- Email: [email protected]
Platelet-rich plasma-enriched autologous fat graft in regenerative and aesthetic facial surgery: Technical note
Accepted Manuscript Title: Platelet-rich plasma-enriched autologous fat graft in regenerative and aesthetic facial surgery: technical note Author: Fr´ed´eric Picard Barbara Hersant Simone La Padula Jean-Paul Meningaud PII: DOI: Reference:
S2468-7855(17)30095-2 http://dx.doi.org/doi:10.1016/j.jormas.2017.05.005 JORMAS 50
To appear in: Received date: Accepted date:
30-3-2017 22-5-2017
Please cite this article as: Fr´ed´eric PicardBarbara HersantSimone La PadulaJean-Paul Meningaud Platelet-rich plasma-enriched autologous fat graft in regenerative and aesthetic facial surgery: technical note (2017), http://dx.doi.org/10.1016/j.jormas.2017.05.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title Page
PLATELET-RICH PLASMA-ENRICHED AUTOLOGOUS FAT GRAFT IN REGENERATIVE AND AESTHETIC FACIAL SURGERY: TECHNICAL NOTE.
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Frédéric Picard, MD; Barbara Hersant, MD; Simone La Padula, MD; Jean-Paul Meningaud, MD, PhD, Professor
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Department of Plastic, Reconstructive and Maxillo-facial Surgery Henri Mondor Hospital, 51 avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France,
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Corresponding author: Simone La Padula Department of Plastic and Reconstructive Surgery Henri Mondor Hospital, 51 avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France, Tel: +33 1 49 81 25 31 Fax: +33 1 49 81 25 32 Email: [email protected]
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Abstract
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The goal of adding platelet-rich plasma (PRP) to autologous fat graft is to increase the survival rate of the graft. After their activation, platelets release some important growth factors. As a result, PRP may increase the proliferation and differentiation of Adipose-derived Stem Cells (ASCs) into adipocytes, improve fat graft vascularisation, and may block the apoptosis of grafted adipocytes. The other benefit expected from the addition of PRP to fat graft is the improvement of cutaneous trophicity above the grafted areas. An exhaustive review of the literature retrieved 11 clinical studies on humans and 7 on animals. A statistically significant increase of the survival rate of fat grafts has been found in 9 comparative studies. Our synthesis allowed us to set up the following protocol: addition of 20% of PRP activated with calcium hydrochloride to fat grafts. It may enhance the results of autologous facial fat graft in regenerative and aesthetic facial surgery. Key words:
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Platelet-rich Plasma. Autologous growth factors. Lipofilling. Fat graft. Fat transfer. Conflicts of interest statement
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The authors have no conflicts of interest.
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INTRODUCTION
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It has been demonstrated that autologous fat graft restores or increases subcutaneous volumes and improves skin quality and trophicity of the treated areas (1). Its tissue-regenerative capacity resides not only in pre-adipocytes, but also in mesenchymal stem cells contained in the adipose-derived stromal vascular fraction (AD-SVF) (2). To improve fat graft survival rate, some technical details should be applied. Adipose tissue mainly contains adipocytes whose function is to produce, store and release triglycerides, and AD-SVF composed of different cell types including adipose stem cells and mesenchymal stem cells. The composition of the fatty tissue obtained from a liposuction differs according to the patients, the donor site and the method of collection. Platelet-rich plasma (PRP) is an autologous biological fluid containing a high concentration of platelets, which can be obtained from a simple blood sample, but whose composition varies according to patients and commercial kits used (3). Platelets are interesting for regenerative medicine and reconstructive surgery because they contain growth factors (GF), such as TGF, VEGF, FGF, IGF, and PDGF, cytokines, and proteins (4). Platelet activation induces GF and cytokines release by degranulation (5). PRP activation can be obtained through two main strategies: either brutally or gradually. To brutally activate PRP, it has to be mixed with certain substances such as calcium or thrombin, which results in a massive and almost instantaneous release of all the platelet derived GF (5). The other way of releasing growth factors is a more gradual and prolonged pathway (5), which involves placing the platelets in a biological tissue that is not blood, like the adipose tissue. Hence, the PRP gets activated progressively over several days, which results in a slow and progressive release of the growth factors. Several physiopathological hypotheses (6) can explain the positive effects of the addition of PRP to adipocytes grafts. -The pro-angiogenic effect of certain growth factors such as VEGF and EGF which would lead to the synthesis of a higher density of neo-vessels within the graft (1). -The anti-apoptosis effect of certain cytokines that would block the degeneration of adipose cells in lipid vacuoles and cyst (6). -The anti-inflammatory effect of certain cytokines which would diminish the arrival of inflammatory cells such as fibroblasts and macrophages, which would decrease the formation of fibrosis and necrosis(1;6). -The proliferative and cellular differentiation effect, which would lead to the proliferation and differentiation of stem cells and pre-adipocytes of adipose tissue into mature adipocytes (1).
