COSMETIC PRP OR HYALURONIC DERMAL ACID FILLER FOR FACIAL WRINKLES?  WHICH OPTION?

Work has been in progress for several years with the application of PRP in aesthetic medicine in various countries such as Japan, England, China, Thailand, Australia, Germany, South Africa, Taiwan, Chorea, to mention a few. For those of us toiling in the field of operative and non-operative facial-rejuvenation of facial wrinkles it is clear that we are still selling “hope” and cannot ensure permanence of wrinkle amelioration with autologous platelet-rich plasma or gel.  BUT WHERE DO WE NOW STAND 4-YEARS LATER WITH PLATELET-RICH PLASMA (PRP) IN AESTHETIC PRACTICE AIMED AT AMELIORATION OF FACIAL WRINKLES OR AGE-RELATED BLEMISHES? PRP is still looking for an aesthetic indication, although it seems to have modest regenerative or rejuvenating characteristics. In contrast, more than 16 million doses of FDA-approved hyaluronic-acid have been administered to address the ageing process and facial wrinkling and we now have a  good idea when and when-not to use a filler. That goes for IPL, Lasers and RF. PRP was introduced into the filler-market or antiaging field (using your own cells to beautify or regenerate oneself as an anti-aging device) and the initial enthusiasm has now worn off. For the skilled user of fillers, light-therapy and mesotherapy,  it is quite obvious that platelet-rich plasma (PRP), compared to established fillers (i.e. Juvederm® or Restylane®) cannot achieve certain goals in end-point analysis in the restoration or reversal of wrinkles and has proven reasonably disappointing ( for clients and doctors), although it has a place:

• PRP is not a filler nor is the plasma-gel a filler and has not lived up to proposed initial rejuvenation expectations. Non-responsiveness and irregular results are problematical compared to the more consistent use of hyaluronic acid dermal fillers.
• PRP does not provide any stem cells, whatsoever.
• PRP induces very modest skin-morphological changes and rejuvenation on skin testing.
• PRP rejuvenates by platelet-derived GF’s  and possible fibronectin etc.
• PRP repairs the injection pricks with the GF released by the harvested platelets contained in the PRP and enhances the local inflammatory-process including the recruitment of mesenchymal-cells. Resident stem cells may play no role at all.
• PRP does not provide volume and is not a volumetric enhancer. For this one needs particulate matter. See reference by Ohrlund et al 2009 ( ref 12).
• PRP effect lasts for 3-6 months and does not reach the 12-months rejuvenation potential of Restylane®.
• PRP may enhance the result of fat-transfer if mixed with the fat-injectable.
• PRP is unable to enhance or plump a lip as seen after Restylane® rejuvenation (need for particulate matter).
• PRP does not have the impact or level of evidence to compare with Macrolane® for facial malar enhancement or breast enhancement.
• PRP cannot replace lost hyaluronic acid as seen in aging skin.
• PRP (REGENKIT®, MyCells®, Neokit®) is far more expensive than conventional hyaluronic acid fillers, needs topping up at 6-months and enhancement with RF or light-therapy at 3-months. But fillers also need topping up and also cannot completely turn back the “ aging clock”).
• PRP has not proven superior to conventional hyaluronic-acid fillers such as Restylane® or Juvederm®.
• Based on existing evidence, the intervention of choice for the short-term amelioration of facial wrinkles in an appropriate or compliant client with high aspirations would include Botox® or hyaluronic-acid filler (Juvederm® or Restylane®) rather than platelet-rich plasma (PRP).

Table 1: Shows Clinical Proof-of-Science ( PRP vs Hyaluronic Dermal Fillers) relevant to aesthetic and anti-aging practice. BOLAND CELL 2010©.

GENERAL BACKGROUND READING RELEVANT TO THE USE OF INJECTABLES, HYALURONIC-ACID FILLERS, DERMAL FILLERS, HYALURONIC ACID IMPLANTS.

