Dr Vincent Wong and Dr Maria Toncheva discuss the combination of platelet-rich plasma and platelet-rich fibrin treatments as an alternative to dermal fillers
Since its introduction into the field of aesthetic medicine, we believe that platelet-rich plasma (PRP) has revolutionised the industry with the concept of non-surgical autologous facial rejuvenation. Patients who are against traditional non-surgical treatments with fears of having ‘foreign bodies’ injected into them are now able to improve their visage using their own cells. With increasing demand, the indications and uses of PRP are ever-growing.
Apart from having great healing and rejuvenation properties, recent histology studies have also shown that PRP helps with neocollagenesis.1,2 A concern with PRP, however, is early washout.3 In addition, traditional PRP (as a standalone treatment) does not address volume loss that comes with facial ageing, instead addressing skin conditioning and skin health. In this article, we discuss a way of using PRP and liquid fibrin, known as platelet-rich fibrin (PRF), to prevent the initial washout and to revolumise the face.
In order to understand how PRF works, we must first understand the clotting process and wound healing. When the endothelial layer is disrupted, platelets are anchored to the subendothelium by collagen and von Willebrand factor (VWF), which plays an important role in haemostasis following vascular injury.3 Within seconds after adhesion occurs, platelet activation begins. Platelets transform from biconcave disks to fully spread cells.3 Tissue factor is released into the bloodstream and binds to VWF to initiate the extrinsic coagulation cascade, thus increasing thrombin production, which activates the molecule that forms blood clots.4
Apart from being a potent platelet activator, thrombin also converts soluble fibrinogen into tough, insoluble strands of fibrin through polymerisation.4 With the presence of VWF, the cross-linked fibrin mesh contracts and hardens, forming a mesh atop the platelet plug and completes the clot.3,4 After haemostasis, the wound-healing process can be divided into three stages. In the inflammatory phase, platelet-derived growth factors are released into the wound site, resulting in the migration and division of a variety of cells, ready for the proliferative stage. The proliferation stage is characterised by angiogenesis, collagen deposition, granulation tissue formation, epithelialisation and wound contraction. With the variety of growth factors secreted by the platelets, fibroblasts are signalled to grow and form a new extracellular matrix; vascular endothelial cells form new blood vessels to supply the area and myofibroblasts decrease the size of the wound by gripping the wound edges and contracting. Once the roles are completed, unneeded cells undergo programmed cell death (apoptosis). During wound maturation and remodelling, newly-formed collagen is realigned along tension lines to provide strength and elasticity.4
The platelet-rich plasma (PRP) consists of high concentration of autologous platelets suspended in a small amount of plasma after centrifugation of the blood of the patient. The PRP is a product derived from blood. Its characteristic is due to the fact that the platelets present in the PRP release numerous substances that promote tissue repair and affect the behaviour of other cells.
The platelet-rich fibrin (PRF) is a modern platelet concentrate and it is achieved with a simplified preparation, with no biochemical manipulation of blood. This technique does not require anticoagulants or bovine thrombin (or any other gelling agent). This feature makes the product easily usable, with a low rate of mistakes during the preparation stage. The fibrinogen is initially concentrated in the upper part of the tube but, upon the contact with thrombin, normally present in the blood, it is converted into fibrin. The platelets are retained into the meshes of fibrin.13, 14
Despite having the ability to stimulate cellular proliferation and tissue growth, PRP is still limited when it comes to revolumisation and dermal augmentation due to fluidity of plasma and early washout5-8 where it only stays in the tissue for approximately 48 hours.9 However, when PRF is formed by mixing PRP with liquid fibrin, the presence of a fibrin mesh means that the platelets are held in place for longer.9 Furthermore, the cross-linking of the fibrin network adds viscosity to the mixture, making it an ideal alternative to dermal fillers for restoring lost volume. As a second generation platelet concentrate, PRF has been used in bone grafting, bone growth, graft stabilisation, wound healing and various other dental surgical indications with excellent results.10,11,12 Indeed, a recent study of 15 patients with an average age of 54 has suggested that PRF is effective in providing significant long-term diminution of deep nasolabial folds, with results lasting more than 12 weeks from one treatment session.9 Additionally, there were no reports of fibrosis, irregularity, hardness, restricted movement or lumpiness.9
As part of our training protocol, to achieve the best results, platelets must be harvested and mixed with the fibrin matrix correctly. Dr Maria Toncheva has pioneered a simple yet effective protocol for combining PRP and PRF as an alternative to traditional fillers. In this protocol, whole blood is collected into two PRP tubes and one PRF tube. After centrifugation, PRP is extracted from the PRP tubes. In the PRF tube two components will be present: a plasma clot and liquid thrombin serum (LTS). The extracted LST is mixed thoroughly with PRP into the syringe. This mixture must be injected into the desired treatment areas using dermal filler techniques, in a timely fashion. The treated area can then be massaged and moulded accordingly. PRF provides a 3D structured scaffold for revolumisation.9,10,11
