This overview provides data on the clinical application and preparation of human PRP by REGENKIT , and earlier methodology pioneered by Dr. Robert Marx of the United States . REGENKIT TM is produced in Mollens, Switzerland by a patented process ( REGENLABT ), and the side-room generation of autologous platelet-rich plasma ( PRP for ACR ) for medical, dental, oral, and aesthetic medicine is available in South Africa as of July 2007 ( see www.REGENLAB.COM ). Not all PRP generated in labs is the same (Marx et al 2005), and few commercial preparations meet entry and benchmark requirements ( backed by scientific publications in this regard), except REGENLAB PRP/ACR , regarding ex vivo molecular and cell biology testing and proliferative cell index for connective tissue cells. Product quality assurance backed by molecular and cell biology testing is critical, as is the case with REGENLAB KITS that are benchmark at the present time. Other biological preparations are not suitable for clinical application. Specialist consultants, schooled in the art of tissue regeneration and renewal by PRP and autologous cellular regeneration (ACR), and molecular cell biology, currently assist surgical specialities in South Africa, maxillo-facial surgeons, practitioners , dentists, aesthetic physicians and plastic surgeons in their rooms and theatres with the optimal and correct application thereof.
REGENKIT TM offers health-care providers opportunity of using autologous, platelet-rich plasma (PRP) for induction of tissue regeneration, repair and enhanced biological wound healing. The concept of PRP was pioneered in the USA by Dr Robert Marx ( Marx et al 2005): REGENKIT has been in use in England , Switzerland , Europe, India , Chorea , Malaysia , Japan and Thailand including other markets in Asia . Autologous PRP has been in clinical use for about 10 years and has been shown to be effective and safe is applied for the correct indications and under supervision. Wound healing and tissue regeneration is enhanced by the anabolic growth factors released by activated human platelets in PRP. Therefore PRP has unique wound healing benefits, possibly by shifting the wound healing cascade to the left, as well as sealant properties. The GF include release of PDGF, TGF, IGF, EGF, VEGF which facilitate regeneration of the extra cellular matrix, by unique actions on stem cells, fibroblasts, myofibroblasts, myoblasts, keratinocytes, chondrocytes, adult adipose derived stem cells, Schwann cells etc. In Cape Town , an expert in miolecular cell biology, advises private and academic specialists in the use of PRP and ACR. This entails advanced updates on cell biology including aspects of cell signalling, cell kinetics, crawling, ruffling, filo-and lamellapodia development including tissue markers, immunological aspects, cell differentiation and phenotypic morphological aspects relevant to the clinic and well being of patients. This encludes consultant advice on the tissue engineering as well as the availability of ReGenExtracellT technology, which avails the specialist with PRP and keratinocytes for wound repair and regeneration. Supportive publications are available for assistance ( see Don du Toit et al. SOFT AND HARD TISSUE AUGMENTATION WITH PLATELET-RICH PLASMA:TISSUE CULTURE DYNAMICS, REGENERATION AND MOLECULAR BIOLOGY PERSPECTIVES: IJSS 2007 1:64-73 : further supportive publications include STATE-OF-THE ART APPLICATION OF PLATELET-RICH-PLASMA, THE SPECIALIST FORUM,SEPTEMBER 2007). This latter review avails the specialist with synoptic and academic input regards the application of PRP/ACR in cardiovascular surgery, orthopaedics, diabetic feet management, wound healing, plastic surgery, burns, eye surgery, neurosurgery, dental oral and maxillo-facial interventions( sinus augmentation and implant surgery).Emphasis is on clinics, specialist application, safety, efficacy and molecular and cell biology perspective basis regarding quality assurance.
The new technology, now available in South Africa , addresses tissue regeneration especially skin, cartilage, muscle, tendon, adipose tissue, cornea, peripheral nerves, spine, pancreas including islet cell regeneration.
REGENKIT TM ( see www.acr-prp.com , www.regenlab.com ) successful application and unsurpassed implementation in South Africa and other countries is based on:
AVAILIBILITY OF REGENLAB KITS IN SOUTH AFRICA
- CE mark, ISO registration, CTI certification, SwissMedic registration, Swiss Biotech approval
- Scientific marketing strategy by experts with identifications in new trends
- Ease of use, and availability in side rooms and theatres at low capital cost
- Consultation service available in the privacy of specialist rooms on individual basis supported by commerce
- Support service for specialists and health care providers
- Authorization for human use
- Safety profile by nature of the autologous nature
- Academic publications and scientific presentations including peer-review and live demonstrations available in South Africa
- Efficacy of RegenACR in dermal regeneration and volumetric therapy profile via autologous cell rejuvenation in South Africa
- Extensive molecular and cell biology quality assurance, regarding cell dynamics and cell proliferative efficacy ( including publications to address proof-of-science) in South Africa
- Extensive case studies in clinical application, in South Africa
- Product back-up, consultation service, informative surgeon education program in South Africa
- Cost effectiveness compared to competitors in South Africa
- 24-hour availability of expert consultation in the clinical use of biologicals including platelet-rich-plasma in dental, medical and aesthetic medicine with cell biology input and expertise in South Africa
- Competative edge over other competitors and competition regards, scientific expertise, product service, scientific publications, consultative service by specialist clinician and cell biologist with wide experience in academic, state and private health care service in South Africa
The following REGENLAB KITS are available in South Africa for blood harvesting, processing, blood separation and PRP generation . Each one is specially developed to cater for the needs of the clinician or dentist and correct application/indication.
- Regenkit ATS-A/THT ( THT glass tubes): surgery. Includes double syringe spray applicator, calcium chloride and alcohol ampules.