DORLAND’S ILLUSTRATED MEDICAL DICTIONARY defines hyaluronic acid as a glycosaminoglycan found in joints, eye, cartilage, blood vessels, skin and the umbilical cord. In the extracellular matrix, the hyaluronan molecule is a core-protein. The fibroblast , a protein-secreting  cell is intimately related to production of proteoglycan, collagen and elastin and is an important component of connective tissue: 3 variants play vital roles in wound-healing; fibroblasts, fibrocytes and myofibroblasts. The dermis consists of connective-tissue and varies in thickness. Dermal-papillae are prominent in special areas. Other components consist of ECM, oxytalan fibers, elaunin fibres, elastin and collagen fibres. The area is rich in A-V shunts, blood vessels and lymph channels.

BIOLOGICAL MODALITIES FOR FACIAL SKIN REJUVENATION

• Facial rejuvenation with autologous platelet-rich plasma or gel ( platelet-rich plasma, A-PRP, REGENKIT®, Plateltex®, MyCells®, Neokit®) or fat transfer (Lipokit®).
• Facial rejuvenation with hyaluronic-acid implants/fillers: Juvederm®, Restylane®.
• Facial rejuvenation with living-cells (fibroblasts): Isolagen®.
• Facial rejuvenation with platelets/gels/growth factors (ACR/PRP): REGENKIT®, Plateltex®, MyCells®, Neokit®.
• COSMETIC PRP: REGENLAB™, from Le Mont-sur-Lausanne, Switzerland has emphasized that REGENLAB -generated autologous platelet-rich plasma (PRP) is directed at tissue-repair, biocellular-regeneration and regenerative medicine thinking. PRP-generation device, products including blood-collection tubes are distributed by Gauteng-based Omnimed (PTY) (LTD) (www.Regenkit.com).  Dr Alain Gondinet has presented important data on PRP in the East and Professor Don du Toit at IMCAS-2008.In South-Africa, REGENLAB-PRP® is the most cost-effective and renders superior platelet-counts and yields compared to other products and competitors. It is widely used in aesthetic-medicine and clinic, and the PRP of choice. Autologous-PRP is one arm of the aesthetic specialist’s armamentarium and compliments RF, MDA, peels, IPL and laser treatments. PRP is not a general panacea for facial wrinkles, but can help with rejuvenation. Provided rules are adhered to, the product is safe to use. FDA has given the “nod” to use PRP clinically (November 2009). Medically registered persons need training in the use of biologicals for facial-rejuvenation purposes. Generally speaking, 2-3 collection-tubes are needed for face and neck-rejuvenation. Sometimes three. Minor swelling after treatment is common and subsides. This is because of intradermal-injection of plasma derived from a small sample of the client’s blood. PRP should not be injected close to the eye. No other treatments should be tried on the day the PRP is injected. Modest amelioration of fine wrinkles can be expected and reported in level-2 evidence based clinical-studies. For optimal results resurfacing, with plasma is needed twice a year. PRP-mesotherapy has become a fairly popular cosmetic treatment and is far safer than laser-treatment.
• REGENKIT® AND NEOKIT®: NEW GENERATION PLATELET-RICH PLASMA PREPARATIONS: The two most popular PRP-products in South-Africa include REGENLAB-PRP® and MyCells®. Other role players have entered the market place including PLATELTEX®. It is a rapid setting gel. MyCells®, an Israeli-based product, has recently during November 2009 received a nod from the FDA for clinical use, and currently needs acceptance by the medical community. Sales have been recorded in Europe and Japan and launching in the USA is expected. In South-Africa, MyCells® is distributed by Neokit (PTY) (LTD), a Durbanville-based company in the Western Cape. Most salons and clinics favour the use of REGENKIT-PRP® because of cost-effectiveness and the consistency of treatment compared to newer competitors.  In South Africa some clinics are hesitant to use autologous PRP for facial rejuvenation, because of the possible sensitivity of product-failure (or clinical failure, or no-response) and the potential loss of clients. So, resistant to change and prefer to stick with tried and tested  treatments such as superficial chemical-peels and LED-photofacial, for which there is robust science and proof-of-concept. PRP costs more than ten-times the price of a peel and incurs significant cost to the salon,  that can affect cash-flow. A very heavy professional fee is needed to recover the salon-costs of PRP consumables such as tubes . To get started, the doctor will need a kit or tubes, and a centrifuge. The initial financial layout for the equipment is about R45,000. Consumables such as tubes are very expensive thereafter, and range from R1200-R1300 per tube (remember 2-3 tubes are often needed per client).These are far more, and cost ineffective compared to injectable fillers.
• A cost-analysis (cost to the salon) is reflected in other sections of this website and compares the current cost-price of other products such as Juvederm®, Botox®, Cosmelan/Dermamelan® and PRP devices. In the current financial crises, when cosmetic budgets are compromised, careful planning is needed. This is a realistic comparison as the most common conditions treated in a beauty salon include wrinkling, solar damage, sagging, and pigmentation. Also, the assessment is based on the most popular treatments such as Botox®, fillers, peels and IPL/Laser rejuvenation.