LITERATURE REVIEW
MATHERIAL AND METHODS
An exhaustive review of the literature retrieved 7 animal studies (7-13) and 11 human studies (14-24), including 5 on face lipofilling, 4 on breast lipofilling, one on buttocks lipofilling and one on soft tissue lipofilling. The results are presented in Table 1 and Table 2. RESULTS Among the studies on PRP-enriched autologous fat graft, Cervelli et al. found a survival rate of fat graft of 65% versus 26% (P <0.05) for facial lipofilling (17) and soft tissues (14), and Gentile et al. showed a maintenance rate of 69% versus 39% (p <0.05) for breast lipofilling (15, 16). The study of Keyhan et al. (18), which compared 2 different types of PRP for facial lipofilling, showed very high survival rates of 82% and 87%. On the other hand, 2 authors found results that did not show a significant benefit for the addition of PRP: the randomized
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study of Fontdevila et al. (19) who compared the use of PRP for facial lipofilling in HIV patients, and Salgarello et al. (20) who studied the use of PRP for breast lipofilling in a retrospective study. The study of Fontdevila et al. (19) had a major bias since it evaluated the fatty tissues of patients under triple therapy, a treatment known to alter the physiology of fatty tissue. In animals, out of 7 controlled studies, 4 (7, 8, 9, 10) found a significant increase of the survival rate of fat grafts versus 3 (11, 12, 13). Among the histological explanations found, there was an increase in vascularization in 3 studies (8, 9, 10) versus 2 (11, 13), an increase in viable adipocytes in 2 studies (8, 9) versus 1 (11), a decrease of necrotic zones, fibrous zones, cysts and vacuoles in 3 studies (8, 10, 11) versus 1 (13). DISCUSSION The addition of PRP appears to improve the rate of lipofilling. The lack of controlled randomized and homogeneous studies did not allow us to validate this strategy with certainty, although 5 studies in humans (14, 15, 16, 17, 18) and 4 in animals (7, 8, 9, 10) found a statistically significant benefit. Moreover, a major limitation of this review was the lack of control of the PRP platelet count, which we believe is crucial for a scientific study that attempts to evaluate the efficacy of a platelet-rich biological fluid. PRP is a biological fluid that originates from the patient himself but it has the disadvantage that its composition depends on the patient's platelet concentration and its mode of collection that is not standardized (3). In addition, there are no contraindications for PRP, except that some authors avoid using it for sites that have been diagnosed with cancer. On the other hand, the methods of use of PRP varied according to the studies, in particular the amount of PRP added to the lipofilling and the activation of the PRP before being mixed. Human clinical studies used a concentration between 10 to 50%, i.e., a PRP volume of 0.1 (18, 21) to 0.5 mL (14, 16, 17) to form a 1mL graft. All studies in humans except 2 (21, 24) used PRP in activated form, i.e. with the addition of calcium or thrombin, thus favoring a massive release of the growth factors contained in the platelets.
We activate PRP directly with calcium hydrochloride (1mL). Our adipocyte / PRP graft mix has a 20% concentration of PRP, which means that to form 1mL graft, we mix 0.2mL of PRP and 0.8mL of fat. This composition is only valid for small quantities of lipofilling. We make this mixture directly in a 10 mL syringe and then transfer it into 1mL syringes using a 3-ways luer lock. CONCLUSIONS Adipose tissue grafting has become the standard treatment for increasing subcutaneous volumes and an effective way to improve cutaneous trophicity. The addition of PRP probably reduces the rate of resorption of adipocyte grafts, although the results in the literature are discordant and have methodological weaknesses.
Acknowledgements All contributors meet the criteria for authorship. Financial Disclosures The authors have no competing interests to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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References 1. Brongo S, Nicoletti GF, La Padula S, Mele CM, Dʼ Andrea F. Use of lipofilling for the treatment of severe burn outcomes. Plast Reconstr Surg. 2012; 130: 374-376.
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2. Mojallal A, Foyatier J-L. [Historical review of the use of adipose tissue transfer in plastic and reconstructive surgery]. Ann Chir Plast Esthet. oct 2004;49(5):419-25.
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3. Magalon J, Bausset O, Serratrice N, Giraudo L, Aboudou H, Veran J, et al. Characterization and comparison of 5 platelet-rich plasma preparations in a single-donor model. Arthroscopy. mai 2014;30(5):629-38.
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4.Evanson JR, Guyton MK, Oliver DL, Hire JM, Topolski RL, Zumbrun SD, et al. Gender and age differences in growth factor concentrations from platelet-rich plasma in adults. Mil Med. juill 2014;179(7):799-805.
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5.Everts P a. M, Hoffmann J, Weibrich G, Mahoney CB, Schönberger JP a. M, van Zundert A, et al. Differences in platelet growth factor release and leucocyte kinetics during autologous platelet gel formation. Transfus Med. oct 2006;16(5):363-8.
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6. Serra-Mestre JM, Serra-Renom JM, Martinez L, Almadori A, D’Andrea F. Platelet-rich plasma mixed-fat grafting: a reasonable prosurvival strategy for fat grafts? Aesthetic Plast Surg. oct 2014;38(5):1041-9.
