The authors report their experience about the use of P.R.L. PLATELET RICH LIPOTRANSFERT method (platelet rich plasma mixed fat grafting) in 223 patients affected by soft tissue defects (ulcers, Romberg syndrome, Hemifacial atrophy, loss of substance, and signs of aging). This paper introduces the reader to PRP therapy and reviews the current literature on this emerging treatment modality, showing at the current clinical use of PRP in plastic and reconstructive surgery, with description of innovative methods and future prospects. This technique provides a promising alternative to surgery by promoting safe and natural healing. Here recent studies concerning the use of PRP in the treatment of chronic ulcers and soft tissue defect are reviewed.
In Europe, and more recently in the United States, an increased trend emerged in the use of autologous blood products to facilitate tissue regeneration and healing [
Its use of PRP has been firstly described in 1975 by Oon and Hobbs [
In the 1999 Anitua [
This paper is a focused review of the literature about the clinical approaches of the use of PRP, describing also the experience of authors who coined the term of P.R.L. PLATELET RICH LIPOTRANSFERT (method of mix and use of platelet rich plasma with fat grafting) and methods of application updated.
The authors used [
From July 2009 to July 2012, 223 patients (134 males and 89 females), aged from 18 to 75 years ( Group A: composed of 132 patients affected by soft-tissue defects with loss of volume and elasticity, associated with signs of aging (70 males and 62 females); Group B: composed of 87 (63 males and 24 females) patients affected by chronic venous lower extremity ulcers; Group C: composed of 4 patients affected by Romberg syndrome and Hemifacial atrophy (1 male and 3 females).
Patients of Group B (venous low extremity ulcers) are affected by the following comorbidity: dislipidemie in 16 patients (18%), cardiological disease in 15 patients (17%), hypertension in 10 (12%), diabetes in 32 (37%), arteriopathy of lower extremity in 4 (5%), and no comorbidity in 10 patients (12%).
The authors compared their results with three homogeneous control groups, presenting these features: Control Group A: 132 patients affected by outcomes of scars (70 males and 62 females) treated with fat injection only (Figure Control Group B: 87 patients affected by venous low extremity ulcers (60 males and 27 females) treated with curettage and application of biomaterials (hyaluronic acid and collagens); Control Group C: 4 patients affected by Romberg Syndrome (2 males and 2 females) treated with fat injection only.
Analysis of patients affected by outcomes of scars. (a) Preoperative situation in lateral left projection. (b) Preoperative situation in
General exclusion criteria were: platelet disorders, thrombocytopenia, antiaggregating therapy, bone marrow aplasia, uncompensated diabetes, sepsis, and cancer. Local exclusion criteria were infection or diastasis.
Tissue regeneration was evaluated by the analytical comparison of pre- and postoperative images. In addition three methods for the evaluation of outcomes were used: (1) team evaluation, (2) NMR (nuclear magnetic resonance) and Ultrasound, (3) patient self-evaluation.
The Team evaluation is an evaluation method based on clinical observation, using a scale of six values (excellent, good, discreet enough, poor, and inadequate). The factors/variables, considered were pigmentation, vascularization, pliability, thickness, itching, and pain.
The patient evaluation is an evaluation method based on clinical observation, using a scale of six values (excellent, good, discreet enough, poor, and inadequate).
In addition, in complicated cases, a high-resolution CT scan with 3D imaging for a better view of the anatomical structures was performed. In the venous low extremity of patients affected by ulcers a biopsy punch 2–4 mm of diameter was collected.
A followup of the patients was performed at the second and fifth weeks and at 3, 6, and 12 months and then annually.
The traditional PRP preparation consisted in a slow centrifugation; platelets remain suspended in the plasma, while the leukocytes and erythrocytes are displaced to the bottom of the tube. A rapid centrifugation can cause mechanical forces and can raise the temperature, inducing changes in the ultrastructure of platelets that stimulate partial activation, with a consequent loss of its content [
Generally, the authors prepared PRP (using centrifuge at 1100 g for 10 min) from a small volume of blood (18 cc) according to the Cascade [
Anitua et al. [
Standard cell separators and salvage devices can be used to produce platelet-rich plasma [
Many surgical procedures require the use of relatively small volumes of platelet-rich plasma [
Consequently, small, compact office systems that produce approximately 6 mL of platelet-rich plasma from 45 to 60 mL of blood have been developed [
There are many of such systems, including the GPS (Biomet, Warsaw, IN), the PCCS (Implant Innovations, Inc., Palm Beach Gardens, FL), the Symphony II (DePuy, Warsaw, IN), the SmartPReP (Harvest Technologies Corp., Norwell, MA), and the Magellan (Medtronic, Minneapolis, MN) [
The authors used in the personal experience Cascade-Fibrinet (Cascade Medical Enterprises, Plymouth, Devonshire, UK), Vivostat (Vivostat A/S, Borupvang 2, DK-3450 alleroed, Denmark), and Regen (Regen Lab, En Budron B2, CH-1052 Le Mont-sur-Lausanne, Switzerland).
In general, a lot of systems do not concentrate on the plasma proteins of the coagulation cascade [
With this system, up to two-thirds of the aqueous phase is removed by filtration; thus, the concentrations of the retained plasma proteins and formed elements are correspondingly increased [
Fat harvesting was performed in the same moment of the PRP preparation. We harvested fat tissue in the abdominal region using some specific cannula, with diameters of 2 to 3 mm and 1.5 mm, for grafting (Coleman Kit, Tucson, AZ) [
The fat volume was injected in the selected areas according to the defect to be corrected; in the scars the volume ranges between 10 cc and 80 cc, and in the ulcers ranges between 5 cc and 50 cc, in the Romberg syndrome ranges between 60 cc and 140 cc.
