PRP FACE LIFT: COSMETIC AUTOLOGOUS PLATELET-RICH PLASMA OPTION FOR FACIAL REJUVENATION

COSMETIC PRP: REGENLAB™, from Mollen, Switzerland has emphasized that REGENLAB -generated autologous platelet-rich plasma (PRP) is directed at tissue-repair, biocellular-regeneration and regenerative medicine thinking (www.regenlab.com). PRP-generation device, products including blood-collection tubes are distributed by Gauteng-based Omnimed (PTY) (LTD).  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.

BIOMEDICAL SCIENCES RELEVANT TO WOUND HEALING AND USE OF AUTOLOGOUS PLATELET-RICH PLASMA (REGENKIT® OR NEOKIT®, MyCells®)
The three phases of wound healing are as follows:

• Inflammation: days 0-6
• Proliferation: days 4-14
• Maturation: days 8->16

Deposition of wound matrix composition over time:

• Early matrix: day 0-6: fibronectin and collagen type III deposition
• Later matrix: days 2-16+: collagen type I (associated to wound-breaking strength.

Wound healing: cellular proliferation with time:

• Neutrophils: day 1-6
• Macrophages: day 1-13
• Lymphocytes: days 1-17
• Fibroblasts: day 5-17+ (After Janis JE et al. Current Concepts in Wound Healing. Plast Reconstr Surg 117: June supplement 18s-31s, 2006 and Surg Clin North Am. 77: 509, 1997).

General remarks:
PDGF and EGF are the main signals for fibroblast proliferation and released by platelets (as in PRP) and macrophages. TGF-beta-1 helps transform “wound fibroblasts” to myofibroblasts. PDGF promotes fibroblast release of provisional matrix, collagen type III, glycosaminoglycans and fibronectin. TNF-alpha upregulates integrins that helps anchor cells. TGF-beta directs extracellular matrix production including collagen I release from fibroblasts. Autocrine and paracrine signalling is important with PDGF.

GROWTH FACTORS released  by platelets in autologous platelet-rich plasma: Include PDGF (AB), transforming GF-beta, VEGF, and fibroblast GF. These have been quantified and verified in top class laboratories. In one recent study PLATELTEX (which uses Batroxobin® instead of thrombin to induce platelet-gel) has been shown to release equivalent amounts of GF as competitors. Of special interest is that Plateltex® releases the anabolic GF slowly giving a prolonged action and therefore more effective signalling for wound healing. See Mazzuco L et al. Platelet-rich plasma and platelet gel preparation using PLATELTEX®. Vox Sanguinis ( 2008).

Nitrous oxide (NO) plays a role in wound healing: vasodilatation, antimicrobial action, antiplatelet aggregation activity, and improved vascular permeability. In the inflammatory cascade NO peaks at 3 days and then rapidly declines by day-15. This is the phase in which neutrophils are prominent and deposition of collagen III and fibronectin occurs. At this time NO down-regulates MCP-1 which may transform the wound from an inflammatory state towards regeneration and repair. Low doses of NO are known to stimulate endothelial cells and keratinocyte proliferation. NO also plays a pivotal role in wound healing.  NO regulates VEGF, an angiogenic GF released by platelets in PRP and in the wound. There is a strong relationship between NO and collagen deposition.

T-Lymphocytes play an integral role in wound healing as well. Inflammatory T cells express IL-2, IFN-alpha and TNF-beta. Helper T-Cells express IL-4, IL-5, IL-6, IL-10 and IL-13. Cd4+ to CD8+ ratios is important. CD4+ is upregulatory and CD8+ is downregulatory. Addendum to text 11/11/2009.

KEY REFERENCE: Marx E et al. Dental and craniofacial applications of platelet –rich plasma. Quintessence, New York,  2005. REGENKIT® AND NEOKIT®: NEW GENERATION PLATELET-RICH PLASMA:

The two most popular PRP-products in South-Africa include REGENLAB-PRP® and MyCells®. Other role players have entered the market place including PLATELTEX® (www.plateltex.com). 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 (www.my-cells.net). 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 (www.neokit.biz). 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, which 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).
A cost-analysis (cost to the salon) is reflected in the following realistic table below 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.

• Hydroquinone prescription for melasma costs R80 per client
• Isolagen R25,000 ( discontinued)
• REGEN®® (R800 per tube; MyCells® R1300 per tube)
• Neostrata® cosmeceutical creams: vary from R250-R300 per tube

The cost analysis Table-1 gives the salon-management an opportunity to consider what the costs will be to purchase such stock and go down a risky financial road where they may never re-coup their expenses. Especially regarding purchases of Botox, filler, PRP-kits  and Cosmelan®. To have the products in stock, costs money, and effects the cash-flow of the salon. These costs impact negatively on the running cost of the salon, especially where rental and therapist-salaries are costly.