UPDATE 2010 AND  FACTS ON DERMAL FILLERS OR HYALUROIC ACID INJECTABLES:

• Hyaluronic -acid is an integral part of the ECM.
• Synthetic forms of hyaluronic-acid have proven effective as a temporary measure to treat frown lines, Marionette lines, forehead lines, Crow’s feet, cheek depressions, redefining the lip border. Often the results persist for 12 months that is pleasing to the client.” Top-ups” are usually needed. In most cases, hyaluronic-acid therapy (filler) is well tolerated. Small nodules at the injection site can persist for months. Most often this phenomenon cannot be prevented and is a feature draw-back of fillers. Restylane® has a proven track-record with over 10 million treatments worldwide. The incorporation of lidocaine in Restylane® has made the injectable very comfortable.

REFERENCES RELEVANT TO SKIN REJUVENATION WITH AUTOLOGOUS PLATELET-RICH PLASMA (PRP) OR ACR/PRP:

• Dardik T et al. Evaluation of the molecular mechanism underlying the regenerating effects of MyCells® (Abstract 2008).
• Du Toit  DF et al. New research developments and advances in the application of autologous cellular regeneration (ACR) and platelet-rich plasma in South Africa. The Specialist Forum. 2007: 7; 30-31.
• Du Toit DF et al. Stem-cell science and regenerative medicine: latest trends in biological wound care. The Specialist Forum 9:23-27, 2009.
• Du Toit DF et al. New advances in biological wound-care and aesthetic-medicine. The Specialist Forum  9:27-33, 2009
• Du Toit DF. Rejuvenation of the ageing-face by mesotherapy and autologous platelet-rich plasma (PRP) ( Abstract: IMCAS 2008 Conference Paris, 9-12, 2008).
• Du Toit DF et al. Soft and hard-tissue augmentation with platelet-rich plasma: tissue culture dynamics, regeneration and molecular biology perspectives. Int. Journal of Shoulder Surgery 1: 64-73, 2007.
• Du Toit DF. Skin-analysis is essential before facial non-ablative light or biological therapy. South African Aesthetic Review : 25-29, 2008 ( incorporating PRP facial-mesotherapy).
• Mazzuco L et al. Platelet-rich plasma and platelet gel preparation using Plateltex®. Vox Sang 94: 202-208, 2008
• Marx RE et al. Dental and craniofacial applications of Platelet-Rich Plasma. Quintessence, Chicago 2005.
• Junguiera LC. Basic Histology. 10th ed, Saunders, Lange, 2003
• Kierszenbaum AL. Histology and cell biology. Mosby, 2003
• Ohrlund A et al. Size and shape of gel particles in hyaluronic-acid dermal fillers . Congress of The European Academy of Dermatology and Venereology ( EADV), Berlin, October 7-11, 2009.

DISCLAIMER: This website provides no medical or aesthetic advice. The doctor advises and the client has a choice or declines therapy. Patient’s should contact a dermatologist, plastic surgeon of aesthetic physician regarding aesthetic or beauty-therapy for treatment options, draw-backs and complications.

ABOUT BOLAND CELL: International Biomed Experts, specialist clinicians and IMCAS Faculty 2008, CBA.

WEB-POSTING: 7 December 2009.