Healing and hair growth with platelet rich plasma (PRP)

[latinlotus]

Any of you heard of Platelet rich plasman (PRP)? I read a post back in 2005 but not many replies. I am scheduled for HT next month, and the doctor is recommending this. Any feedback/comment/advice is greatly appreciated.

 

Basically, a small amount (50cc) of your blood is taken before surgery. The platelets, which are part of your blood and help with healing of wounds, are separated to form a solution called platelet rich plasma. The grafts are bathed in this PRP before being implanted. The PRP is also injected in the scar and recipient sites.

 

The main advantages are: (i actually copy and paste from an article, my vocabulary is not that wide

(1) to enhance donor site wound healing,

(2) to decrease the incidence of infection,

(3) to reduce donor scarring,

(4) to increase donor scar tensile strength,

(5) to enhance recipient site healing (which should increase growth), and

(6) to be utilized as an effective treatment protocol in severe cases of wound dehiscence or infection.

 

Disadvantages:

none, apart from pain from needles (which should not be a problem for patients doing for HT) and cost which i think is about 500$-1000$ extra.

 

It seems that this procedure had been used for over a decade with plastic surgeons. It just gradually started to get into the HT field.

 

Is it a safe procedure?

 

Thanks.

[Dr. Timothy Carman]

Originally posted by latinlotus:

It seems that this procedure had been used for over a decade with plastic surgeons.

Thanks.

The main use for these agents is in the area where flaps are created, which is generally not a feature of most of today's hair restoration procedures. As from the article cited:

"The potential advantages of the use of such substances include prevention of hematoma, reduction in surgical time, elimination of the need for drains, reduction of tension on flaps, and shorter recovery times.

These 20 cosmetic surgery cases involving the creation of skin flaps demonstrate that autologous fibrin glue is effective in sealing capillary beds during the surgery and thereby easily controlling bleeding. The control of such bleeding improves the outcome of such surgery as it reduces the amount of postsurgical swelling. Additionally, there are cost benefits that can be achieved from the reduction or elimination in the use of drains and dressings, as well as decreased postoperative complications. The most common of these complications following cosmetic surgical procedures involving the creation of surgical flaps is hematoma formation, often requiring surgical re-exploration. Apart from the increased risk, inconvenience, and distress which it engenders to the patient, re-exploration is extremely costly to all parties involved. The use of autologous fibrin glue and platelet gel should reduce the incidence of this complication significantly, which in and of itself should lead to significant cost savings. Furthermore, the improvement in wound healing can help lead to shorter recovery with earlier discharge for patients undergoing procedures on an inpatient basis."

 

Again, while these agents (PRP and fibrin glue) can control bleeding, this usually is not an issue in routine , appropriately carried out HT procedures. Without these agents, your surgeon should be able to meet all the "goals" you list above:

1) Donor site healing in a well approximated closure that is not under undue tension should not need "improving".

2) Infection in HT surgery is already a quite rare phenomena.

3) See #1

4) I doubt this one..

5) Recipient sites should normally heal well.

6) This is considered a post op complication, not an intra-operative one necessitating the above agents.

 

Bottom line, my opinion: a lot of money for which there is little indication or gain in traditional state of the art hair restoration surgeries.

 

Article here .

[latinlotus]

Dr. Carman:

 

Thank you very much for providing your assessment of PRP. If I understand your conclusion correctly, there is no drawback for using PRP in hair transplantation surgery, which is what i wanted to verify in the first place. In fact, i presume that you think it may be helpful, should complication occur, although quite rare in HT. There is always the issue of cost but Dr. Cooley told me that he might be charging an extra $500 just to cover the cost of supplies, thus not a big deal considering the overall cost of the HT.

 

Note by the way the article you referred was dated 2001, involving plastic surgeries.

 

In my next post, I will post a little more recent study dated 2003. It tested PRP on actual hair restoration surgeries. Please let me know what do you think. Thanks.

