Platelet-rich plasma (PRP), a rich source of growth factors, has gained popularity as a method to boost healing after facial plastic surgery and rejuvenation procedures, such as laser skin resurfacing and facelift surgery. Supporters of the treatment claim that delivering platelet-rich plasma (usually in a gel form) to the wound prior to closure has many benefits. Some convenience sample studies, for example, have documented an elimination of the need for drains; reduction in the need for compressive dressings; reduction in pain and postoperative swelling; improved wound healing; and shorter recovery time (Plast Reconstr Surg. 2001;107(1):229-237).
The advantage to platelet gel is that you are introducing into the wound a higher-than-native concentration of growth factors and angiogenesis factors, and other factors involved in the coagulation cascade, that facilitate the healing. – Ross A. Clevens, MD
Other researchers are more circumspect regarding the treatment, noting that a certain amount of euphoria surrounds the use of growth factors to speed healing. The current scientific evidence about the treatment as an adjunct in facial cosmetic surgery, they say, does not warrant it becoming a standard of care.
Advantages of Platelet Gel
For the past 10 years, Ross A. Clevens, MD, has specialized in facial plastic surgery. At his Center for Facial Cosmetic Surgery in Melbourne, Fla., Dr. Clevens has used the gel extensively (in an estimated 300 to 500 cases per year) and sees evidence of less bruising and swelling after facelift or local and regional flap reconstructive surgery, as well as better take and increased survival of grafted skin flaps. In addition, patients may also have decreased discomfort, although the latter is hard to quantify, Dr. Clevens noted.
The advantage to platelet gel, said Dr. Clevens, is that you are introducing into the wound a higher-than-native concentration of growth factors and angiogenesis factors, and other factors involved in the coagulation cascade, that facilitate the healing. Although the wound-healing cascade is still not completely understood, laboratory-based research has shown that platelets play a key role in hemostasis and wound healing. When activated, platelets release secretory proteins which drive the complex wound-healing cascade. Many studies have established that platelet concentration procedures can cause a three- to eight-fold increase in platelet concentration ratios.
Clinical use of platelet rich plasma has been reported in the spine, periodontal, cardiovascular, and craniofacial literature. In the orthopedic surgery literature, platelet gel has been used to increase the take of bone grafts. Clearly, said Dr. Clevens, platelet gel is growing in popularity in the orthopedic surgery world. When he performs laser skin resurfacing, Dr. Clevens also has seen a faster re-epithelialization rate when using the gel. Several studies, he noted, have demonstrated a markedly faster rate of re-epithelialization-sometimes as much as 40% faster, he said.
Results reported in other specialties appear to demonstrate strong justification for the use of PRP. For example, patients undergoing cardiopulmonary bypass given PRP used 65% less banked blood products during their treatment; grafts for mandibular bone augmentation matured faster with PRP; diabetic foot ulcers treated with PRP were 14% to 59% more likely to heal; and patients with decubitous ulcers who were given PRP also had faster healing than those who did not receive PRP (Jrl Craniofac Surg. 2005:16(6):1043-1054). So why is the clinical evidence for using PRP in facial cosmetic surgery called into question?
Scientific Rationale for Treatment
Barry L. Eppley, MD, DMD, Professor of Plastic Surgery at Indiana University School of Medicine in Indianapolis, pointed out that there are problems with the body of clinical evidence supporting the use of platelet gel. There are different ways to isolate and prepare the platelet-rich plasma, he said. So, even though there may be some prospective trials, these are not standardized. As a result, he said, the scientific evidence [supporting use of the treatment] is not compelling.
For instance, in a recent journal study (Plast and Reconst Surg. (2004;114(6):1502-1508), Dr. Eppley conducted an analysis of platelet-rich plasma produced from blood of 10 plastic surgery patients, using a commercially available office model device. The results from this study revealed that the levels of growth factors were indeed increased in the gel preparations compared to levels in whole blood. However, the authors cautioned, the method of preparation of the gel introduces several variables, and gels produced from different devices can yield different platelet concentrations, platelet activation rates, and growth factor profiles.
Producing the Gel
PRP is usually delivered as a gel concentrate produced from the patient’s own blood. Facial plastic surgeons are probably most likely to use one of several office-based devices. Before surgery, the patient’s blood (typically 20 to 60 cc, depending on how extensive a procedure is planned) is drawn and placed into a processing vessel. The vessel is then placed in the concentrate system. After a 12 to 15 minute cycle, during which the blood is centrifuged in the device, a platelet-rich plasma concentrate is produced. At this stage, the platelet rich plasma concentrate is in an anti-coagulated state; its activation is accomplished by adding a solution of 1000 units of topical bovine thrombin per milliliter of 10% CaCl2 to the PRP. The gel is sprayed over the wound within 10 minutes of activation. There are a variety of mixing techniques: some use dual spray applicator tips that mix the platelet and thrombin solutions as they are applied. With other mixing techniques that initiate activation before application, it is important to transfer the gel quickly to the surgical site, before clot retraction, since the transferred clot may be deficient in the expressed secretory proteins.
The use of this technology is probably driven by the doctor, who believes in it and makes the time commitment and investment to do it. But, it is not a magic powder; it is a valueadded service. – Barry L. Eppley, MD, DMD
The placement of the volume of gel must be judicious, Dr. Clevens pointed out, so that there is no hematoma formation as a result of applying excessive volume of fluid to the wound. However, physicians can quickly learn to apply the gel, he believes. For orthopedic procedures and mammoplasty, which require larger volumes of the gel, the production of PRP may be done using a hospital-based system. In that case, the gel treatment is often reimbursable, since it is part of a more extensive surgical procedure.
A Down Side?
According to Dr. Clevens, the disadvantages of using platelet gel are minimal. The added cost-about $300 per case-is simply added to the procedure total. And because his patients demand quicker recovery times from cosmetic surgery-which is performed on a self-pay basis-this minimal added cost has not been an issue in his experience. Practitioners and patients alike are also enthusiastic about the ability to produce the concentrate from the patient’s own blood. Because platelet gel is an autologous product, there is clearly no risk of disease transmission or allergic reaction, said Dr. Clevens.
Dr. Eppley agrees that the theoretical appeal of using platelet gel to speed wound healing is great. And, from a technical standpoint, he said, producing the gel is relatively convenient, and the costs-which get passed on to the patient-are reasonable.
However, in view of the small number of clinical studies with prospective or retrospective controls demonstrating the enhancement of healing with PRP, Dr. Eppley and others believe that the jury is still out on this treatment. Scientifically, he reiterated, the evidence is not compelling. Probably what [the use of platelet gel] represents is the forerunner of better things in the future. I think the concept of extracting factors from a patient, and re-implanting them, to aid the healing process, is not going to go away. However, for the typical patient who does not have a healing problem, the benefits may not be as clear.
In the right patient-such as a person who smokes or who has compromised healing-it probably has some benefit. The use of this technology is probably driven by the doctor, who believes in it and makes the time commitment and investment to do it. But, he concluded, it is not a magic powder; it is a value-added service.
©2006 The Triological Society