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ACR 2007
AUTOLOGOUS CELLULAR REGENERATION (ACR): COSMETIC APPLICATION 2007.
BOLANDCELL promotes through balanced review the new evolution and innovations in aesthetic biotechnology. Click-on PRP , and updated details on the use of Platelet Rich Plasma are provided.
ACR, in this overview is difficult to define accurately, but addresses a new innovative technology to combat age; rejuvenate the face by the direct use of platelet-derived growth factors, as an injectate. This new advanced technology is focused on facial skin rejuvenation by the application of platelet rich plasma (RRP). The pioneer in this field is Dr. M. J. Otto, Scientific advisor to Regenlab in Switzerland (see www.regenlab.com ). He practices as a Cosmetic Physician in Harley Street London (see www.cosmedicate.com ). Details of ACR for cosmetic purposes were presented at IMCAS-Paris (10-13 January 2007). Furthermore, the ACR dermal injection technique was jointly developed during 2006 by Dr. Kubota (Plastic Surgeon, Tokyo , Japan ) and Dr. Otto, Cosmetic Physician ( London , UK). See also Aesth Plast Surg 2005, 29:295-299 ( Growth Factors In Plastic Surgery: Chajchir et al). For background reading on PRP, the reader is referred to Professor Marx's textbook on PRP. It is state-of-the art.
Looking at the physiological response in time regarding the wound healing cascade, it is evident that wound healing time may well be shortened. Compacting of homeostasis, inflammation, tissue regeneration and tissue remodeling are affected.
Elastolysis is a degeneration of elastic fibers and is especially evident after the age of 60-years. Collagen derangement is also an important factor in the ageing process.
The proposed mechanism of action of ACR and the regeneration process by PRP are as follows:
- Intradermal and hypodermal injection of ACR rich plasma acts as a bio- scaffold.
- This facilitates the formation of a tri-dimensional fiber network.
- Release of growth factors by thrombocytes and leucocytes in a biologically determined ratio.
- Chemoattraction of macrophages and stem cells.
- Stem cell proliferation (mitosis).
- Stem cell differentiation.
THEORY BEHIND FACIAL REJUVENATION BY ACR: BOLANDCELL
Rejuvenation of the dermis is facilitated by the use of platelet-rich-plasma (PRP). This preparation in the activated form releases secretory proteins and platelet derived growth factors (PDGF, TGF-B, PF4, IL-1, PDAF, VEGF, EGF, PDEGF, ECGF, IGF, Oc, On, Fg, TSP-1). There is evidence to support this.
BOLANDCELL emphasizes that the following processes are affected through the use of platelet factors.
- Intracellular signal proteins
- Expression of gene sequences
- Cellular proliferation
- Matrix formation
- Osteoid production
- Collagen synthesis.
BUT HOW DOES PLATELET RELEASATE AND THE CYTOKINES WORK?
The evidence for the precise effect on wound healing is presently lacking. But it is logical that platelet factors that are released into a wound haematoma, after platelet activation will "kick-start" the wound healing and repair cascade. Possible mechanism forwarded by BOLANDCELL include:
- PDGF : is a mitogen for fibroblasts. Collagen synthesis is increased and elastosis is addressed. The ECM and ECM- network is rejuvenated.
- TGF -B1 : is a mitogen for fibroblasts, fibroblasts, stromal cells, osteoblasts and angiogenesis. Cytoskeleton is rejuvenated by elastin, fibronectin and laminin.
- VEGF : is a mitogen for angiogenesis
- EFG : is a mitogen for fibroblasts, EC and keratinocytes .
- EFG : facilitates epithelialization.
- Summary : Enhanced chemoattraction (fibroblasts) of ECM (collagen, elastin proteoglycan, multi-adhesive glycoprotein, stimulation of both fibroblasts and myoblasts). Overall effect is that the wound healing cascade is regenerated by the initiation of platelet secretory proteins in PRP. The reader is referred to Review of Medical Physiology, by William Ganong, 2005: Lange. Mc Graw Hill. See details on the inflammatory process.
Advantages of ACR : Dual effect of regeneration and rejuvenation of the face. But other surgical sites would benefit from this biological mode of rejuvenation by the action of platelet-rich growth-factors:
- Face lift flaps
- PRP mixed with keratinocytes may ameliorate acne facial scarring and pitting.
- Reduced surgical incision scarring and possibly keloid formation or hypertrophic wound scarring.
- Chronic leg ulcers (diabetic and non-diabetic).
Potential of ACR in Aesthetic Practice : Bio-glue, haemostatic and rejuvenation capabilities. Safe (because autologous plasma is used, the transmission of human and animal diseases are avoided), enhanced wound healing, user friendly process, convenience of being able to offer rejuvenation and the technology in the practitioners rooms, cost effectiveness. One ACR-kit delivers about 8-10 ml PRP (see www.regenlab.com ).