[latinlotus]

Preliminary Experience and Extended Applications for the Use of Autologous Platelet-Rich Plasma in Hair Transplantation Surgery Joseph Greco, PhD, PA/C, Robert J. Brandt Siesta Key, Florida

 

Joe Greco has indicated no financial interest relevant to this article; Robert Brandt is president of Blood Recovery Systems.

 

The use of platelet rich plasma (PRP) in hair restoration surgery reported increased yield when utilized as a graft storage medium (Uebel, 2005).1 When grafts are bathed in activated PRP, there appears to be higher graft survival and quicker healing.

 

Based on five months of experience involving more than 30 cases, the authors suggest expanding the use of PRP in hair restoration surgery for the following reasons:

(1) to enhance donor site wound healing,

(2) to decrease the incidence of infection,

(3) to reduce donor scarring,

(4) to increase donor scar tensile strength,

(5) to enhance recipient site healing, and

(6) to be utilized as an effective treatment protocol in severe cases of wound dehiscence or infection.

In addition to the PRP, platelet poor plasma (PPP) also has potent sealant properties that can be utilized for hemostasis during the procedure.

 

Platelet-derived growth factor (PDGF) is the evolutionary sentinel growth factor that initiates all wound healing. Platelet rich plasma (PRP) contains several growth factors, including PDGF and transforming growth factor-beta (TGF-beta 1) at high levels and vascular endothelial growth factor (VEGF). PDGF's main function is to stimulate cell replication (mitogenesis) of healing capable stem cells.

 

It also stimulates cell replication of endothelial cells. This will cause budding of new capillaries into the wound (angiogenesis), a fundamental part of all wound healing. In addition, PDGF seems to promote the migration of perivascular healing capable cells into a wound and to modulate the effects of other growth factors

 

.

 

Numerous studies and practical applications have also demonstrated how growth factors are essential for regulating the cellular events involved in wound healing by attracting cells to the wound, stimulating proliferation, and significantly influencing matrix deposition (Declair, 1999).2 TGF-beta is extremely important because it affects most aspects of tissue wound repair, namely initiation and termination, and also promotes differentiation and proliferation (Choi and Fuchs, 1990).3 PDGF improves dermal regeneration, acts locally to promote protein and collagen synthesis, causes endothelial migration or angiogenesis (Ross, 1987),4 and induces the expression of TGF-beta (Pierce, et al., 1989).5

 

It was further established that wounds treated with PRP gel exhibited not only enhanced wound repair compared to control, but possess more organized collagen than control tissues, without excessive deposition of connective tissue or scar formation (Carter, et al., 2002).6 This equine study by Carter, et al. demonstrated biopsy wounds treated with PRP gel to be densely organized, tightly packed fiber bundles parallel to the overlying epidermis suggesting the dense collagen lattice had increased tensile strength in the repaired wound.

 

The use of PDGF in surgery is widely documented and has become standard intra-operative and post-operative protocol to promote hemostasis, accelerate wound healing, and decrease the incidence of wound infection.

 

It is therefore suggested that PRP gel is an excellent protocol in hair transplantation for donor wound closures. Pre-operatively, 50cc of blood is drawn from the patient and processed according to the established protocol to create the PRP gel. After the donor strip is harvested, the subcuticular layer is closed with 3.0 Monocryl, activated PRP gel is injected into the wound from end to end (Figure 1), and the second layer is approximated with a running 3.0 Prolene suture. After utilizing PRP gel in the donor site, wounds appear to bleed less post-operatively than those not treated with PRP.

 

Fear of linear donor scaring is a major concern in our patients today. In our experience, the use of platelet-rich plasma during donor closure results in better healing and less scarring.

 

After the follicular units are dissected, they are bathed in activated PRP gel (PRP can be activated with calcium chloride/thrombin or fibrinogen and becomes a gel-like substance) approximately 15 minutes prior to implantation (Figure 2).

 

While dissection is ongoing and the graft design pattern is completed, the PRP is then injected into the recipient scalp area after the graft pattern is completed to maximize the multiple effects of growth factors. The PRP provides an enriched environment of concentrated growth factors to accelerate the wound response, thus promoting healing and angiogenesis for the newly implanted follicular units (Figure 3).