- Regenkit AZ/BCT ( BCT polyester tube): surgery.Includes two BCT polyester tubes, calcium chloride and alcohol ampules, and spray applicator.
- Regen ACR-C/BCT ( BCT polyester tube): aesthetics. Includes, blood withdrawl set, two BCT, polyester tubes for blood collection, needles and syringes with one ampule of calcium chloride. A spray applicator is not needed with this kit but the specially sized 30 gauge needles should be used.
- Regen BCT-D1 ( BCT polyester): diabetic foot and dental. Kit includes one ET vacuum tube, one BCT vacuum tube, one ampule of calcium chloride and alcohol. This kit does not have a spray applicator in it.
- Regenlab/extracell ( PRP and cells) available during 2008 with keratinocytes ( aimed at rapid biological resurfacing with autologous keratinocytes)
REGENLAB provides top of the range biotechnology and 5 kits for your PRP/ACR needs and convenience, product availability, testimonials, and each one can be tailored made with consultation backup and product service, country wide. Be it therapeutic regeneration/rejuvenation of aesthetic use. All the REGENKITS except the ACR-C/BCT are packed with applicator device ( double syringe for spray on). Illustrations are provided for specialists requiring more knowledge on individual kits. Click on the images with the mouse and the label is provided for the appropriate kit. All kits are inclusive, sterile, practical, CE marked, authorised for human use and complete for clinical use either in the rooms or theatre.
REGEN ATS NOW AVAILABLE FOR DERMATOLOGY AND PLASTIC SURGERY IN SOUTH AFRICA
- Chronic wounds ( suitable for RegenPRP )
- Skin grafting ( donor site)
- Skin grafting: recipient site ( Zimmer meshed): With RegenPRP and PRP+K ( keratinocytes)
- RegenACR: Dermal regeneration volumetric therapy via" Autologous Cell Rejuvenation". " A biostimulation injection technique that utilises the patient's own bioactive platelet rich plasma ( RegenPRP ) with the aim to regenerate aged and damaged skin and hypodermal tissues"
- RegenKIT: ATS & ACR ( PRP protocols)
UPDATES ON PRP AND CLINICAL APPLICATION FROM THE SCIENTIFIC LITERATURE RELEVANT TO CLINICAL AND DENTAL PRACTICE IN RSA.
CLINICAL APPLICATION OF PLATELET-RICH-PLASMA (PRP) IN SOUTH AFRICA
- PRP and PPP can be sprayed onto wounds, and both possess haemostat properties (Pietrzak et al 2007). There are unique aspects of spray applied hemostatic agents .
- These autologous products may be used as haemostats to reduce surface wound bleeding. These act as topical haemostats.
- Several systems are commercially available to intraoperatively produce PRP from a total blood draw of 45-60 ml ( Pietrzak et al 2007)
- PRP has positive wound healing effects.
- The addition of thrombin and calcium to PRP and PPP allow both preparations to gel.
- Some workers have been successful in obtaining haemostasis in iliac crest donor sites using calcium chloride/ thrombin-activated PPP
- In Pietrzak's publication (2007) he referred to other studies where PRP applied during wound closure after total-knee arthroplasty provides measured outcomes and reduced requirements for transfused blood
- Commercial availability of fibrin sealants prepared from pooled blood increase the risk of disease transmission ( Pietrzak et al 2007)
- Eppley et al 2003, of the USA , has indicated that PRP achieves hemostasis through the formation of a fibrin clot that is initiated by the activation and aggregation of platelets. They go on to state that the clot is generated by the polymerization of fibrin from the monomer fibrinogen in the presence of calcium and thrombin. The fibrin clot then provides a matrix for the migration of tissue-forming cells, including fibroblasts that are responsible for collagen synthesis and endothelial cells involved in angiogenesis. Clearly, tractional forces generated by the migrating myofibroblasts on the fibrin clot can aid in wound contraction. This allows for remodelling of the clot into repair tissue ( Eppley et al 2003). PDGF has reported chemotactic effects on monocytes, neutrophils, fibroblast, mesenchymal stem cells and osteoblasts. TGFB is a mitogen for fibroblasts, smooth muscle cells, and osteoblasts. VEGF promotes angiogenesis and can promote healing of chronic wounds. EGF is a mitogen for fibroblasts, endothelial cells and keratinocytes all relevant for chronic wound healing. IGF can regulate bone maintenance, is an important modulator of cell apoptosis and together with PDGF can promote bone regeneration.
- Marx et al study of 1998 showed that combining PRP with autogenous bone in mandibular continuity defects resulted in significantly faster radiographic maturation and histomorphometrically denser bone regenerate.
- In Freymillar's publication of 2004, they highlight that platelets are responsible for increasing cell mitosis, increasing collagen production, recruiting other cells to the site of injury, initiating vascular in-growth, and inducing cell differentiation.
- Preparation of PRP is relatively simple but platelet counts can be variable. Centrifugation speeds are relevant and two spins may be advisable to concentrate the platelets into a small pellet. REGENPRP renders the most consistent results at the moment and the best separation technology and most practical kits available in South Africa .
- The clinical use of PRP for a wide range of applications has been reported in the scientific literature, most prevantly in the problematical wound, maxillofacial, and spine areas ( Eppley et al 2006). Application in cardiovascular surgery, and burns have recently been reported. Usage of PRP in aesthetic medicine to treat rhytids and the sagging face has recently been presented at IMCAS ASIA 2007 in Bankok.
- The secretory proteins released by activated platelets play an important direct and indirect role in the wound healing cascade.
- REGENLAB and REGENKIT provide techniques for the autologous concentrating process of a blood specimen and have streamlined the extraction of PRP, allowing accessibility of platelet gel technology to almost most physicians abroad, and in South Africa .
