Platelet-Rich Plasma: Evolving Role in Plastic Surgery

Edward S. Chamata, M.D.; Erica L. Bartlett, M.D.; David Weir, N.P.-C.; Rod J. Rohrich, M.D.

Plast Reconstr Surg. 2021;147(1):219-230.

Platelet Physiology and Platelet-rich Plasma Science

Platelets play a vital role in the initiation of hemostasis and wound healing, setting the pace for wound repair.^[10,11] In response to tissue and vascular damage, a platelet plug is formed, with subsequent release of biologically active proteins. These proteins, released from alpha-granules within the platelet, initiate a cascade of events leading to tissue healing and regeneration.^[12] Although constituting only 10 percent of platelet volume, over 30 biologically active proteins are released, including transforming growth factor-β, platelet-derived growth factor, vascular endothelial growth factor, fibroblast growth factor, and epithelial cell growth factor. These factors not only aid in coagulation but drive angiogenesis and promote wound repair.^[13–18] Proposed therapeutic effects from platelet-rich plasma result from locally released growth factors within the target tissue. Table 1 lists the common growth factors within platelet-rich plasma and their proposed mechanism of action.^[19–23]

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Next Section

Abstract and Introduction
Platelet Physiology and Platelet-rich Plasma Science
Platelet-rich Plasma Preparation
Platelet and Growth Factor Concentration
Applications in Plastic Surgery
Safety and Adverse Effects
Shortcomings and Lack of Data
Conclusions
References

Table 1. Platelet Factors and Their Function
Growth Factors Released by Platelets	Function
VEGF¹⁹	• Promotes endothelial cell migration and proliferation • Increases vascular permeability • Promotes angiogenesis, epithelization, and collagen deposition • Formation of granulation tissue
PDGF²⁰	• Stimulates breakdown of old collagen • Potent activator for cells of mesenchymal origin • Stimulates chemotaxis, proliferation, and gene expression in monocytes-macrophages and fibroblasts
FGF²¹	• Initial stimulus for angiogenesis • Plays role in tissue remodeling • Promotes migration of fibroblasts • Mitogen for vascular endothelial cells
EGF²²	• Increases keratinocyte migration • Enhances epithelialization • Assists in granulation tissue formation
TGF-β²³	• Mediates extracellular matrix production, collagen production • Promotes angiogenesis • Increases proliferation of fibroblasts and keratinocytes • Inhibitor of metalloproteinase

VEGF, vascular endothelial growth factor; PDGF, platelet-derived growth factor; FGF, fibroblast growth factor; EGF, epidermal growth factor; TGF-β, transforming growth factor-β.

Table 2. Platelet-Rich Preparations
Preparation Name	Description
P-PRP	• Platelet-rich • Leukocyte-poor • Low-density fibrin network
L-PRP	• Platelet-rich • Leukocyte-rich • Low-density fibrin network
P-PRF	• Platelet-rich • Leukocyte-poor • High-density fibrin network
L-PRF	• Platelet-rich • Leukocyte-rich • High-density fibrin network

P-PRP, pure platelet-rich plasma; L-PRP, leukocyte- and platelet-rich plasma; P-PRF, pure platelet-rich fibrin; L-PRF, leukocyte- and platelet-rich fibrin.

