Platelet-Rich Plasma Combined with Fractional Laser Therapy for Skin Rejuvenation

Keywords:laser, treatment, fibers,  Time:23-11-2015
The use of PRP has recently been applied to aesthetic medicine, but there are few studies on the rejuvenation effects of PRP.1,2 PRP contains significant amounts of platelet-derived growth factor, transforming growth factor, vascular endothelial growth factor, epidermal growth factor, and fibroblast growth factor3,4 and has been shown to enhance early healing through the release of growth factors.

Subjects and Study Design

Exclusion criteria were concomitant treatments (other than topical therapy) of the involved skin areas; a history of keloid scarring; isotretinoin use within 1 year of study enrollment; photosensitivity or immune suppression; treatment with other skin rejuvenation techniques such as chemical peeling, botulinum toxin, injectable fillers, and laser skin resurfacing in the previous year; and use of cosmeceuticals containing retinoids, vitamin C, or copper peptides, which could influence collagen synthesis.
Eligible subjects underwent three sessions of fractional surgical laser fibers at 4-week intervals. The outcome assesements included the subjective satisfaction scale, improvement score according to blinded investigators (using standardized photography), biophysical measurements, and skin biopsies. Measurements were conducted before the first treatment and 1 month after the last treatment session. Subjects who did not use cosmeceuticals containing retinol, retinoids, alpha or beta hydroxyl acids, or peptides were enrolled.

Preparation of the PRP

A 12-mL blood sample was drawn and collected in a sterile tube containing 1 mL of citrate phosphate dextrose adenin solution. The tubes were then centrifuged at 3,000 revolutions per minute (rpm) for 5 minutes. The blood samples were separated by centrifugation to obtain two parts of the plasma; the upper part consisted of 3 mL of platelet-poor plasma (PPP) and the lower part consisted of 3 mL of PRP. The 3 mL of PPP was first gently aspirated to avoid mixing it with the PRP. Then the PPP was centrifuged again at 3,000 rpm for 5 minutes. The residual 3 mL of PRP was subsequently aspirated from each test tube and prepared for activation by adding calcium chloride (0.1 mL per 0.9 mL of PRP) to obtain a 3-mL concentration of activated PRP. Topical anesthetic (EMLA cream, Astra, Westborough, MA) was applied for 30 minutes before treatment and then completely removed. A 1,550-nm fractional erbium glass laser (MOSAIC, Lutronic Corporation, Gyeonggi, Korea) was used for the fractional medical fibers treatment. We used the static mode (40 mJ, 50 spots/cm2) and one pass. Three milliliter of the PRP was applied topically and occluded on the full face for 20 minutes.

Outcome Measures

Subjective Satisfaction Scale Subjects completed a self-assessment questionnaire and rated their improvement on a scale from 0 (aggravated) to 4 (much improved). The investigator subjectively graded erythema after treatment on a scale from 0 to 4 (0 = absent, 1 = trace, 2 = slight, 3 = moderate, 4 = prominent). The duration of erythema was investigated through interviews. After treatment, subjects were asked to grade their intraprocedure pain on a visual analog scale from 0 to 4 (0 = no pain, 4 = severe pain). Pain scores and any adverse events and complications were recorded at the time of each treatment and at the follow-up visit. The number of subjects who reported adverse effects at least once during the four visits was determined.

Two dermatologists who were blinded to subject treatment group evaluated the serial photographs in a randomized fashion (before and after treatment, without labeling) to determine whether discernible clinical improvement had occurred. If a particular masked reviewer detected a change, the reviewer was asked to identify the posttreatment image. If the correct image was identified as the posttreatment image, the assessment from the reviewer was considered an improvement (a score of 1 point); if the reviewer identified the wrong image as the post-treatment image, the assessment from the reviewer was considered as worsening (a score of "1 point). If the reviewer reported no difference between the two photographs, the assessment was considered to be indicative of no change (a score of 0 points). The sum of the assessment scores was calculated as the improvement score.

