When Charles Runels, M.D., the creator of the Vampire Facelift started using platelet-rich plasma (PRP) for cosmetic purposes, he was doing what many cosmetic surgeons were doing at the time. He was using it like Juvéderm, and injecting it into the nasolabial folds.
“I didn’t like that because I like to sculpt out a natural restored look. PRP is aqueous, so, it wasn’t holding the shape,” Dr. Runels says. “But all the patients were coming back saying their faces were glowing from the neovascularization.”
Dr. Runels, an internal medicine physician, studied the literature on PRP in wound care and decided to try a different approach with his cosmetic patients. He instead used the hyaluronic acid (HA) to act as a scaffold and, immediately after, applied PRP, subdermally — not only to where he had injected the HA, but in other critical areas of the face.
PRP is all the rage in cosmetic and other types of surgery, says Chicago-based facial plastic surgeon Steven Dayan, M.D.
Physicians’ cost is minimal; patients love that it is “all natural”; and one can’t ignore the impressive anecdotal and empirical evidence that it has a magical effect on facial skin, according to Dr. Dayan.
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NEXT: PRP in the Literature
PRP in the Literature
The claims are panning out, to some degree, in the literature. In an article in the December 2015 issue of the Journal of Cosmetic Dermatology (Leo MS, et al.), researchers systematically reviewed clinical cosmetic applications of PRP for androgenetic alopecia, scar revision, acne scars, skin rejuvenation, dermal augmentation and striae distensae. A total of 22 manuscripts fulfilled their criteria.
“Four [of the manuscripts] evaluated hair-related applications, eight evaluated the treatment of scars and postprocedure recovery, eight evaluated skin rejuvenation and dermal augmentation, and two evaluated treatment of striae distensae. PRP is a relatively new treatment modality with studies suggesting its utility in aesthetic dermatology. The combination of PRP with other therapies is particularly interesting. Future studies should include controls, including incorporation of split-face comparisons, to reduce intersubject variability,” they write.
PRP is a tool aesthetic physicians can use with many facial procedures, according to Dr. Runels. In most cases, PRP doesn’t take the place of an aesthetic procedure, rather, it enhances procedure results and outcomes, including healing.
PRP applied post microneedling offers superior results compared to microneedling, alone, according to Dr. Runels. Dr. Runels also owns the trademark the Vampire Facial, where PRP is applied topically over microneedling.
“There’s a split face [acne scar] study, where they took one side of the face, did microneedling and used a vitamin C serum. The other side of the face had microneedling with PRP. And the PRP side had a superior result,” he says. (Chawla. J Cutan Aesthet Surg. 2015)
In another split face study published this year (Asif M, Kanodia S, Singh K. J Cosmet Dermatol. 2016), researchers concluded that PRP is useful for managing atrophic acne scars and can be combined with microneedling to enhance the final clinical outcomes in comparison with microneedling alone.
PRP applied after fractional laser resurfacing does much the same. In addition, PRP improves wound healing post laser, Dr. Runels says.
In fact, researchers reported in JAMA Facial Plastic Surgery in March-April 2015 (Kim H, Gallo J) that PRP seems to be an efficacious adjunctive treatment to carbon dioxide laser resurfacing and can help quicken patient recovery.
It has been shown to result in better resolution of hypertrophic or hypotrophic scars, because the PRP stimulates stem cells to remodel tissue, according to Dr. Runels.
“You get an improvement with even old scars,” he says.
Hair transplant surgeons are also making PRP part of their protocols.
“It’s standard of care now because it increases survival of the transplanted hair follicle,” Dr. Runels says. “With women, they’ll get almost all their hair back. With men, you’ll get about 30 to 40% back. While there is still a place for surgery, PRP is being done as a stand-alone.”
Practical PRP Application
Oral and maxillofacial surgeon Manolis G. Manolakakis, M.D., says he uses PRP.
“For years, [I used it] in bone grafting. We would notice that the incisions and wounds would heal faster and nicer. Knowing that PRP is rich in tissue growth factors, it makes sense that it has a role in early healing in cosmetic surgery,” Dr. Manolakakis says.
In other uses, Dr. Manolakakis sprays PRP under facelift flaps. The advantages are it decreases hematoma formation and improves flap healing.
He mixes PRP with fat transfer to increased fat cell survival during transfer.