Previously the authors published in Tissue Eng 2009 [
When the authors added 0.3 mL of PRP per each mL of fat tissue, they observed 55.5% and 72.2% of chronic lower extremity ulcers 100% reepithelization during an 7.1 and 9.7-week average.
When the authors added 0.2 mL of PRP per each mL of fat tissue, they observed 44.4% and 66.6% of chronic lower extremity ulcers 100% reepithelization during an 7.1 and 9.7-week average. We also observed in patients affected by soft tissue defect treated with reconstructing three dimensional projection by fat grafting and PRP at concentration of 0.5 mL or 0.4 mL per each ml of fat tissue, a 70% maintenance of contour restoring and three-dimensional volume after 1 year, and only 31% in control patients (
Liposuction aspirates were washed three times with phosphate-buffered saline (PBS), suspended in an equal volume of PBS and 0.1% collagenase type I (C130; Sigma-Aldrich, Milan, Italy), and prewarmed to 37°C [
ASCs at the third passage were seeded at a density of 5000 cells/cm2 in 24-well plates and incubated for 24 h in DMEM containing 10% FBS. Medium was then replaced with DMEM containing 0.1% FBS for starvation. After 24 h the medium was changed, for the treatment, with DMEM 10% FB (control) and DMEM 10% FBS 5% PRP. The medium containing the respective supplements was replaced every 2 days. After 0, 2, 4, 6, and 8 days of culture, cells were digested with 0.25% trypsin solution and then counted, with trypan-blue exclusion, using hemocytometer. Cell viability by trypan blue exclusion was consistently more than 98%. The reported results were the mean value of triplicate samples. Each assay was performed twice. As reported previously [
The present findings demonstrated that the different concentration of PRP (ranging from 0.2 mL to 0.4 mL) influence the
PRP, being produced during surgical procedures under sterile conditions, is easy to produce and safe to use; moreover, PRP is lacking of surface antigens, responsible of potential allergic reactions [
Our results clearly documented that the use of PRP during fat grafting favours adipose tissue maintenance and survival. Moreover, our
The authors feel that there are new issues in the literature about the selection of the most appropriate regenerative methods. Indeed, there are many publications regarding the use of PRP with/without fat graft in plastic and reconstructive surgery; the authors divided the review of the application of PRP in the following pathologies.
About this topic there is not paper in the literature describing the use of PRP mixed with fat graft but a large number of paper based on use of only PRP or PRP with biomaterials (hyaluronic acid and collagen). Nonhealing cutaneous wounds represent a challenging problem and are commonly related to peripheral vascular disease, infection, trauma, neurologic, and immunologic conditions, as well as neoplastic and metabolic disorders.
These chronic ulcerative wounds represent significant impact both psychologically and socioeconomically. An analysis of the surfaces of chronic pressure wounds (decubitus ulcers) revealed a decreased growth factor concentration compared with acute wound [
Patients failed conservative treatment for 6 months with a lack of reduction of surface area. The wounds were injected with PRP every 2 weeks. Successful wound closure and epithelization was obtained in 20 wounds. The mean time for closure was 11.15 weeks. Five wounds displayed no improvement [
Rigotti et al. [
The authors described the use of fat grafting combined with platelet-rich plasma for chronic lower-extremity ulcers [
Bar graphs showing effects of PRP at different concentrations on percentages of skin chronic ulcer reepithelization.
Bar graphs showing effects of PRP at different concentrations on percentages of maintenance of restored fat.
P.R.L. PLATELET RICH LIPOTRANSFERT procedure. (a) Platelet rich plasma preparation according to Cascade centrifuge; (b) fat graft preparation according to Coleman Centrifuge; (c) purified fat graft after centrifugation; (d) addition of PRP to purified fat graft; (e) mix of 0.4 mL of PRP with 1 mL of fat graft in a 10 mL luer-look syringes (P.R.L. PLATELET RICH LIPOTRANSFERT); (f) injection of P.R.L. PLATELET RICH LIPOTRANSFERT according to lipostructure technique.
Effects of platelet-rich plasma on proliferation of human adipose-derived stem cells. Growth curves show the dose-dependent increase of proliferation with PRP.
Powell et al. [
PRP was also shown to be effective in stopping capillary bleeding in the surgical flaps of a series of 20 patients undergoing various cosmetic surgery (face lift, breast size changes, or neck lifts) reported by Man [
Anderson [
Recently, the authors described the use of fat graft with platelet rich plasma [
Lipostructure evolved from lipofilling and is better known as Coleman’s technique [
In addition Yoshimura et al. [
A new aim could be the use of SVF isolated from half of fat tissue mixed with platelet rich plasma and recombined with the other half.
Azzena et al. [
Zocchi [
This work suggest two fundamental points: first, PRP added in concentration of 0.4 mL (40%) per each mL of fat tissue favours an optimal ASCs proliferation with correct architectural adipocytes distribution, 58 298 better cell-to-cell interaction, adipose tissue growth, and differentiation from ASCs; this offers early protection from surrounding inflammatory events [
Authors suggest that growth factors present in the PRP play a role in improving tissue healing. VEGF should be used to implement the neoangiogenesis in patients affected by vascular disease that has generated a loss of substance and which prevents or delays the healing process; the FGF may be used to implement the rejuvenation of the tissues and the PDGF-BB to implement chemotaxis and mitogenic effects. The perspective future start from the paper of Katz et al. [
A statement that the study was conducted with the understanding and the consent of the human subject.
The authors confirm that there are no conflict of interests. The authors do not have a financial relation with the commercial identities mentioned in the paper.