Skin Rejuvenation and dermal filling using the body’s own cells MYCELLS (autologous platelet rich plasma)
INTRODUCTION:
Skin rejuvenation devices such as lasers (ablative and non-ablative), intense pulsed light (IPL) and radio-frequency (RF) rely on the body’s natural healing ability. The mode of action of these devices is controlled thermal injury of the skin followed by new collagen and elastin production and improved blood supply necessary for skin rejuvenation.
Softening of deep wrinkles and lines and augmentation of lips, cheeks and chin areas are currently treated mostly with non-permanent synthetic products such as hyaluronic acid (bacterial source) , calcium hydroxylapatite, poly-l-lactic acid, animal derived bovine collagen and hyaluronic acid and autologous lipofilling (using fat cells from other parts of the body to be injected in the face).The synthetic permanent product silicone, although illegally, are still being injected by some practitioners! The non-permanent products are eventually metabolised by the body and very little fibroblast stimulation takes place, except in the case of calcium hydroxylapatite and poly-l-lactic acid. Silicone is a permanent filler and has been linked to long-term complications such as chronic infection and disfigurement due to fibrosis. Some of these products have also been associated with hard nodule (granuloma) formation. Of all the products mentioned so far, autologous (body’s own) lipofilling (own fat tissue) is probably the safest because the product used is from another part of the same body and thus eliminates the risk of rejection (allergy). However, lipofilling requires sometimes general anaesthesia, a large gauge needle to inject it causing extensive swelling and bruising because of the high viscosity of fat cells.
Platelets on the other hand are cells present in the blood that play a part initially in cessation of bleeding and later in the healing of the wound caused by injury or surgery. This is also the case when a tiny wound is created by a needle injection (injury) of the skin.
Platelets, when present in body tissue outside the blood stream, are activated by various chemicals to release growth factors and to release chemicals that attract stem cells to the area of injury (Fig. 1). The growth factors stimulate cells such as fibroblasts to produce new collagen and the stem cells can change into epidermal cells that are normally present in the outer layer of the skin, fibroblasts in the dermis (deep layer of the skin) or even pre-adipocytes which are cells with the ability to convert into fat cells, important in the face to maintain plumpness. At the same time, production of new extra-cellular matrix (the substance that ‘binds’ cells together) and microscopic blood vessels take place.
Platelet Rich Plasma Applications:
Platelet rich plasma has been used with great success in clinical practice since the 1990’s. It was initially used to enhance wound healing in maxillo-facial surgery (dental implants and sinus elevations) and soon after became popular in disciplines such as heart surgery, orthopaedic surgery and dermatology (chronic wound healing). At present, platelet rich plasma is also utilized as a culture medium for cell expansion in the laboratory.
The latest application of autologous platelet rich plasma now includes cosmetic indications as well. This skin rejuvenation technique has been used since 2004 in countries such as Japan, United Kingdom, Spain, Portugal and Argentina to mention but a few. It is now also available in Ireland.
Autologous Platelet Rich Plasma:
The term autologous means that the source of origin is the patient’s own body and the source is not from another human donor or from animal origin. Thus, when a patient’s own platelet rich plasma is used to treat damaged or aged skin, the term autologous platelet rich plasma (A-PRP) indicates that the source of the platelet rich plasma is from the patient herself/himself. Platelet enriched plasma contains several million more platelets resulting in more growth factor release and more stem cell attraction compared to the normal wound healing process.
Because no external wound is created, patients can return to normal activity "immediately".
Radiofrequency differs from laser energy in that light (laser) energy tends to scatter or absorb in the upper layers of the skin, making it difficult to deliver sufficient energy to the deep layers without damaging the skin's surface. When comparing non-ablative techniques, lasers such as the Superior and NLite affect upper dermal collagen, improving fine wrinkles and skin texture, while radiofrequency affects the deeper dermis and subcutaneous layers, causing tightening but with little change in texture or fine wrinkling.
How can plasma be ‘enriched’ ? Several enrichment systems are in existence, but the majority are expensive and the process very laborious. A new way of enrichment is now possible in the practitioner’s own rooms or clinic and the whole process takes less than 30 minutes (excluding injection time).
Approximately 16 ml (2 tubes of 8 ml each) of venous blood is collected from the patient’s fore-arm and placed in a centrifuge for 10 minutes. Centrifugation separates the red blood cells from the plasma and platelets. The platelets in the plasma are now enriched 2 – 5 times compared to the native concentration in blood.
Effects of platelet activation: The platelets need to be activated prior to injection with CaCl2, because active platelets release growth factors and attract stem cells. The activated platelet rich plasma will react with fibrin present in the plasma to form a biologically active fibrin-strand ‘scaffold’ in the skin, contrary to a synthetic dermal filler that is not biologically active. The ‘scaffold’ hosts the platelets entrapped within the fibrin strands and over the next approximately 300 days new micro blood vessels (neo-vascularisation) grow into it as well as fibroblasts and stem cells (Fig. 2). The ‘scaffold’ is gradually replaced by normal extra-cellular matrix, cells and blood vessels resulting in natural tissue rejuvenation.