When not to use ACR : Persons with platelet disorders, fibrin abnormalities, sepsis, chronic liver disorders, and persons on anti-coagulation therapy (Aspirin and possibly Vitamin E). The latter will contribute to bruising and skin discolouration, especially the cheeks.
Preparation of PRP : this is done in the doctor's side-room or in theatre. Infrastructure needed:
- Centrifuge (FDA or CE recommended)
- Regen-kit® (tubes, needles)
- Platelet activator (calcium chloride, lignocaine, thrombin).
- Mask, gloves, trolley
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Basis of PRP : Place venous blood obtained from venesection from the medial cubital vein of the forearm, in tubes containing anti coagulation ACD). Centrifuge, avoiding cell fragmentation to obtain PRP, platelet poor (fibrin) and RBC layers. Aspirate off PRP and re-spin. Activate platelets with calcium chloride/ thrombin which form a gel. See click-on button for PRP for detailed review.
Informed consent : is needed and the patient should be informed that swelling and bruising can occur (volumetric effect!). An example is given in Professor Marx's excellent book on the application of PRP (Dental and craniofacial applications of platelet-rich plasma: 2005. Quintessence Books).
Areas of facial Rejuvenation: amelioration of wrinkles, scars and lines
- Cheeks (zygomatic)
- Eyelids ( care is needed and anatomy and physiology must be reviewed)
- Chin
- Naso-labial
- Lips
- Forehead
Injection Techniques
Physicians need hands-on training (by workshop) to facilitate the serial puncture and linear threading technique (both recommended for the treatment of wrinkles and folds ). Needle choice is as follows:
- Linear threading : 30 g needle for eyelids
- Rest of face : 27 g needle
- For shaping of facial contours ; a fan and cross hatching technique has been found to be useful. Local lignocaine and nerve blocks are advisable. A discoloration may occur and NSAIDS must be avoided if possible.
Potential Side-effects and Complications of ACR
BOLANDCELL ACADEMIC REFERENCES ON PRP
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Marx R. E. Platelet-Rich Plasma: Evidence to support its use. J Oral Maxillofac Surg. 62:489-496, 2004.
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Pietrzak W. S, Eppley B. L. Platelet-Rich Plasma: Biology and New Technology. J Craniofasc Surg, 2006,16:1043-1054.
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Robiony M, Polini F, Costa F, Politit M. Osteogenesis distraction and Platelet-Rich Plasma for bone Restoration of the severely atrophic mandible: preliminary results. J Oral Maxillofac Surg, 60: 630-635, 2002.
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Della Valle A, Sammartino G, Marenzi G, Tia Mariano, Di Lauro A. E, Ferarri F, L. Lo Muzio. Prevention of post-operative bleeding in anticoagulated patients undergoing oral surgery: use of Platelet-Rich Plasma Gel. J Oral Maxillofac Surg, 61:1275-1278, 2003.
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Freymillar E. G, Aghaloo T. Platelet-Rich Plasma: Ready or Not? J Oral Maxillofac Surg, 62: 484-488, 2004.
- Man D, Plosker H, Windland-Brown J. E. The use of autologous platelet-rich plasma (platelet-gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg. 107: 229-237, 2000.
- Eppley B. L, Woodell J. E, Higgins J. Platelet quantification and Growth factor Analysis from Platelet-rich plasma: Implications for wound healing. Plast Reconstr Surg, 114:1502-1508, 2004.
- Roukis T. S, Zgonis T, Tiernan B. Autologous Platelet-Rich Plasma for wound and Osseous Healing: A review of the literature and commercially available products. Advances in Therapy. 23,:218-237, 2006.
- Eppley B. L, Pietrzak W. S, Blantou M. Platelet-Rich Plasma. A Review of Biology and Applications in Plastic Surgery. Plast Reconstr Surg, 118:147 e-159e, 2006.
- Bhanot S, Alex J. C. Current applications of platelet gels in facial plastic surgery. Facial Plastic Surgery, 18:27-33, 2002.
- Marlovits S, Mousavi M, Gäbler C, Erdös J, Vécsei V. A new simplified technique for producing platelet-rich plasma: A short technical note. Europ Spine J 13 (Suppl1): S102-S106, 2004.
- Cenni E, Ciapetti G, Pagani F, Giunti A, Baldaini N. Effects of activated platelet concentrates on human primary cultures of fibroblasts and osteoblasts. J Periodontol, 76:323-8, 2005.
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Du Toit DF, Otto MJ, Kleintjes WJ, Morkel JA. Current controversies in the application of platelet-rich plasma and growth factors in maxillo-facial surgery and oral surgery. SADJ 2007, In Press.
 
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