As the platelets are held in place by the fibrin mesh, PRF provides gradual growth factor release, thus making it an effective treatment for rejuvenation with a longer-lasting result than regular PRP.11 The platelet concentration is also higher compared to standalone PRP, allowing PRF treatments to produce superior results. As the regeneration process involves all soft tissue layers from skin to bone, the results are very natural with no risk of over-filling as the treatment stimulates natural revolumisation and there is a natural limit to the rate of tissue or cell replication. Excess cells will undergo apoptosis and the volume from the fibrin will gradually wear off like dermal filler.9 By harnessing the power of platelets, PRF also has strong natural healing properties – we find this is particularly useful in younger patients who would like to prevent the first signs of ageing. As with PRP treatments, PRF is 100% autologous, making it a safe treatment choice with no risks of allergies.1
The side effects of PRF treatments are minimal and transient when done correctly. These include bruising, swelling, erythema and discomfort, which are common for all injectable treatments. However, due to the nature of the treatment, good knowledge of facial anatomy is extremely important. As the treatment involves injecting a viscous material into the face, it is crucial that we do not obstruct or occlude any vessels. Unlike hyaluronic acid dermal fillers, there are no straightforward methods of dissolving PRF. For safety reasons, it is recommended not to inject PRF in highly vascular areas such as the temple region, tear trough and lips. As with PRP treatment, the results can vary from patient to patient and some patients may require more than one treatment session after 12 weeks. This is due to the fact that the treatment relies heavily on platelet count and the quality of the platelets. Hence, patient selection plays a vital role in having a successful PRF treatment. Ideal candidates should be fit and healthy and not pregnant or breastfeeding at the time of the treatment. Other exclusion criteria should include patients with clotting disorders (or medications affecting blood clotting, such as aspirin), liver pathology, and those suffering from or battling with cancer.
The cross-linking of the fibrin network adds viscosity to the mixture, making it an ideal alternative to dermal fillers for restoring lost volume
A 43-year-old female patient presented with mid-facial volume loss. After the initial consultation, treatable areas were identified. The patient’s expectations were discussed and they seemed realistic and achievable. We presented the patient with a list of treatment options, including dermal fillers and surgical interventions, with the pros and cons explained in detail. As this was the patient’s first aesthetic treatment, she opted for PRF, as she perceived this to be the most natural option.
Photos were taken before treatment using a facial volume and skin complexion analysis system and all consent forms and medical questionnaires were signed. During treatment, whole blood was collected, centrifuged and platelets were harvested and mixed with liquid fibrin as per the PRP manufacturer’s protocol. For patient comfort, we applied topical numbing agent (EMLA) for thirty minutes prior to treatment. A total of 5ml of PRF was injected using a needle as the injection has to be done quickly before the PRF becomes too viscous to inject. The PRF was then distributed between the cheeks and nasolabial areas.
The patient tolerated the treatment well. Overall the treatment took 45 minutes; 30 minutes for numbing and 15 minutes of injection time. Photos were taken again immediately after the treatment.16 We reviewed the patient eight weeks after the treatment. She was very pleased with the outcome. Apart from small bruises, she did not experience any other side effects.
More photos were taken during this visit, and we analysed all photos for volume differences using our imaging system software. As seen in Figure 2, there was a significant change in volume immediately after the treatment. Figure 3 compares the photo taken at follow-up with the photo taken immediately after treatment. Although the volume was less at the follow-up visit, this change was not significant and the difference was probably due to swelling immediately post procedure. Figure 4 compares the change in volume before the treatment and at follow-up. There were no significant changes in overall facial volume between immediately after the treatment and eight weeks after, meaning that the volume lasted eight weeks. To maintain results, we recommend that patients have another treatment after 12 weeks as the skin quality and texture will improve each time. However, this varies from patient to patient as some can wait longer between treatments. As the tissues naturally limit how much revolumisation a patient receives, there is no risk of overfilling.
PRF is a safe and reliable treatment option for soft tissue rejuvenation and dermal augmentation. With the ability to restore lost volume, it adds to the ever-expanding list of aesthetic indications for PRP. Although it will not replace dermal fillers in aesthetic practice, it is an effective alternative for patients who might feel they are too young for dermal fillers and those who would prefer a more natural treatment.
Disclosure: Dr Vincent Wong and Dr Maria Toncheva are both ambassadors for PRP Lab UK.
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16. Data on file