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INTRODUCTION TO FACIAL ESTHETICS AND PRF

Richard J. Miron

Catherine Davies

Facial esthetics has become one of the fastest-growing industries in the world. While originally a number of minimally invasive procedures were utilized effectively in facial esthetics (including Botox [Allergan], hyaluronic acids, and polydioxanone [PDO] threads), more recently platelet concentrates have gained momentum because of their more natural regenerative approach. The main advantage of platelet concentrates is that they offer a safe, easy-to-obtain, and completely immune-biocompatible method for the healing or regeneration of aging skin. This differs significantly from previous modalities that aim to act as fillers or paralyzers, which initiate a foreign body reaction once placed within living tissue. As the population continues to age and becomes more concerned with their esthetic appearances, more and more clinicians and practitioners wish to offer patients a natural approach with platelet concentrates and more specifically platelet-rich fibrin (PRF). As trends continue to support minimally invasive esthetic procedures, it is clear that both beginner as well as advanced practitioners seek convenient, safe, and effective therapies. Platelet-rich plasma (PRP) was the first platelet concentrate utilized in facial esthetics because of its supraphysiologic accumulation of platelets and their respective growth factors, known stimulators of tissue regeneration. However, one of its main limitations is its incorporation of anticoagulants, known inhibitors of wound healing. Today, with advancements in centrifugation protocols and centrifugation tube characteristics, it has become possible to utilize a liquid injectable PRF without incorporation of anticoagulants. This formulation has been studied and utilized extensively in various fields of medicine and has become increasingly popular in facial esthetics. This textbook provides a first-of-its-kind introduction to the use of PRF in facial esthetics.

Aging of the Skin

Aging of the skin is an inevitable process that gradually occurs as we get older1,2 (Fig 1-1). Several factors have been associated with this process, including both genetic and environmental factors.3 Exposure to sun, pollution, and various chemicals have been known to cause skin and/or DNA damage, speeding the aging process.3 A number of changes to the skin may occur as a result, including skin atrophy, telangiectasia, fine and deep wrinkles, yellowing (solar elastosis), and dyspigmentation.3 Furthermore, poor diet, lack of exercise, caffeine intake, smoking, and drug use are additional factors known to speed the aging process.4

FIG 1-1

The process of skin aging. With age, facial features tend to sag, with a volume shift downward of facial tissues.

One key element certainly important for overall health and particularly skin attractiveness is hydration. Dehydration of the skin may lead to epithelial cell apoptosis and flaky skin complexion. From this standpoint, skin dehydration is a major risk factor for skin aging, and many topical applications, including hyaluronic acid creams, are geared toward water retention as a modality to prevent dryness of the skin. Aging skin is also related to a number of obvious demarcations of the face (see chapter 2). Depressions in the corners of the mouth, cheeks, forehead, eyebrows, eyelids, and nose are all associated with aging5 (Box 1-1; see Fig 1-1). Based on visible differences that occur with aging, a variety of treatment options have been proposed to favor a more youthful appearance, but hydration is a key feature.

As the body ages, it undergoes many changes that directly impact the physiology of human tissues, resulting in lower cellular activity.6 These changes include a loss in density, increases in fat storage, and lower production of collagen. A reduction in collagen synthesis as well as its associated increase in collagen degradation both have apparent disadvantages leading to a net loss of facial volume, resulting in skin folds and wrinkles7 (see chapter 2). Based on these changes associated with aging, several years ago it was proposed that platelet concentrates could be utilized in facial esthetics to improve collagen synthesis and restore facial volume.8–10 The main function of platelet concentrates is to increase recruitment and proliferation of cells and to further speed revascularization/blood flow toward defective areas. Many advancements have been made since the first-generation platelet concentrate—platelet-rich plasma (PRP). Several devices and isolation kits have since been fabricated based on the concept of isolating platelets for regenerative purposes, eliminating the inclusion of anticoagulants and speeding the preparation protocols. This second-generation platelet formulation, termed platelet-rich fibrin (PRF), has formed the basis for more than 600 scientific publications on the topic and has now extended into the field of facial esthetics. This textbook addresses this topic in detail and introduces the concept of PRF as a safer, more effective regenerative platelet concentrate that is 100% natural and thereby prevents a foreign body response.

Traditional Methods for Facial Rejuvenation

One of the first methods proposed for facial rejuvenation incorporated acupuncture.11 This concept was derived based on accumulating evidence that trauma to the skin in the form of a needle and/or syringe, dermal roller, or more recently microneedling (see chapter 7) could induce slight tissue damage leading to new angiogenesis, growth factor release, and subsequent new tissue regeneration. This tissue regeneration resulted in a more youthful appearance.

Because of the popularity of such treatments in facial esthetics and rapidly increasing trends in the field, more invasive techniques have also been proposed. These include facelifts, aggressive laser treatment modalities, and various grafting procedures.12–14 One of the advantages of platelet therapies is their ability to be used in combination with microneedling (see chapter 7), lasers (see chapter 10), plastic surgery (see chapter 12), and hair restoration (see chapter 9) simply to improve healing outcomes.

Traditional Biomaterials for Facial Rejuvenation

While various protocols and injectable materials have been proposed in facial esthetics, patients generally seek more natural regenerative approaches with the shortest possible downtime. In addition, medicine has gradually and naturally progressed toward more minimally invasive procedures. Today, many different agents and biomaterials can be utilized to accomplish this task, including Botox, fillers (eg, silicone, calcium hydroxyapatite, polymethyl methacrylate, hyaluronic acid products, hyaluronic acid + calcium hydroxyapatite, polylactic acid), various laser therapies at different wavelengths/intensities, and polydioxanone (PDO) threads.15–21 These products and modalities have been made popular by extensive marketing and celebrity endorsements and have been demonstrated to be successful in various esthetic procedures to improve cosmetic appearance (Box 1-2).

Importantly, however, these techniques heavily rely on normal protective mechanisms of the epidermis, which can be altered or disrupted following their use. The use of Botox, for example, has shown secondary effects that may cause a cascade of reactions with potential consequences.22 Botox causes temporary denervation and relaxation of muscles by preventing the release of the neurotransmitter acetylcholine at the peripheral nerve endings.23 Clinicians generally recommend repeated injections every 6 months or so to maintain the facial appearance, but these injections may lead to secondary effects associated with an increased granular layer or thinning of the epidermis as a result of a foreign body reaction to this material.24,25 Other reported secondary effects include cases of muscle paresis including muscle weakness, brow ptosis, upper and/or lower eyelid ptosis, lateral arching of the eyebrow, double or blurred vision, loss or difficulty in...