Biophysical Evaluations All measurements were taken after subjects had undergone an acclimatization period of at least 20 minutes in an air conditioned room under standardized conditions (22– 25°C, 50% humidity). The parameters assessed were in vivo skin surface roughness, elasticity, hydration, erythema, and the melanin index. Each measurement was performed on the left and right cheeks of each subject. Percentage improvement was calculated as (final value " baseline value)/ baseline value 9 100.
Skin Surface Roughness A camera (Visioscan VC 98; Courage & Khazaka Electronic GmbH, Cologne, Germany) with a high-resolution blackand-white video sensor and an ultraviolet A light source built into it to illuminate the skin was used to measure the skin surface roughness. Based on the gray-level distribution of the image produced, computer software was used to quantify skin surface roughness. The roughness parameter investigated in this study was R3. R3 is the average of the roughness of different segment from five successive measurements of the same length and is regarded as the most useful parameter for measuring skin wrinkles.

Elasticity Elasticity was determined using a commercially available noninvasive suction skin elasticity meter (Cutometer MPA 580; Courage & Khazaka Electronic GmbH) that created negative pressure and drew the skin into the aperture of the probe. Penetration depth is determined using a noncontact optical measuring system in which the light intensity varies according to the depth of penetration of the skin. The ability of the skin to return to its original position is displayed as a curve, which is translated into a measure of overall elasticity (R2) using standard computer software.This device can quantify the humidity levels of the stratum corneum based on the distinct dielectric constant of the water.12
Erythema and Melanin Index Skin erythema and pigmentation were measured using a reflectance spectrophotometer (Derma-Spectrophotometer, Cortex Technology, Hadsund, Denmark), a narrow-band spectrophotometer designed to measure specific colors caused by two major chromophores (hemoglobin and melanin). The light sources are two light-emitting diodes with selected narrow bands of emitted wavelengths. The peaks of the two bands are centered at 568 nm (green light) and 655 nm (red light); the diodes emit light in sequence, and the reflected light from the skin is detected with a photodetector. After conversion into a digital form with a built-in microcomputer, the reflectance in the two bands is transformed into an erythema index (E-index) and a melanin index (M-index).

Histologic Analysis

In six subjects, skin biopsies were obtained from the lateral cheek for histologic evaluation at baseline and 1 month after the final PRP treatment. We obtained three randomly chosen histologic photographs per subjects, therefore analyzing 18 histologic photographs in total.

Statistical Analyses

Statistical analyses were performed using SPSS for Windows (SPSS Inc., Chicago, IL). Before-and-after treatment comparisons were performed using the parametric t-test for paired samples. The statistical tests were two-sided, and a probability value of less than 5% was considered statistically significant. The differences in the degree of improvement and percentage improvement between groups were compared using an independent sample t-test.

Subjective Satisfaction Scale

One hundred percent of the group that received combination treatment and 58% of the group that received fractional laser treatment alone reported improvement in skin texture or fine wrinkles (Figure 1); 92% and 67%, respectively, reported improvement in skin elasticity; 25% and 0%, respectively, reported improvement in skin texture, and 8% and 0%, respectively, reported an increase in skin elasticity.

Objective Clinical Assessment

The improvement score for overall appearance of the face was 1.73 for the group that received combination treatment and 1.18 for the group that received fractional laser treatment alone (Figure 2). Two blinded reviewers felt that five of 11 (45%) in the fractional group and eight of 11 (73%) in the combined PRP group improved. The difference between the two groups was not statistically significant.

Biophysical Analysis

Skin Surface Roughness Skin surface roughness decreased statistically significantly (from 37.2 ± 3.1 to 34.3 ± 2.3; 7.5%) in the group that received fractional laser treatment alone and more significantly in the group that received combination treatment (from 34.1 ± 2.9 to 30.4 ± 2.3; 10.3%).