Table 3. Studies of Platelet-Rich Plasma and Facial Rejuvenation
Reference	Study Type	Volume of Whole Blood (ml)	Final Volume of PRP Injected (ml)	Platelet Concentration above Baseline	Injection Technique	No. of Treatments	Findings
Redaelli et al., 2010⁴¹	Case series	16	3.08	Not reported	Direct injection	3	• Improved skin texture and elasticity • Increased volume • Decreased acne scarring • Increased patient satisfaction
Sclafani, 2010⁴⁰	Case series	18	2–5	Not reported	Direct injection	1	• Improvement in wrinkle severity scores
Yuksel et al., 2014³⁵	Case series	8	1.5	Not reported	Direct injection and topical	3	• Improved skin general appearance • Decreased wrinkles • Increased skin firmness
Mehryan et al., 2014⁶⁸	Case series	10	1.5	Not reported	Direct injection	3	• Improved infraorbital color • Increased patient satisfaction
Kang et al., 2014⁵⁵	Prospective, randomized, split-face trial	12	1	Not reported	Direct injection	3	• Decreased wrinkles • Improved skin tone • Decreased erythema and melanin
Diaz-Ley et al., 2015⁸³	Case series	36	Not reported	Not reported	Direct injection	3	• Increase in skin thickness • Decrease solar elastosis
Sevilla et al., 2015⁴⁹	Case series	34	5	Not reported	Direct injection	1	• Decrease nasolabial fold severity
Abuaf et al, 2016⁶¹	Prospective, nonrandomized, controlled trial	8	2	Not reported	Direct injection	1	• Increased dermal collagen
Cameli et al., 2017⁶⁴	Case series	9	4	Not reported	Direct injection	3	• Improved skin texture • Improved skin elasticity • Improved skin barrier function
Elnehrawy et al., 2017¹⁰⁸	Case series	18	5–6	Not reported	Direct injection	1	• Decreased wrinkle severity • Improved skin texture
Gawdat at al., 2017⁶³	Prospective, randomized, split-face trial	10	2	Not reported	Direct injection	6	• Increased skin thickness texture • High patient satisfaction
El-Domyati et al., 2018⁶⁶	Prospective, randomized, split-face trial	10	Not reported	Not reported	Topical after microneedling	6	• Increased skin thickness • Increase in organized collagen
Everts et al., 2018²⁹	Case series	50	7	Not reported	Direct injection	3	• Decrease in brown spots • Decrease wrinkles • Increase skin firmness • High patient satisfaction
Lee et al., 2018¹⁰⁹	Case series	8	4	Not reported	Direct injection	1	• High patient satisfaction

PRP, platelet-rich plasma.

Table 4. Overview of Studies with Platelet-Rich Plasma for Alopecia
Reference	Study Type	Volume of Whole Blood (ml)	Final Volume of PRP Injected (ml)	Platelet Concentration above Baseline	Injection Technique	Findings
Uebel et al., 2006⁷²	Split-scalp study	80	16	4–6×	Follicular units soaked in PRP	• Increase in follicular density
Khatu et al., 2014⁷⁴	Prospective	20	2–3	Not reported	Nappage	• Reduction in hair loss • Increased hair count • Negative hair pull test
Trink et al., 2013⁷³	RCT, split-scalp study	36	Not reported	3–5×	N/A	• Increase hair regrowth • Decrease hair dystrophy • Higher Ki-67 levels with PRP
Ferrando et al., 2017⁷⁵	Prospective	18	3	Not reported	Nappage	• Most showed improved grade for Ebling's scale
Jha et al., 2018⁸⁴	Prospective	15	Not reported	Not reported	Nappage	• Hair growth started after first session • Increase in number of vellus and total hairs • Increased hair shaft diameter • Negative hair pull test
Singhal et al., 2015⁵⁷	Prospective	20	8–12	Not reported	Nappage	• Clinical improvement in hair count, hair thickness, hair root strength, and overall alopecia
Gkini et al., 2014³⁹	Prospective cohort	16	6	5.8×	Nappage	• Reduced hair loss • Hair density peaked at 3 mo • Significantly increased hair density at 6 mo and 1 yr
Kachhawa et al., 2017⁷⁶	Prospective, split-scalp study	16	1–2	Not reported	Nappage	• Hair loss reduced • New hair growth • Improved hair density, quality, and thickness
Alves and Grimalt, 2016⁸¹	RCT, split-scalp study	18	3	3×	Nappage	• Improvement in mean anagen hairs, telogen hairs, hair density, and terminal hair density compared with baseline
Butt et al., 2018⁸⁵	Prospective	9	Not reported	Not reported	Nappage	• Clinical improvement in hair counts, hair thickness, hair root strength, and overall alopecia
Rodrigues et al., 2018⁸⁰	RCT	51	2	5×	Nappage	• Significant increase in hair count, hair density, and percentage of anagen hairs • No correlation with platelet counts or quantification of the growth factors in PRP
Gentile et al., 2015³⁴	RCT	78	9	Not reported	Nappage	• Improvement in mean number of hairs and hair density • Increase in Ki-67⁺ bulge cells and increase in vessels around hair follicles • 4 of 20 patients with relapse 12 mo after last treatment

PRP, platelet-rich plasma; RCT, randomized controlled trial; N/A, not applicable.

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Platelet-Rich Plasma: Evolving Role in Plastic Surgery

Platelet Physiology and Platelet-rich Plasma Science

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