- A further use of PRP in the treatment of chronic nonhealing wounds is anticipated (diabetic and non-diabetic).
- REGENLAB and REGENKIT have introduced into South Africa , a commercially available harvesting and separation system by a patient-friendly, and operator-safe alternative for the preparation of high quality PRP. This allows for spray-on double syringe technology.
- Clearly, the significant benefits of REGENLAB PRP , is its autologous nature, endogenous derivation, easy availability and lack of immunogenicity, avoidance of transmission of diseases with the application of state-of-the art REGENKIT, with satisfactory service of the product( Marlovits et al 2004).
Platelet-Rich Plasma (PRP) , has been in clinical use for more than 10 years and the safety and efficacy is well documented in the medical literature. The chief reason being the autologous nature of the preparation. Application roots are in the discipline of oral and maxillo-facial surgery. Dr. Roberts Marx of the University of Miami defines PRP as, " An otherwise normal autogenous blood clot that contains a highly concentrated number of platelets". Some authors use the term gel, and there are subtle differences between a blood clot and gel. Activated platelets secrete growth factors (GF), that impact positively on the wound healing cascade. Various separation systems are commercially available, but few provide satisfactory biological evidence of the complete range of product platelet releasate growth factor biosimulatory cellular activity ex vivo. GF released from the platelet releasate and alpha granules include platelet derived growth factor ( PDGF, alpha and beta), transforming growth factor ( TGF-1 and TGF-B2), vascular endothelial growth factor (VEGF) and epithelial growth factor (EGF). In concert, GF induce growth stimulation of fibroblasts, mesenchymal stem cells, osteoblasts, endothelial cells thereby facilitating the development of the ECM, bloodvessels, and collagen deposition, all important and relevant in biological wound healing. PRP shows strong enhancement of soft tissue healing by epithelial proliferation ( keratinocytes), ECM formation and capillary in-growth. PRP-GF's have now been applied in aesthetic and regenerative medicine. To-day , the preparation of PRP is relatively simple and the science behind wound-healing GF understood. GF's stimulate tissue regeneration and wound healing. REGENLAB PRP is the favoured choice for the clinician or dentist because of outstanding benchmark product characteristics such as safety, platelet recovery, enrichment, concentration of platelet GF such as PDGF-alpha and beta., EGF, AND VEGF, and ex vivo cell biology testing in various cells lines relevant to wound healing. To be effective, stringent PRP testing and quantification is necessary to show benchmark platelet dynamics and viability, GF release profile and biological/cellular stimulatory capability ex vivo. Cheap , untested substitutes, tubes and kits, failed product service, will result in suboptimal, cost ineffective wound healing. This review focuses on molecular components of cell biology, and the clinical application of PRP in cosmetic surgery, aesthetic medicine, wound healing, ulcer treatment, ophthalmic surgery and dry-eye, open heart surgery, burns, orthopaedic and spinal surgery, diabetic foot ulcer care, dental, cranial, maxillo-facial and neurosurgery.
PLATELET-RICH PLASMA (PRP) AND TISSUE REGENERATION BY PLATELET SPECIFIC GROWTH FACTORS: AVAILABLE IN SOUTH AFRICA
Aesthetic physicians, medical and dental clinicians have a vested interest in the field of soft tissue regeneration for the chronological and photoaged skin, rejuvenation by fibroblasts/keratinocytes and regarding the application of activated platelet-derived cytokines or growth factors in the clinic. Potential benefits to patients by the intraoperative application of PRP for specific indications during surgery, include reduced capillary bleeding and oozing in surgical flaps, reduced need for drains, reduced postoperative pain and swelling, accelerated post-operative recovery time and improved wound healing (Marx et al 2005). So, the benefits would be a sealant and trophic growth factors to enhance wound healing. These local effects are related to and orchestrated by the trophic and anabolic nature of platelet releasate following activation in the wound (Marx et al 2005). Seven anabolic and trophic factors identified in platelet-rich gel have now been described, the best known include platelet derived factor (PDGF) and transforming growth factor-beta 1 (Marx et al 2005) Details are reflected in Table 1. These factors are commercially available, but seldom used individually. Clinicians prefer PRP biologicals that contain the full compliment of secretory proteins, activities can be substantiated, with provision of ex vivo cell stimulatory/proliferative activity including fibroblast, myofibroblasts, keratinocytes, mast cells, macrophages, and stem cells relevant to wound healing. Other important secretary proteins that influence wound healing and derived from alpha granules of activated platelets include, vascular endothelial growth factor ( VEGF), epidermal growth factor ( EGF), insulin-like growth factor (IGF), osteocalcin ( Oc), osteonectin (On), vitronectin ( Vn), fibronectin (Fn) and thrombospondin-1 ( TSP-1), (Marx et al 2005). These factors can supposedly increase the rate of collagen deposition, angiogenesis, fibroblast proliferation, extra cellular matrix synthesis relevant to wound healing and soft tissue regeneration (Marx et al 2005).
