PRF in Facial Esthetics
PRF
IN FACIAL
ESTHETICS
CATHERINE DAVIES, mbbch, mba
Private Practice Specializing in Facial Esthetics
Johannesburg, South Africa
RICHARD J. MIRON, dds, bmsc, msc, phd, dr med dent
Group Leader, The Miron Research Lab
Lead Educator, Advanced PRF Education
Venice, Florida
Library of Congress Cataloging-in-Publication Data
Names: Davies, Catherine, author. | Miron, Richard J. (Richard John), 1983author.
Title: PRF in facial esthetics / Catherine Davies, Richard J. Miron.
Other titles: Platelet-rich fibrin in facial esthetics
Description: Batavia, IL : Quintessence Publishing Co, Inc, [2020] |
Includes bibliographical references and index. | Summary: “This book
gathered numerous experts across many fields to collectively provide
information on leading esthetic PRF therapies to expand treatment
possibilities”-- Provided by publisher.
Identifiers: LCCN 2020009383 | ISBN 9780867159578 (hardcover)
Subjects: MESH: Face | Cosmetic Techniques | Fibrin--therapeutic use |
Platelet-Rich Fibrin | Skin Aging | Rejuvenation | Esthetics, Dental
Classification: LCC RD119 | NLM WE 705 | DDC 617.9/52--dc23
LC record available at https://lccn.loc.gov/2020009383
97%
© 2020 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc
411 N Raddant Road
Batavia, IL 60510
www.quintpub.com
5
4
3
2
1
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written
permission of the publisher.
Editor: Leah Huffman
Design: Sue Zubek
Production: Angelina Schmelter
Printed in USA
To Dr David Koski
When I moved to the United States 3 years ago, somehow you convinced me to think BIG.
You took time out of your schedule to mentor me, volunteered many of your hours freely
to support our education programs, and have been supportive beyond my comprehension.
You called me Lebron when I didn’t understand. You taught me to “scale” when I knew only
science. And you provided endless advice on topics I never considered relevant. I never
expected to find such a wonderful role model and mentor, all calmly behind the scenes.
You never asked for recognition. I have no words to express my gratitude and wanted to
somehow show my appreciation. I therefore dedicate this book to you, Dr Koski. This one
is for you, big guy! —RJM
Contents /
Preface
viii
Acknowledgments
Contributors
x
1/
ix
Introduction to Facial Esthetics and PRF
1
Richard J. Miron and Catherine Davies
2/
Facial Anatomy, Skin Biology, and the Effects of Aging
Catherine Davies and Richard J. Miron
3/
Photography in Facial Esthetics
27
Walter Rozen, Richard J. Miron, and Catherine Davies
4/
Consultation for the Facial Esthetic Patient
43
Richard J. Miron and Catherine Davies
5/
Consultation for the Hair Loss Patient
63
Alan J. Bauman, Catherine Davies, and Richard J. Miron
6/
Use of Platelet-Rich Fibrin in Facial Esthetics
79
Richard J. Miron, Yufeng Zhang, Ana Paz, Masako Fujioka-Kobayashi, and Catherine Davies
9
7/
Biology of Microneedling
99
Erin Anderson, Nichole Kramer, Richard J. Miron, Ana Paz, and Catherine Davies
8/
Injection Techniques with Platelet-Rich Fibrin
123
Catherine Davies, Ana Paz, Alireza Panahpour, Ana Cristina, and Richard J. Miron
9/
Hair Regeneration with Platelet-Rich Fibrin
165
Catherine Davies and Richard J. Miron
10 / Lasers in Facial Esthetics
175
Ana Paz, Harvey Shiffman, Miguel Stanley, Catherine Davies, and Richard J. Miron
11 /
Skin Care Products and Their Effect on Aging Skin
201
Geir Håvard Kvalheim, Catherine Davies, and Richard J. Miron
12 /
Future Trends in Esthetic Medicine
217
Carlos Fernando de Almeida Barros Mourão, Delia Tuttle, Ruth Delli Carpini, Scott Delboccio,
Richard J. Miron, and Catherine Davies
Index
230
Preface /
Facial esthetics has become one of the fastestgrowing industries in the world. The esthetic demand
for patients worldwide has never been higher, leading
to this multibillion-dollar, booming industry. As the
field continues to evolve, it is important that all medical practitioners are able to provide solid, evidencebased procedures while minimizing complications.
Platelet concentrates have long been utilized in regenerative medicine, and over the years, the removal of
anticoagulants has further improved their safety and
effectiveness. Today, platelet-rich fibrin (PRF) has
nearly replaced platelet-rich plasma in many fields
of medicine and has gradually made its way into the
medical esthetic arena. Furthermore, its use has been
combined with other leading therapies to expand
treatment possibilities. As trends continue to support
minimally invasive esthetic procedures, it is clear that
both the beginner as well as the advanced practitioner
seek convenient, safe, and effective therapies.
viii
This textbook is a first of its kind and an introduction
to PRF in facial esthetics. The book was a true joy to
put together, as many international experts in various
fields of medicine have tremendously improved the
quality of the final chapters. It has been a privilege to
collaborate with basic scientists, the developers and
clinician-scientists of microneedling, leading experts
in laser therapy and low-level laser therapy, experts
in photography, as well as plastic surgeons and hair
restorative surgeons. This book is truly unique in that
it gathered numerous experts across many fields with
the ultimate goal of collectively providing as much
knowledge on this topic as possible. We are therefore
thrilled to present the first edition of our textbook,
PRF in Facial Esthetics, and we look forward to your
future feedback.
Acknowledgments /
We greatly acknowledge the tremendous contributions of our coauthors. Each of your specific expertise has been greatly valuable, and what a privilege
to continue to work with each of you. The field will
certainly continue to progress, and we sincerely enjoy
our collaborations with each of you.
We equally want to thank Quintessence Publishing for
their trust, commitment, and devotion to this project.
Thank you to Bryn Grisham (Director of Book Publications), Leah Huffman (Senior Editor and Deputy Editorial Director), Angelina Schmelter (Senior Digital & Print
Production Specialist), and William Hartman (Executive
Vice President & Director). The quality work at Quintessence Publishing and the attention to detail regarding the
preparation of this manuscript are truly special.
To the team at KVM Publishing who originally
designed and provided some of the anatomical illustrations in this book, thank you. In particular, we thank
Gerhard Sattler and Uliana Gout for laying the groundwork with their fantastic book on facial fillers.
To Advanced PRF Education at prfedu.com and all of
its staff members, including Erin Anderson and Nichole
Kramer from Dermapen, thank you for making teaching and education a top priority filled with exciting new
challenges and ongoing learning experiences.
From Catherine Davies
I would like to express special thanks and gratitude to
my amazing family—Paco, Zahra, Cuba, and Lila—for
putting up with all the long working hours this year.
I would also like to thank Dr Richard Miron for his
belief in me and for his invaluable guidance and advice
during the writing of this book.
From Richard J. Miron
To my parents and family: Your unconditional love and
support during this past year never goes unnoticed.
Thank you for everything!
To Dr Catherine Davies: It has been a true joy and
pleasure to work with you. Your bubbly personality and
easy-to-understand teaching style is enlightening and
seems to perfectly blend with my serious and rigorous scientific approach. I’ve enjoyed every moment
of it—let’s keep going!
To Leah Huffman: How we managed three books
together in 1 year is not something I could ever have
imagined. Thank you endlessly for being dedicated,
passionate, punctual, and simply the most outstanding and prolific editor!
ix
Preface
Contributors /
Erin Anderson
Ruth Delli Carpini, DMD
Master Aesthetician
AO Surgical Arts
Salt Lake City, Utah
Private Practice Specializing in Cosmetic Dentistry
and Facial Esthetics
Milan, Italy
Director of Education
Dermapen
Masako Fujioka-Kobayashi, DDS, PhD
Alan J. Bauman, MD
Private Practice Specializing in Hair Transplant Surgery
Boca Raton, Florida
Ana Cristina, DDS, MSc
Private Practice Specializing in Facial Esthetics,
Implantology, and Oral Maxillofacial Surgery
São Paulo, Brazil
Catherine Davies, MBBCh, MBA
Private Practice Specializing in Facial Esthetics
Johannesburg, South Africa
Scott Delboccio, DMD
Private Practice
Naples, Florida
x
Research Associate
Department of Cranio-Maxillofacial Surgery
University Hospital of Bern
University of Bern
Bern, Switzerland
Nichole Kramer
Medical Aesthetician and Clinical Manager
Utah Body and Soul
Holladay, Utah
Co-director of Education
Dermapen
Geir Håvard Kvalheim
Founder of Čuvget
Tromsø, Norway
Richard J. Miron, DDS, BMSc, MSc, PhD,
Harvey Shiffman, DDS
Dr med dent
Private Practice Specializing in Laser Therapy
Boynton Beach, Florida
Group Leader, The Miron Research Lab
Lead Educator, Advanced PRF Education
Venice, Florida
Carlos Fernando de Almeida Barros
Mourão, DDS, MSc, PhD
Private Practice
San Pedro, California
Alireza Panahpour, DDS
Private Practice Specializing in Cosmetic Dentistry
Los Angeles, California
Ana Paz, DDS, MS
Private Practice
Lisbon, Portugal
Miguel Stanley, DDS
Private Practice
Lisbon, Portugal
Delia Tuttle, DDS, MD
Private Practice
Lake Elsinore, California
Yufeng Zhang, MD, DDS, PhD
Professor, Department of Dental Implantology
School of Stomatology
Wuhan University
Wuhan, China
Walter Rozen
Professional Photographer
Venice, Florida
xi
1/
INTRODUCTION
TO FACIAL
ESTHETICS
AND PRF
Richard J. Miron
Catherine Davies
xii
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.
1
1 / Introduction to Facial Esthetics and PRF
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
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,
FIG 1-1
The process of skin aging. With
age, facial features tend to sag,
with a volume shift downward
of facial tissues.
Youthful appearance
Youthful
appearance
Optimal
volume
distribution
Optimal volume distribution
2
A sign of the time
Aged volume
appearance
Increased
shift
Increased volume shift
Traditional Biomaterials for Facial Rejuvenation
BOX 1-1
Progressive changes expected in normal aging
•
•
•
•
•
•
•
•
•
Corners of the mouth move inferiorly, resulting in a slight frown look
Cheeks sag inferiorly, resulting in the appearance of jowls
Tissue around the eyes sags inferiorly
Eyelids (upper and lower) sag inferiorly
Tissue of the forehead drifts inferiorly, creating wrinkles and dropping
the eyebrows downward with flatter appearances
Nose may elongate and the tip may regress inferiorly
Nose may develop a small to pronounced dorsal hump
Tip of the nose may enlarge and become bulbous
Generalized wrinkling to the face naturally occurs
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
3
1 / Introduction to Facial Esthetics and PRF
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,
BOX 1-2
Unesthetic features that can be
treated or eliminated with
esthetic medicine procedures
•
•
•
•
•
•
•
•
•
•
Scars
Skin laxity
Wrinkles
Moles
Liver spots
Excess fat
Cellulite
Unwanted hair
Skin discoloration
Spider veins
FIG 1-2
Esthetic medicine focuses on improving cosmetic appearance via a variety
of procedures aimed at restoring the patient’s youthful look. (a) PRF naturally regenerates tissues, resulting in a natural-looking outcome. (b) Dermal
fillers, on the other hand, fill tissues unnaturally, resulting in a less naturallooking appearance. Full lips in women are often considered attractive and
desirable in modern society, and lip augmentation with fillers is the traditional method by which to achieve that look.
a
b
Esthetic Medicine
brow ptosis, upper and/or lower eyelid ptosis, lateral
arching of the eyebrow, double or blurred vision, loss
or difficulty in voluntary eyelid closure, upper lip
ptosis, uneven smile, lateral lip ptosis, lower lip flattening, orbicularis oris weakness, difficulty in chewing,
dysphagia, altered voice pitch, and neck weakness.
And dermal fillers have been associated with over 40
cases of blindness!
Despite the potential for negative outcomes, Botox
and dermal fillers are generally considered safe and
effective (Box 1-3). Nonetheless, such cases of blindness and ptosis are sure to create some fear within
the community. Therefore, other materials (especially
those with limited complications) are constantly being
investigated as potential alternatives that do not bear
significant secondary side effects. The goal of therapy
with PRF is not to replace these previously utilized
materials but simply to offer an additional and safer
modality to the field that regenerates tissues naturally
(Fig 1-2a) as opposed to filling or paralyzing tissues
unnaturally (Fig 1-2b). PRF therapy therefore offers a
natural regenerative approach with natural-looking
outcomes (see Fig 1-2a). While each of the previously
utilized materials offers its respective advantages and
limitations (like any material), it is important to note
that each is also foreign to the body and creates an
additional inflammatory response when entering the
body. These products have certainly demonstrated
low patient morbidity and complication rates, but less
invasive therapies offer a decreased risk of potential
complications and a reduction in patient fear. This is
often heavily favored by new patients wishing to enter
their first facial esthetic regimen.
BOX 1-3
Safety of Botox and dermal fillers
These materials have been utilized
in millions of patients with relatively
few serious adverse effects. While
there have been some negative case
reports, medical use of Botox and
fillers is generally considered safe and
effective. Proper training and use of
high-quality products (ie, approved
materials) are recommended.
BOX 1-4
Procedures in esthetic medicine
Surgical
• Liposuction
• Facelift
• Breast implants
• Radiofrequency abrasion
Nonsurgical
• Mesotherapy
• Radiofrequency skin tightening
• Nonsurgical liposuction
• Chemical peel
• Laser treatment
Esthetic Medicine
The field of esthetic medicine typically encompasses
three specialties: (1) plastic surgery, (2) dermatology,
and (3) reconstructive surgery. These specialties offer
both surgical and nonsurgical esthetic procedures to
improve cosmetic outcomes (Box 1-4), and these
procedures can improve quality of life, psychologic
well-being, and social function for many patients.
