )                              ( x)                            ( )

provide sufficient

background and include

 all relevant references?

 

Is the research                               ()                      ( )                             (x )                            ( )

 design appropriate?

 

Are the methods                            ()              ( )                                      (x)                              ( )

adequately described?

 

Are the results                                ( )                    ( )                               (x )                          ( )

 clearly presented? 

 

Are the conclusions                        ( )                  ()                                     (x )                        ( )

supported by the results?

 

Comments and Suggestions for Authors

First of all, congratulations to the authors for their apparent interest in minimally invasive aesthetic procedures.

I agree that we are witnessing a change in paradigm regarding botulinum toxin and hyaluronic acid as means for aesthetic reconstructive surgery.

Nevertheless, the paper has, in my opinion, some issues that must be corrected before publication:

 

- the number of included cases is way too low. I believe 24 months to be a long enough interval for retrieving a more significant number of patients in the study.

 

- the article presents a retrospective study with a follow-up period of nine weeks, which is also way too low. The authors mention assessing the results at more extended periods in some patients, but a questionnaire of patient satisfaction after only nine weeks is unacceptable.

 

 - are hyaluronic acid fillers readily available at the authors' institution? If the answer is yes, then congrats on using them in reconstructive cases as well. If the answer is no, how was the study financed?

 

- although I have no doubt the cited papers are excellent, the number of self-citations is unusually high.

 

- finally, the authors' goal is to demonstrate that fillers are at least as valuable as fat grafting which is considered the gold standard, especially for volume replacement and contour improvement. The way to do so is with facts, not opinions. I am afraid I have to disagree with two statements presenting personal opinions as facts: "Even if its benefits are simplicity and minimal donor site morbidity, this procedure requires a harvest procedure, additional operative time, relevant downtime, patient postoperative discomfort and an unpredictable longevity of the results." "Compared to a fatty tissue transfer, HA injections achieve excelent aesthetical results, perfectly natural and symmetrical, without the necessity of surgical procedure or anesthesia and without visible or palpable irregularities due to the rheological features of the filler." Both downtime and patient postoperative discomfort are practically the same with facial fat grafting and filler; the longevity of the results for fat grafting is well known; fillers can produce visible or palpable irregularities depending on the area and injection technique; filler results, no matter how beautiful, are still temporary; the use of filler instead of fat, especially for young patients, might add higher total costs long-term. I suggest the authors change the article's proposed title slightly and reconfigure the paper as a limited sequence of successfully solved cases. In my opinion, hyaluronic acid fillers might replace fat as the gold standard in the distant future, and only after the discovery of the ideal temporary filler.

 

 

 

 

 

 

 

 

 

 

 

 

 

Response to Reviewer 2 Comments

 

We would thank you for your precious comments.

We really appreciate your estimation in our interest in minimally invasive aesthetic procedures according to a rising concern in the paradigm-shift regarding botulinum toxin and hyaluronic acid as means for aesthetic reconstructive surgery.

 

We apologize for the low number of included cases. We have recognized the weakness of our small sample size as a potential limitation to the study. Moreover, we have stated the need for further randomized clinical trials in HA filler injection for rehabilitative purposes. In fact, although hyaluronic acid is widely used for cosmetic purposes, in literature little is known about this procedure in a reconstructive approach. To the best of our knowledge, this is the first description of several cases of facial surgery sequelae treated with a HA injection procedure. The presented experience represents a preliminary study of this reconstructive ladder in selecting the best HA filler injective approach to the reconstructive needs of each patient.

As you kindly suggested, we have provided to improve the follow-up period, thus we have reported questionnaire of patient satisfaction at 3 and 6 months.

 

We confirm that hyaluronic acid fillers are readily available at our institution and we really appreciate your congratulations on using them in reconstructive cases as well.

We have provided to decrease the rate of self-citations as you kindly suggested.

 

We have provided to make the suggested correction in the two statement reported. Our purpose is not to demonstrate that HA filler are at least valuable as fat grafting: in fact we completely agree with your brilliant observation that fat grafting could be considered as a gold standard in facial reconstruction, as widely reported in literature. Thus we have provided to specify the fat grafting charming features in both reconstructive and regenerative medicine. Moreover, we have underlined the extensively debated topics of visible or palpable irregularities of injectables depending on the area and injection technique. Furthermore, we have discussed the issue of fat grafting longevity and survival in receiving tissues and its cost-effectiveness. In this regard, we completely agree with your statement that HA filler might add higher total costs long-term respect to fat grafting, especially for young patients.

We have provided to modify the article title and to configure the paper as you kindly suggested.

Furthermore, we agree that hyaluronic acid fillers might replace fat as the gold standard only in the distant future, being up to date in literature a lack of evidence in the existence of an ideal temporary filler with rheological and physiochemical features suitable of every reconstructive scenarios.

 

 

                   

 

 

 

Again, we are grateful for the feedback and we are really thankful for all your recommendations. These have been precious to improve the quality of our work.

 

We look forward to your comments on the revised version.

Kind Regards,

 

 

Fabrizio Chirico MD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Congratulations on extensively modifying the article, the present form is much improved. Apart from some minor text editing, it is excellent now.