Using the MicroPen [Eclipse Aesthetics] microneedling device, Dr. Manolakakis says he injects platelets into the epidermis.
“This is good option for patients with darker skin tones that can potentially have complications from laser for chemical peels,” Dr. Manolakakis says. “It improves texture of skin, complexion and elasticity. I also like to inject into hollows of lower eyelid-tear trough. [There’s] no risk of Tyndall effect and no foreign object.”
He also uses PRP for scar revision and skin flap reconstruction. He injects into acne scars after subcision and laser resurfacing. And Dr. Manolakakis is starting to inject PRP into the scalp to treat thinning hair.
Dr. Dayan says he injects patients with PRP once a month for facial rejuvenation.
“Patients are loving it. Obviously, there’s no risk of rejection because it’s from patients’ own factors. It’s natural. The results are gradual. And pretty much everyone is seeing improvement in the quality of their skin,” Dr. Dayan says.
Dr. Dayan does fat transfers with PRP and is just beginning to inject scalps for hair growth. He also applies PRP post laser resurfacing to reduce redness and erythema, he says.
“The good is that PRP supply is limitless; the bad is it can get little costly,” Dr. Manolakakis says. “We would like to see a more profound effect, but there definitely is an improvement in skin texture [and] tone. There is little to no downtime when injected or used.”
While doctors use PRP for its positive effects on procedures and outcomes, little is known about how PRP works or how best to use it. For example, it isn’t clear if cosmetic surgeons should use 10 times, seven times or even two times the concentration of whole blood, according to Dr. Runels.
“In the orthopedic literature, they found that you get best results somewhere around five times the concentration of whole blood. But we don’t really know what the best concentrations are for microneedling, the Vampire Facelift, etc. Some of the studies in the cosmetic literature were done with two times the concentration of whole blood. Logically speaking, when you do surgery, you’re doing it with the concentration of blood,” Dr. Runels says.
NEXT: A Word of Caution
A Word of Caution
Dr. Dayan says he is hesitant to treat a patient with active skin cancer with PRP.
“I’ve been treating patients for about a year and haven’t seen any side effects,” Dr. Dayan says. “If someone has cancer, I wouldn’t want to be injecting it. In theory, you don’t want to stimulate cancer with growth factors.”
But Dr. Runels says evidence of a PRP-cancer link hasn’t surfaced in studies.
“[If you do a PubMed search on platelet-rich plasma,] you’ll come up with about 10,000 research papers on multiple tissue types: skin, bone, hair, heart…. Many involve biopsies, and you’ll find many review papers. You cannot find one serious side effect,” Dr. Runels says. “The most common side effect you’ll find is a few cases of urticaria, which is kind of unexplainable. How do you have an allergic reaction and a rash from your own platelets? But the bottom line is there has never been a case of neoplasia ever documented in any of those tissue types.”
NEXT: Best Practices for PRP
Best Practices for PRP
Dr. Runels says cosmetic and other surgeons who use PRP should use an FDA-approved device, or kit. There are about 20 of these kits approved in the U.S. today, he says.
“There’s a difference to isolating platelets to measure them in a laboratory versus isolating platelets to inject them back into your body or to irrigate a surgical wound,” Dr. Runels says. “So, the best practice would be make sure you’re using a kit that’s FDA approved.”
Dr. Dayan says labs charge various amounts for their kits, so doctor beware.
“We’re using a company called Regen Lab. I have no interest in Regen Lab, but what they do is make PRP affordable. Some of the other commercial suppliers are more expensive and claim better ability to concentrate growth factors, and perhaps they are better, but it is too early in my experience to conclude,” Dr. Dayan says.
PRP timing also may make a difference. While PRP can be safely used for up to several hours, Dr. Runels says, there is evidence that the faster one uses it, the better.
Dr. Manolakakis adds that, as with all procedures, it's important for physicians to document their cases.
“Before and after photos with standardized lights is very important,” Dr. Manolakakis says. “This can help you evaluate, as well as promote and show the results.”
Also, don't oversell PRP, says Dr. Manolakakis.
“It is helpful but will not completely reverse signs of aging,” he says.
For more information about using PRP in practice, Dr. Runels heads a professional group called the American Cosmetic Cellular Medicine Association, which he says is an international group of physicians interested in and trained in PRP.
Dr. Runels owns PRP trademarks, which are listed in the article. Drs. Dayan and Manolakakis have no relevant disclosures.