5
1 / Introduction to Facial Esthetics and PRF
7,500,000
nn Collagen
nn Hyaluronic
acid
6,000,000
nn Soft tissue
fillers
4,500,000
nn Botox
3,000,000
1,500,000
0
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
FIG 1-3
Number of minimally invasive procedures performed annually in the United States, a total of 16 million.
(Adapted from the American Society of Plastic Surgeons.26)
It is now estimated that roughly 16 million esthetic
procedures are performed annually in the United
States alone, as reported by the American Society
of Plastic Surgeons26 (Fig 1-3). Furthermore, reports
have estimated that one billion people worldwide seek
out solutions to help their facial and neck skin appear
more youthful. This demand for facial esthetic procedures is only expected to further increase, as the skin
care products market is valued at $177 billion annually.
Therefore, the ability to offer a more natural, autologous concentrate of growth factors derived from
6
peripheral blood offers a very easy-to-obtain and
low-cost method to regenerate facial tissues for
patients. These less-invasive procedures have further
become a norm in combination with microneedling,
facial skin rejuvenation procedures, and hair restoration. Blood concentrates offer the ability to reach
supraphysiologic doses of growth factors and cells
responsible for the healing of various tissues using a
natural healing approach.
References
References
1. Branchet M, Boisnic S, Frances C, Robert A. Skin thickness
changes in normal aging skin. Gerontology 1990;36:28–35.
2. Helfrich YR, Sachs DL, Voorhees JJ. Overview of skin aging
and photoaging. Dermatology Nursing 2008;20:177.
3. Herbig U, Ferreira M, Condel L, Carey D, Sedivy JM. Cellular
senescence in aging primates. Science 2006;311:1257–1257.
4. Puizina-Ivi N. Skin aging. Acta Dermatoven APA 2008;17:47.
5. Friedman O. Changes associated with the aging face. Facial
Plast Surg Clin North Am 2005;13:371–380.
6. Dimri GP, Lee X, Basile G, et al. A biomarker that identifies
senescent human cells in culture and in aging skin in vivo.
Proc Natl Acad Sci U S A 1995;92:9363–9367.
7. Lorencini M, Brohem CA, Dieamant GC, Zanchin NI, Maibach
HI. Active ingredients against human epidermal aging. Ageing Res Rev 2014;15:100–115.
8. Kim DH, Je YJ, Kim CD, et al. Can platelet-rich plasma be used
for skin rejuvenation? Evaluation of effects of platelet-rich
plasma on human dermal fibroblast. Ann Dermatol 2011;
23:424–431.
9. Redaelli A. Face and neck revitalization with platelet-rich
plasma (PRP): Clinical outcome in a series of 23 consecutively treated patients. J Drugs Dermatol 2010;9:466–472.
10. Na JI, Choi JW, Choi HR, et al. Rapid healing and reduced
erythema after ablative fractional carbon dioxide laser resurfacing combined with the application of autologous
platelet-rich plasma. Dermatol Surg 2011;37:463–468.
11. Barrett JB. Acupuncture and facial rejuvenation. Aesthet Surg
J 2005;25:419–424.
12. Ramirez OM, Maillard GF, Musolas A. The extended subperiosteal face lift: A definitive soft-tissue remodeling for facial
rejuvenation. Plast Reconstr Surg 1991;88:227–236.
13. Rohrich RJ, Ghavami A, Lemmon JA, Brown SA. The individualized component face lift: Developing a systematic approach to facial rejuvenation. Plast Reconstr Surg
2009;123:1050–1063.
14. El-Domyati M, Medhat W. Minimally invasive facial rejuvenation: Current concepts and future expectations. Exp Rev
Dermatol 2013;8:565–580.
15. Cooke G. Effacing the face: Botox and the anarchivic archive.
Body and Society 2008;14:23–38.
16. Park MY, Ahn KY, Jung DS. Botulinum toxin type A treatment
for contouring of the lower face. Dermatol Surg 2003;
29:477–483.
17. Carruthers JD, Glogau RG, Blitzer A. Advances in facial rejuvenation: Botulinum toxin type A, hyaluronic acid dermal
fillers, and combination therapies—Consensus recommendations. Plast Reconstr Surg 2008;121(5 suppl):5S–30S.
18. Majid O. Clinical use of botulinum toxins in oral and maxillofacial
surgery. Int J Oral Maxillofac Surg 2010;39:e197–e207.
19. Johl SS, Burgett RA. Dermal filler agents: A practical review.
Curr Opin Ophthalmol 2006;17:471–479.
20. Wang L, Sun Y, Yang W, Lindo P, Singh BR. Type A botulinum
neurotoxin complex proteins differentially modulate host
response of neuronal cells. Toxicon 2014;82:52–60.
21. Allemann IB, Kaufman J. Fractional photothermolysis—An
update. Lasers Med Sci 2010;25:137–144.
22. Dayan SH. Complications from toxins and fillers in the dermatology clinic: Recognition, prevention, and treatment.
Facial Plast Surg Clin North Am 2013;21:663–673.
23. Sadick NS, Manhas-Bhutani S, Krueger N. A novel approach
to structural facial volume replacement. Aesthet Plast Surg
2013;37:266–276.
24. El-Domyati M, Attia SK, El-Sawy AE, et al. The use of botulinum toxin A injection for facial wrinkles: A histological and
immunohistochemical evaluation. J Cosmet Dermatol
2015;14:140–144.
25. Li Y, Hsieh ST, Chien HF, Zhang X, McArthur JC, Griffin JW.
Sensory and motor denervation influence epidermal thickness
in rat foot glabrous skin. Exp Neurol 1997;147:452–462.
26. American Society of Plastic Surgeons. 2017 Plastic Surgery
Statistics Report. https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-report2017.pdf. Accessed 16 August 2019.
7
2/
FACIAL ANATOMY,
SKIN BIOLOGY,
AND THE
EFFECTS OF
AGING
Catherine Davies
Richard J. Miron
Understanding facial anatomy is fundamental for any clinician interested in
offering esthetic medical procedures. A thorough understanding of skeletal
and soft tissue anatomy, facial features and landmarks, and the biology
of the skin and hair is required to safely implement the various therapies
described in later chapters of this book. The face is comprised of various
layers, including the skin, connective tissue, subcutaneous fat, muscles,
ligaments, and underlying bone. Within this network, an array of arteries,
veins, and nerves also exist. Each layer must be reviewed independently in
order to understand the goals and treatment strategies for augmentation of
each specific layer and/or tissue type. Minimally invasive injections should
avoid damage to key anatomical structures and aim to activate or accelerate wound healing. This chapter reviews the facial anatomy of the face and
the biology of the skin and hair and presents an overview of the associated
changes to these anatomical structures that occur over time with aging.
9
2 / Facial Anatomy, Skin Biology, and the Effects of Aging
Facial Anatomy
Facial Characteristics and
Age-Related Changes
The face in general plays a crucial role in society,
particularly during social interactions. Facial features
are highly relevant to revealing one’s age, mood, and
stress level. They are also relevant to facial attractiveness and facial expression, a pivotal language communicator. Younger-looking individuals have plump facial
muscles and tight skin with the ability to fully express
themselves during facial communication, whereas
Horizontal
forehead lines
Atrophy
of the temples
Glabellar lines
aging individuals have drooping muscles and loose
skin with less facial expression.
Regardless of how beautiful one’s appearance is
in their youth, age-related changes and loss of facial
volume and features are inevitable. These are often
more pronounced and specific to certain areas. A gradual loss of soft tissue occurs in the upper midface region
in conjunction with a downward migration of superficial buccal fat. Consequently, the upside-down triangle
associated with a youthful look (see Fig 1-1) becomes
inverted, with a larger proportion of soft tissue drooping below the midface. While the rate of aging varies
among individuals based on genetics, environmental
factors, sex, and ethnicity, the following traits are eventually common in all individuals (Fig 2-1):
FIG 2-1
Clinical characteristics of the
aging face.
Eyebrow ptosis
Supraorbital hollow
Blepharochalasis
Periocular and
lateral canthal lines
Infraorbital
hollow (IOH)
Atrophy of the
posterior cheek
and malar fat pad
Nasolabial fold
Loss of
lip volume and
perioral wrinkles
Marionette lines
Jawline with
relative sagging
Discontinuous
chin shape
Horizontal
neck lines and
neck elastosis
10
All figures in this chapter except Figs 2-11 and 2-12
are reprinted from Sattler and Gout’s Illustrated
Guide to Injectable Fillers (Quintessence, 2016).
Anatomy of the Face
• Drooping of the skin and soft tissues (with loss of
subcutaneous fat)
• Wrinkles and creases around the eyes, lips, and
forehead
• Changes in skin contour
• Changes in skin pigmentation (eg, dark circles)
• Eyebrow sagging (ptosis)
• Appearance of sunken eyes
• Loss of lip volume
• Irregular chin contour and sagging
Anatomy of the Face
This section of the chapter explores each layer of the
face independently so that readers can gain a solid
understanding of each before moving on to the next.
Each of the images used to illustrate these layers serves
as a reference that can be referred to when reading
about injection techniques in later chapters. Figure 2-2
depicts common anatomical features of the face that
should be standard language for the treating clinician.
Trichion
(hairline)
FIG 2-2
Landmarks that may be
used for facial measurements (lateral view).
Glabella
Soft tissue nasion
(the deepest point
of the concavity)
Porion (opening
of the ear canal)
Tragus
Apex nasi
Columella
Subnasale
Most anterior rim
of the upper lip
Stomion
(lip closure point)
Most anterior rim
of the lower lip
Soft tissue B point
(the deepest point of
the concavity of the
labiomental fold)
Soft tissue
pogonion
Soft tissue
menton
Cervicale
11
2 / Facial Anatomy, Skin Biology, and the Effects of Aging
Facial skeleton
Figure 2-3 illustrates the various skull bones and their
muscle attachment sites.
Frontal bone
Nasal bone
Maxilla,
frontal process
Supraorbital
foramen
Lacrimal bone
Temporalis
Parietal bone
Corrugator
supercilii
Sphenoid
Temporal bone
Orbit
Depressor
supercilii
Orbicularis oculi
Procerus
Zygomaticus
major
Zygomatic bone
Infraorbital
foramen
Maxilla
Temporal bone,
mastoid process
Zygomaticus
minor
Levator labii
superioris
Masseter
Levator
anguli oris
Nasalis
Buccinator
Orbicularis oris
Mental foramen
Body
(of mandible)
Mentalis
Depressor
labii inferioris
Depressor
anguli oris
Platysma
FIG 2-3
The facial skeleton (left) and muscle attachment sites projected onto it (right).
12
Anatomy of the Face
Muscles of the face
The face consists of 30 different muscles. These are
typically divided via three muscle planes and are thus
distinguished as (1) superficial, (2) middle, and (3)
deep (Fig 2-4). As dynamic coplayers in soft tissue
complexes, muscles play an extremely important role
in facial aging. Dynamic movements and facial expression require these muscles to contract, and naturally
with age, these muscles become hypertrophic, permanently causing visible wrinkles that are involuntary
and undesirable.
Galea
aponeurotica
Frontal bone
Occipitofrontalis,
frontal belly
Temporalis
Procerus
Corrugator
supercilii
Orbicularis
oculi
Nasalis
Levator labii
superioris
alaeque nasi
Levator labii
superioris
Zygomaticus
minor
Levator
anguli oris
Zygomaticus
major
Masseter
Depressor
anguli oris
Depressor
labii inferioris
Buccinator
Ramus
of mandible
Orbicularis
oris
Body
(of mandible)
Mentalis
FIG 2-4
Schematic representation of the facial muscles in three planes: superficial (green), middle (blue), and deep (red).
13
2 / Facial Anatomy, Skin Biology, and the Effects of Aging
Subcutaneous fat and connective tissue
The subcutaneous fat in the connective tissue of the face
acts as a volumizing cushion for the facial soft tissues. It
plays a prominent role in protecting the face from external
injury but also ensures a continuous supply of vital fluids and
nutrients to facial tissues. The face has a continuous superficial fat compartment (Fig 2-5) and a discontinuous deep
fat compartment (Fig 2-6). The superficial compartment
is located superior to the superficial fascia of the superficial musculoaponeurotic system (SMAS), while the deep
compartment is located beneath the SMAS. Both compartments resemble honeycombs in shape and provide an even,
smooth distribution of the skin. Areas with high volume
of superficial fat in the face are typically well defined and
homogenous in layer. These include the cheeks, nasolabial folds, glabella, and the jaw-chin region (see Fig 2-5).
In older patients, this specific tissue decreases with age,
with a resulting atrophy typically caused by reduced blood
flow. Because there is little superficial fat in the area of the
temples and forehead, and almost none in the periorbital
and perioral region, these areas are more prone to wrinkles
and folds with aging and are one of the first visible signs of
facial aging in individuals.
Figure 2-6 illustrates the deep fat layers. These
include the SMAS, retro-orbicularis oculi fat (ROOF),
glabellar fat pad, buccal fat pad, and inferior process
of the Bichat’s fat pad, among others. These fat pads
are larger and, in youthful faces, fully prominent. With
aging, atrophy and loss of volume occur, and this again
is one of the main visible signs of aging.
Periorbital
absence of
superficial
fat
Lateral cheek
fat compartment
Medial cheek
fat compartment
Infraorbital fat
compartment
Nasolabial fat
compartment
Labial-mandibular
fat compartment
Perioral
absence of
superficial
fat
Jowls fat compartment
Pre-mental
fat compartment
Pre-platysmal
fat compartment
FIG 2-5
Superficial fat distribution in the face.
ROOF
Superficial
temporal fat pad
Superior process of
the Bichat’s fat pad
Glabellar fat pad
Suborbicularis
oculi fat (SOOF)
Buccal fat pad
Inferior process
of the Bichat’s
fat pad
Submental
(chin) fat
FIG 2-6
Deep fat compartments of the face.
14
Anatomy of the Face
Blood supply
A prominent and complex blood vascular network
exists throughout the entire region of the face (Fig 2-7).