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7.Liu B, Tan X-Y, Liu Y-P, Xu X-F, Li L, Xu H-Y, et al. The adjuvant use of stromal vascular fraction and platelet-rich fibrin for autologous adipose tissue transplantation. Tissue Eng Part C Methods. janv 2013;19(1):1-14. 8. Pires Fraga MF, Nishio RT, Ishikawa RS, Perin LF, Helene A, Malheiros CA. Increased survival of free fat grafts with platelet-rich plasma in rabbits. J Plast Reconstr Aesthet Surg. déc 2010;63(12):e818-22. 9. Nakamura S, Ishihara M, Takikawa M, Murakami K, Kishimoto S, Nakamura S, et al. Platelet-rich plasma (PRP) promotes survival of fat-grafts in rats. Ann Plast Surg. juill 2010;65(1):101-6. 10. Oh DS, Cheon YW, Jeon YR, Lew DH. Activated platelet-rich plasma improves fat graft survival in nude mice: a pilot study. Dermatol Surg. mai 2011;37(5):619-25. 11. Rodríguez-Flores J, Palomar-Gallego MA, Enguita-Valls AB, Rodríguez-Peralto JL, Torres J. Influence of platelet-rich plasma on the histologic characteristics of the autologous fat graft to the upper lip of rabbits. Aesthetic Plast Surg. août 2011;35(4):480-6. 12.Kim D-Y, Ji Y-H, Kim D-W, Dhong E-S, Yoon E-S. Effects of platelet-rich plasma, adipose-derived stem cells, and stromal vascular fraction on the survival of human Transplanted adipose tissue. J Korean Med Sci. nov 2014;29 Suppl 3:S193-200.
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13. Por Y-C, Yeow VK-L, Louri N, Lim TK-H, Kee I, Song I-C. Platelet-rich plasma has no effect on increasing free fat graft survival in the nude mouse. J Plast Reconstr Aesthet Surg. août 2009;62(8):1030-4. 14.Cervelli V, Bocchini I, Di Pasquali C, De Angelis B, Cervelli G, Curcio CB, et al. P.R.L. platelet rich lipotransfert: our experience and current state of art in the combined use of fat and PRP. Biomed Res Int. 2013;2013:434191.
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15.Gentile P, Orlandi A, Scioli MG, Di Pasquali C, Bocchini I, Curcio CB, et al. A comparative translational study: the combined use of enhanced stromal vascular fraction and platelet-rich plasma improves fat grafting maintenance in breast reconstruction. Stem Cells Transl Med. avr 2012;1(4):341-51.
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16.Gentile P, Di Pasquali C, Bocchini I, Floris M, Eleonora T, Fiaschetti V, et al. Breast reconstruction with autologous fat graft mixed with platelet-rich plasma. Surg Innov. août 2013;20(4):370-6.
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17. Cervelli V, Gentile P, Scioli MG, Grimaldi M, Casciani CU, Spagnoli LG, et al. Application of platelet-rich plasma in plastic surgery: clinical and in vitro evaluation. Tissue Eng Part C Methods. déc 2009;15(4):625-34.
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18. Keyhan SO, Hemmat S, Badri AA, Abdeshahzadeh A, Khiabani K. Use of platelet-rich fibrin and platelet-rich plasma in combination with fat graft: which is more effective during facial lipostructure? J Oral Maxillofac Surg. mars 2013;71(3):610-21.
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19. Fontdevila J, Guisantes E, Martínez E, Prades E, Berenguer J. Double-blind clinical trial to compare autologous fat grafts versus autologous fat grafts with PDGF: no effect of PDGF. Plast Reconstr Surg. août 2014;134(2):219e - 230e. 20. Salgarello M, Visconti G, Rusciani A. Breast fat grafting with platelet-rich plasma: a comparative clinical study and current state of the art. Plast Reconstr Surg. juin 2011;127(6):2176-85. 21. Willemsen JCN, van der Lei B, Vermeulen KM, Stevens HPJD. The effects of plateletrich plasma on recovery time and aesthetic outcome in facial rejuvenation: preliminary retrospective observations. Aesthetic Plast Surg. oct 2014;38(5):1057-63. 22. Cervelli V, Palla L, Pascali M, De Angelis B, Curcio BC, Gentile P. Autologous plateletrich plasma mixed with purified fat graft in aesthetic plastic surgery. Aesthetic Plast Surg. sept 2009;33(5):716-21. 23. Fiaschetti V, Pistolese CA, Fornari M, Liberto V, Cama V, Gentile P, et al. Magnetic resonance imaging and ultrasound evaluation after breast autologous fat grafting combined with platelet-rich plasma. Plast Reconstr Surg. oct 2013;132(4):498e - 509e. 24. Willemsen JCN, Lindenblatt N, Stevens HPJD. Results and long-term patient satisfaction after gluteal augmentation with platelet-rich plasma-enriched autologous fat. Eur J Plast Surg. 2013;36:777-82.
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TABLE LEGENDS: Table 1: Human studies on PRP-enriched autologous fat graft.
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Table 2: Animal studies on PRP-enriched autologous fat graft.
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Table 1: Human studies on PRP-enriched autologous fat graft.