Platelet-Rich Plasma (PRP) can be defined as "an autologous concentration of human platelets in a small volume of plasma" ( Marx et al 2005 ). This concentrate contains the trophic growth factors that are released once the platelets therein are activated either by calcium chloride, thrombin or fibrinogen (Marx et al 2005). All seem equally effective in activating the platelets ex vivo. In the process a gel is created that can be used as a suitable carrier for bone chips that are destined to be used in cranio-facial interventions such as sinus augmentation or lifting (Marx et al 2005). The plasma poor plasma (PPP) has potent fibrin-sealant properties like Tisseel® (Marx et al 2005). The side-room preparation of PRP has been documented and has been simplified by the availability of table-top high speed centrifuges that are commercially available. But not all centrifuges render the same concentrate of PRP (Marx et al 2005). We have devised in our laboratories, state-of-the-art autologous PRP production, that provides a good harvest of activated, viable small and large platelets with powerful GF stimulatory dynamics ensuring optimal proliferation of keratinocytes , fibroblasts and myofibroblasts and that can be verified and morphologically quantified ex vivo and in tissue culture (TC). Paying attention to fine detail, and avoiding contamination, is important during the generation of PRP (Marx et al 2005). The static apparatus can be installed in an office side-room or adjacent to an operating theatre. In order to ensure quality assurance of the PRP, designated FDA or CE approved automated platelet concentrate systems and trained personnel must be utilized (Marx et al 2005). The surgeon needs to determine how much PRP he or she wants to generate for the particular procedure. Fifty milliliter venous blood can generate about 16 ml of PRP. This is possible in a 30 minute period and can easily be performed by a suitably qualified and board certified clinical, technologist who assists the surgeon. Less can be generated for smaller procedures, in which case, only 20 ml of venous blood is needed. Upholding aseptic principles during cell separation is mandatory to avoid contamination (Marx et al 2005). Briefly, 50 ml of venous blood is obtained from the patient by venesection of the median cubital forearm vein, shortly before the surgical procedure. Surgery activates the platelets, so timing of the venesection is important, as well as using the correct arm band during venesection (Marx et al 2005). The blood is collected and inserted into special designated tubes containing an anticoagulant. Storage of the blood should be avoided due to loss of platelet activity. Special cost effective venesection kits are available ( RegenkitT , Switzerland ), for blood collection and preparation of PRP. A two stage, controlled centrifugation concentrates the platelets into a small volume without fragmentation. It is an easy task and the technology is available ( Marx et al 2005). The layer containing the PPP, which can be differentiated from the plasma-rich plasma, is aspirated into a sterile tube. A second spin is needed to obtain PRP. For the platelet growth factors to be released, platelets have to be activated ( Marx et al 2005). This is intentionally induced, shortly before use of the gel, and affected by addition of calcium chloride ( provided in the preparation kit) and or thrombin to the platelet concentrate ( Marx et al 2005). The gel thus created, is available for soft tissue infiltration and augmentation or admixture with a bone graft (Marx et al 2005). The blood clot is useful in maxillo-facial surgery and for placement in sockets or admixture with bone chips (Marx et al 2005). There are numerous commercially available machines, all of which yield slightly different concentrations in platelet and leucocyte cell counts (Marx et al 2005). Clear identification of the buffy coat is needed after centrifugation. The potential advantages of the biological approach of PRP are safety, quick release of platelet-derived growth factors, autologous nature of the preparation and avoidance of disease transmission (Marx et al 2005).
CELL BIOLOGY RELEVANT TO THE APPLICATION OF PRP/ACR
PRP has many theoretical unique and biomedical mechanisms of actions, albeit not fully understood, some of which are enumerated below:
- Stimulation of cell proliferation ( fibroblasts) from tendon explants in culture .Tendons have been cultured in explant fashion in PRP . In these studies, the cultured tendons showed enhanced expression of the matrix collagen molecules COL1, COL3A1 and COMP, with no increase in catabolic molecules MMP-3 and MMP-13. This reflects an anabolic effect of PRP on tendon metabolism, tendon matrix gene expression and matrix synthesis . Some studies recommend that tissue culture should be affected in PRP-enriched mediums of less than 40%, or in dilute PRP. This is the experience of the authors. The monolayer of leucocytes may have to be extracted because of the presence of pro-inflammatory mediators, such as neutral proteases and acid hydrolases contained in white blood cells. These are potentially catabolic or pro-inflammatory mediators released by white cells and possibly explains the increased post-application pain, observed by the authors, in wounds treated with PRP. This observation has to be carefully considered proactively and weighed up as the mononuclear white blood cells have the potential for inciting an undesirable inflammatory clinical reaction in an environment such as a tendon or joint .
- Stromal cell proliferation in culture, including keratinocytes
- Increased epithelial regeneration, enhancement of dermal collagen deposition .
- Stimulation of fibroblasts in cell culture . In the author's experience, the enhanced stimulation of human dermal fibroblast proliferation ex vivo by 10-40% PRP differs from photo-light biomodulation of the same cell line.
- Prevention of ecchymosis, fluid collections and haematomas .
- Enhanced proliferation of nucleus pulposis cells in culture ( intervertebral disc and cartilage chondrocytes) .
- Prevention of surgically induced alopecia by increase in capillary in-growth and hair follicle survival ( especially associated with temple line plastic surgery).
- Improved haemostasis by the interaction of fibrin-fibronectin-vibronectin cell adhesion molecules due to PRP (Marx et al 2005).
- Increase of capillaries, collagen and nerve in-growth from deep fascia .
- Improved angiogenesis ( Marx et al 2005).
TISSUE CULTURE DYNAMICS AND PLASMA-RICH PLASMA (PRP) RELEVANT TO QUALITY ASSURANCE PRODUCT EFFICACY AND CLINICAL PRACTICE
In wound healing, whole cell movements and locomotion, are dependant on intracellular filament systems, structural polarity co-ordination of microtubules and actin filaments (Albert's 2002). During cell locomotion, cross-talk is needed between the cytoskeleton and cell adhesion as the cell moves through the ECM. This impacts strongly on the speed of cell crawling in the senior authors laboratory experience. Both dermal fibroblasts and skin keratinocytes, in our experience in the light laboratory, have rapidly progressive leading edges in tissue culture (TC), and with planar proliferation in 2D culture. Lamellipodium and filopodium activity promotes formation of new attachment sites and cell crawling in the culture dish, but initial cell polarization is important.
