Regenerative medicine is a relatively new and exciting field of medicine that already today has many known health applications that are proven effective. A passionate area of interest for me is autologous Platelet Rich Plasma (A-PRP) and its role in the safe advancement in aesthetic and anti-aging therapies. PRP has been used extensively in orthopedics, sports medicine, and dentistry, and today, applications in the aesthetic world are currently at the cutting edge of clinical practice and innovation.
There has been exponential growth in the many new therapies that PRP can enhance and we continue our excitement in the discovery of new surgical and non-surgical benefits with its use in cosmetic and reconstructive plastic surgery.
Such applications include, but are certainly not limited to use as fillers, alone or in combination with hyaluronic acid fillers, as an important adjunct to laser skin resurfacing, a nonsurgical option for hair restoration and/or as an adjunct in hair transplantation, and even intra-operatively during surgical procedures like blepharoplasty, facelifts, and rhinoplasties with proven reduction in bruising and a faster recovery time.
My journey with PRP began in my facial plastic fellowship with Dr. Ross Clevens at Cleven’s face and Body Specialists in Melbourne, Florida. Dr. Clevens has been using PRP for over 20 years. Through his mentorship, I learned a great deal about PRP and shared a contribution of research on the topic. In a small split-face study, we discovered that the data showed positive trends for longer lasting and better cosmetic results when PRP was added to filler in the treatment of nasolabial fold rhytids, In addition, we found that crows feet rhytid treatment with laser skin resurfacing was better enhanced with the addition of PRP. I have presented these findings at several medical conferences throughout the United States and was invited to share our results at the Biobridge Foundation conference in Venice, Italy in 2016.
I am excited about continued growth in regenerative medicine and helping other providers learn simple techniques in this field that will augment the aesthetic practices throughout the world. I am honored to be a faculty member of the International Society of Regenerative Medicine and I am thrilled about this website as an open forum for all thoughts, innovations, breakthroughs, challenges, and discussions. Finally, a website that is one source and one synchronized voice, that we all hope will help connect and better organize the world of Regenerative Medicine.
When one breaks down the science of wound healing, it makes sense that Platelet Rich Plasma (PRP) can accelerate the healing cascade. This is an important concept in surgical procedures, which are really controlled tissue injury that we perform in order to achieve a specific outcome.
In wound healing, there are four important processes; hemostasis, inflammation, regeneration, and remodeling. Platelet Rich Plasma can accelerate this entire sequence of events, thus achieving faster recovery and less downtime. For that reason, I introduce PRP into the surgical site in many of my surgeries including blepharoplasties, facelifts, and rhinoplasties.
There are a variety of PRP kits available, but I am most familiar with the materials from RegenLab. Their website has a nice video that demonstrates how to obtain PRP and this can be easily performed in the office. Their representatives are very helpful as well for additional support as one familiarizes themselves and their staff with the procedure process.
Once the PRP is obtained, I proceed with my surgical case. Prior to closure, I spray the PRP into the surgical site, usually with a 3 or 5 cc syringe attached to an angiocath. There are other spray applicators available, but I have found that this works just as well and is a bit more user-friendly in relatively small spaces like in eyelid surgery.
Non-surgical alternatives are a huge component of the aesthetic and anti-aging practice and in a world where nonsurgical options are in high demand; it is imperative that we utilize these techniques to their fullest capacity. Platelet Rich Plasma is an effective and safe nonsurgical option in of itself and/or in combination with other current non-surgical procedures like fillers and skin resurfacing.
PRP As A Filler:
The clear advantage here is that we are using the patient’s own blood in order to fill areas of volume loss. Other synthetic materials, like hyaluronic acid fillers, work very well at this and are very safe, but it is nice to be able to have an autogolous material option, especially for the patients that desire purely natural alternatives to aesthetics and anti-aging. Since we use the patient’s own blood, there is zero chance of an allergic reaction. The importance of this is nicely illustrated in bovine collagen-based fillers, which require a skin test prior to application. Historically fillers were made of this xenographic material until hyaluronic fillers dominated the market. Of importance to note though is that currently, a “permanent filler” option that lasts up to 5 years does have bovine collagen, so skin/allergy testing prior to administration is paramount. Again, PRP naturally avoids this allergic risk, although it appears to last anywhere from 6 months to some claim 2 years. My experience with PRP alone is around 6 months.