Study Design
Method of use,
Results, Side effects,
Cervelli (14) 2013, Italy
Controlled Prospectiv e
Mix of purified fat and 20% or 30% or 40% or 50% of PRP
At the 18th month, fat graft survival rate of: -20%: 38% -30%: 60% -40%: 65% -50%: 65% -without PRP:26%, No side effect,
Gentile (15) 2012, Italy
Controlled Prospectiv e
Breast reconstructi on, 23 patients
Mix of purified fat and 40% of PRP
Gentile (16) 2013, Italy
Controlled Prospectiv e
Breast reconstructi on, 100 patients
Mix of purified fat and 50% of PRP
At the 12th month, fat graft survival rate of 69% vs 39%, Side effects: one macro calcification and one cyst,
Cervelli (17) 2009, Italy
Controlled Prospectiv e
Facial lipofilling, 35 patients
Mix of purified fat and 50% of PRP
At the 18th month, fat graft survival rate of 65% (PRP group) vs 26% (control group). No side effect,
Keyhan (18) 2013, Iran
Controlled Prospectiv e
Facial lipofilling, 25 patients
At the 12th month, fat graft survival rate of: 82% with PRP and 87% with PRF, No side effect,
Fontdevi la (19) 2014, Spain
Randomiz ed
Salgarell o (20) 2010, Italy
Retrospect ive Controlled
Facial lipofilling of HIV patients, 49 patients Breast lipofilling, 42 patients
PRP group : Mix of purified fat and 10% of PRP, Platelet-rich fibrin (PRF) group: Injections of millimetric pieces of PRF in the lipofilling site, Mix of purified fat and 25% of PRP
Mix of purified fat and 10% of PRP
At the 9th month, no statistical difference between the 2 groups, No side effect,
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Type of Lipofilling, Number of patients Soft tissues, 223 patients
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At the 12th month, fat graft survival rate of 69% (PRP group) vs 39% ( without PRP), Side effects: one macro calcification and one cyst,
At the 12th month, no statistical difference between the 2 groups, No side effect,
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Mix of purified fat and 10% of PRP
Cervelli (22) 2009, Italy Fiaschett i (23) 2013, Italy
Prospectiv e Uncontroll ed Prospectiv e Uncontroll ed
Facial lipofilling, 15 patients
Mix of purified fat and 30 to 50% of PRP
Breast reconstructi on, 15 patients
Not described
Willems em (24) 2013, Netherla nds
Retrospect ive Uncontroll ed
Buttocks lipofilling, 24 patients
Mix of purified fat and 10% of PRP
Lipofilling only : significant difference regarding the aesthetic result and the recovering time for the PRP group, Face Lift + lipofilling : significant difference regarding the aesthetic result for the PRP group, No side effect, Aesthetic improvement of the face, No side effect,
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Facial lipofilling or face lift and lipofilling, 82 patients
At the 12th month : -Mean resorption rate of 28,2% -Micro calcifications rate of 20,2% -Macro calcifications rate of 12,5% -Cysts: 45,8% Side effects : 2 micros calcifications,
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Retrospect ive Controlled
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Willems em (21) 2014, Netherla nds
-Mean volume of fat graft: 481mL. -Satisfaction score (9 patients over 24) : -Before lipofilling: 3.6 -At 3 months: 6.1 -At 44 months : 5.3, Side effects : 1 case of recurrent swelling and 2 cases of hardened areas,
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Table 2. Animal studies on PRP-enriched autologous fat graft. Type of lipofilling
Method of use
Results, Side effects,
Randomiz ed
Lipofilling of the ears 30 rabbits,
Mix of purified fat and 10% of PRP
At the 24th week, fat graft survival rate of 65,4% (PRP group) versus 50,6% (control group) (p<0,05) No side effects,
Pires Fraga (8) 2010, Brazil
Prospectiv e Controlled
Lipofilling of the ears 30 rabbits,
Fat was soaked with PRP
At the 6th month, significant difference for the PRP group for the survival rate of the fat graft, the vascularization, the adipocytes viability, the decrease of necrotic areas and fibrosis, No side effect,
Nakamur a (9) 2010, Japan
Prospectiv e Controlled
Lipofilling of the back, 64 rats
Mix of purified fat and PRP then addition of calcium,
At the 4th month : increase of the survival rate of the graft, the adipocytes viability and the vascularization, No side effect
Oh (10) 2011, Korea,
Prospectiv e Controlled
Lipofilling of the scalp, 20 mice,
Mix of purified fat and 33% of PRP, then activation of platelets with calcium and thrombin
Rodrigue z- Flores (11) 2010, Spain
Prospectiv e Controlled
Lipofilling of the lips, 9 rabbits,
Mix of purified fat and 50% of PRP
At the 8th and 12th week: -Significant difference for the PRP group regarding the decrease of inflammation and cysts formation, -No significant difference regarding vascularization, adipocytes viability and fibrosis, No side effect,
Kim (12) 2014, Korea,
Prospectiv e Controlled
Lipofilling of the back, 18 mice,
Mix of purified fat and 6% of PRP
At the 4th week, fat graft survival rate of 91,3% (PRP group) versus 78,2% (p<0,05) At the 8th week, fat graft survival rate of 56,1% (PRP group) versus 49% (p>0,05) No side effect,
Por (13) 2008, Singapor e
Prospectiv e Controlled
Lipofilling of the scalp, 24 mice,
Mix of purified fat and 25% of PRP
At the 16th week : no statistical difference for the volume, the weight, the vascularization, the fibrosis, the necrosis and the cysts,
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Study design
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Name, Year, Country Liu (7) 2012, China
At the 10th week : Significant increase of the fat graft survival rate of 74,9% versus 69% (p<0,05%) and the vascularization, Significant decrease of the fibrosis, cysts and necrotic areas, No side effects,
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No side effect,
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S2468-7855(17)30095-2 http://dx.doi.org/doi:10.1016/j.jormas.2017.05.005 JORMAS 50
To appear in: Received date: Accepted date:
30-3-2017 22-5-2017
Please cite this article as: Fr´ed´eric PicardBarbara HersantSimone La PadulaJean-Paul Meningaud Platelet-rich plasma-enriched autologous fat graft in regenerative and aesthetic facial surgery: technical note (2017), http://dx.doi.org/10.1016/j.jormas.2017.05.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title Page
PLATELET-RICH PLASMA-ENRICHED AUTOLOGOUS FAT GRAFT IN REGENERATIVE AND AESTHETIC FACIAL SURGERY: TECHNICAL NOTE.