Injection techniques:
The autologous platelet rich plasma is injected either as a mesotherapy technique (multiple injections very superficially into the skin) or exactly like a synthetic dermal filler into wrinkles and lines and also for lip-, cheek- and chin augmentation. As already mentioned, the duration of the rejuvenation process is approximately 300 days, but the clinical effect should last longer because of new collagen and elastin formation.
Patient selection
From approximately age 27 years, our bodies produce less collagen and elastin and especially the skin of the face looses elasticity and begins to ‘sag’. This process is complicated by our environment (UV light exposure), our lifestyle (excess alcohol and smoking) and disease.
Age 30 – 40 years: In this age category the main aim is rejuvenation and prevention of collagen degradation and re-stimulation of new collagen and elastin production, thus attempting to slow down the ageing process. One treatment every 2-3 years is sufficient.
Age 40 – 50 years: In this age category the aim is rejuvenation and to attempt reversal of the ageing process which is more difficult. More re-stimulation of collagen and elastin production is necessary. The initial treatment should be followed by a second treatment 6 months later and a third treatment 9 months after the second treatment. Follow-up ‘maintenance’ treatments may be necessary every 12-18 months.
Age 50+ years: In this age category the aim is rejuvenation and to attempt more intense reversal of the ageing process. The initial treatment should be followed by a second treatment 3-6 months later and a third treatment 6 months after the second treatment. Follow-up ‘maintenance’ treatments may be necessary every 12 months.
Below
image, of 82 year old woman before and 3 months post treatment.
INDICATIONS:
Mesotherapy technique: This is a multiple minor skin puncture technique to improve skin texture but which does not necessary treat wrinkles and lines.
Dermal filler injection technique: This technique is aimed at treating fine wrinkles or lines as well as volumetric filling of the ‘tear trough’, eyelids, nose-to-lip lines, mouth corner lines, lips, and augmentation of lips, cheeks and chin areas. It is also indicated for acne scars.
CONTRA-INDICATIONS:
Platelet abnormalities, a low platelet count, infection in the area of proposed treatment, febrile illness, chronic liver disease and anti-coagulation therapy (warfarin or heparin).
CAUTIONS:
Aspirin, vitamin E and St. John’s Wort can facilitate more bruising than usual (blood ‘thinning’ effect). Patients do not have to stop taking these products, but must be warned of more potential side-effects.
PAIN CONTROL:
Topical anaesthetic cream 30-45 minutes pre-injections plus ice packs are most of the time sufficient in terms of analgesia. Very sensitive areas such as the lips and forehead areas may require infiltration with local anaesthesia. Ironically, the eyelids are not very sensitive although they are close to the eyes, because the skin is very thin and is effectively numbed with topical anaesthetic creams and ice. Patients are advised not to take any anti-inflammatory drugs such as ibuprofen or aspirin after the treatment, because these drugs suppress inflammation. Inflammation is one aspect responsible for platelet activation.
SIDE-EFFECTS:
Bruising is usually minor, especially when after the treatment a vitamin K containing cream is applied. Swelling is to be expected but usually settles down in 1-2 days’ time except around the eyes that can take 4-7 days to subside completely.
POTENTIAL COMPLICATIONS:
These complications have not yet been encountered when using autologous platelet rich plasma. They are also very rarely related to dermal filler injections such as collagen, hyaluronic acid, calcium hydroxylapatite, silicone and even autologous fat (lipofilling). Thus, the following complications can potentially occur when injecting platelet rich plasma: infection, direct injection into a bloodvessel or a nerve. However, it has to be emphasised that these complications can happen with any of the thousands of ‘filler’ products injected everyday on a world-wide basis.
Pre-treatment patient preparation:
Oral products: Patients are advised to start taking products that stimulate fibroblasts to produce more collagen such as vitamin C (1,000 mg daily and vitamin D (not more than recommended daily requirement) from 7-14 days before the day of treatment.
Topical products:Again, vitamin A cream and vitamin C serum 7-14 days pre-treatment will also start to activate fibroblasts. Patients are advised to continue indefinitely with these topical products in any event.
Combination treatments: Devices such as lasers (ablative and non-ablative), and radio-frequency (RF) stimulate fibroblasts to produce new collagen. These treatments can be used to enhance the effect of platelet rich plasma and vice versa. treatment and again RF two weeks after treatment and again IPL four weeks after treatment.
Combination treatments are certainly of great value in the age groups 40+ years.
CONCLUSION:
Autologous platelet rich plasma is a safe and cost-effective technique, using the patient’s own body to help in rejuvenating the skin in the face, neck, decolette (breast area) and back of the hands.
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