The peripheral skin layers receive their blood supply
from fine capillary vessels. These small vessels allow
Supratrochlear v.
adequate diffusion into all facial layers. When injecting into areas of the face, a thorough understanding of the location of the major blood vessels is
crucial. This will avoid potential complications related
to intravascular injections, most commonly reported
with fillers.
Deep temporal
aa. and vv.
Supraorbital
a. and v.
Superficial
temporal a. and v.
Supratrochlear
a. and v.
Angular
a. and v.
Superior
labial v.
Angular v.
Superior
labial a.
Inferior labial
a. and v.
Facial
a. and v.
FIG 2-7
Blood vessels of the face projected onto the facial skeleton (left) and the position of the deep arteries and veins of the face
relative to the deep muscles (right) (a., artery; aa., arteries; v., vein; vv., veins).
15
2 / Facial Anatomy, Skin Biology, and the Effects of Aging
The anatomy of the facial arteries and veins in relation to the muscles of the face is also important to
understand (Fig 2-8).
Supratrochlear v.
Superficial
temporal
a. and v.
Infraorbital
a. and v.
Submental
a. and v.
Facial a. and v.
Submental
a. and v.
FIG 2-8
Position of the facial arteries and veins relative to that of the moderately deep (left) and superficial (right) muscles (a., artery;
v., vein).
16
Anatomy of the Face
Innervation
Along with blood supply to the face, a complex innervation system exists within the face mainly from two
sources: the trigeminal nerve and the facial nerve.
The sensory innervation of the face is provided by
the trigeminal nerve. This nerve is divided into three
branches: The V1 ophthalmic nerve exits the orbit
via the supraorbital foramen and fissure and supplies
sensation to the upper part of the face. The V2 maxillary
nerve exits from the infraorbital foramen and innervates
the midface. And the V3 mandibular nerve innervates
the mandibular and temporal regions (Fig 2-9).
Supraorbital n.,
lateral branch
Supraorbital
foramen
Frontal notch
Supraorbital n.,
medial branch
Supratrochlear n.
Infratrochlear n.
Temporal
branches
Zygomaticofacial n.
Inferior
palpebral branch
Infraorbital n.
Infraorbital
foramen
Buccal branches
Marginal
mandibular
branch
Mental n.
Cervical
branch
Mental
foramen
FIG 2-9
Overview of the nerves of the face projected onto the facial skeleton (left) and the position of the deep facial nerves relative to
the deep muscles (right) (n., nerve).
17
2 / Facial Anatomy, Skin Biology, and the Effects of Aging
The facial nerve, on the other hand, innervates
muscles that are involved with facial expression. It
divides into five major branches within the parotid
gland, and most run superficial to a number of muscles
(Fig 2-10). In brief, the temporal branch innervates
the temporal, frontal, and palpebral muscles; the
zygomatic branch innervates the zygomatic region
and lower eyelid muscles; the buccal branch innervates
the cheek and periorbital region muscles; the marginal
mandibular branch innervates the chin muscles; and
the cervical branch innervates the platysma muscles
(see Fig 2-10).
Supratrochlear n.
Supraorbital n.,
medial branch
Supraorbital n.,
lateral branch
Infratrochlear n.
Inferior
palpebral branch
Temporal
branches
Zygomaticofacial n.
Infraorbital n.
Buccal n.
Mental n.
FIG 2-10
Position of the facial nerves relative to the moderately deep (left) and superficial (right) muscles (n., nerve).
18
Skin Aging
Biology of the Skin and Hair
Structure and Function of the Skin
As the body’s largest organ, the skin is vital for maintaining human health. While the skin performs many
vital functions, its core function is to provide a protective barrier and waterproof sheath for the body. As
such, it protects the body’s organs against ultraviolet (UV) light, water loss, microbes, and chemicals.
It further assists in temperature regulation and is
actively involved in immunologic activities. In addition to executing these vital functions, the skin is also
closely related to one’s self-esteem, perception of age,
and general well-being. The skin may have a profound
impact on social interactions and has been described
as playing a key role in esthetics.
The skin is composed of three layers:
1. Epidermis: The epidermis is the outermost layer of
the skin and is made up mainly of keratinocytes. The
vital barrier function of the skin resides primarily
in the top stratum of the epidermis, the stratum
corneum. This layer provides a barrier to loss of
water from the skin, thus protecting against dehydration, and provides a barrier to irritants of the
skin. Melanocytes are the pigment-producing cells
of the epidermis and are found at the basal layer.
Langerhans cells are scattered in the suprabasal
region of the epidermis and provide an important
immune barrier.
2. Dermis: The dermis is located beneath the epidermis and is between 1.5 and 4 mm thick. It is the
thickest of the three skin layers and makes up
approximately 90% of the thickness of the skin.
The main functions of the dermis are to supply the
epidermis with nutrients, to regulate temperature,
and to store much of the body’s water supply. The
upper papillary layer has a thin, extensive vascular system that controls the amount of blood flow
through the skin. The lower reticular layer is thicker
and made of collagen fibers that strengthen the
skin, providing structure and elasticity. This layer
supports other components of the skin, such as
hair follicles, sweat glands, and sebaceous glands.
3. Subcutaneous tissue: Also known as the hypodermis, the subcutaneous tissue is the deepest skin
layer and varies in thickness from a few millimeters
to several centimeters. It is made of fat, divided
by loose connective tissue into fat clusters, and is
separated from the underlying tissues by fascia.
Skin Aging
Human skin naturally ages over the course of one’s
lifetime as a result of evolutionary imperfection.
However, skin is also directly exposed to environmental influences including smoke, UV light, and
chemicals, which over the course of a lifetime may
drastically speed the aging process. As skin ages, a
number of phenotypic and common features may be
observed, linked to dryness of skin, wrinkles, and loss
of elasticity and/or pigmentation. With advancements
made in microscopic imaging, it has become easier
than ever to better understand the damage of the skin
(caused by UV radiation, chemicals, etc) as seen in
changes in collagen and elastic fibers. It is also known
that aging causes a reduction in sebaceous and sweat
glands typically described as senile xerosis with itching. Hair therefore becomes white and thin, spurring
hair loss. Furthermore, aging also causes loosening of
the subcutaneous fat layer, which results in a reduction of its thickness and strength and thereby causing a more droopy look. Especially in individuals with
lighter skin, the appearance of extrinsic aging tends to
be more pronounced and related to atrophy, whereas
in darker skin types, a predominant thickening is more
commonly observed.
Structural differences in skin also exist between the
sexes and among different ethnic groups. In general,
under similar climate conditions, the skin of Asian
people develops wrinkles on average a decade later
when compared to people of central European ancestry. Whereas Europeans typically show a gradual linear
change in skin wrinkles and lines, Asians rapidly and
dramatically begin to show signs of aging typically
19
2 / Facial Anatomy, Skin Biology, and the Effects of Aging
between 40 and 50 years of age. However, in everyone,
the number of melanocytes typically decreases by 8%
to 20% per decade.
While many extrinsic factors play a role in skin
aging—including UV exposure, smoking, ionizing
radiation, excessive alcohol intake, malnutrition, poor
diet, and emotional stress—up to 80% of overall skin
damage is caused by direct UV light exposure. This is
especially pronounced in lighter skin types. UV light
increases the enzymatic activity of matrix metalloproteinases (MMPs), proteins known to be responsible
for the degradation of collagen. Furthermore, UV light
increases the amount of reactive oxygen species (ROS)
in cells, which leads to DNA damage and increased
chance for neoplasms. During such prolonged activity, the body accumulates ROS and the detox system
is often overloaded. Antioxidants, such as vitamin C,
have since been applied topically and have been shown
to play a role in minimizing skin aging.
Intrinsic (genetic) factors also play a key role in
aging. Typically, thinning of the skin occurs between
the 3rd and 8th decades of life, generally accompanied
by marked hypocellularity. This leads to a 10% to 50%
reduction in skin thickness. Clinically this presents as
loosening of the skin and a reduction in subcutaneous fat layers. A dramatic reduction in vascularity of
skin tissues is also observed with aging and may be a
primary link to the histologic observation of hypocellularity and reduction in skin thickness. The concept
of utilizing a concentration of growth factors derived
from blood (platelet concentrates) has therefore been
proposed as a means to reverse or slow down the
aging process, as discussed later in this textbook.
Structure and Function of the Hair
The average human scalp contains between 90,000
and 140,000 terminal hairs. These hairs can grow
approximately 1 cm per month. Meanwhile, hair loss
is continuous, with people losing about 100 hairs per
day on average.
The pilosebaceous or hair follicle unit is made up
of the hair follicle along with an attached sebaceous
20
Sebaceous
gland
Infundibulum
Isthmus
Erector
muscle
Inferior
segment
Bulb
Matrix
FIG 2-11
Representative image of a hair follicle. Injection techniques
with platelet concentrates aim for the bulb of the hair follicle,
located between 1.5 and 4 mm below the surface of the scalp.
gland and arrector pili muscle. Hair follicles vary
considerably in size and shape, depending on their
location, but they all have the same basic structure.
The number and distribution of hair follicles over the
body and the future phenotype of each hair is established during fetal development; no additional follicles
are added after birth.
The hair follicle begins at the surface of the epidermis
and extends into the dermis. Vellus hairs may extend only
into the reticular dermis, whereas terminal hairs extend
deeper, sometimes even into the subcutis (Fig 2-11).
Structure and Function of the Hair
Hair zones
Each follicle can be divided into distinct regions: the
bulb, suprabulbar zone, isthmus, and infundibulum.
The infundibulum begins at the surface of the epidermis and extends to the opening of the sebaceous duct.
The isthmus is the area between the sebaceous duct
opening and the bulge. The bulge is an area of the
follicle marked
The bulge contains several epidermal
by the insertion
stem cells that are part of the outer
of the arrector
root sheath and may be a target for
pili muscle. The
hair loss treatments.
bulge contains
several epidermal stem cells that are part of the outer root sheath
and may be a target for hair loss treatments.
The suprabulbar zone extends from the bulge to the
top of the bulb. The hair bulb sits between 1.5 and 4
mm deep. The bulb contains matrix cells that proliferate
regularly. These cells surround the sides and top of the
dermal papilla and are responsible for the production
of the hair shaft as well as the inner and outer root
sheaths. The dermal papilla contains capillaries and
interacts with the matrix cells in the hair bulb.
Melanocytes among the matrix cells provide the
hair with its individual color. Hair color is determined
by the distribution of melanosomes in the hair shaft.
The hair bulb contains melanocytes that synthesize
melanosomes and transfer them to the keratinocytes
of the bulb matrix. Aging causes a loss of melanocytes
and a corresponding decrease in the production of
melanosomes, resulting in graying hair.
Hair layers
The hair shaft consists of an inner core known as
the medulla. This is surrounded by the cortex, which
makes up the bulk of the hair. Moving outward, there is
a single layer of cells making up the shaft cuticle. The
shaft cuticle is then encased in three layers that form
the inner (internal) root sheath. The inner sheath is
important in shaping the hair shaft as it grows upward
from the matrix. The inner sheath keratinizes from the
outside in and will eventually disintegrate midfollicle
around the level of the isthmus. Finally, the outer
(external) root sheath encases the entirety of the hair
shaft. This layer undergoes trichilemmal keratinization
around the level of the isthmus.
Sebaceous glands are acinar holocrine-secreting
appendages of the epidermis and are a crucial component of the pilosebaceous unit. They are found all over
the body, especially in certain areas of the skin such
as the face. These glands open onto the hair follicles,
except in areas such as the lips, where they empty
directly onto the mucosa surface because lips do not
contain hair follicles. When stimulated by hormones
such as androgens, sebaceous glands produce and
release sebum, an oily and waxy material. This contributes to the hydrophobic barrier of the skin.
The arrector pili muscle is a small band of smooth
muscle bundle that attaches to the external root sheath
of the bulge region of the follicle and extends to its
superior attachment in the upper dermis. It is innervated by the sympathetic branch of the autonomic
nervous system. In cold climates, sympathetic stimulation causes these muscles to contract. This raises the
level of the skin slightly and causes the hair to stand
erect, which is commonly referred to as “goosebumps.”
The hair growth cycle
Hair growth occurs in a cyclical manner, but each follicle follows its own hair cycling schedule, completely
independent of other hairs on the scalp. A normal hair
growth cycle has three phases: anagen, catagen, and
telogen (Fig 2-12).
The anagen phase is the active growth stage and
typically lasts approximately 2 to 7 years on the scalp.
Approximately 85% to 90% of hair is in the anagen
phase at any given time.
The catagen phase, also known as the transition
phase, lasts about 2 weeks and is a period of involution
resulting in club hair formation after many cells in the
outer root sheath undergo apoptosis. The club hair has
a white, hard node on the end.
The telogen phase is also known as the resting
phase. Club hairs, which are essentially dead, are held
on the scalp. They are typically held for about 100 days
21
2 / Facial Anatomy, Skin Biology, and the Effects of Aging
Anagen
Active growth phase
2–6 years
Catagen
Transition phase
1–2 weeks
Telogen
Resting phase
2–4 months
and then released and shed so that the anagen phase
can begin again with a new hair.
Other sites on the body tend to have shorter
anagen and longer telogen phases, causing most
body hair to be shorter and remain in place for
longer periods of time.
Hair loss and the growth cycle
When hair loss occurs, regardless of the cause, the hair
growth cycle is almost always affected. An abnormal
or disrupted hair growth cycle can occur at any phase:
• Shortened anagen phase: The duration of the growth
phase is shortened, and the entire hair growth cycle
becomes affected.
• Early catagen phase: When the growth phase is
shortened, the hair follicle enters the transition
phase earlier than normal.
• Prolonged telogen: As more hairs enter the resting phase prematurely, the normal resting phase
becomes prolonged, causing increased shedding.
A prolonged resting phase means that fewer hair
follicles reenter the growth phase, which results in
weaker or no regrowth.
22
Return to
Anagen
FIG 2-12
Hair growth cycle.