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Frédéric Picard, MD; Barbara Hersant, MD; Simone La Padula, MD; Jean-Paul Meningaud, MD, PhD, Professor
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Department of Plastic, Reconstructive and Maxillo-facial Surgery Henri Mondor Hospital, 51 avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France,
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Corresponding author: Simone La Padula Department of Plastic and Reconstructive Surgery Henri Mondor Hospital, 51 avenue du Maréchal de Lattre de Tassigny, Créteil 94010, France, Tel: +33 1 49 81 25 31 Fax: +33 1 49 81 25 32 Email: [email protected]
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Abstract
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The goal of adding platelet-rich plasma (PRP) to autologous fat graft is to increase the survival rate of the graft. After their activation, platelets release some important growth factors. As a result, PRP may increase the proliferation and differentiation of Adipose-derived Stem Cells (ASCs) into adipocytes, improve fat graft vascularisation, and may block the apoptosis of grafted adipocytes. The other benefit expected from the addition of PRP to fat graft is the improvement of cutaneous trophicity above the grafted areas. An exhaustive review of the literature retrieved 11 clinical studies on humans and 7 on animals. A statistically significant increase of the survival rate of fat grafts has been found in 9 comparative studies. Our synthesis allowed us to set up the following protocol: addition of 20% of PRP activated with calcium hydrochloride to fat grafts. It may enhance the results of autologous facial fat graft in regenerative and aesthetic facial surgery. Key words:
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Platelet-rich Plasma. Autologous growth factors. Lipofilling. Fat graft. Fat transfer. Conflicts of interest statement
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The authors have no conflicts of interest.
Page 2 of 11
INTRODUCTION
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It has been demonstrated that autologous fat graft restores or increases subcutaneous volumes and improves skin quality and trophicity of the treated areas (1). Its tissue-regenerative capacity resides not only in pre-adipocytes, but also in mesenchymal stem cells contained in the adipose-derived stromal vascular fraction (AD-SVF) (2). To improve fat graft survival rate, some technical details should be applied. Adipose tissue mainly contains adipocytes whose function is to produce, store and release triglycerides, and AD-SVF composed of different cell types including adipose stem cells and mesenchymal stem cells. The composition of the fatty tissue obtained from a liposuction differs according to the patients, the donor site and the method of collection. Platelet-rich plasma (PRP) is an autologous biological fluid containing a high concentration of platelets, which can be obtained from a simple blood sample, but whose composition varies according to patients and commercial kits used (3). Platelets are interesting for regenerative medicine and reconstructive surgery because they contain growth factors (GF), such as TGF, VEGF, FGF, IGF, and PDGF, cytokines, and proteins (4). Platelet activation induces GF and cytokines release by degranulation (5). PRP activation can be obtained through two main strategies: either brutally or gradually. To brutally activate PRP, it has to be mixed with certain substances such as calcium or thrombin, which results in a massive and almost instantaneous release of all the platelet derived GF (5). The other way of releasing growth factors is a more gradual and prolonged pathway (5), which involves placing the platelets in a biological tissue that is not blood, like the adipose tissue. Hence, the PRP gets activated progressively over several days, which results in a slow and progressive release of the growth factors. Several physiopathological hypotheses (6) can explain the positive effects of the addition of PRP to adipocytes grafts. -The pro-angiogenic effect of certain growth factors such as VEGF and EGF which would lead to the synthesis of a higher density of neo-vessels within the graft (1). -The anti-apoptosis effect of certain cytokines that would block the degeneration of adipose cells in lipid vacuoles and cyst (6). -The anti-inflammatory effect of certain cytokines which would diminish the arrival of inflammatory cells such as fibroblasts and macrophages, which would decrease the formation of fibrosis and necrosis(1;6). -The proliferative and cellular differentiation effect, which would lead to the proliferation and differentiation of stem cells and pre-adipocytes of adipose tissue into mature adipocytes (1).