Fibroblast crawling can rapidly be established in 3D culture. By 4 weeks of TC, monolayers are tightly packed and cell growth exceeds those in serum starved control media. In culture, fibroblasts of the leading edge rapidly translocate from the 3D media and assume conventional phenotype expression on an adjacent fibronectin treated culture base, but cell proliferation becomes slower. Growth pattern of the fibroblasts in various media differ but are enhanced in PRP.
Regarding the maintenance of the integument, both keratinocytes and fibroblasts play major reparative roles in the epidermis and dermis. In recent years, cultured keratinocytes have played an adjunctive and supportive role in the treatment of partial-thickness burns in both adults and children. Regen ATS makes provision for clinical setting.
Single and co-cultured keratinocytes/ fibroblasts can render established monolayers within 3 weeks. One and 5 million cells in G 2 phase, respectively are used for analysis for image phase contrast evaluation. Growth, locomotion and ruffling is greater in fibroblasts compared to keratinocytes presumably due to enhanced endowment of filopodia and lamellipodia with cytoskeletal actin projections. This can be confirmed by differential interference phase contrast imaging. H&E and Masson Trichrome staining at LM level confirm strong migration in the D&E junction region, also referred to as the space of Grenz. In PRP-enriched wells ( activated and non-activated), monolayers of both keratinocytes and fibroblasts are strongly in evidence. The presence of collagen is confirmed by the Masson Trichrome staining at light-microscopic level.
Fibroblasts and myofibroblasts are integral components of the extracellular matrix (ECM). Both are important for restoration, rejuvenation, wound healing and maintenance of the ECM , together with GAG, fibronectin, hyaluronic acid, mucopolysaccharides, collagen and elastin. Platelet-Rich Plasma releases 7 secretory proteins (growth factors) on activation and plays an important role in the inflammatory healing cascade including wound healing. Secretary proteins include VEGF, PDGF, TGF-beta-1, EGF, IGF, osteocalcin and nectin, VN, FN, FG and thrombospondin, all relevant to wound healing. ( Table 1).
TABLE 1: GROWTH FACTORS RELEASED BY ACTIVATED PLATELETS IN PLATELET RICH PLASMA ( AFTER MARX ET AL 2005 AND EPPLEY ET AL 2004.2006)
- Fibronectin ( and fibrinogen)
Fibroblasts and myofibroblasts can be cultured in all mediums by static technology, but PRP enriched medium ( activated and non-activated) provides good results compared to planar spreading. Both activated (by Cacl 2 or thrombin) and non-activated work equally well. PRP ( REGENLABT ) forms a fibrin matrix within 12 hours and changes the culture technology from 2 D to 3 D, eliminating partially the need for fibronectin. The presence of fibroblast branching, lamellipodia and filopodia indicate active cell locomotion. ECM network formation is clearly visible in monolayers within 3-4 weeks.
An early effect of platelet-rich-derived growth-factor (PDGF) on cultured human fibroblasts, is induction of dorsal plasmalemma or membrane ruffling from the forming face. This morphological outcome is due to the formation of motile cell surface protrusions facilitated by a meshwork of newly polymerized actin filaments. Rac , a small GTP-binding, protein is a key regulator of membrane ruffling. Our group is interested in PDGF-induced circular ruffle formation and on the dorsal surface because of the documented presence of cytokines in PRP ( REGENLABT ). This membrane modulated ruffling is of interest because it is cytokine driven, and stimulated by protein kinase C (PKC)( See Albert's et al 2002).
Compared to 2 D culturing, both cells lines show dendritic cell extensions that contain microtubule cores (fibroblasts> keratinocytes), allowing cross talk between cells. Cell ruffling is more pronounced in cells exposed to platelet cytokines and 3 D culturing. These observations allow us to speculate, that the 3 D environment of platelet-derived fibrin, permits cell extensions to engage integrins on both dorsal and ventral cell surfaces simultaneously, thereby activating unique signaling mechanisms as proposed by Beningo et al 2004. Planar 2 D surfaces allow lamellipodial extensions, cell crawling and spread. A 3 D matrix derived from PRP, facilitates microtubule-dependent dendritic cell locomotion and motility.
OPTHALMIC SURGERY PRACTICE AND APPLICATION OF PRP ( REGENKIT).
PRP has been shown to be very effective in the treatment of dormant corneal ulcers. It has now been possible to produce autologous PRP in topical eyedrops for the treatment of recalcitrant neurotrophic, herpetic and immunologically induced corneal ulceration ( Alio et al 2007). Treatment included chronic nonhealing ulcers in persons that had been unresponsive to conventional topical therapy. In these studies, measured outcomes included ulcer size, inflammation, healing, visual acuity and patient's subjective symptoms. In all groups studied, improved healing was observed. Pain, is particularly improved in all patients. In conclusion autologous platelet-rich plasma promoted healing of dormant corneal ulcers in eyes threatened by corneal perforation and was accompanied by a reduction in pain and inflammation. The same group studied the effect of PRP in the treatment of symptomatic dry eye. Significant dry eye symptoms with autologous PRP proved to be very effective, improving both patient symptoms and major clinical signs ( Alio et al 2007). The same authors showed the usefulness of PRP in the treatment of symptomatic ocular surface syndrome following LASIK. Topical PRP eye-drops were prepared from total blood and enriched platelets by centrifugation. 80% of patients responded positively. Conclusions from this work show that autologous PRP was effective in the treatment of patients with ocular surface syndrome following LASIK with symptoms generally relieved and a positive effect on punctuate keratitis. These positive changes indicate that PRP will in future play an important strategy in these patients. The main focus of PRP will be on enhancing wound healing of the cornea by the bioavailability of GF derived from the platelet gel / clot.
