Three Different Types of Fat Grafting for Facial Systemic Sclerosis: A Case Series

Round 1

Reviewer 1 Report

It is interesting to talk about the treatment of facial scleroderma.

In the chapter on surgical technique, it is first necessary to give the characteristics of the sampling cannula, the size of the cannula and above all the size and number of orifices.

The terminology used is wrong.

You can add in the bibliography

Amy L STRONG PRS and  

SAUTEREAU N, . Efficacy of autologous microfat graft on facial handicap in systemic sclerosis patients. Plast Reconstr Surg Glob Open.2016 Mar 22;4(3):e660. 

macrofat depends on the orifices of the sampling cannula, the original technique of Sydney Coleman

There is no microfat but emulsified fat without filtration, the microfat retains intact lobules of less than 1mm

What the authors call nanofat is emulsified fat filtered at 400 microns

There is a lot of confusion in product types

Author Response

Thank you for these precious corrections, your observations are very appreciated, giving us the opportunity to improve our work. Here is a point-by-point response to your letter:

According to your observation we modified the chapter on surgical technique adding the information about he sampling cannula, the size of the cannula and above all the size and number of orifices. (lines 64-78 colored in yellow).   About the processing phases of our study we provided to add a figure and  we reported more details about the cannulas used in each step.   We provided then to add as request in the bibliography the article entitled: "Efficacy of autologous microfat graft on facial handicap in systemic sclerosis patients."  This Article is the n.12 in our references list.   We hope our changes are satisfying, otherwise we will proceed with the additional modifications you shall require.    

Reviewer 2 Report

The authors present their surgical approach and results of facial fat grafting in 5 patients with systemic scleroderma.

Plastic surgery, especially when considering aesthetic outcome, is usually judged on post-operative appearance and patient satisfaction. I feel that including photographs of more than one patient would be beneficial.

In “surgical technique” the description of Klein solution is not consistent, i.e. the concentrations cannot be calculated, as the volumes of NaCl or lidocaine are not shown. No information is given about the estimated volume of fat injected, only the amount harvested.

Lines 78-81 would greatly benefit from adding a facial figure or a photograph with regions marked where different types of fat grafts were placed, perhaps also the incision placement for cannulae?

Does the questionnaire address general patient tolerability or specific post-operative pain/itching? If post-operative, then consider measuring functional and aesthetic outcomes separately.

 Lines 174-180 should be moved to a Conclusion section.

The title of the paper suggests that it will include a detailed instruction on how the authors perform fat grafting in SSc, however a novice surgeon may find trouble replicating such a procedure just after reading this paper.

In conclusion, the strength of evidence obtained through the questionnaire alone is low, therefore I feel that more emphasis should be placed on the "how we do it" part.

Moreover, the paper requires significant English editing, some remarks are listed below:

Line 2 – “types” instead of “type”

Line 29 “can involve” or “involves”

Lines 34-37 require revision to improve readability

Line 65 “raw” instead of “row”

Author Response

Thank you for these precious corrections, your observations are very appreciated, giving us the opportunity to improve our work. Here is a point-by-point response to your letter:

1) we provided to add the details about Klein solution and fat injected (lines 85-96 colored in sky-blue);

2) As required we added a photo with regions marked where different types of fat grafts were placed;

3) About the questionnaire: we provided more details on how the assessment was conducted. In particular, questions were asked to study the functional and aesthetic aspects separately at different times in the follow-up visits (lines 100-107 colored in sky-blue);

4) We added then the conclusion section as required;

5) We have organized an English revision by a native speaker and we corrected:

Line 2 – “types” instead of “type”

Line 29 “can involve” or “involves”

Lines 34-37 require revision to improve readability

Line 65 “raw” instead of “row”

We hope that our changes are satisfactory. If this is not the case, we will proceed with any additional modifications that you may require. I am writing on behalf of all the authors,

Kind regards

Umberto Committeri

Round 2

Reviewer 2 Report

I have no further comments, thank you.

Author Response

Dear Reviewer,

as required we provieded to a comprehensive language review by native language reviewer.