 

Injecting PRP into the recipient area may have other advantages for the non-transplanted hairs because PRP contains several growth factors, including PDGF and VEGF. Takakura, et al. (1996)7 demonstrated that PDGF signals are involved in both epidermis-follicle interaction and the dermal mesenchyme interaction required for hair canal formation and the growth of dermal mesenchyme, respectively. In 2001, Yano, et al.8 identified VEGF as a major mediator of hair follicle growth and cycling providing the first direct evidence that the improved follicle vascularization promotes hair growth and increases follicle and hair size.

 

This author has observed a more rapid healing after injecting PRP into the recipient site in hair transplantation. Based on the previously mentioned studies regarding the effects growth factors have on hair growth, studies are planned to test the effects PRP and growth factors have on the non-transplanted hair.

 

In 2003, one of us demonstrated rapid healing and hair regrowth utilizing PRP on a severely traumatized wound in an equine model. While it generally takes nine months for a wound such as this to heal, if the animal survives at all, in this PRP-treated animal, rapid healing of the wound occurred. At one month, complete wound closure and hair regrowth was evident, which never occurs in these cases. Enlarged photos of this case can be seen at the website http://bloodrecovery.com/wound_ba2.htm.9

 

This equine case is a significant example of the extraordinary effects that PRP has on rapid wound repair and hair regrowth in especially difficult cases. It illustrates yet another very valuable use for PRP, especially, in cases of severe infection or wound dehiscence. Rapid use of PRP in this instance cannot only promote healing of the infected wound, but will also promote the regrowth of hair, thus avoiding possible impending scarring traumatic alopecia.

 

In conclusion, we are seeing encouraging results with these expanded applications for PRP. Further experience will help delineate the role for this exciting technology in our specialty.

 

REFERENCES

 

1. Uebel, C. O. Presented at the Annual Scientific Meeting of the American Society of Plastic Surgeons in Philadelphia, Pennsylvania, Oct. 9??“ 13, 2004.

 

2. Declair, V. (1999). The importance of growth factors in wound healing. Ostomy Wound Manage. 45; 64??“68.

 

3. Choi, Y., Fuchs, E. (1990). TGF-beta and retnoic acid regulation of growth and modifiers of differentiation human epidermal cells. Crell regal. 1; 791??“809

 

4. Ross, R. (1986). Platelet-derived growth factor. Am. Rev. Med. 38; 71??“79.

 

5. Pierce, G. F., et al. (1989). Transforming growth factor B reverses the glucocorticoid-induced wound healing defect in rats: possible regulation in microphages by platelet-derived growth factor. Proc. Natl. Acad. Sci. 86; 2229??“233.

 

6. Carter, C. A., et al. (2003). Platelet-rich plasma gel promotes differentiation and regeneration during equine wound healing. Experimental and Molecular Pathology 74; 244??“55.

 

7. Takakura, N., et al. (1996). Involvement of platelet-derived growth factor receptor-a in hair canal formation. Journal of Investigative Dermatology 107; 770??“77.

 

8. Yano, K., Brown, L., and Detmar, M. (February 2001). Control of hair growth and follicle size by VEGF-mediated angiogenesis. J Clin Invest 107(4); 409??“17.

 

Preliminary Experience and Extended Applications for the Use of Autologous Platelet-Rich Plasma in Hair Transplantation Surgery Joseph Greco, PhD, PA/C, Robert J. Brandt Siesta Key, Florida

[Dr. William Lindsey]

Way back in 1987, I developed and tested Fibrin Glue's effect on flap adherence and published this in the American Journal of Surgery, Archives of Surgery, and over the next 8 years I won 5 national research awards on this general topic(American Medical Assn, Trilogical Society, Plastic Surgery Research Council, American Academy of Facial Plastic and Reconstructive Surgery). I say this not to toot my horn, but to show that I have some degree of expertise in the biologic effects of the products discussed herein.