CARDIOVASCULAR AND OPEN HEART SURGERY: PLACE OF REGENLAB/KIT FOR OPTIMAL USE.
The literature shows that it is possible to stimulate the bodies natural healing at cellular level through the application of platelet-derived growth factors ( Vang et al 2007). Recent work shows that it is now possible to apply activated-PRP ( by either calcium or thrombin) to surgical wound sites of patients undergoing cardiac surgery ( Vang et al 2007). Growth factor enriched PRP, in these studies has been directed at the sternum before and after re-approximation and before skin closure. The aims of this approach were to enhance osteointegration and facilitate sternal ( bony) healing thereby reducing the incidence of post-operative sternal disruption which is a documented complication of thoracic surgery. Apart from the wound healing properties of PRP, the platelet poor plasma component ( PPP component of centrifuged plasma) is also valuable as a sealant, and haemostatic agent ( via fibrin deposition), thereby reducing haematoma formation and fluid collections in dead space. Possibly deep and superficial sternal infections can be obviated by the application of PRP in the theatre to the wound edges shortly before closure. This approach adds no time to the operation as the PRP is rapidly deployed and sprayed or dripped on the edge. For the sternum and skin, 10 and 7 ml enriched PRP, are recommended ( Vang et al 2007; Mercy Medical Center , Sioux City , Iowa , USA ). Thirty-two ml venous blood is needed approximately to produce 16 ml PRP. Preliminary studies indicate that PRP may well confer beneficial effects on pain, bloodloss and bruising in the postoperative phase following cardiac surgery. Other benefits of the use of PRP transfusion during cardiopulmary bypass has been reported ( Crowther et al 2000; University of Aberdeen ). Hiramatsu et al 2002 have reported the benefits of PRP administration after open heart surgery in patients ( including paediatric cases) with non-cyanotic congenital heart disease. More than 10-years ago, cardiac surgeons from Japan showed that PRP intra-operatively could reduce the perioperative blood loss, the rate, and the volume of homologous blood transfusion ( Misumi et al 1995). Application of PRP to the leg harvest vein wounds may well also speed up skin healing and reduce postoperative swelling. PRP use is also indicated as a sealant in ascending aortic surgery.
ORTHOPAEDIC AND SPINAL SURGERY:NEW APPLICATIONS OF REGENLAB PRP/ACR
The wound healing and sealant properties of PRP have been documented in the orthopaedic literature. The following indications have appeared in the literature and relevant to clinical practice:
- Enhanced healing and functional recovery after surgical repair of human Achilles tendon tears using PRP matrices ( Sanches et al 2007).
- Bone grafting ( bone healing).
- Soft tissue healing ( use of autologous growth factors).
- Spinal fusion surgery: osseus healing ( Roukis et al 2006).
- Treatment of recalcitrant tennis elbow.
DIABETIC FOOT ULCER CARE: COMPLIMENTARY USE OF REGENLAB PRP
Recalcitrant diabetic foot and leg ulcer treatment is a huge challenge to ulcer clinics, diabetologists, and vascular surgeons. This stems from the underlying propensity to develop deep compartment sepsis ( because of defective chemotaxis and opsonization), reduced immunecompetency, calcified foot vessels, insensitive sole, forefoot ischaemia and neuropathy. The presence of an unstable and otherwise insensitive foot ( because of sensory, motory and autonomic fiber loss), " rocker-bottom deformity" of the sole and instep, autosympathectomy predispose the sole to decubitus and pressure ulcers that eventually become secondarily infected. The result is deep compartment abscess formation and gangrene that may necessitate fore-foot or below-knee amputation. Apart from the need for antibiotics, bacteriological cultures, dressings and creams ( L-MezitranT, Omnimed®), off-loading footwear is imperative to facilitate healing of pressure sores. Amputation can be delayed if deep abscesses are drained properly ( optimal debridement and sloughectomy) and dead or necrotic tissue carefully debrided under general anaesthesia. Often conservative amputations can be performed and the patient kept mobile. In these cases special off-loading shoe-ware is necessary. Diabetic foot ulcers, are indeed difficult to treat because of poor wound healing, persistent sepsis and underlying neuropathy. Recently, the use of autologous PRP gel provide an ulcer management option that may avoid or prevent loss of a limb by major amputation ( Driver et al 2006). Together with L-MezitranT(Omnimed®), even better wound healing results may be achieved, thus enhancing good standards of ulcer care.
ROLE OF REGEN-PRP IN THE TREATMENT OF BURNS AND AESTHETIC SURGERY
In this surgical discipline, both the sealant and wound healing properties of PRP are utilized. The clinical application and indications are enumerated as follows, in order to facilitate wound healing, reduce pain, swelling, bruising and surgical down time.
- Face lifts with and without fat augmentation ( Marx et al 2005)
- Blepharoplasty ( upper and lower lids), ( Marx et al 2005)
- Breast augmentation, reductions and neck lifts (Man et al 2001)
- Surgical flaps ( to reduce swelling, fluid or blood collections and to enhance haemostasis by a sealant effect)
- Bone grafting ( enhanced osteointegration)
- Burns ( recipient site after debridement, in preparation for skin grafting or use with other wound care devices ( Biobrane®) ( See Kleintjes et al 2007)
- Burns : donor site ( to reduce pain, accelerate epithelialization, reduce secondary infection, improve mobilization and rehabilitation)( Kleintjes et al 2007,and Marx et al 2005).
