L-PRF in aesthetic rhinoplasty

L-PRF stands for Leukocyte and Platelet-Rich Fibrin, which in English can be translated as leukocyte- and platelet-rich fibrin. Behind the technical name is a simple idea: it is a small portion of your own blood that, through a centrifugation process, is separated into its components and a natural matrix rich in regenerative elements is obtained.

This matrix, which has a gelatinous and malleable consistency, contains activated platelets, leukocytes (the cells of the immune system) and an important reservoir of growth factors: the molecules that the body uses naturally to repair and regenerate tissues. The difference is that in L-PRF these elements are concentrated and trapped in a fibrin network that releases them in a sustained manner for several days after application.

In plastic surgery, L-PRF has earned a place as an autologous biological adjuvant – which means that it is obtained from the patient himself and is not rejected – of growing application in various interventions where the aim is to improve the quality of the treated tissues.

The process of obtaining the L-PRF is simple, fast and entirely ambulatory. It is performed in the operating room at the beginning of the surgery, with no need for prior preparation by the patient beyond the usual fasting for any intervention.

This entire process is performed during the surgery itself, so it does not require additional visits or specific prior preparation. The only added inconvenience for the patient is the withdrawal of blood, equivalent to that of a standard blood test.

In the context of rhinoplasty, L-PRF has a specific role: to combine with nanogreas to form the biological mantle that is applied on the nasal dorsum in patients with thin skin, within the framework of Duvet Rhinoplasty.

In this combination, each component provides a different function:

• Nanofat provides the cell substrate: tiny particles of your own fat with regenerative cells and biological matrix.
• L-PRF acts as a gel-like vehicle that holds the nanofat in position on the nasal dorsum and, at the same time, releases growth factors that stimulate graft integration and regeneration of the overlying skin for days.

The result is a thin, autologous, bioactive biological covering that protects the nasal dorsum against the transparency of irregularities of the underlying skeleton and progressively improves the quality of the skin envelope over the following months.

Not exactly. PRP (platelet-rich plasma) is probably the best known autologous biomaterial, popularized by its use in aesthetic medicine for facial and hair treatments. Both PRP and L-PRF are obtained from the patient’s blood, but have important differences in their preparation, handling and what they provide.

L-PRF is particularly suitable for reconstructive or cosmetic surgery where a material is needed to maintain its position in a given area and slowly release its regenerative factors. They are not substitutes: they are tools with different use profiles.

L-PRF, first described by Choukroun in 2001, is a second-generation autologous concentrate derived from peripheral blood that belongs to the broader family of platelet concentrates used in regenerative surgery. Its distinguishing feature compared to conventional PRP preparations is that it is obtained without the use of anticoagulants or exogenous activators, which allows the natural formation of a fibrin clot that retains circulating platelets and leukocytes in its three-dimensional lattice, together with a reservoir of progressively releasable growth factors.

Functional composition

The resulting product has three functionally relevant components:

• Natural fibrin matrix, slowly polymerized without exogenous intervention, with flexible three-dimensional architecture that favors cell migration and angiogenesis.
• Platelet and leukocyte concentrate, physiologically activated during the coagulation process, with progressive release of its granular content.
• Reservoir of growth factors: PDGF (Platelet-Derived Growth Factor), TGF-β1 (Transforming Growth Factor beta), VEGF (Vascular Endothelial Growth Factor), IGF-1 (Insulin-like Growth Factor), EGF (Epidermal Growth Factor), among others.

Release kinetics

Unlike activated PRP, where the release of growth factors is massive in the first few hours, L-PRF has sustained release kinetics for 7-14 days thanks to the gradual entrapment of platelets and leukocytes in the fibrin matrix. This kinetic is more physiological and better adapted to the natural process of tissue healing, which requires growth signals throughout the proliferative phase, not only at the initial moment.

Material required

• Standard venous extraction system.
• Glass or plastic tubes with activating surface, without anticoagulant (typically 4 units of 10 mL).
• Specific centrifuge for L-PRF, calibrated according to Choukroun protocol.
• Compressor box (PRF Box) for obtaining membranes or sterile forceps for clot processing.