LITERATURE REVIEW
MATHERIAL AND METHODS
An exhaustive review of the literature retrieved 7 animal studies (7-13) and 11 human studies (14-24), including 5 on face lipofilling, 4 on breast lipofilling, one on buttocks lipofilling and one on soft tissue lipofilling. The results are presented in Table 1 and Table 2. RESULTS Among the studies on PRP-enriched autologous fat graft, Cervelli et al. found a survival rate of fat graft of 65% versus 26% (P <0.05) for facial lipofilling (17) and soft tissues (14), and Gentile et al. showed a maintenance rate of 69% versus 39% (p <0.05) for breast lipofilling (15, 16). The study of Keyhan et al. (18), which compared 2 different types of PRP for facial lipofilling, showed very high survival rates of 82% and 87%. On the other hand, 2 authors found results that did not show a significant benefit for the addition of PRP: the randomized
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study of Fontdevila et al. (19) who compared the use of PRP for facial lipofilling in HIV patients, and Salgarello et al. (20) who studied the use of PRP for breast lipofilling in a retrospective study. The study of Fontdevila et al. (19) had a major bias since it evaluated the fatty tissues of patients under triple therapy, a treatment known to alter the physiology of fatty tissue. In animals, out of 7 controlled studies, 4 (7, 8, 9, 10) found a significant increase of the survival rate of fat grafts versus 3 (11, 12, 13). Among the histological explanations found, there was an increase in vascularization in 3 studies (8, 9, 10) versus 2 (11, 13), an increase in viable adipocytes in 2 studies (8, 9) versus 1 (11), a decrease of necrotic zones, fibrous zones, cysts and vacuoles in 3 studies (8, 10, 11) versus 1 (13). DISCUSSION The addition of PRP appears to improve the rate of lipofilling. The lack of controlled randomized and homogeneous studies did not allow us to validate this strategy with certainty, although 5 studies in humans (14, 15, 16, 17, 18) and 4 in animals (7, 8, 9, 10) found a statistically significant benefit. Moreover, a major limitation of this review was the lack of control of the PRP platelet count, which we believe is crucial for a scientific study that attempts to evaluate the efficacy of a platelet-rich biological fluid. PRP is a biological fluid that originates from the patient himself but it has the disadvantage that its composition depends on the patient's platelet concentration and its mode of collection that is not standardized (3). In addition, there are no contraindications for PRP, except that some authors avoid using it for sites that have been diagnosed with cancer. On the other hand, the methods of use of PRP varied according to the studies, in particular the amount of PRP added to the lipofilling and the activation of the PRP before being mixed. Human clinical studies used a concentration between 10 to 50%, i.e., a PRP volume of 0.1 (18, 21) to 0.5 mL (14, 16, 17) to form a 1mL graft. All studies in humans except 2 (21, 24) used PRP in activated form, i.e. with the addition of calcium or thrombin, thus favoring a massive release of the growth factors contained in the platelets.
We activate PRP directly with calcium hydrochloride (1mL). Our adipocyte / PRP graft mix has a 20% concentration of PRP, which means that to form 1mL graft, we mix 0.2mL of PRP and 0.8mL of fat. This composition is only valid for small quantities of lipofilling. We make this mixture directly in a 10 mL syringe and then transfer it into 1mL syringes using a 3-ways luer lock. CONCLUSIONS Adipose tissue grafting has become the standard treatment for increasing subcutaneous volumes and an effective way to improve cutaneous trophicity. The addition of PRP probably reduces the rate of resorption of adipocyte grafts, although the results in the literature are discordant and have methodological weaknesses.
Acknowledgements All contributors meet the criteria for authorship. Financial Disclosures The authors have no competing interests to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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References 1. Brongo S, Nicoletti GF, La Padula S, Mele CM, Dʼ Andrea F. Use of lipofilling for the treatment of severe burn outcomes. Plast Reconstr Surg. 2012; 130: 374-376.
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2. Mojallal A, Foyatier J-L. [Historical review of the use of adipose tissue transfer in plastic and reconstructive surgery]. Ann Chir Plast Esthet. oct 2004;49(5):419-25.
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3. Magalon J, Bausset O, Serratrice N, Giraudo L, Aboudou H, Veran J, et al. Characterization and comparison of 5 platelet-rich plasma preparations in a single-donor model. Arthroscopy. mai 2014;30(5):629-38.
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4.Evanson JR, Guyton MK, Oliver DL, Hire JM, Topolski RL, Zumbrun SD, et al. Gender and age differences in growth factor concentrations from platelet-rich plasma in adults. Mil Med. juill 2014;179(7):799-805.
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5.Everts P a. M, Hoffmann J, Weibrich G, Mahoney CB, Schönberger JP a. M, van Zundert A, et al. Differences in platelet growth factor release and leucocyte kinetics during autologous platelet gel formation. Transfus Med. oct 2006;16(5):363-8.
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6. Serra-Mestre JM, Serra-Renom JM, Martinez L, Almadori A, D’Andrea F. Platelet-rich plasma mixed-fat grafting: a reasonable prosurvival strategy for fat grafts? Aesthetic Plast Surg. oct 2014;38(5):1041-9.