Several factors affect hair growth:
• Genetics
• Androgens (testosterone and its active metabolite,
dihydrotestosterone [DHT])
• Estrogens
• Thyroid hormones
• Glucocorticoids
• Retinoids
• Prolactin and growth hormone
• Drugs
• Nutritional status
• Stress
Androgens are the hormones with the greatest
impact on the hair follicle. Testosterone and DHT act
through androgen receptors in the dermal papilla.
These hormones are responsible for androgenic alopecia later in life for genetically susceptible individuals
as they cause miniaturization of follicles in the scalp.
In adolescence, however, they increase the size of
hair follicles in androgen-dependent areas such as
the beard area.
The goal of any treatment approach, no matter
the cause, type, or hair growth issue, is to normalize and restore the hair growth cycle.
Treating Facial Aging
Treating Facial Aging
As previously explained, there are a number of factors
related to facial aging. While initially these changes
occur on the anatomical and cellular levels below the
skin surface, eventually they become apparent on the
skin. Many of the early signs of aging are found in sites
with little to no superficial fat layers.
When developing strategies for facial rejuvenation
procedures, it is important to understand the anatomy
and also the mechanism of tissue breakdown. The
treating clinician may begin to wonder the following:
Was the skin damage caused by UV exposure with
resulting loss of collagen synthesis? Was it caused by
smoking affecting blood flow? Are the wrinkles and
facial folds caused by hyperactive muscles? These
are all important questions to ask as a practitioner in
order to develop and recommend effective therapeutic
strategies.
Age-related changes in facial tissues most often
alter blood supply, and as a result, atrophy-related
deterioration is observed. This markedly decreases
the thickness of fat tissue layers, the rate of cell division of skin cells, and collagen synthesis. Each of the
above-mentioned scenarios also impairs the regeneration capacity of various tissue types as well as the
natural barrier function of the skin. Skin hydration is
also affected, leading to further signs of facial aging.
Many of the signs of aging are found in “hot spot”
areas of the face. Figure 2-13 demonstrates the topographical comparison of sites with subcutaneous fat
distribution versus those without. Notice that the
regions with low fat content (around the eyes and
around the lips) are more frequently clinically related
to visible signs of aging. Therefore, the periorbital and
perioral regions are starting points during facial rejuvenation strategies.
Furthermore, deep fat atrophy is a significant
age-related factor for skin aging and is primarily
caused by a decrease in age-related blood flow, which
decreases the supply of oxygen and nutrients to facial
tissues and therefore causes shrinkage of deep fat
stores. This gradual loss of fat volume from underlying
subcutaneous tissues results in a decrease in skin tone
and fluid levels in the facial tissue complex. Hence,
vascular degeneration is considered a major cause of
the initiation of facial aging and hence why platelet
therapies such as PRF have been deemed extremely
effective strategies for minimizing further facial aging
and potentially reversing existing changes. Furthermore, this loss of deep fat stores is one of the main
reasons why fat grafting has been commonly utilized
as a strategy in facial esthetics, as discussed later in
this textbook.
A loss of muscle and ligament attachment is also
observed with facial aging, affecting esthetics. Consequently, when muscle activity decreases, skin laxity
ensues. A gradual shift is observed over time, leading
to increases in wrinkles and lines that can be involuntarily produced in areas of facial expression, especially
when the face is relaxed.
Lastly, aging will affect bone. When bone mass is
decreased and the facial skeleton shrinks, further
skin laxity is observed. This is most pronounced in
the cheek area, where early signs of bone loss lead
to drastic and noticeable facial aging.
Each of these associated age-related aspects must
be considered when designing ideal therapeutic
strategies.
Remember: The visible signs that are
observed externally in the skin (wrinkles, skin
laxity, and folds) are almost always related to
an underlying cause at a deeper tissue level
not clinically visible.
23
2 / Facial Anatomy, Skin Biology, and the Effects of Aging
Temporal
fat pad
ROOF
Glabellar
fat pad
SOOF
Malar fat pad
Anterior cheek
(nasolabial)
compartment
Posterior cheek
compartment
Lower cheek (jowls)
compartment
Pre-mental
fat pad
Pre-platysmal
fat pad
FIG 2-13
Split view of the clinical signs of aging and subcutaneous fat distribution of the face. It is apparent at first glance that there is a
correlation between them. At sites where superficial fat is absent, alongside facial atrophy due to deep fat loss, the clinical signs
of aging become apparent at a particularly early age. Sites of fat loss around the eyes and mouth are therefore considered to be
facial aging “hot spots.”
24
Summary
Summary
Today it is clear that the causes of facial aging
are multifactorial and affect multiple tissue types.
Because many facial changes occur anatomically
below the skin surface, including a decrease in blood
flow and subsequent fat loss, a solid understanding of
the multidimensional processes involved in the skin,
subcutaneous fat, connective tissues, muscles, and
bone is required for any clinician wishing to perform
facial rejuvenation procedures.
Superficial defects such as minor wrinkles can be
treated with a variety of different modalities, such
as PRF in combination with microneedling. Platelet
concentrates like PRF are known inducers of angiogenesis and have since become pertinent to the
field of facial rejuvenation, with the ability to further
improve blood flow in deficient tissues. The following
chapters provide strategies to improve angiogenesis
via improved centrifugation techniques to formulate
effective platelet concentrates such as PRF (see chapter 6), which may then be entered into facial tissues
either by microneedling (see chapter 7), injection (see
chapters 8 and 9), in combination with lasers (see
chapter 10), or utilizing novel approaches (see chapter
12). While the field continues to evolve rapidly, these
chapters provide an up-to-date overview of the use
of PRF in facial esthetics.
25
3/
PHOTOGRAPHY
IN FACIAL ESTHETICS
Walter Rozen
Richard J. Miron
Catherine Davies
Photography is an essential component of medical esthetics to evaluate
and track changes over time following therapy and/or aging. This becomes
even more critical in the field of facial esthetics, where patient demand and
expectations are continuously rising and patients seek the “youthful look.”
Treatment with platelet-rich fibrin (PRF) is known to stimulate new tissue
regeneration by supplying soft tissues with a slow and gradual release of
growth factors, resulting in a naturally rejuvenated look. This is opposite
to other facial esthetic modalities, such as fillers or Botox, where a more
instantaneous change in facial features is encountered following treatment,
providing the patient with more immediate gratification. Photography therefore becomes essential during PRF therapy to evaluate progress over time.
This chapter highlights the importance of photography in facial esthetics
and provides an overview of documentation requirements. First, equipment
setup is discussed, including a critical assessment of background, lighting,
and camera features (camera, lens, and flash). Thereafter, a photographic
series of 17 images is presented with patient photographs taken in both
static (relaxed) and active (contracted) poses to highlight facial features.
In summary, this chapter provides the clinician the necessary steps to
adequately perform quality photography essential in today’s marketplace.
27
3 / Photography in Facial Esthetics
Photography for Documentation
Medical photography is a means to accurately document patient features and conditions utilizing a device
to capture an image or video. Photography has been
utilized in medicine for over a century, and prior to that
medical drawings and illustrations were considered
the norm to portray disorders or changes to various
medical conditions and transmit new information to
colleagues. Today medical photography is more popular than ever, and its essential use in modern medicine
is not only highly recommended but in some fields
an absolute necessity. The field of facial esthetics
and facial rejuvenation balances a fine line between
medicine and cosmetics, and for this reason, it is the
authors’ recommendation that all doctors adhere to
strict protocols when it comes to documenting facial
esthetic procedures. Because photography is essential
for documenting cases over time, patient files should
be stored in secure places and digital files should be
backed up in ideally two places.
Photography can also serve many other functions.
Well-conducted photography can improve case acceptance because incoming referrals and new patients
can visualize before and after photographs performed
within that office, helping to build credibility and trust.
Photography is also useful to facilitate treatment planning, monitor overall progress over time, research and
optimize techniques, as well as improve office marketing.
Unfortunately, in the field of facial esthetics, there is
an ever-growing number of “failed” procedures, protocols, and devices because of the number of low-grade
products brought to market (eg, bargain facial fillers),
resulting in lawsuits and negativity toward the field.
Furthermore, with the increased visibility of facial rejuvenation procedures being performed on virtually all
celebrities in modern culture, patient expectations
have also increased tremendously. It is therefore
anticipated that some patients will demonstrate some
resistance following treatment, expressing that little
to no effect or benefit was observed over time.
Patients forget fast, and photography therefore becomes essential.
28
Naturally, the most effective method to transmit
information regarding changes to facial features is by
properly and adequately documenting before and after
photographs in a photographic series. This becomes
particularly important when regenerating tissues with
PRF, because a slow and gradual change is expected
over time, unlike the instantly gratifying result that
may be observed with facial fillers and/or Botox (Allergan). The photographic series demonstrated later in
this chapter illustrates effective ways to bring out
facial wrinkles and problem areas. These photographs
may be captured predictably within a 2-minute period
when the office is adequately set up.
General Requirements
Prior to any procedure commencing in a medical office
or cosmetic spa, collection of all relevant patient medical history is essential. All treatments carried out must
be well documented in each specific patient file, even
if utilizing a totally natural regenerative approach such
as with PRF. Even though no adverse reactions have
been documented in the literature to date with PRF,
it is always important to provide the patient with
an array of possible treatment options with a full
consultation that includes discussion of the relevant
risks and potential complications of each treatment
option prior to commencing any procedure. A written
informed consent is also a requirement for all facial
procedures performed.
One of the first steps following a thorough medical history assessment is a complete photographic
series documenting the patient in both static and
active poses. This is vital in order to accurately and
objectively record the patient’s facial features. These
photographs are taken without makeup and allow
the photographer (often a trained office assistant)
to adequately visualize the entire face, including
troublesome areas and/or facial aging features. Once
completed, it is routine to allow patients to visualize
their own facial photographic series. Allow time for
patients to evaluate their own facial contour, features,
and troublesome areas prior to beginning discussion
Background
with the treating medical provider. During consultation, patients are more prone to disclose their troublesome areas, and the medical provider may then begin
discussing realistic expectations for each treatment
option provided within their facility.
Ideally, photography for facial esthetics should be
performed in a dedicated space or room within the
office. This will greatly assist in taking uniform photographs over time as the image distance, flash settings
(both intensity and length), camera lens settings, as
well as a variety of other options found in digital
photography can be fixed, stationary, and therefore
reproducible. Unfortunately, many practices do not
function like this, and slight changes in any of these
parameters (especially lighting) can have a drastic and
marked impact on the final photograph. This chapter
features a professional setup for adequate medical
photography.
Background
a
The background can have a tremendous impact on the
final photograph; a busy background can be distracting and result in less focus toward the troublesome
facial areas (Fig 3-1). While some clinicians utilize a
white door or a room divider as a background, the
authors highly recommend the use of a background
support stand with a white wrinkle-resistant backdrop (Fig 3-2). These can be purchased for under $100
and can offer great background clarity. We further
recommend pure white seamless background paper
(typically around $30), which can be rolled if wrinkles
are observed over time.
FIG 3-1
A proper background can have a tremendous impact on the
final photograph, because background disturbances can be
distracting to the overall photograph. (a) Patient photograph
with busy background. (b) Same patient with a seamless white
background.
b
29
3 / Photography in Facial Esthetics
a
b
FIG 3-2
FIG 3-3
The authors recommend the use of a background support stand
with a white wrinkle-resistant backdrop for facial photography.
Two types of cameras are typically used in facial esthetics. (a)
Digital compact cameras are easy to use and offer a variety of
preprogrammed image modes. They are inexpensive and relatively small in size. (b) Digital reflex cameras are the preferred
choice because they offer a much wider range of accessories,
high optical performance, and the ability to change lenses depending on function.
Camera and Lens
detail in the brightest and darkest areas being photographed. These cameras offer numerous advantages:
(1) the ability to include indirect flashes (multiple), (2)
high optical performance, (3) the ability to change
lenses, and (4) the ability to attach special accessories. While there is a learning curve to operate reflex
cameras and a basic knowledge of photography is
needed, most of the settings required are highlighted
throughout this chapter to ease this learning curve
(Fig 3-3). Ideally, the clinician should test various
systems prior to purchase by taking long and close-up
photographs of skin areas.
Many cameras are available in today’s market, and
it is often difficult to decipher the advantages and
disadvantages of each. While digital compact cameras
were once considered an easy-to-use photography
device with preprogrammed image modes, they have
limited applications in facial esthetics because they
are incapable of utilizing indirect flash. Instead, clinicians should ideally purchase a digital reflex camera.
A modern 20- to 30-megapixel model with low noise
at 100 ISO speeds is preferred for the least noise with
excellent detail and the greatest ability to reproduce
30
Camera and Lens
Setup
B
a
c
k
g
r
o
u
n
d
20”
Chair
72”
24”
24”
FIG 3-4
Recommended distance setup for an office to perform photography in facial esthetics. Note the three flashes: one behind the
patient to avoid shadows, and two near the camera angled facing the patient on either side.
A basic set of requirements is necessary to take
adequate photographs. Ideally, the operator and patient
should be still. For these reasons, the patient should
always be sitting upright, and the camera should be
installed on a rigid tripod to minimize camera motion.
The first or baseline shot of the documentation series
should always be critically assessed to ensure that the
lighting, focal spots, and image quality represent the
office norm. The remaining photographs can then be
taken. All images should be taken as perpendicular to
the patient as possible.
As a general rule of thumb, a certain distance is
needed from the patient in order to avoid having
larger-than-usual central facial features (such as the
nose), often encountered when the image distance is
too small. The authors recommend a 6-feet distance
from the patient as illustrated in Fig 3-4. While zoom
shots were once captured in order to better visualize
certain troublesome areas, the improvement in camera
technology allows a single headshot to be taken and
then zoomed in digitally to visualize specific areas with
extremely high quality (Fig 3-5).
31
3 / Photography in Facial Esthetics
b
c
d
a
e
f
FIG 3-5
Demonstration that from a single headshot (a), multiple areas can be visualized incredibly well with the zoom function due to improvements in technology of modern-day cameras. (b) Neck. (c) Forehead wrinkles. (d) Lower eyelid. (e) Nasolabial fold. (f) Jowls.