MAXILLO-ORAL, CRANIOFACIAL AND NEUROSURGICAL APPLICATIONS OF REGEN-PRP
Dr. Robert Marx, of the University of Miami, Florida, USA, is the doyen, champion and pioneer regards the use of PRP in this discipline ( Marx et al, 2005, Quintessence Publishing Co, Inc). Indications for PRP in dental, maxillo-facial, oral and neurosurgery are as follows:
- Jaw surgery ( mandibular bone defects); guided bone regeneration of mandibular bone ( Wojtowicz et al 2007)
- Alveolar ridge and maxillary sinus augmentation ( Marx et al 2005., Lee et al 2006)
- Sinus lifting grafting ( Marx et al 2005)
- Third molar sockets: to avoid alveolar osteitis, reduced bone regeneration ( Marx et al 2005)
- Free gingival grafts ( Marx et al 2005)
- Reconstruction of major tumour-and trauma-related defects ( Marx et al 2005)
- Soft tissue augmentation: rhytidectomy, blepharoplasty, dermal fat grafts for lipoatrophy( Marx et al 2005)
- Skin grafting; bone grafting ( Marx et al 2005)
- Mid-face reconstruction
- Split calverial bone grafting for hemimaxillectomy ( Marx et al 2005)
- Dental implant oral surgery
- Autogenous corticocancellous block grafts ( Marx et al 2005)
- Total mandibular reconstruction ( Marx et al 2005)
- Free gingival grafts to cover a root dehiscence or an implant exposure
- Socket preservation
- Cranial fossa surgery: dural repairs, skull augmentation, tumour excision and cranial fossa haemostasis control
AESTHETIC MEDICINE: REGEN/ACR T DERMAL REGENERATION AND VOLUMETRIC THERAPY VIA AUTOLOGOUS CELL REGENERATION (ACR)
Because of the safety of PRP ( by nature of the autologous blood component), activated platelet gels are now both applied in therapeutic and aesthetic medicine. In the latter discipline, the term " Autologous Cellular Regeneration" or ACR, has been coined. Simply, this means rejuvenation of the face, neck, arms and hands by multiple small dermal and hypodermal injections of biologically active PRP ( Du Toit et al 2007). The growth factors released by the activated platelet gel, supposedly leads to rejuvenation of the dermis, ECM, with the stimulation of fibroblasts, stem cells and keratinocytes, and collagen production ( Du Toit et al 2007). For the moment, the conventional options used as anti-wrinkling treatments, with skin tightening, include thermal lasers, IPL, radiofrequency (RF), athermal LED ( 633nm) together with moisturizing and anti-aging creams, some of which contain concentrations of vitamin-A ( Retin-A®., Renova®., Retacnyl®., Environ®). Results, regards amelioration of lines, wrinkles, sagging, mid face ptosis, crow feet, upperlip lines are very variable and are influenced by smoking and alcohol consumption habits, degree of solar damage or photo-aged face, chronological factors, dietary habits and genetic make-up. In the authors experience a synergistic effect can be observed by a combination of microdermabrasion and PRP given as a staged procedure together with anti-aging creams such as Neostrata® or Prevage®. Applying a skin barrier ( SPF 30-100) against the sun is critical if good results are to be achieved. The patients Fitzpatrick status and Glaucou classification also determine outcome of anti-aging treatment. Non invasive ultrasound assessment or diagnostics of the skin and dermis may also help with the prediction of treatment outcomes. PRP on its own is unlikely to reverse the aging process in all cases and will have to be given in addition to lasers, IPL, RF and LED. If PRP on its own is superior to lasers, IPL, and RF regards skin tightening remains to be seen. Multimodal and maintenance therapy is inevitable to reverse and combat further skin aging. A balanced diet is needed, rich in vegetables and fruit, and at least two liters of water should be drunk daily. If PRP is to be considered as part of an ACR program for facial rejuvenation, then client aspirations need to be taken seriously into account. Regardless of what treatments are applied, facial rejuvenation is gradual and a slow process. Not all treated clients show collagen regeneration, and in most cases it is impossible to reverse mid-face ptosis by non-surgical face-lift. In these cases, a face-lift or use of threads, gives far superior results. Dermal atrophy also cannot be reversed by non-invasive thermal light devices, some of which induce permanent dermal scarring, and dry up sebaceous glands. For persons with acne scarring, needling ( Environ®) plus vitamin-A creams or growth factors will render superior results than PRP alone.
Conditions that preclude the application of PRP for ACR of the face include, aspirin ingestion, vitamin-E containing medications, warfarin therapy, sepsis, acute and chronic infections, fibrinogen disorders, very low platelet counts and any coagulation disorders. Facial intradermal injection of PRP is painful and there is a need for topical anaesthesia and even regional nerve blocks. Ice packs are needed because the swelling can be alarming in susceptible individuals. A purple discolouration can be anticipated. Haemorrhage into the skin may occur from tiny telangiectasis and staining for a few weeks can follow the deposition of haemosiderin. Bruising on the temple lines and below the eyes should be avoided especially in women with a thin skin. Careful, informative and skilled informed consent ( also allowing for redress) is needed that includes a discussion on the potential of dermal discoloration, nerve paresis, down-time, danger of inadvertent intravascular injection with a biological filler compared to other fillers, secondary infection, danger of cavernous sinus thrombosis and haematoma formation. Be careful in patients taking unspecified herbal products that could result in serious and transient hypertension. Contact the Medical Protection Society, in advance, to obtain the correct medical insurance rating ( in the event of a potential lawsuit, complaint, or patient dissatisfaction), if aesthetic or cosmetic work is done. Be comprehensive with informed consent. CME accreditation in the application of PRP is sensible and supervised workshops are available at an academic institution in Cape Town .
PUBLICATIONS ON PRP/ACR FOR FURTHER REFERENCE
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Akeda K. An HS, Pichika R, Attavia M, Thonar EJ, Lenz ME, Uchida A. Platelet-rich plasma (PRP) stimulates the extracellular matrix metabolism of porcine nucleus pulposus and annulus fibrosus cells cultured in alignate beads. Spine 31:959-66, 2006.