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7.Liu B, Tan X-Y, Liu Y-P, Xu X-F, Li L, Xu H-Y, et al. The adjuvant use of stromal vascular fraction and platelet-rich fibrin for autologous adipose tissue transplantation. Tissue Eng Part C Methods. janv 2013;19(1):1-14. 8. Pires Fraga MF, Nishio RT, Ishikawa RS, Perin LF, Helene A, Malheiros CA. Increased survival of free fat grafts with platelet-rich plasma in rabbits. J Plast Reconstr Aesthet Surg. déc 2010;63(12):e818-22. 9. Nakamura S, Ishihara M, Takikawa M, Murakami K, Kishimoto S, Nakamura S, et al. Platelet-rich plasma (PRP) promotes survival of fat-grafts in rats. Ann Plast Surg. juill 2010;65(1):101-6. 10. Oh DS, Cheon YW, Jeon YR, Lew DH. Activated platelet-rich plasma improves fat graft survival in nude mice: a pilot study. Dermatol Surg. mai 2011;37(5):619-25. 11. Rodríguez-Flores J, Palomar-Gallego MA, Enguita-Valls AB, Rodríguez-Peralto JL, Torres J. Influence of platelet-rich plasma on the histologic characteristics of the autologous fat graft to the upper lip of rabbits. Aesthetic Plast Surg. août 2011;35(4):480-6. 12.Kim D-Y, Ji Y-H, Kim D-W, Dhong E-S, Yoon E-S. Effects of platelet-rich plasma, adipose-derived stem cells, and stromal vascular fraction on the survival of human Transplanted adipose tissue. J Korean Med Sci. nov 2014;29 Suppl 3:S193-200.
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13. Por Y-C, Yeow VK-L, Louri N, Lim TK-H, Kee I, Song I-C. Platelet-rich plasma has no effect on increasing free fat graft survival in the nude mouse. J Plast Reconstr Aesthet Surg. août 2009;62(8):1030-4. 14.Cervelli V, Bocchini I, Di Pasquali C, De Angelis B, Cervelli G, Curcio CB, et al. P.R.L. platelet rich lipotransfert: our experience and current state of art in the combined use of fat and PRP. Biomed Res Int. 2013;2013:434191.
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15.Gentile P, Orlandi A, Scioli MG, Di Pasquali C, Bocchini I, Curcio CB, et al. A comparative translational study: the combined use of enhanced stromal vascular fraction and platelet-rich plasma improves fat grafting maintenance in breast reconstruction. Stem Cells Transl Med. avr 2012;1(4):341-51.
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16.Gentile P, Di Pasquali C, Bocchini I, Floris M, Eleonora T, Fiaschetti V, et al. Breast reconstruction with autologous fat graft mixed with platelet-rich plasma. Surg Innov. août 2013;20(4):370-6.
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17. Cervelli V, Gentile P, Scioli MG, Grimaldi M, Casciani CU, Spagnoli LG, et al. Application of platelet-rich plasma in plastic surgery: clinical and in vitro evaluation. Tissue Eng Part C Methods. déc 2009;15(4):625-34.
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18. Keyhan SO, Hemmat S, Badri AA, Abdeshahzadeh A, Khiabani K. Use of platelet-rich fibrin and platelet-rich plasma in combination with fat graft: which is more effective during facial lipostructure? J Oral Maxillofac Surg. mars 2013;71(3):610-21.
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19. Fontdevila J, Guisantes E, Martínez E, Prades E, Berenguer J. Double-blind clinical trial to compare autologous fat grafts versus autologous fat grafts with PDGF: no effect of PDGF. Plast Reconstr Surg. août 2014;134(2):219e - 230e. 20. Salgarello M, Visconti G, Rusciani A. Breast fat grafting with platelet-rich plasma: a comparative clinical study and current state of the art. Plast Reconstr Surg. juin 2011;127(6):2176-85. 21. Willemsen JCN, van der Lei B, Vermeulen KM, Stevens HPJD. The effects of plateletrich plasma on recovery time and aesthetic outcome in facial rejuvenation: preliminary retrospective observations. Aesthetic Plast Surg. oct 2014;38(5):1057-63. 22. Cervelli V, Palla L, Pascali M, De Angelis B, Curcio BC, Gentile P. Autologous plateletrich plasma mixed with purified fat graft in aesthetic plastic surgery. Aesthetic Plast Surg. sept 2009;33(5):716-21. 23. Fiaschetti V, Pistolese CA, Fornari M, Liberto V, Cama V, Gentile P, et al. Magnetic resonance imaging and ultrasound evaluation after breast autologous fat grafting combined with platelet-rich plasma. Plast Reconstr Surg. oct 2013;132(4):498e - 509e. 24. Willemsen JCN, Lindenblatt N, Stevens HPJD. Results and long-term patient satisfaction after gluteal augmentation with platelet-rich plasma-enriched autologous fat. Eur J Plast Surg. 2013;36:777-82.
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TABLE LEGENDS: Table 1: Human studies on PRP-enriched autologous fat graft.
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Table 2: Animal studies on PRP-enriched autologous fat graft.
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Table 1: Human studies on PRP-enriched autologous fat graft.