When it comes to camera lenses, an array of choices
exists. We recommend a camera with a 100mm lens
(Fig 3-6). A 100mm lens is the best choice because
it is fixed and not subjected to inadvertent zoom
changes. It provides uniformity. Furthermore, a camera
distance of 6 feet just behind the flashes allows for the
greatest enlargement with the 100mm lens. Moving
the camera back further will produce a smaller image
with lower resolution upon zoom. Wide-angled lenses
should be avoided because they can produce undesirable distortions (fish eye perspective), which are not
appropriate for facial documentation.
FIG 3-6
100mm Canon lens.
32
Once setup is complete, image quality will remain
the same, so the setup process is very important
and should be given serious effort.
Lighting
TABLE 3-1
Camera model, lens, and camera settings for
facial photography
Camera model
Nikon D7200 or
equivalent SLR
Lens
100mm fixed or zoom
to 100mm
Flashes
Flashpoint Studio 300
Monolight with Built-in
R2 2.4GHz Radio
Remote System
Flash set to
1/8 power
Camera set to
Manual
Shutter speed
1/160 sec
f-stop
F11
ISO
100
White balance
Flash
Lighting
Lighting can be complicated because every light
source has different color temperatures with
differing effects on color reproducibility. We highly
recommend using the settings given in this book
to ensure proper photography. Using the camera/
flash settings given in Table 3-1 will ensure proper
color balance and exposure. This will minimize and
negate interference from room light. In general, it is
assumed that artificial light sources will be utilized
to document patients. When mixed light situations
occur (daylight, various fluorescent lamps, or other
types of lights), it increasingly complicates the ability
to capture a photograph accurately. For an adequate
method to measure light intensity, a histogram is
recommended to calibrate the photograph (Fig 3-7).
The histogram provides a graphic representation of
the brightness distribution within a photograph, and
this objectively allows the photographer to adjust
conditions accordingly. Ideally, the image brightness
should span across the entire histogram; the two
ends represent dark (left) and bright (right) areas
in the image. The highest peak in the histogram will
always be located to the far right, which represents
the background white (purest white). The rest of
the photograph should appear to the left, and the
peaks should end before the end of the frame, which
represents total black (see Fig 3-7b). We recommend
a set of Studio Monolight flashes. In this set of three,
two flashes come angled facing the patient on each
side, and one is located behind the patient to avoid
backdrop shadows (see Fig 3-4).
With respect to lighting, the proper ISO speed,
lens aperture, and flash unit performance all need
to be considered and adjusted accordingly. Hiring
a professional photographer during setup is highly
recommended as a one-time consultation because
they can work through minor issues with much more
effectiveness than can most clinicians (Fig 3-8).
Previously, some clinicians recommended direct
(on-camera) flash light versus indirect flash (Fig 3-9).
We personally prefer indirect flash light because the
light may better detect facial features more readily,
and it provides more uniform lighting throughout the
face. Some disadvantages, however, are that indirect
light requires more powerful flash units, the room
needs proper setup, it requires an adequate flash
transmitter from the camera, and it also requires a
higher degree of technical experience.
33
3 / Photography in Facial Esthetics
FIG 3-8
➤
a
It is highly recommended to hire a professional photographer
during the setup and management of digital photography to
help set up the overall landscape and lighting. Thereafter, it
becomes easy to reproduce images from session to session.
b
➤
c
34
FIG 3-7
Three images taken of the same person in (a) underlit, (b)
normal, and (c) overlit intensities. Notice the subsequent histograms for each image. Ideally, a well-spanned histogram
should be observed following image capture.
Documentation Series
a
jump into facial esthetics for the first time with limited
space requirements (8 to 10 feet total). The recommended settings are presented in Table 3-1. All settings
should be used as given. The only variable should be
the f-stop, which is used to make a final fine tune of the
histogram. This may vary from clinic to clinic. All other
parameters remain fixed to ensure the highest quality.
If you lower the f-stop number, the exposure increases
and moves the histogram to the right. If you increase the
f-stop number, the exposure will decrease and moves the
histogram to the left.
In the event that a photograph is taken with a
need for measurement (eg, the size of a benign skin
tumor), typically a 6-inch ruler is included within the
photograph.
Documentation Series
b
FIG 3-9
Differences between on-camera flash (a) versus indirect flash
(b). Notice that in direct flash (a), more shadows are created
along the sides of the person’s face, whereas indirect flash
has a better ability to capture those locations.
Taking the Photographs
Photographs should ideally be taken in a dedicated office
space where lighting, patient position, and distance to
the camera can be controlled and reproduced predictably. Figure 3-4 demonstrates the setup with highlighted
recommended distances for offices. This is an excellent
starting place for new medical providers who wish to
The photographic documentation series is one of the
first and most important steps when acquiring new
patients for facial esthetics. Shortly following the information session and a thorough review of the informed
consent sheets, the patient is asked to remove any
makeup and jewelry and prepare for a series of facial
photographs aimed at revealing potential problematic
areas. It is important to plan this first appointment
with an appropriate time slot for consultation and
photography. This allows the patient’s concerns to be
explored comprehensively and completely in a professional manner. Listening to patient concerns and then
providing a documented photographic series is a highly
effective approach to treatment, especially in offices
that can show before and after photographs of patients
who were effectively treated for similar issues.
In the facial esthetic field, it is also a benefit not to
rush this first appointment, because typically patients
who enroll in facial rejuvenation programs are longterm clients. Therefore, if the treatment outcome
initially satisfies the patient, the opportunity then
exists to create a solid and long-lasting patient relationship. Furthermore, a positive treatment outcome
will surely lead to growth by word of mouth, the ideal
form of practice growth.
35
3 / Photography in Facial Esthetics
FIG 3-10
Images 1 through 5 of the facial esthetic
photographic series, including two profile
views, two oblique views, and a frontal view
of the patient while the face is relaxed.
Tip: Most camera brands allow the user
to select multipoint or single-point focus
points. A single point must be selected,
and it must be the center point only. For
technical reasons, this will ensure the
most accurate photograph; otherwise,
much of the face will be out of focus. On a
Canon camera, for instance, the sharpening should be set to the maximum in the
camera’s dropdown menu. The focus point
should be placed over the subject’s nostril
for the frontal and oblique view shots. For
the profile shots, the earlobe area where
there is contrast or the corner of the lip
should be used. These focus points are
near the same plane that the cheeks and
forehead lie on, which brings the entirety
of the image into proper focus.
The PRFEDU facial esthetic photographic documentation series, established by Advanced PRF Education
(www.prfedu.com), includes a series of 17 photographs in both static (relaxed) and active (contracted)
poses to highlight facial features. First, a set of five
relaxed photographs is taken: a frontal image, two
45-degree (oblique) images, and two sagittal (profile)
36
images (Fig 3-10). Then a series of active photographs begins. First, the patient is asked to contract
the neck muscles with clenched teeth (expression
of sadness), and three images are taken at different
angles: a frontal image and two oblique images (Fig
3-11). These same three photographs are taken with
the patient actively smiling (Fig 3-12). The patient is
Documentation Series
FIG 3-11
Images 6 through 8 of the facial esthetic photographic series, including three different angles of the patient with contracted
neck muscles and clenched teeth.
FIG 3-12
Images 9 through 11 of the facial esthetic photographic series, including three different angles of the patient actively smiling.
then asked to squint like they are in a sandstorm to
allow for adequate wrinkle formation of crow’s feet.
Once again three photographs are taken here from
frontal and oblique angles (Fig 3-13). Lastly, a series
of three photographs is taken with only the frontal
view showing. These include (1) scrunching of the
nose to allow for the nose and lip area to reveal aged
wrinkles (Fig 3-14), (2) lifting of the eyebrows to reveal
line wrinkles in the forehead area (Fig 3-15), and (3)
pulling of the skin of the cheek outward (Fig 3-16). This
final photograph is utilized to observe skin tightening
over time following therapy, because certain modalities (such as microneedling) are known to effectively
tighten skin and reduce skin laxity.
37
3 / Photography in Facial Esthetics
FIG 3-13
Images 12 through 14 of the facial esthetic photographic series, including frontal and oblique views of the patient squinting to
allow for adequate wrinkle formation of crow’s feet.
FIG 3-14
FIG 3-15
FIG 3-16
Image 15 of the facial esthetic photographic series: The patient is asked to
scrunch the nose to allow for the nose
and lip area to reveal aged wrinkles.
Image 16 of the facial esthetic photographic series: The patient is asked to lift
the eyebrows to reveal line wrinkles in
the forehead area.
Image 17 of the facial esthetic photographic series: The patient is asked to
stretch the skin by pulling the skin of the
cheek outward.
38
Documentation Series
The PRFEDU Facial Esthetic Photography Documentation Series
Relaxed
Sagittal left
Oblique left
Frontal
Oblique right
Sagittal right
Active
Contract neck muscles with clenched teeth (expression of sadness)
Oblique left
Frontal
Oblique right
FIG 3-17
Full PRFEDU photographic series.
The combination of these 17 photographs (Fig
3-17), which can be taken by experienced staff
within 2 minutes, will drastically improve patient
documentation and allow visualization of the full
scope of facial changes that occur over time following therapy.
39
3 / Photography in Facial Esthetics
The PRFEDU Facial Esthetic Photography Documentation Series
Active
Smile with your teeth showing
Oblique left
Frontal
Oblique right
Active
Squint like you’re in a sandstorm
Oblique left
Frontal
Oblique right
Scrunch nose
Active
Eyebrows up
Pulling outward
Frontal
Frontal
Frontal
FIG 3-17 (cont)
Full PRFEDU photographic series.
40
Conclusion
Archiving
As previously stated, all photographs must be archived
in a reliable and easy-to-access storage system. All
data must also be capable of being quickly retrieved
upon patient request. A variety of commercial systems
exist, all providing various options. While each clinician may have their own personal preferences, we
always recommend backing up photographs in at least
two areas (ideally in two different physical locations).
It is highly recommended to utilize some sort of automated web-based uploading system to back up all
photographs in order to protect your data in case of
fire or other physical damage to your office.
Marketing with Photography
A picture tells a thousand words. Before and after
photographs of patients treated with various modalities in facial esthetics are therefore one of the most
effective means to market one’s skill set. For this, the
PRFEDU facial photography series is a highly valuable
commodity because individual photographs can be
utilized for marketing purposes provided the patient
gives signed consent. These photographs can and
should be utilized in professional brochures and/or
leaflets that are displayed and handed out in the practice waiting room. This a great way to present new technologies to incoming patients who may not be familiar
with each technology present within the practice.
One successful modality highly effective in today’s
modern world is the use of waiting room television
programming to showcase cases treated within the
office. Rotating before and after photographs is a
highly effective tool to increase patient acceptance
rate. Furthermore, infomercial-type interviews with
doctors discussing new office techniques are also
an excellent way to educate patients effectively on
new therapies offered within the office. This allows
for professional delivery of new material and information to patients before they even meet the clinician.
Conclusion
Photographic documentation is valuable in order to
visualize any underlying troublesome areas and accurately document facial aging over time as well as the
improvements seen with facial rejuvenation procedures. As patient demand continues to rise steadily, it
is the authors’ greatest hope that all treating clinicians
take responsibility for adequate documentation and
implement quality photography within their offices.
41
4/
CONSULTATION
FOR THE FACIAL
ESTHETIC PATIENT
Richard J. Miron
Catherine Davies
Consultation following a thorough documented photographic series is the
most important time spent between the patient and practitioner. During
this initial visit, a series of questions are addressed to build rapport, better
understand the personal objectives/goals of each patient, and familiarize
and educate the patient with various treatment strategies. This chapter
highlights the importance and necessity of an adequate initial consultation
and provides a specific set of questionnaires to conduct during this initial
consultation. Discussion over key medical-related issues and a manual
assessment strategy are provided with the Merz classification utilized to
objectively evaluate current patient facial features and wrinkles. Once a
treatment plan is selected (with written and signed informed consent), it
then becomes important to clarify expectations and treatment timelines
with the patient. Adequate communication during this initial consultation
favors the establishment of trust and long-term confidence between practitioner and patient.
43
4 / Consultation for the Facial Esthetic Patient
Initial Consultation
The initial consultation with the patient following a
thorough documented photographic series (see chapter 3) is the most important meeting between the
patient and clinician. Here the patient can discuss his
or her goals and objectives with the clinician, while
the clinician can clarify expectations with respect to
the facial esthetic protocols and procedures.
This consultation is very different from most classic
medical consultations in that most patients are more
personal and eager to seek recommendations regarding their current facial features/appearance. The most
successful practitioners are therefore individuals who
are exceptional listeners and communicators. This fact
should not be overlooked by the medical provider, as
many clients are expressing personal issues.
Patients often set high expectations, especially in the
glorified world celebrities live in, often looking 15 to 20
years younger than their actual age. Furthermore, office
before and after photos may be “best-case scenarios”
and not necessarily the norm. It is therefore important
for the clinician to set realistic expectations for each
patient and provide realistic goals and milestones. For
instance, therapy with platelet-rich fibrin (PRF) is known
to require a treatment protocol of three to four sessions
spanned 1 month apart to reach the desired outcome.
Therefore, before and after photographs comparing a
given patient on day 0 and at a 4-month recall would be
most realistic to assess the effects. This might not be
an ideal treatment strategy for everyone (waiting this
4-month period versus the more “instant gratification”
of Botox [Allergan] or fillers).
It is also important to adequately characterize the
patient’s current facial condition. For this, the Merz classification system is utilized as presented in Fig 4-1 and
Table 4-1. Because facial esthetic procedures are generally not necessary for “medical purposes,” the majority are elective procedures (many remain off-label). It
is therefore essential that patients receive adequate
information in both written and verbal format with a
written informed consent adequately highlighting the
benefits, risks, and potential complications of each
discussed therapy.