PRP ( autologous  platelet-rich plasma,  ACR or  A-PRP) COSTS: REGENLAB® blood-collection tubes are a third cheaper than Neokit’s, MyCells®.  This is important when considering a PRP-product for the salon. The salon needs comparative prices from distributors. Keeping a large stock of PRP-tubes in reserve, is beyond the budget of all smaller salons. Centrifuges are costly, and need maintenance. On-hands training are needed under supervision. Smaller new desk-top  4-barrel/cartridge centrifuges are available in South-Africa and cost about R4000. These also produce quality PRP and are a saving up to R25,000 on larger cumbersome centrifuges.

BOTOX®  and Chemical Peels: Botox® was always known to be expensive, but is a highly effective product a salon cannot do without. PRP cannot achieve what BOTOX® or DYSPORT® offers. PRP cannot take the frown-line away or make the forehead flat. Chemical peels and LED-photofacial rejuvenation is very popular and far less expensive than platelet-rich plasma. Buying two tubes to generate the PRP will cost between R1600 and R2400. This cost is very difficult to re-coup in a small salon. Regen® is cheaper than Mycells® collection tubes. MELASMA treatment costs: Hydroquinone is recommended by most dermatologists  in concentrations varying between 1-5%. There is level-1 evidence and publications to support this. In most cases melasma is incurable but can be palliated. Recurrence is common after treatment has stopped. Hormone-stressors should be stopped and the condition will improve. Sunscreens are important. It is mainly a cosmetic issue and generally is a harmless dermatological condition. Cosmelan® is exceedingly expensive, and beyond the budget of most salons and clients in Cape Town. Application thereof will be needed for about 12-months (maintenance therapy), costing the client more than R1500 per month, excluding the professional-fee. Keeping  Cosmelan® Packs in  stock is far too expensive for smaller salons with low client turn-over. A hydroquinone prescription is far more cost-effective and probably more effective.

DISCLAIMER: This website provides no medical advice. Patient’s should contact a dermatologist, plastic surgeon of aesthetic physician regarding aesthetic or beauty-therapy for treatment options.

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

REFERENCES RELEVANT TO AUTOLOGOUS PLATELET-RICH PLASMA (PRP):

1. Dardik T et al. Evaluation of the molecular mechanism underlying the regenerating effects of MyCells® ( Abstract 2008).
2. 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.
3. Du Toit DF et al. Stem-cell science and regenerative medicine: latest trends in biological wound care. The Specialist Forum 9:23-27, 2009.
4. Du Toit DF et al. New advances in biological wound-care and aesthetic-medicine. The Specialist Forum  9:27-33, 2009
5. Du Toit DF. Rejuvenation of the ageing-face by mesotherapy and autologous platelet-rich plasma (PRP) ( Abstract: IMCAS 2008 Conference Paris, 9-12, 2008).
6. 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.
7. 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).
8. Mazzuco L et al. Platelet-rich plasma and platelet gel preparation using Plateltex®. Vox Sang 94: 202-208, 2008
9. Marx RE et al. Dental and craniofacial applications of Platelet-Rich Plasma. Quintessence, Chicago 2005.

WEB-POSTING: 9 November 2009.

TABLE 1: TECHNICAL PERFORMANCE ANALYSIS, STANDARDIZATION, COMPARATIVE  AND VERIFICATION DATA REGARDING PLATELET-RICH PLASMA ( A-PRP) OF VARIOUS PRODUCTS WITH THE SAME INTENT IN AESTHETIC FACIAL REJUVENATION . INCLUDES CELL-BIOLOGY DATA. ( After Du Toit,  Mazzucco et al and MJ Otto© 2009).

Source: Du Toit et al. Int J Shoulder Surg 2007: 1; 64-73. Mazzucco et al. Vox Sanguinis 2008,2:1-5.  M.J.Otto©2009. Borzini P et al. ISBT Science Series 2007, 2: 272-1726.
Comment: PRP is classically used for the growth factor content and not stemcells. As far as we know the few CD34+ cells in peripheral blood and PRP are physiological as seen after  excersize and commited, thereby losing totipotency. There is no level of scientific evidence to suggest that these small numbers of CD34+ cells play any role in skin-rejuvenation. There are too few. Normally, to gain the benefit of BMSC, one would need a marrow aspirate to gain sufficient numbers of cells, but this approach is not ethically appropriate for skin-rejuvenation. Currently, it is not known if non-activated PRP works properly. Few products can show by cell-biology, that they can stimulate HSC ex vivo  in tissue-culture and that a product proliferation-ratio can be studied. Web-posting  and updating 31/3/2010