Procedure

1. Venous extraction at the beginning of the surgery, once the line has been cannulated. Complete filling of the tubes without anticoagulant.
2. Immediate centrifugation according to established protocol (parameters of approximately 2700 rpm × 12 minutes in standard Choukroun centrifuge; specific parameters may vary according to the equipment used).
3. Recovery of the clot from each tube. After centrifugation, three phases are distinguished: acellular plasma in the upper part, L-PRF clot in the middle part (the fraction of interest) and erythrocytes in the lower part. The central clot is removed by sectioning with scissors the erythrocyte transition zone, preserving a small portion of adherent erythrocytes to maintain the viability of the platelets close to the interface.
4. Processing according to use: for combination with nanofat, the coagulum is fragmented into small portions or lightly pressed to obtain a malleable consistency; for application as a membrane, the PRF Box is used to obtain thin sheets of uniform thickness.

Operating parameters

In the context of aesthetic rhinoplasty, L-PRF is not applied in isolation but combined with autologous nanofat, forming what in the context of Duvet Rhinoplasty is called a biological mantle. The synergy between the two materials provides what neither of them alone can offer.

Contribution of nanograss

• Regenerative cell substrate (adipocytic mesenchymal stem cells, vascular stromal fraction).
• Bioactive extracellular matrix.
• Minimum volume of tissue supply in the recipient site.

Contribution of L-PRF

• Gelatinous vehicle that keeps the nanograss in position on the nasal dorsum.
• Sustained reservoir of growth factors during the critical integration phase (7-14 days).
• Angiogenic and cell migration stimulus.
• Modulation of the local inflammatory response.

Combination process

Once the nanofat (by mechanical emulsification of the lipoaspirate) and L-PRF (by centrifugation and processing) have been obtained, both materials are mixed in a ratio of approximately 1:1 until a manageable and homogeneous matrix is obtained that retains the necessary consistency to remain in the recipient area for the time necessary for its integration. This combined matrix is applied directly to the remodeled nasal dorsum prior to skin closure.

The application of L-PRF combined with nanofat was documented in the 2024 publication in Cirugía Plástica Ibero-Latinoamericana on a series of patients with thin nasal skin (Type I classification according to soft tissue thickness) operated on between 2022 and 2023, with a minimum follow-up of 12 months.

Main indications in rhinoplasty

• Type I patients (nasal skin envelope < 3 mm) candidates for primary rhinoplasty.
• Secondary rhinoplasty with irregular dorsum or atrophy of the skin envelope.
• Selected Type II cases with marked alterations of the nasal skeleton or high aesthetic expectations.

Published results

These results are consistent with the available evidence on the use of L-PRF in other surgical contexts (maxillofacial surgery, periodontal surgery, chronic wound management), where improvement of scar quality, acceleration of tissue regeneration processes and reduction of inflammatory response have been documented.

Contraindications

• Significant hematological disorders affecting platelet function or coagulation (severe thrombocytopenia, thrombocytopathies, coagulopathies).
• Active anticoagulant therapy not susceptible to perioperative suspension, since natural fibrin clot formation depends on the intact coagulation cascade.
• Active systemic or surgical site infectious processes.
• Patients undergoing active oncological treatments or with a recent oncological history that contraindicates the administration of growth factors.

Recognized limitations

• Operator-dependent variability. The quality of the final product depends on factors such as the time between extraction and centrifugation, the integrity of the tubes used or the manual processing of the clot. It requires standardized protocol and training.
• Product for immediate use. L-PRF must be used in the same surgical procedure, with no possibility of storage or preservation. This limits its use to planned procedures with available equipment and material.
• Inter-patient reproducibility. Platelet concentration and response to centrifugation vary between patients according to individual factors (age, hematocrit, concomitant medication), which introduces biological variability intrinsic to the product.
• Clinical evidence in limited rhinoplasty. Although the use of L-PRF is well documented in other surgical contexts, its specific application in aesthetic rhinoplasty has a still small literature base, in which the series published in 2024 constitutes one of the references.