44
TABLE 4-1
Esthetic scale from Merz classification
Scale
Severity of wrinkles and volume changes
0
No wrinkles or volume changes
1
Mild wrinkles and volume changes
2
Moderate wrinkles and volume changes
3
Severe wrinkles and volume changes
4
Very severe wrinkles and volume
changes
In the end, the consultation should fulfill the following criteria:
• Record the baseline photographic series and store
images accordingly. Discuss with written documentation the patient’s openness to utilize photographs
for future teaching or marketing purposes.
• Evaluate the current facial characteristics and classify
each area utilizing the Merz classification system.
• Understand the patient’s desires and goals.
• Communicate and provide a realistic understanding
of the timeline required to achieve such goals.
• Assess the potential rejuvenation potential for the
individual patient based on their current age, skin
age, and medical conditions that might affect final
outcomes such as smoking.
• Critically assess the patient’s psychologic wellbeing and openness/expectations regarding therapy (some patients may not be worth the potential
complications/heartaches).
• Present a detailed treatment plan with available options
and time frames. Discuss the pros and cons as well as
financial implications of each therapeutic method.
• Provide the patient with adequate time to decide
which therapy, if any, to proceed with. Follow-up
phone calls are often necessary to have the patient
review the proposed treatment outlines and financial implications.
Initial Consultation
Forehead at rest
Brow positioning
0
High arch of
the eyebrow;
youthful,
refreshed
look
0
No wrinkles
©Merz
©Merz
1
Medium high
arch of the
eyebrow
1
Mild wrinkles
©Merz
©Merz
2
Slight arch of
the eyebrow
2
Moderate
wrinkles
©Merz
©Merz
3
Flat arch of the
eyebrow; mild
ptosis, tired
appearance
3
Severe
wrinkles
©Merz
©Merz
4
Sunken
arch of the
eyebrow;
severe
ptosis,
very tired
appearance
4
Very severe
wrinkles
©Merz
FIG 4-1
©Merz
(cont)
Merz full esthetic scales at rest. (Reprinted from Sattler G, Gout U. Illustrated Guide to Injectable
Fillers. London: Quintessence, 2016.)
45
4 / Consultation for the Facial Esthetic Patient
Lateral canthal lines at rest
Marionette lines
0
No lines
0
No wrinkles
©Merz
©Merz
1
Mild lines
1
Mild wrinkles
©Merz
©Merz
2
Moderate
lines
2
Moderate
wrinkles
©Merz
©Merz
3
Severe lines
3
Severe
wrinkles
©Merz
©Merz
4
Very severe
lines
4
Very severe
wrinkles
©Merz
©Merz
(cont)
46
Initial Consultation
Fullness of the lips
0
Very thin
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
1
Thin
2
Normal
fullness
3
Full
4
Very full
(cont)
47
4 / Consultation for the Facial Esthetic Patient
Glabellar lines at rest
Nasolabial lines
0
No wrinkles
0
No lines
©Merz
©Merz
1
Mild wrinkles
1
Mild lines
©Merz
©Merz
2
Moderate
wrinkles
2
Moderate
lines
©Merz
©Merz
3
Severe
wrinkles
3
Severe lines
©Merz
©Merz
4
Very severe
wrinkles
4
Very severe
lines
©Merz
©Merz
(cont)
48
Initial Consultation
Lip wrinkles at rest
Oral commissures
0
No wrinkles
0
No sunken
labial angles
©Merz
©Merz
1
Mild wrinkles
1
Mildly
sunken labial
angles
©Merz
©Merz
2
Moderate
wrinkles
2
Moderately
sunken labial
angles
©Merz
©Merz
3
Severe
wrinkles
3
Heavily
sunken labial
angles
©Merz
©Merz
4
Very severe
wrinkles
4
Very heavily
sunken labial
angles
©Merz
©Merz
(cont)
49
4 / Consultation for the Facial Esthetic Patient
Jawline
0
No relative
sagging
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
©Merz
1
Mild relative
sagging
2
Moderate
relative
sagging
3
Severe
relative
sagging
4
Very severe
relative
sagging
(cont)
50
Initial Consultation
Neck
Back of the hands
0
No
horizontal
lines and
no elastosis
0
No volume
loss, no skin
aging
©Merz
©Merz
1
Mild
horizontal
lines and
no elastosis
1
Mild volume
loss, no skin
aging
©Merz
©Merz
2
Moderate
horizontal
lines and
initial
elastosis
2
Moderate
volume loss,
initial skin
aging
©Merz
©Merz
3
Severe
horizontal
lines and
severe
elastosis
3
Severe
volume loss,
severe skin
aging
©Merz
©Merz
4
Very severe
horizontal
lines and
very severe
elastosis
4
Very severe
volume loss
and very
severe skin
aging
©Merz
©Merz
(cont)
51
4 / Consultation for the Facial Esthetic Patient
Infraorbital hollowness (IOH)
Clarifying expectations
0
No
hollowness
©Merz
1
Mild
hollowness
©Merz
2
Moderate
hollowness
©Merz
3
Severe
hollowness
©Merz
4
Very severe
hollowness
©Merz
52
The initial consultation is a great opportunity to clarify
patient expectations. Results vary between patients, and
treatment with various materials including PRF vary from
patient to patient based on their age, regenerative potential, and concentration of growth factors and cells within
their blood, among other factors. Therefore, it is critical that
the treating clinician gauges the patient’s expectations
and sets realisIt is better to underpromise and
tic expectations
overdeliver than to overpromise and
in turn. Ideally,
underdeliver.
this should not
reduce patient
enthusiasm toward therapy. Remember: It is better to
underpromise and overdeliver than to overpromise and
underdeliver. Word of mouth travels fast, and patient satisfaction is the easiest way to spread the word, particularly
in facial esthetics.
In general, two types of patients present to the
clinic. The first patient has specific and precise
changes requested. These are always the preferred
patients. The second type of patient has little idea
what should be changed, modified, or improved but
is generally dissatisfied with their overall appearance.
Naturally this second patient presents a very difficult situation in that patient outcomes are hard to
anticipate. Thorough photographic documentation
becomes a must, and this second patient may never
be satisfied. It is helpful if you can better understand
the motivation behind the desire for treatment: Is it
simply to appear younger? To impress someone? To
improve job acceptance? A proper assessment of the
patient’s level of self-esteem and confidence should
be noted within the patient file.
During the consultation, it is highly recommended
that the patient spend adequate time with their photographic series (see chapter 3). In this way, patients
can visualize details of the face that they may not
have noticed previously, especially those in active
motions. During the one-on-one consultation, it is
also advised to provide the patient with a mirror to
point directly to the feature they wish to alter. Always
make note of the desired goals of each patient, and
Initial Consultation
carefully manage additional objective assessment of
the face. A simple method to facilitate this is to asked
the question, “Would you like an objective assessment from my perspective?” In this way, the treating
medical practitioner can provide valuable information
to the patient without appearing forceful or aggressive. If patient acceptance is received, the patient is
less likely to take offense to observation notes and
comments and is likely more open to guidance and
advice. Certain features that imply dissatisfaction,
especially with aging, include the “angry” (depressed
nasolabial fold or downturned corners of the mouth)
and “tired” (droopy eyes and crow’s feet around the
eyes) features. These are worth noting to the patient.
This will certainly spur some conversation, and realistic expectations may then be set thereafter.
It is also important to remember that each of us is
generally our worst critic when it comes to our own
appearance. Therefore, even in the unlikelihood that
certain features may not stand out to the practitioner,
most patients often know precisely the areas they
would like changed or modified. It remains our duty to
offer objective assessment of the patient with realistic
expectations clarified.
Good ethics and proper photographic documentation are necessities for a long-lasting and successful career. A consultation period allows a beautiful
platform for the practitioner to build a rapport with
the patient and educate them on the importance of
achieving a natural, well-balanced, and harmonious
treatment outcome. From this point of view, treatment with PRF is ideal in that it is very difficult to
achieve an unnatural look with this material because
the body naturally regenerates tissues based on its
genetic limitation. For example, lips cannot be overinflated with PRF because the body will resorb whatever is considered “excess.” Respecting the human
form and adequately promoting natural regeneration
is an effective means to bring a patient into a facial
esthetic regimen.
Important things to consider
• What exactly does the patient wish to change/
accomplish? Why?
• What motivates the patient to want these changes?
• Can the patient provide a previous photograph of
a time they appreciated their facial appearance? If
not, can the patient provide a photograph of their
desired changes?
• Can the expectations of the patient be managed
accordingly by the practitioner? If not, how can the
practitioner effectively communicate this?
• What is the self-esteem level of the patient? Are
they confident that therapy will improve their
self-image? How will they handle a less optimal
treatment outcome?
• Does the patient have friends or family members
that have previously received therapy in facial
esthetics? What were outcomes and were they
satisfied?
• How does the patient’s attitude affect the potential
therapy? What is the patient’s attitude toward staff
and the practitioner? Is this an ideal patient for facial
esthetic treatment?
• Does the practitioner anticipate a compliant patient?
Will the patient return for therapy for three or four
sessions of treatment with PRF? Compliance must
be specified.
• What is the anxiety level of the patient?
During this lengthy consultation period, the objective of the practitioner is to characterize exactly what
the patient expectations are and what they sincerely
wish to accomplish. It is highly recommended to ask
patients to bring photographs of themselves from a
time when they were more at ease with their appearance. Then a discussion over what can be predictably
achieved and expected can be had.
Remember: The most authentic look that a
patient can achieve is their own, and creating
false-looking appearances should never be
the end goal of facial esthetics.
53
4 / Consultation for the Facial Esthetic Patient
Medical Examination
History taking comprises an important step during the
initial consultation. Not only does the practitioner need
to clarify the treatment protocols and clarify expectations, but he or she must also spend some time reviewing the patient’s medical and medication history. This
becomes particularly essential when utilizing PRF as
a natural regenerative modality because many medications can alter blood clotting. The treating clinician
must therefore be aware of potential changes to PRF
and its protocols. Illnesses or diseases, in particular
autoimmune issues and blood conditions, are generally
contraindications for elective esthetic procedures.
Because this book is specific to treatment with PRF,
a thorough blood assessment is needed. The factors
that affect fibrin clot formation and structure include
genetic factors and acquired factors, such as abnormal
concentration of thrombin and factor XIII in plasma,
blood flow, platelet activation disorders, hyperglycemia, hyperhomocysteinemia, medications related to
blood diseases, and cigarette smoking. All patients
with any of the above-mentioned conditions should
be carefully monitored when treated with PRF.
The practitioner should also be aware of what facial
procedures the patient may have undertaken thus
far, whether surgical or nonsurgical, as well as which
products/agents or other devices are currently being
used by the patient. Does the patient take any type
of nonsteroidal anti-inflammatory agent, corticosteroid, anticoagulant, or immunosuppressant? Does the
patient smoke or consume alcohol? Has the patient
ever had any adverse reaction, allergic reaction, or complication resulting from any of the above-mentioned
procedures? Does the patient have any history of
herpes simplex (cold sores)? If the patient is not
sure what procedures they have previously undergone, it is always advised to liaise with their previous
practitioner to gather relevant information. It is also
recommended not to rush into further therapy until all
information gathering is performed with due diligence.
In addition to patient age, many other factors related to
lifestyle must be noted. These include but are not limited
to general health. Skin conditions, lifestyle, smoking habits,
54
alcohol/narcotics consumption, weight, diet, skin hydration, skin type, sun exposure, and other potential diseases
or syndromes may affect the skin. From this evaluation,
a patient who is young (20 to 30 years of age) with less
damaged skin should expect to see better improvements
with therapy, most noteworthy in prevention of aging.
A thorough psychologic assessment should also be
conducted during this time to determine the patient’s
reasoning for requesting facial esthetic therapy. This
remains one of the most effective times to critically
assess the patient. Does the patient have any existing
history of psychiatric disorder or depression? Does
the patient maintain unrealistic expectations regarding therapy? Be wary of patients who have seen many
practitioners and are yet to be fully satisfied. Also be
wary of patients looking to remedy a failed relationship
or solve a personal problem. Should the practitioner
detect any of the above-mentioned related psychologic problems, it may be best to avoid treatment. This
may be unpleasant, especially considering that these
patients are generally pretty adamant, but nevertheless
it is usually necessary to avoid future problems (legal).
Visual Examination
Once expectations are clarified and the medical examination is complete, the practitioner can then begin the
various visual examinations. Here the objective is to
chart the current skin condition by investigating skin
quality, volume of soft tissues, bony proportions, and
facial symmetry. The practitioner should also utilize
the photographic series to further detail and note
facial features.
First, the visual assessment should assess the
patient’s skin type using the Fitzpatrick classification
(Fig 4-2 and Table 4-2).
Furthermore, the Glogau classification can be
utilized to assess damage/photoaging (Table 4-3).
Within this evaluation, the level of photoaging/actinic
damage can be qualitatively assessed. Wrinkle types
and activity of the sweat glands as a marker for overall
skin health and activity can further be assessed.
Visual Examination
Skin type I (Emma Stone): Pale skin commonly
with freckles, red or fair hair, green or blue eyes.
Burns very easily and never tans, and very sensitive to UV exposure.
Skin type II (Gwyneth Paltrow): Pale skin;
blonde, darker blonde, or red hair; green, blue,
gray, or hazel eyes. Burns easily and rarely tans,
and fairly sensitive to UV exposure.
Skin type III (Gisele Bündchen): Neutral skin
color; light brown, dark blonde, or chestnut hair;
brown, blue, hazel, green, or gray eyes. Skin is defined by gradual tan and sometimes burns, and
moderately sensitive to UV exposure.
Skin type IV (Eva Longoria): Skin is naturally
tanned, olive; brown, dark brown, or medium
brown hair; hazel or brown eyes.
Skin type V (Freida Pinto): Darker complexion
that never burns, tans easily, and quickly darkens; dark brown to black hair; brown eyes. Minimally sensitive to UV exposure.
