PRP and combination treatments
There are many possible PRP combination treatments in aesthetic and reconstructive medicine. Mr Taimur Shoaib discusses how we can put these to use
A lot of the treatments that we use in our aesthetic practice—certainly some of the very good ones—have a background in reconstructive treatments, and PRP is no exception. In orthopaedic surgery it’s been used for joint pain, tendonitis, Achilles heel tendonitis and knee injuries. There have even been reported cases of famous sports people who have had PRP to aid their recovery and to bring them back to their competitive states.
I have a special interest in head and neck plastic surgery. About nine years ago we began using PRP for the treatment of osteoradionecrosis—where a patient with oral cancer has radiotherapy and the radiotherapy cuts off the blood supply to the mandible. The mandible is a stress bearing bone and so dies back and needs to be replaced with a vascularised piece of bone either from the hip or the leg.
The vascularity of the neomandible was not compromised in any way, but at the edge of the native mandible, sometimes there would be delayed bone healing. Therefore we started using all different types of PRP in cases of osteoradionecrosis. We would double-spin it and add thrombin to get a suturable material to be placed in-between the native mandible and the neomandible.
PRP also has a background in the treatment of diabetic foot ulcers, dramatically improving healing time. Systematic reviews show there is no doubt that PRP favours the healing process for diabetic foot ulcers, indicating infection rates are lower and wound healing more rapid.
PRP has a favourable effect on wound healing in general—even the topical application of PRP onto a wound decreases the infection rate associated with the overall treatment for that particular condition.
The addition of platelets or PRP to a wound works due to the release of growth factors and cytokines. We know that there are a number of different growth factors and cytokines that are released and are involved in the cascade of wound healing and repair and regeneration.
From our experience in reconstructive surgery and treatments, PRP has made its way into our aesthetic practices.
PRP has many uses; we can activate the platelets with thrombin agents and calcium chloride, and use PRP in combination treatments with lasers, dermal rollers, ReCell and fat injections.
ReCell and PRP
ReCell is effectively “spray-on skin”. A postage stamp sized skin graft is put through a series of enzymes which break down the epidermis from the dermis. It allows us to scrape off the epidermis, including the melanocytes. They are then mashed up, and form a skin graft the size of a postage stamp we can get epidermis to cover the area of an A4 sheet of paper. This is useful where epidermis is of a premium, for example with burns patients.
ReCell has its background in treating burns, but it’s also used for stable vitiligo, as we take melanocytes from an area of normal skin and can apply them to vitiligo patches.
Sometimes when performing reconstructions we use skin flaps which invariably have a different colour to the reconstructed area. In order for ReCell to work we have to ablate the skin first, removing a layer of epidermis so that the spray-on epidermis will take as a graft onto the ablated area.
ReCell is one area in surgery where PRP is being used in combination. It’s currently undergoing investigation—we are unsure how much PRP to use with spray-on skin, at what concentration, and how the proportions may make a difference. We need to perform scientific studies to determine the best treatments and the best combination treatments for these particular uses.
Fat injections are an important part of our cosmetic and reconstructive practice for restoring volume. The advantage of using fat over dermal filler treatments, is that we have a larger volume of fat that can be used over a larger area and fat injections are permanent.
As well as importing fat cells, fat injections also import stem cells, so the skin is rejuvenated as a side effect. The main problem with fat grafts is the unpredictability of the final result in terms of the volume achieved. Generally speaking, we tell patients that approximately half of the fat graft will not survive. If you have two fat cells, one of which survives and one of which does not survive, your body will simply dissolve the non-surviving fat cell—but it will take about six months.
This means we need to overfill patients by a small amount to achieve desired longer term results. Patients will often say they liked the result three months post-surgery but over time the volume decreases. This is the main degree of unpredictability of fat grafts.
If you have just under 50% of the fat graft taking on one side of the face and just over half surviving on the other side, then you can have a significant difference in the volume and quantity of fat that survives.
Our reconstructive indications for fat grafting are conditions like HIV, drug associated lipodystrophy or acquired hemifacial atrophy, where half the face starts undergoing atrophy. I’ve also used fat injections following tumour treatments where people have had radiotherapy and chemotherapy to their face during childhood, and the development of their facial soft tissues and bony tissues has been compromised as a result.
Sometimes following cancer treatment, patients will have associated volume defects, and fat grafting is a method of restoring volume once the patient is relatively risk-free of having a recurrence of that cancer. This is because fat cells transport stem cells that release growth factors, which we don’t want to use in cancerous tissue.
Fat transfer can be used for volume loss associated with connective tissue disorders where we probably don’t want to use hyaluronic acid fillers because the hyaluronic acid injections will just increase the amount of auto antibodies that a patient has within their bloodstream.
PRP has been known to improve the take of a fat graft. Every graft you can think of will require neovascularisation, and the addition of growth factors with PRP will aid this. The controversy is how much PRP should be used for fat grafts. The current thought is that about a third of the injectable should be PRP and two thirds should be fat.
We know that PRP helps fat grafts survive in rats and rabbits, but we don’t know whether it works in humans because the methodology of these papers are probably not what you would want to use in humans. It would be good to be able to quantify this and have a better idea of the concentration of PRP to use in our fat grafts.
We use a CO2 laser with a fractionated head and additionally an ultrasound head built into it which delivers topically based treatments into the dermis. We start off by creating a series of fractionated perforations with the laser, after which PRP is applied topically to the skin. Then the ultrasound head is used to pass the topically applied product through to the underlying dermis.
We know the laser and PRP work effectively. In a paper by Shin, they performed fractionated laser therapy on one side of the face alone. On the other side of the face they performed fractionated laser therapy in combination with PRP injections and the healing was more rapid and the effect more pronounced.
We also know that you get reduced erythema when you combine PRP with laser treatments. From our wound healing experience we know that infection rates are lower as well. When we set our lasers quite high and we perform fractionated laser treatments, the risk of infection is certainly something that we discuss with our patients.
You can use PRP with dermal rollers especially those with the longer needle length of 2.5mm, so it will pierce into the dermis.
The recovery time is a little longer and the controversial “sandwich” technique is often discussed. This involves treating with a dermaroller to create channels in the skin, then application a topical PRP, then a second dermal roller treatment to mulch the PRP into the dermis. Some people believe this damages the platelets as by spiking them, you cause injury and reduce their efficacy.
Anecdotal evidence however, seems to suggest that dermal rollers can be used with PRP to good effect. Again, we don’t know what length of dermal roller is ideal, how many platelets to use—perhaps 10cc of blood or more—and if the platelet damage is a significant factor.
In summary, PRP can be used in conjunction with other treatments including surgical treatments such as ReCell and fat injections, as well as aesthetic treatments with laser and dermal roller. PRP alone of course is used for repair, generation and volume restoration, but I think combination PRP is something that we’re increasingly using in our clinics to improve the viability of grafted tissues and to promote wound healing.
Mr Taimur Shoaib is a fully accredited specialist consultant plastic surgeon on the General Medical Council’s specialist register for plastic surgery and has his own practice in Glasgow at the La Belle Forme Clinic and in London where he consults at Harley Street.
Shin MK, Lee JH, Lee SJ, Kim, Ni (2012) Platelet-rich plasma combined with fractional laser therapy for skin rejuvenation. Dermatol Surg 38(4): 623–30