Study Design
Method of use,
Results, Side effects,
Cervelli (14) 2013, Italy
Controlled Prospectiv e
Mix of purified fat and 20% or 30% or 40% or 50% of PRP
At the 18th month, fat graft survival rate of: -20%: 38% -30%: 60% -40%: 65% -50%: 65% -without PRP:26%, No side effect,
Gentile (15) 2012, Italy
Controlled Prospectiv e
Breast reconstructi on, 23 patients
Mix of purified fat and 40% of PRP
Gentile (16) 2013, Italy
Controlled Prospectiv e
Breast reconstructi on, 100 patients
Mix of purified fat and 50% of PRP
At the 12th month, fat graft survival rate of 69% vs 39%, Side effects: one macro calcification and one cyst,
Cervelli (17) 2009, Italy
Controlled Prospectiv e
Facial lipofilling, 35 patients
Mix of purified fat and 50% of PRP
At the 18th month, fat graft survival rate of 65% (PRP group) vs 26% (control group). No side effect,
Keyhan (18) 2013, Iran
Controlled Prospectiv e
Facial lipofilling, 25 patients
At the 12th month, fat graft survival rate of: 82% with PRP and 87% with PRF, No side effect,
Fontdevi la (19) 2014, Spain
Randomiz ed
Salgarell o (20) 2010, Italy
Retrospect ive Controlled
Facial lipofilling of HIV patients, 49 patients Breast lipofilling, 42 patients
PRP group : Mix of purified fat and 10% of PRP, Platelet-rich fibrin (PRF) group: Injections of millimetric pieces of PRF in the lipofilling site, Mix of purified fat and 25% of PRP
Mix of purified fat and 10% of PRP
At the 9th month, no statistical difference between the 2 groups, No side effect,
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Type of Lipofilling, Number of patients Soft tissues, 223 patients
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At the 12th month, fat graft survival rate of 69% (PRP group) vs 39% ( without PRP), Side effects: one macro calcification and one cyst,
At the 12th month, no statistical difference between the 2 groups, No side effect,
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Mix of purified fat and 10% of PRP
Cervelli (22) 2009, Italy Fiaschett i (23) 2013, Italy
Prospectiv e Uncontroll ed Prospectiv e Uncontroll ed
Facial lipofilling, 15 patients
Mix of purified fat and 30 to 50% of PRP
Breast reconstructi on, 15 patients
Not described
Willems em (24) 2013, Netherla nds
Retrospect ive Uncontroll ed
Buttocks lipofilling, 24 patients
Mix of purified fat and 10% of PRP
Lipofilling only : significant difference regarding the aesthetic result and the recovering time for the PRP group, Face Lift + lipofilling : significant difference regarding the aesthetic result for the PRP group, No side effect, Aesthetic improvement of the face, No side effect,
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Facial lipofilling or face lift and lipofilling, 82 patients
At the 12th month : -Mean resorption rate of 28,2% -Micro calcifications rate of 20,2% -Macro calcifications rate of 12,5% -Cysts: 45,8% Side effects : 2 micros calcifications,
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Retrospect ive Controlled
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Willems em (21) 2014, Netherla nds
-Mean volume of fat graft: 481mL. -Satisfaction score (9 patients over 24) : -Before lipofilling: 3.6 -At 3 months: 6.1 -At 44 months : 5.3, Side effects : 1 case of recurrent swelling and 2 cases of hardened areas,
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Table 2. Animal studies on PRP-enriched autologous fat graft. Type of lipofilling
Method of use
Results, Side effects,
Randomiz ed
Lipofilling of the ears 30 rabbits,
Mix of purified fat and 10% of PRP
At the 24th week, fat graft survival rate of 65,4% (PRP group) versus 50,6% (control group) (p<0,05) No side effects,
Pires Fraga (8) 2010, Brazil
Prospectiv e Controlled
Lipofilling of the ears 30 rabbits,
Fat was soaked with PRP
At the 6th month, significant difference for the PRP group for the survival rate of the fat graft, the vascularization, the adipocytes viability, the decrease of necrotic areas and fibrosis, No side effect,
Nakamur a (9) 2010, Japan
Prospectiv e Controlled
Lipofilling of the back, 64 rats
Mix of purified fat and PRP then addition of calcium,
At the 4th month : increase of the survival rate of the graft, the adipocytes viability and the vascularization, No side effect
Oh (10) 2011, Korea,
Prospectiv e Controlled
Lipofilling of the scalp, 20 mice,
Mix of purified fat and 33% of PRP, then activation of platelets with calcium and thrombin
Rodrigue z- Flores (11) 2010, Spain
Prospectiv e Controlled
Lipofilling of the lips, 9 rabbits,
Mix of purified fat and 50% of PRP
At the 8th and 12th week: -Significant difference for the PRP group regarding the decrease of inflammation and cysts formation, -No significant difference regarding vascularization, adipocytes viability and fibrosis, No side effect,
Kim (12) 2014, Korea,
Prospectiv e Controlled
Lipofilling of the back, 18 mice,
Mix of purified fat and 6% of PRP
At the 4th week, fat graft survival rate of 91,3% (PRP group) versus 78,2% (p<0,05) At the 8th week, fat graft survival rate of 56,1% (PRP group) versus 49% (p>0,05) No side effect,
Por (13) 2008, Singapor e
Prospectiv e Controlled
Lipofilling of the scalp, 24 mice,
Mix of purified fat and 25% of PRP
At the 16th week : no statistical difference for the volume, the weight, the vascularization, the fibrosis, the necrosis and the cysts,
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Name, Year, Country Liu (7) 2012, China
At the 10th week : Significant increase of the fat graft survival rate of 74,9% versus 69% (p<0,05%) and the vascularization, Significant decrease of the fibrosis, cysts and necrotic areas, No side effects,
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No side effect,
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