Skin type VI (Rihanna): Dark and deep skin color,
defined by the absence of burns and the ability to
obtain a dark tan with ease. Black hair and dark
eyes. Minimally sensitive to UV exposure.
FIG 4-2
Various skin types according to the Fitzpatrick classification. Note: In lighter skin types, signs of sun damage are usually seen
through wrinkling and sagging, thread veins, liver spots, and more. Individuals with darker skin types usually look more youthful
for longer. They have inherent protection, meaning that aging is much slower than it would be for lighter-skinned individuals.
Those with skin type VI mainly produce eumelanin, characterized as highly effective at blocking ultraviolet (UV) rays and protecting the skin against UV damage. While individuals with darker skin types have fewer issues with wrinkling and sagging, they are
more prone to pigmentation, often seen as sun spots or dyschromia, where their skin is no longer an even brown or black tone
but develops areas of light or dark patches.
55
4 / Consultation for the Facial Esthetic Patient
TABLE 4-2
Fitzpatrick classification of skin type
Skin type
Geographic areas of
frequent occurrence
Sunburn potential
Tanning potential
I
Ireland
High
Never
II
Northern Europe
High
Rarely
IIIa
Southern Europe
Moderate to slight
Frequently
IIIb
East Asia
Given to slight
Frequently
IV
South America
Slight
Always
V
Asia
None
Always
VI
Africa
None
Always
TABLE 4-3
Glogau classification of photoaging
56
Glogau
type
Age (y)
Characteristics
I
28–35
• Small wrinkles appearing when the face is in motion
II
35–50
• Wrinkles appearing when the face is in motion
• First signs of dyspigmentation
• Incipient elastosis
III
50–60
•
•
•
•
IV
60+
•
•
•
•
•
Persistent wrinkles in areas of facial mobility
Frequent pigmentation abnormalities
Elastosis dependent on posture
Telangiectasias
Persistent wrinkles in mobile and nonmobile facial areas
Yellowish-gray skin color
Solar lentigines
Telangiectasias
Regions of actinic keratosis with and without transition into invasive
growths are possible
• Pronounced elastosis
Visual Examination
Several medical conditions can also result in
changes in skin texture and color:
• Reddening of the skin can be a sign of high blood
pressure, focal inflammation, or aggressive alcohol
misuse.
• Bluish skin is usually a sign of decreased hemoglobin or oxygen levels in blood. This may be observed
in a patient with a lung disorder, asthma, or allergy.
• Yellowish discoloration results from a potential liver
condition.
• Brownish/yellowish skin spots may occur during
pregnancy or also with liver diseases.
Furthermore, external factors may also affect the
skin:
• Dry skin: May be the result of too many skin care
products or prolonged photodamage. It may also be
Nodule
Macule
a sign of various diseases, including hypothyroidism,
in which the skin appears thickened and rough.
• Autonomic reactions: May be a result of anxiety
or nervousness, which can increase skin moisture.
• Greasy skin: May lead to acne, particularly during
times of hormonal changes (puberty, pregnancy,
use of hormonal agents). A predisposition to acne
or scarring should be assessed during this portion
of the consultation to ensure that the treatment
plan will have a positive effect on these conditions.
• Efflorescence: May be indicative of an inflammatory skin conditions that may represent a contraindication for facial injections in the affected area.
It is also important to note that all skin features
should be properly noted in patient charts. Therefore,
a review of differences between various skin conditions (macule, squama, papule, bulla, pustule, wheal,
erosion, excoriation, and ulcer) is provided in Fig 4-3.
Epidermal bulla
Squama
Papule
Epidermis
Basement
membrane
Dermis
a
b
c
Subepidermal
blister
Ulcer
Erosion
Pustule
FIG 4-3
d
Wheal
e
Excoriation
Overview of various efflorescences found
on the skin: (a) macule and squama, (b)
papule, (c) bulla (blister), (d) pustule and
wheal, (e) erosion, excoriation, and ulcer.
57
4 / Consultation for the Facial Esthetic Patient
FIG 4-4
The skin snap test. In order to conduct the test, skin is grasped
between the thumb and the index finger and tented upward,
held for a few seconds, and then released (snapped back into
place). Hydrated and younger skin tends to snap back right
away, whereas deficiencies in skin elasticity or hydration may
result in a less-effective return. This can provide the clinician
the clue that an overall increase in skin hydration or use of
skin care products that both hydrate the skin and improve
elasticity and collagen formation is needed.
Manual Assessment
The practitioner has the ability to manually palpate
and assess various regions of the skin and face. This
can be utilized to assess various features such as
elasticity, laxity, and hydration using the “snap test”
(Fig 4-4); surface texture and levels of oiliness and
dryness; surface relief (volume assessment and wrinkle depth); and bony prominences (Fig 4-5).
The overall evaluation of skin lines and wrinkles can
then be performed simultaneously with photographs
and palpation. Figure 4-6 provides a typical form utilized
for patient assessment. This includes the patient profile,
treatment types, and products used (including batch
numbers and volumes utilized) to accurately provide all
details while charting. Here the Merz scale is included to
assess wrinkles accordingly (see Fig 4-1 and Table 4-1).
58
FIG 4-5
Bony prominence assessment. The practitioner should determine the location and size of the upper and lateral orbital
margin, cheekbone, lower jaw, and tip of the chin lines. These
may also serve as excellent anatomical guides for planned injections. (Reprinted from Sattler G, Gout U. Illustrated Guide
to Injectable Fillers. London: Quintessence, 2016.)
The classification is particularly useful for selecting adequate augmentation procedures because it
determines the appropriate injection technique, depth
required, product utilized, and expected outcomes
as discussed later in this textbook. Furthermore, it is
always best to be as specific as possible when evaluating and communicating with patients. Wrinkles can
be caused by a variety of things, some of which are
listed in Table 4-4.
It is important for the practitioner to objectively
evaluate and chart all facial features and wrinkles.
Baseline values are crucial to determine results over
time. Furthermore, they provide an essential element
for quality assurance and legal protection if needed
along with proper photographic documentation.
Manual Assessment
Name of patient
Date of birth
Treatment with:
Medical insurance
Treatment with:
Botulinum toxin
Treatment with:
Filler
Botulinum toxin
Filler
Botulinum toxin
Products:
Products:
Products:
Batch numbers:
Batch numbers:
Batch numbers:
Units (mL):
Units (mL):
Units (mL):
Merz scale:
Value:
Merz scale:
Value:
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Date:
Merz scale:
Value:
Merz scale:
Value:
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Date:
Photo today:
No
Botulinum toxin
Filler
Treatment with:
No
Botulinum toxin
Filler
Treatment with:
Products:
Batch numbers:
Batch numbers:
Batch numbers:
Units (mL):
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Date:
Merz scale:
Value:
Merz scale:
Value:
B
C
D
E
F
G
H
I
J
K
L
M
N
No
E
F
G
H
I
J
K
L
M
N
Yes
No
Botulinum toxin
Filler
Merz scale:
Value:
Merz scale:
Value:
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Date:
Photo today:
Yes
D
Units (mL):
A
Date:
Photo today:
C
Treatment with:
Products:
Merz scale:
Value:
Merz scale:
Value:
B
Photo today:
Yes
Products:
Units (mL):
A
Date:
Photo today:
Yes
Merz scale:
Value:
Merz scale:
Value:
Filler
Photo today:
Yes
No
Yes
No
FIG 4-6
Documentation form for esthetic treatments. Here the patient may be evaluated via the Merz scale in an independent fashion.
(Reprinted from Sattler G, Gout U. Illustrated Guide to Injectable Fillers. London: Quintessence, 2016.)
59
4 / Consultation for the Facial Esthetic Patient
TABLE 4-4
Causes of wrinkles and lines in the face
Type of line
Characteristics
Fine wrinkles and puckering of the
skin
• Caused by its thinning
• Needs to be distinguished from coarser lines left behind by subcutaneous tissue atrophy
• Skin may also be altered by scarring, nodules, milia, etc
• May be treated with PRF/fillers
Lines and wrinkles from sun damage
•
•
•
•
Facial expression lines
• Caused by muscular activity
• Most obvious because few or no lines are observed in zones where
there is less expressive activity
• Better treated with Botox
Lines caused by subcutaneous tissue
atrophy
• Caused by shrinkage of the subcutaneous tissue
• Depletion of dermis causing stretching of skin resulting in possible
lines and wrinkles
• Better treated with fillers
Lines caused by gravity
• Most apparent in facial contour, especially of the jawline
• May be treated with PRF/fillers/Botox
Sleep lines
• Caused by sleeping habits
• Typically asymmetric
• May be treated with PRF/fillers
Damages elastic fibers
Leads to slack lines and folds
In extreme cases, may cause the skin to sag
May be treated with PRF/fillers
Treatment Planning
Once all evaluations are completed, the practitioner
can enter discussion over possible treatment options.
During this time, the practitioner should address a
number of important questions and concerns of the
patient. For example, treatment with PRF is known
to take several appointments to slowly regenerate
tissues over time in a natural manner. Will the patient
accept this, or are they looking for immediate results?
How will they feel with gradual improvement? It is
also important to discuss the length of time that the
results are expected to last for each therapy regimen.
60
How long will the PRF last? How frequently must the
patient revisit the office for subsequent appointments? The expected downtime required after each
therapy is another issue to consider: How much time
is the patient willing to miss from work or other pertinent activities? Furthermore, the practitioner must
also consider the patient’s financial situation because
most of these procedures are elective and likely not
covered by medical insurance. Should the practitioner
omit any of the above-mentioned points, dissatisfaction may result, hence the importance of a thorough
consultation.
Conclusion
Informed Consent
Once the practitioner and patient decide on a treatment option, it is important to obtain a written
informed consent that covers all aspects of the therapy. This should include the costs, pros and cons of
each procedure, whether the therapy is off-label, the
selected treatment time, realistic expectations, associated downtime, and necessity for compliance.
Conclusion
This chapter laid the groundwork for conducting an
appropriate initial consultation with each and every
patient that enters your clinic. Dedicated time for this
initial consultation is perhaps the most important
time spent with the patient. Naturally, every practitioner will have a specific and personal style to
approach their patient relationships. Never neglect
or disregard the importance of clarifying expectations with your patients and providing accurate and
easy-to-understand information once a therapy is
established. During the consultation, it is essential to
perform objective medical and manual evaluations,
all while listening to your patient’s treatment objectives and goals. Once a treatment plan is selected,
be sure to document all notes within the patient
chart and provide an informative and precise signed
informed consent. They say a facial esthetic patient
is a patient for life.
Never underestimate the importance of this
initial consultation.
61
5/
CONSULTATION
FOR THE HAIR
LOSS PATIENT
Alan J. Bauman
Catherine Davies
Richard J. Miron
With approximately 80 million Americans affected by hereditary hair loss,
the demand for treatment to manage this condition has never been higher.
In the previous chapter, a full workup of a medical patient was described
including a facial photography series recommended for each patient. In this
chapter, additional documentation is proposed for the management of the
hair loss patient. This chapter once again highlights the importance and
necessity of an adequate initial consultation and provides a specific set of
questionnaires and examination to conduct during the initial consultation
of the hair loss patient. Discussion of key strategies is provided, including
a series of quick and easy tests to perform to better characterize the type
and extent of either male or female pattern baldness. Adequate communication during this initial hair consultation is critical to establishing patient
trust and confidence, and this chapter outlines the initial consultation for
the hair loss patient and makes note of key features and tools necessary
during this first visit.
63
5 / Consultation for the Hair Loss Patient
Hair Loss
It is estimated that approximately 80 million American men and women are experiencing hereditary hair
loss, and as such the desire to manage and treat the
condition has never been greater. However, assessing
hair growth, hair loss, and hair breakage objectively
in a clinical setting has plagued physicians, trichologists, and cosmetologists for decades. Measurements
worthy of published peer-review articles and scientific
presentations are typically cumbersome and difficult
to perform, usually requiring a shaved area, tattoo
landmarks, and phototrichograms, and few clinicians
have access to well-equipped photo suites for true
standardized global photography.
As a result, most clinicians have subjectively
assessed their patients or relied on the patient to
self-assess their progress, which, especially in such
a slowly progressing (and emotionally charged) situation as hair growth, could easily become problematic.
In addition, the successful “maintenance” of optimal
hair growth in a condition hallmarked by gradual
progression is often mischaracterized, unnoticed,
or underappreciated. Signs and symptoms of shedding can often be misinterpreted due to the fact that
shedding occurs during the natural hair growth cycle
during phases of hair loss as well as regrowth. Adding
to the confusion is the fact that significant subclinical
hair loss—up to 50% or more in some cases—can go
undetected to the unaided eye.
It is therefore important that the first consultation
involves a systematic approach in order to diagnose
different types of alopecia. This includes a history,
clinical examination, scalp and hair examination,
use of trichoscopy or a cross-section trichometer
(or HairCheck), as well as laboratory investigations
when needed. The patient should be well positioned
in a well-lit, private space. The differential diagnosis
of alopecia includes both scarring and nonscarring
alopecias. Platelet-rich therapies such as platelet-rich
plasma (PRP) and platelet-rich fibrin (PRF) are only
indicated for nonscarring alopecia as reviewed later
in this textbook.
64
The key to an authentic, successful consultation regarding hair loss begins with your
best intentions and honest feedback.
The Basics
Privacy is very important to patients, as hair loss can
be a very personal, scary, and emotional issue for
many patients to discuss. A few basic rules should be
considered during the initial consultation for hair loss:
• Hair loss can reflect underlying health abnormalities, which need to be managed along with treating
the scalp and hair.
• It is important to exclude scarring alopecias, which
will not respond to treatment with PRP/PRF.
• Always record a baseline status of hair to be able
to monitor progress.
The Consultation
Before the consultation, it is useful for the patient to
fill in an evaluation form (Fig 5-1). The consultation
includes a thorough history (see Fig 5-2), examination
of the patient, examination of the scalp and hair, as
well as laboratory investigations.
History
Figure 5-2 is a history-taking form that can be used
during the hair loss consultation.