Alio JL, Abad M, Artola A. Use of autologous platelet rich plasma in the treatment of dormant corneal ulcers. Opthamology 1:12-13, 2007
Alio JL, Colecha JR, et al. Symptomatic dry eye treatment with autologous platelet-rich plasma 39:124-9,2007
Bhanot S, Alex J. C. Current applications of platelet gels in facial plastic surgery. Facial Plastic Surgery, 18:27-33, 2002.
Carter C. A, Jolly D. G, Worde C. E, Hendren D. G, Kane C J. M. Platelet-rich plasma gel promotes differentiation and regeneration during equine wound healing. Exp Mol Pathol 74:244-55, 2003.
Chajchir A, Fabrizio D, Chajchir G, Celi E. Growth factors in plastic surgery. Aesth Plast Surg 29: 295-99, 2005.
Crowther M, Ford I, et al. Quality of harvested autologous platelets compared with stored donor platelets for use after cardiopulmonary bypass procedures. Br J Haematol 111:175-81,2000
Della Valle A, Sammartino G, Marenzi G, Tia Mariano M, Di lauro A. E, Ferrari F, Lo Muzio L. Prevention of post-operative bleeding in anti-coagulated patients undergoing oral surgery: use of Platelet-Rich Plasma gel. J Oral Maxillofac Surg, 61:1275-1278, 2003.
Driver VR, Hanft J, Fylling CP et al. A prospective, randomized, controlled trial of autologous platelet rich plasma gel for the treatment of diabetic foot ulcers. Ostomy Wound Manage 52:68-70,2006
Du Toit D.F. KleIntjes WG, Otto MJ., Mazyala E, Page BJ. Soft and hard tissue augmentation with platelet-rich plasma: tissue culture dynamics, regeneration and molecular biology perspective. IJSS 1,52-61, 2007
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, 1502-6, 2004.
Eppley B. L, Pietrzak W. S, Blantou M. Platelet-rich plasma. A review of biology and applications in Plastic Surgery. Plastic Reconstructive Surgery, 118: 147e-159e, 2006.
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Grotendorst G. R, Rahmanie H, Duncan MR. Combinatorial signaling pathways determine fibroblast proliferation and myofibroblast differentiation. FASEB J 18:469-79, 2004.
Hiramatsu T, Okamura T, et al. Effects of autologous platelet concentrate reinfusion after open heart surgery in patients with congenital heart disease. Ann Thor Surg 73:1282-5,2002
Kanno T, Takahashi T, Tsujiswa T, Ariyoshi W. Platelet-Rich Plasma enhances human osteoblast-like cell proliferation and differentiation. J. Maxillofac Surg, 63:362-9, 2005.
Kawase T, Okuda K, Wolff L, Yoshie H. Plasma-rich plasma- derived fibrin clot formation stimulates collagen synthesis in periodontal ligament and osteoblastic cells in vitro. J Periodontal 74: 856-64, 2003.
Kleintjes W.G., Du Toit, D.F. New concepts of burn healing using BiobraneT and Platelet-Rich Plasma. Specialist Forum August 2007 ( In Press)
Lee HJ, Choi BH., et al. Maxillary sinus floor augmentation using autogenous bone grafts and platelet-enriched fibrin glue with simultaneous implant placement. Oral Surg 103: 329-333,2007
Lindeboom J. A, Mathura KR, Aartman IH, Kroon FH, Milstein DM. Influence of the application of platelet-enriched plasma in oral mucosal wound healing. Clin Oral Implants Res 18:133-9, 2007.
Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-rich poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg 107:229-237, 2001.
Marlovits S, Mousavi M, Gäbler C, Erdös J, Vécsei V. A new simplified technique for producing platelet-rich plasma: a short technical note. Eur Spine 13 (suppl 1): S 102-S 106, 2004
Marx R. E. Platelet-Rich Plasma: Evidence to support it's use. J. Oral Maxillofac Surg 62:489-496, 2004.
Marx RE, Carlson ER, Eichstaedt RM. Platelet Rich plasma: growth factor enhancement for bone grafts. Oral Surg 85:638-641, 1998.
Marx R. E., Carg A. K. Dental and craniofacial applications of platelet-rich plasma. Quintessence books, Chicago , 2005.
Misumi T, Kiso I et al. Effect of autologous platelet rich plasma on adult open heart surgery. Nippon Kyobu Geka. 43:6-9,1995
Murray M. M, Spindler K. P, Abreu E, Mullwer J. A, Nedder A, Kelly M. collagen-platelet-rich plasma hydrogel enhances primary repair of the porcine anterior cruciate ligament. J Orthop Res 25:81-91, 2007.
Okamura T, Koh E et al. Effect of autologous platelet rich plasma (PRP) in cardiac surgery. Kyobu Geka 54:397-400,2001
Okuda K, Kawase T, Momose M, Murata M, Saito Y, Suzuki H, Wolff LF. Platelet-rich plasma contains high levels of platelet-derived growth factors and transforming growth factor-beta and modulates the proliferation of periodontally related cells in vitro. J Periodontol 74: 849-57. 2003.
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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.
Roukis T. S, Zgonis T, Tiernan B. Autologous Platelet-rich plasma for wound and osseus healing: A review of the literature and commercially available products. Advances in Therapy. 23, 218-237, 2006.
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Schnabel L.V, Mohammed H. O, Mc Dermott W. G, Miller B. J, Jacobson M. S, Santangelo K. S, Fortier L. A. Platelet-Rich Plasma (PRP) enhances anabolic gene expression patterns in flexor digitorum superficialis tendons. J Orthop Res 25:230-40, 2007.
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