 

 

As a facial plastic surgeon, I have seen over the past 5 years, a huge marketing push by biotech/pharmaceutical companies to try to get doctors to use Platelet gels, and Fibrin Glue systems to decrease bruising and increase healing in facial cosmetic surgery.

 

Having now done over 3000 facelifts without these products, I do not feel that these additional products are of significant help for the VAST majority of facial cosmetic surgery patients. In fact, the only thing I think that they offer is the hope of decrease bruising in cases where a large skin flap is elevated (facelift) and needs to be re-attached. We accomplish that with an inexpensive ace bandage.

 

I can see no significant clinical advantage in hair transplantation, since there are no flaps to adhere, and sutures or staples are used to close the strip incision.

 

Also, several of the commercially available options use products from other people, which brings the risk of infectious disease transfer into this elective surgery. And if it is from the patient himself, does he really want a hair transplant practice drawing blood and processing it in a machine used everyday on different patients, and then re-injecting his own blood products for no significant benefit??

 

Now don't get me wrong, if you are having a mastectomy for breast cancer, or heart surgery, these products may make perfect sense. But for hair, sounds like a gimic, with potential risks rather than benefits to me.

 

Dr. Lindsey McLean VA

[latinlotus]

Also, several of the commercially available options use products from other people, which brings the risk of infectious disease transfer into this elective surgery. And if it is from the patient himself, does he really want a hair transplant practice drawing blood and processing it in a machine used everyday on different patients, and then re-injecting his own blood products for no significant benefit??

 

Thank you dr. Lindsey. Your expertise and advice is highly appreciated.

 

There is a debate about the potential benefit of PRP, and i agree with you on this. However, in terms of infectious disease, i don't see how contamination can be made. Based on my understanding of PRP extraction process, a syringe is used to withdraw blood from the patient and then injects the blood into a single use and sterile container, used to store the blood of the patient. A machine is using centrifuge force and osmosis to extract PRP from blood. Another syringe is then used to extract PRP from that container and to inject in the scar and recipient site. The grafts are also bathed in that container before being implanted. At no point, the blood and PRB is in touch with anything other than the container and syringe. While the machine is used on many patients, i believe that during the whole process, the blood is never into contact with that machine.

 

Is there something that i missed? Thanks.

[Dr. William Lindsey]

Maybe or maybe not. I do not have expertise on this particular machine.

 

As late as 2004 though, the machines that were available had some parts/tubes that did interact with blood, and required changing by staff between cases. Since those tubes are expensive and aren't seen without opening the "box"; they could be overlooked.

 

Also, the commerically available fibrin glue kits early on, particularly in Europe, used pooled blood bank blood. Given the lag time between HIV infection and seroconversion (a positive test) there is certainly a potential risk, although small. And don't forget that hepatitis and other blood born illnesses are out there.

 

My point is that exposure to blood products is no trivial matter; and should only be done when a significant benefit can be obtained. As to healing after hair cases, a valid case for these types of products has yet to be made.

 

Dr. Lindsey McLean VA

[Dr. Jerry Cooley]

Please see my full post on Platelet Rich Plasma: http://hair-restoration-info.c...?r=52810352#52810352.

 

The potential benefits of PRP during hair transplantation are:

 

1. Speedier healing: less redness, crusting, etc. My experience has been that subjectively everything just looks better and patients generally agree. Whether this justifies the added time and expense of PRP is debatable.

 

2. Better results: this would presumably occur because of the growth factors released by the platelets (PDGF,VEGF, etc). These promote the formation of new blood vessels (angiogenesis) during the wound healing process. Since the PRP we use represents a 5-10 fold increase in platelet concentration over circulating blood, it is reasonable to think that angiogenesis around the grafts occurs quicker with PRP than without. It is important to remember that grafts initially are not hooked up to the circulation but must become revascularized within a few days if they are to survive. PRP may speed up this process.

 

My impression is that wound healing and the overall results are generally improved with PRP, and especially so in those patients with significant scarring such as from multiple/older technique hair transplants. More research is of course needed. I definitely think that we will be hearing more about PRP in the hair transplant field in the coming years.

 

Jerry Cooley, MD