| FACIAL AESTHETICS | PEER-REVIEW
ABSTRACT Over the past 20 years, the demand for cosmetic procedures among our ageing population has evolved, and there has been an increasing demand for patients to seek less invasive procedures for facial rejuvenation. The improvements in knowledge and techniques, and the introduction of longer-lasting soft tissue fillers have led to an increased acceptance of cosmetic treatments. More patients are looking for less invasive procedures over surgical treatments. Platelet-rich plasma (PRP) is an autologous concentration of human platelets in a small volume of plasma. It is a safe treatment and, thanks to the included growth factors, may represent the perfect option for a large number of procedures.
T
HE DEMANDS OF OUR AGEING population have evolved substantially over the past few decades, with patients from the ‘baby boom’ generation now well into their 60s and demanding to look as young and as healthy as possible.
These requirements have been coupled with the desire of the majority of patients to seek less invasive procedures for facial rejuvenation. The improvements in our knowledge and techniques,
and the introduction of longer-lasting soft tissue fillers, have led to an increased acceptance of cosmetic treatments in society as a whole. A greater number of patients are now looking for less invasive procedures over surgical treatments. However, Sclafani1
argues that
‘the ideal soft tissue filler has not yet been found, one which seamlessly integrates into the surrounding tissues, is easy to place, inexpensive, readily available and persistent. Currently available soft tissue fillers may be degraded, elicit a foreign body response with encapsulation and can be quite expensive’. It is now known that the facial ageing process is not
only a result of gravity, the disappearance of the malar fat pad, and/or lack of collagen, but is a complex puzzle involving a variety of facial elements, which occurs as a cascade effect. This process affects the four main facial layers — bone, muscle, fat and skin — the changes of which fall in two directions simultaneously, from the outside skin layer inward towards the bone, and also from the bone outwards towards the skin. Any modification in one layer will affect the next to progressively impact the effects of ageing. The most significant change in the first layer, the bony
facial skeleton, occurs in the facial apertures. The nose and orbits actually increase in size with age, by as much as 20%; the eye sockets largen over time and the infraorbital bone, just under the eye, moves backwards. Consequently, all other structures (muscle, fat and skin tissues) begin to descend and slip from the surface of the receding bone. Gravity is partly the cause of this effect, but in combination with the changes to the facial skeleton. Contrary to popular belief, the facial muscles actually
tighten with age, not loosen. This can be seen in the platysmal bands of the neck, which stretch from the chin to the clavicle and become more pronounced with age, similar to the appearance of crow’s feet and deep-set glabella lines. At the same time, the amount of fat present in the facial fat pads decreases with age and causes a gaunt
DANIEL L. SISTER, MD, FRCM, BCAM, NYAS, is Aesthetic Doctor, Dr Sister Ltd, London, UK
email:
drsister317@gmail.com
appearance, resulting not only in volume-loss, but also a lack of efficient hydrating and elastic functions. The fibroblast cells producing elastin, collagen and hyaluronic acid (HA) work best when they’re under a degree of stretch. A lessened volume of fat and stretch results in poorer skin functions and the resulting sagging effect. Ultimately, the process of facial ageing is a complex
cascade in which each facial element affects and interacts with the other.
What is platelet-rich plasma? Platelet-rich plasma (PRP) is an autologous concentration of human platelets in a small volume of plasma. It is a multidisciplinary procedure, with a great amount of supporting literature for the field of cosmetic surgery, as well as oral implantology, ophthalmology, orthopaedics and sports medicine. Plasma, which comprises 55% of blood fluid, is mostly
water (90% by volume), and also contains dissolved proteins, glucose, mineral ions, hormones, carbon dioxide (plasma being the main medium for excretory product transportation), platelets, and blood cells themselves. As it is a concentration of platelets, it is also a concentration of the seven fundamental protein growth factors proved to be actively secreted by platelets to initiate all wound healing (Table 1). These growth factors include the three isomers of platelet-derived growth factor. All of these growth factors have been documented to exist in platelets2, 3
, but the platelets will need to be
activated. On activation, they will release alpha granules, within which those growth factors are stored. In addition, the activated thrombocytes have a
multitude of signalisation molecules on their surface: CD9, CD-W17, CD41, CD42a-d, CD51, CD-W60, CD61, CD62P, CD63. As these concentrated platelets are suspended in a small volume of plasma, PRP is more than just a platelet concentrate; it also contains the three proteins in blood known to act as cell adhesion molecules for osteo-conduction and as a matrix for bone, connective tissue, and epithelial migration. These cell adhesion molecules are fibrin itself, fibronectin, and vitronectin.
Platelet origin, morphology and distribution Platelets are cytoplasmic fragments of megakaryocytes (a type of white blood cell), which are formed in the marrow, are round or oval in shape, and approximately 2 µm in diameter4
. They have a trilaminar cell membrane
with a glycoprotein receptor surface overlying and partially interspersed with and penetrating a bilayer of phospholipids and cholesterol5
. Platelets lack nuclei but contain organelles and
structures such as mitochondria, microtubules, and granules (a-, d-, and l-)4–7
. There are approximately 50–80
alpha granules per platelet, each bound by a unit membrane and formed during megakaryocyte maturation8
KEYWORDS PRP, dermal rejuvenation, ageing, literature review
.
prime-journal.com | June 2013 ❚ . The granules are approximately 200–
500 nm in diameter and contain over 30 bioactive proteins, many of which have a fundamental role in haemostasis and/or tissue healing8, 9
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