PRP in combination with hyaluronic acid (HA) fillers:
This, to me, is where PRP really plays an exciting role. We know that platelets provide essential growth factors such as FGF, PDGF, TGF-B, EGF, and VEGF, which are involved in stem cell migration, differentiation, and proliferation. We also know that they stimulate fibroblasts and endothelial cells to induce new extracellular matrix deposition and neovascularization respectfully. With all of these growth factors and a matrix for the organization of cells, it makes sense that a perfect environment is created for tissue regeneration, or is it? The introduction of hyaluronic acid, at least in my mind, really makes sense when we are looking to regenerate tissue, especially tissue volume that has been lost from the natural aging process. RegenLab does have tubes that contain HA within them and can easily be added to the patient’s blood, thus creating a platelet-rich plasma with HA, which is called Cellular Matrix. I believe that the availability of this in the United States is soon approaching.
General Filler applications that I employ:
As I evaluate a face, typically, I find that it is most advantageous to augment from lateral to medial. For example, my first move as I inject filler (ideally PRP with HA in my hands), is to augment the lateral zygomatic arch with a deep injection just superficial to the periosteium. This is a very safe place to inject and it can lift the face dramatically if placed in the correct spot. Generally, I continue deep injections anteriorly as needed, up to just short of the mid-pupilary line, so as to avoid the infraorbital neurovascular bundle.
My next favorite place to inject is the pre-jowl sulcus. Just a small amount of filler, again just superficial to the periostium, can camouflage the jowls very nicely with this technique.
Another off-label technique that I find helpful is augmenting the lower eyelid and cheek junction with the use of a canula. The canula , I use 22 gauge, provides a blunt instrument that safely threads the filler. I typically use a combination of anterograde and retrograde injection techniques in the subcutaneous region. I also find that the cheeks inferior to zygomatic arch that have deficient volume benefit with the canula technique in the subcutaneous plane as well. Here I generally fan out my filler with the apex of the fan medially and fanning out laterally.
PRP in Skin Resurfacing:
There are a variety of ways to resurface the skin including chemically with peels, mechanically with dermabrasion/microdermabrasion, and by using heat/light energy with laser technologies.
In my practice, I typically prefer to resurface full face and necks using lasers, usually the CO2 laser. Immediately after the procedure, I apply the PRP topically and allow time for it to settle in the resurfaced skin, usually about 10 min. I strongly feel that this is a nice way to not only speed up the recovery time, but also augment the skins natural radiance.
Laser, then filler? Or Filler, then Laser?
In my mind, it makes sense to rejuvenate the skin first with laser and then, sometime later, use fillers to replace the volume loss. You could argue that lasers should not affect the filler, especially if the filler is placed in the subcutaneous /deep dermal layer where lasers typically used for skin resurfacing shouldn’t penetrate, But I still feel that there could be some denaturing of HA bonds if they are incorporated into the collateral damage of the laser. You could counter argue that the laser “trauma” could stimulate or activate more chemotactic messengers from the PRP promoting additional wound healing effects, but again I worry that this may negatively affect the final outcome. More research needs to be done here.
A really nice “middle ground” alternative to hair restoration is an injection of PRP into the scalp. When it comes to hair restoration, there are well-studied and effective medical treatments with finasteride (Propecia) and minoxidil (Rogaine) and well-studied and effective surgical treatments to include, but not limited to Follicular hair unit transplantation. PRP injected into the scalp nicely bridges the medical and surgical applications! PRP injected into the scalp as a stand-alone treatment in androgenic alopecia (male pattern baldness) has been shown to not only increase the hair follicle thickness but also demonstrates an increase in the actual number of hair follicles. Medical therapies like finasteride and minoxidil are encouraged in combination with PRP for enhanced results. Furthermore, hair transplantation surgery has enjoyed an increase in hair transplant survivability and better overall results when PRP is applied and or injected at the time of transplantation.
If your practice has not embraced the hair restoration niche yet, simply injecting PRP into the scalp is a nice way to enter this fast-growing and exciting area of medicine. I find that injection into the subcutaneous/deep dermal plane is best for this is where the hair follicles are located. I feel that injection deeper into the subgaleal plane are less effective. The technique does require several injections, an area of about 1 cm squared using a 27 gauge needle. Again, this works best in androgenic alopecia and has had better results in those with Norwood classifications 2-5. I do council patients that results can vary. I also inject women as well as men, but for women I screen more for other causes of alopecia like thyroid disease (TSH), iron deficiency anemia (CBC, serum iron, and ferritin), basic endocrine panel (free testosterone, prolactin, 17-hydroxy progesterone, cortisol) and occasionally labs to rule out possible autoimmune contributions (antinuclear antibody, SED rate).
Regenerative medicine, although a relatively new discipline, has already shown great growth and I believe that we’ve only scratched the surface of its full potential. As an open forum, once again, I sincerely invite all thoughts to help further develop this area of medicine by sharing ideas, techniques, successes, and challenges. In a world where there is access to a wealth of information, our hope here is to streamline one source, one synchronized voice, one purpose; the advancement of regenerative medicine to its highest potential.