Examination
First the patient should undergo a general examination, including vital signs. The patient’s scalp and hair
should then be evaluated as follows.
The Consultation
Patient Information Form
Date _____________________
Name ____________________________
Birthdate ____________
Age _____
Address ______________________________________________________________
Phone _______________________
Email __________________________________
Occupation _________________________
Employer _________________________
In order to give you the best medical care possible, please answer the following questions:
Are you concerned about hair loss or the thinning of hair?
Hair loss
Thinning
Both
When did you first notice your hair was thinning? _______________________________
Do you want to stop hair loss or obtain some regrowth?
Stop hair loss
Obtain regrowth
Do you have any underlying medical conditions?
Yes
No
If yes, list all here: __________________________________________________
Are you currently taking any medications?
Yes
No
If yes, list all here: __________________________________________________
Are you currently using a hair loss product?
Yes
No
If yes, which one? ____________________________
Do you use any styling aids?
Yes
No
If yes, list them here: ___________________________________________________
Do you use hairpieces or wigs?
Yes
No
Has anyone in your family suffered from hair loss?
Do you perspire excessively?
Yes
Do you wear a cap or hat often?
Do you exercise regularly?
Have you had major stress recently?
No
No
Yes
Have you changed your diet recently?
No
Yes
No
Do you think about your hair loss constantly/most of the day?
For women only:
Are you pregnant or breastfeeding?
Do you use birth control medication?
No
No
Yes
Yes
Yes
Yes
Yes
Are you in perimenopause or menopause?
Yes
No
No
No
Yes
No
FIG 5-1
Patient information form.
65
5 / Consultation for the Hair Loss Patient
History Checklist
Age _____
Present health and medical history
Medication history
Nutritional history
Psychosocial history (including recent stresses)
Hair loss history
What is the duration of the hair loss? ______________
Was the onset sudden or slow?
Sudden
Slow
How much hair is shed per day? ______________
Pattern of hair loss:
Diffuse
Localized
Are there any associated symptoms?
❒ Itching
❒ Pain
❒ Burning
Is there a family history of hair loss?
❒ Mother
❒ Father
❒ Uncles/aunts
❒ Grandparents
❒ Siblings
Is there an excess of androgen? (women only)
Yes
No
Is the patient undergoing any current hair loss treatment?
❒ Topical
❒ Oral
❒ Other
❒ Transplant
History of hair care practices and/or use of cosmetics/wigs/hairpieces
FIG 5-2
History-taking form.
66
The Consultation
FIG 5-3
FIG 5-4
FIG 5-5
Image demonstrating scalp examination and condition.
Clinical demonstration of the hair pull test.
Clinical demonstration of the hair tug test.
Scalp examination
At first, a thorough inspection of the scalp should be
performed, including inspection for the presence of
skin conditions or lesions (Fig 5-3). Some considerations during this inspection include the following:
• Recognizing the pattern and distribution of hair
loss can help reach the correct diagnosis.
• Scalp, facial, and body hair should all be assessed.
• It is important to differentiate between scarring
and nonscarring alopecia.
• Redness, scales, dyspigmentation, atrophy, and
the presence of telangiectasia should all be noted.
Hair pull test
For the hair pull test, grasp 50 to 60 hairs between
your thumb, index, and middle fingers. Pull firmly but
gently away from the scalp and along the hair shafts
(Fig 5-4). Normally, up to 10% of the scalp hair is in
the telogen phase; being able to pull out 5 or 6 hairs
with this test indicates ongoing hair loss activity and
is considered a positive pull test. A positive hair pull
test indicates active hair shedding and can be seen
in telogen effluvium and in active stages of alopecia
areata or different scarring alopecias (see Box 5-1).
Hair tug test
The hair shaft fragility can readily be detected using
the tug test (Fig 5-5). The tug test is a simple clinical
test that is used to show hair fiber fragility. With one
hand, hold a group of hairs while your other hand pulls
away the distal ends. Any hair breakage is considered
abnormal and is a sign of hair fragility.
Cross-sectional trichometry
Advances in dermoscopy in the form of USB microscopes and iPhone attachments have made microscopic assessment of the scalp in terms of hair density
(numbers of hair fibers) and quality of hair (diameter
and pigmentation) accessible to any clinician if they
choose. While manual counting or software-assisted
counting of hairs with a phototrichogram may be
useful, some patients may not agree to the hair trimming or tattooing required to track their progress over
time using these methods.
While no method is 100% accurate, a new noninvasive scientific tool has been proposed for use for
professionals to help assess hair growth during an
initial evaluation, establish baseline measurements,
and assist in tracking the progression of hair loss,
hair maintenance, or hair regrowth over time. This
67
5 / Consultation for the Hair Loss Patient
a
b
FIG 5-6
(a) The cross-sectional trichometer (HairCheck) device is a portable tool capable of quantifying hair within a fixed area. (b) The
HairCheck tool comes with a small 2 × 2 cm, four-pronged “stamp” that can be utilized to quantify HMI.
tool is based on the concept of cross-sectional hair
bundle trichometry, otherwise known as Hair Mass
Index (HMI). The cross-section trichometer (or HairCheck) device is a portable, convenient, quick, and
noninvasive system designed to measure the amount
and quality of hair in several areas of the scalp while
also being able to assess changes in hair growth over
time (Fig 5-6a). It also has the capability to quantify
hair breakage.
The system was developed with the concept of
ponytail volume in mind. A woman may notice her
hair volume is decreasing as her ponytail size changes.
While she may once have needed to wrap her typical elastic hairband twice to hold the ponytail, years
later she may notice that she now needs to wrap the
hairband three times. The total volume of hair within
the hairband is a function of the number of strands
as well as the thickness of each individual strand. As
either or both of these variables (ie, the number of
strands or the diameter of the strands captured in the
hairband) decrease, the cross-sectional area of the
ponytail will decrease proportionately. This scientific
68
concept of cross-sectional area, otherwise known as
the HMI, is how the system is able to capture data.
A small 2 × 2 cm, four-pronged “stamp” is supplied
with the HairCheck tool (Fig 5-6b). This allows for
temporary marking and isolation of exactly a 4-cm2
area on the scalp. Hair within the square is separated
carefully under loupe-assisted microscopic vision from
the rest of the hair on the scalp and gathered together
to be measured.
The advantage of this system is that a digital caliper
device with a stereotactic tool allows the same area
of the scalp to be measured predictably over time,
without having to place a permanent tattoo on the
scalp (Fig 5-7). Using the fixed anatomical structures
of the pinnae and nasal root, the clinician is able to
locate and measure hair at the same “tab” during each
visit. Typically, cross-sectional bundle measurements
are performed at several tabs during each hair loss
management visit (Fig 5-8). The areas to be measured
include the occipital, vertex, midscalp, frontal, and
temple (left and right).
The Consultation
a
b
FIG 5-7
(a) A digital caliper device with a stereotactic tool that allows reproducible measurements of the same area of the scalp. (b) The
digital caliper being utilized on a patient. This allows for the exact fixation of the HairCheck tool in the same area of the scalp in
repeat patient visits.
a
b
FIG 5-8
(a) Use of a cross-sectional bundle measurement. (b) Note here that the HairCheck tool producing a 2 × 2 cm area is demarcated,
and the hair from that area is then quantified accordingly.
69
5 / Consultation for the Hair Loss Patient
FIG 5-9
FIG 5-10
Microscopic view of the scalp and hair follicles.
Microscopic camera.
is very useful in diagnosis, documentation, and patient
counseling. A dermoscope unit with a camera attached
is very useful to save and document images. There are
many dermoscopes available on the market that have
adapters to attach to digital cameras (Fig 5-10).
FIG 5-11
A fixed-angle Canon Veos-SLR/Hair photography system. These
devices allow for precise camera settings and distances for
proper hair photography.
Trichoscopy examination
This type of examination can be useful to view the
scalp and follicles with a digiscope or scalp microscope
providing high resolution of problematic areas (Fig
5-9). Hair dermoscopy (also called trichoscopy) usually
uses a magnification of 10× and can be combined with
still or video images (videodermoscopy). Trichoscopy
70
Photographic documentation
Photograph the area with a camera to establish a
baseline. A global photograph of a patient with hair
loss should record the patient’s hair esthetic state.
Typically, images are captured for the hair loss patient
using specific devices for the task, such as the
Canon Veos-SLR/Hair
The patient must have clean,
photography package
dry hair, and the photographer
(Fig 5-11). This allows
must take the time to comb and
a fixed distance and
prepare the hair precisely the
fixed camera settings
same way at each office visit.
specific for hair loss
that are able to generate specific images frequently
utilized in the field in a standardized manner (Fig 5-12).
Furthermore, high-magnification images can also be
utilized and cell counts can be made accurately using
such technology, as described later in this chapter. The
patient must have clean, dry hair, and the photographer must take the time to comb and prepare the hair
precisely the same way at each office visit.
The Consultation
allowing for only the change in a patient’s condition
over time. Most of the recommendations apply as in
general clinical photography:
FIG 5-12
Hair and scalp image produced on the fixed-angle Canon.
Photographic documentation of patient progress
is especially useful in recording the subtle changes
that a hair loss patient may have between treatments.
Serial photography (sequential photographs) can be
used by both the physician and the patient to assess
these changes. The hair physician’s challenge as the
photographer is significant: to take photographs that
allow for the assessment of change and not a critique
of photographic technique. Consistency in technique
is critical. This includes patient preparation, background, lighting, camera settings, camera-to-patient
registration, film, and processing.
High-quality clinical photography can be accomplished in the examination room, perhaps even with
the camera equipment you already have in your office,
to construct a methodic approach for taking reproducible serial photographs. Controlled, reproducible
serial photographs should read like a time-lapse movie,
• Always obtain the patient’s written consent before
photographing, especially if the shots are taken
during a surgical procedure when the patient may
not be aware of the same. A written informed
consent would be the best and is a must if one
is planning to use the photograph for publication.
• Include the patient’s identification number in all
of the images so as to enable easy identification
later. Hair photography seldom includes the face
or a recognizable feature, so labeling is essential.
• Stick to the same labeling format for every photograph (eg, Name/patient ID_year_month_date_
serial number).
• Use autofocus and a tripod as often as possible.
• Store and catalog photographs meticulously.
• Make it a point to show the images to the patient
and discuss any clarification regarding the
photographs.
• Take plenty of images. You can always delete the
unused ones later.
• Baseline photographs must be available for reference at all follow-up photography sessions. This
allows the patient’s hair and position to be consistently maintained.
• A small area of the scalp can be selected (marked
with a tattoo or permanent marker) and assessed
for hair count. The target area on the scalp is
chosen, clipped and prepared, and permanently
landmarked with a single tattoo for future site
location.
• Controlled photographs are then taken, centrally
processed, monitored for technical adequacy, and
counted. One way to accomplish consistent results
is to always keep the camera lens parallel to the
floor and position the patient to the camera; the
use of a tripod is ideal. For global photography of
androgenetic alopecia, the camera should ideally
be held in the vertical format to maximize the clinical information recorded. An adjustable stool can
be used in adjusting the patient position.
71
5 / Consultation for the Hair Loss Patient
Stage (if patterned hair loss)
Norwood
scale
H–N 2
H–N 3
H–N 4
Ludwig
scale
L I–2
L II–2
L II–1
FIG 5-13
Classifications of hair loss. The Norwood scale is used for men, and the Ludwig scale is used for women.
It is recommended to note the stage of hair loss on
each chart. The Norwood scaling system is typically
used for men, whereas the Ludwig scaling system is
typically used for women (Fig 5-13).
72
Scalp biopsy
A 4-mm punch biopsy of the scalp is not always necessary
but can be useful to diagnose scarring types of alopecia
and to help with diagnosis in nonscarring alopecia.
Figure 5-14 is a hair examination form that can be
used during this initial consultation examination.
The Consultation
Hair Examination Form
Name ________________________________ Age _______
Pattern:
Patterned/focal
Date ________________
Diffuse
Stage (if patterned hair loss):
Norwood
scale
H–N 2
H–N 3
H–N 4
Ludwig
scale
L I–2
Scalp:
Lesions
L II–2
L II–1
Hair:
___________________
Color
___________________
Condition ___________________
Density ___________________
Scars
Texture ___________________
___________________
Pull test: ___________________
Tug test: ___________________
FIG 5-14
(cont)
Hair examination form.
73
5 / Consultation for the Hair Loss Patient
Digiscope:
Density area 1:
___________________
Density area 2:
___________________
Density area 3:
___________________
Vertex
Temporal scalp
Parietal scalp
Frontal scalp
Temporal
recession
Biopsy:
Blood tests:
Diagnosis:
Plan:
FIG 5-14 (cont)
Hair examination form.
74
Frontal
hairline
The Consultation
Laboratory investigations
The patient should be further investigated if any
underlying medical conditions are suspected.
Blood tests ordered usually include complete blood
count (CBC), ferritin levels, thyroid, autoimmune
indicators, as well as female hormones. If indicated
clinically, it may be useful to assess fasting glucose,
vitamin B, and vitamin D levels.
Differential diagnosis
Based on the history and examination, the type of hair
loss may then be established according to Box 5-1.
BOX 1-1
Type of hair loss according to pattern
Patterned
Focal
Male pattern hair loss
• Gradual onset
• Family history
• Miniaturized hairs on trichoscope
• Typical pattern of temporal or crown recession
Alopecia areata
• Bare patches, often coin-shaped
• Exclamation point hairs
Female pattern hair loss
• Gradual onset
• Family history
• Miniaturized hairs on trichoscope (> 20%)
• Typical pattern of widening part
Diffuse
Tinea capitis
• Bare patches
• Common in children
• Patient may have scales and broken hairs
Traction alopecia
• History of hairstyling or braiding
• Hair loss along the area of traction, usually the
hairline in women
Telogen effluvium
• History of shedding
• Positive pull test
• May occur after a trigger
Scarring alopecia
• Abnormal scalp
• No regrowth
• Scarring and loss of follicles
Alopecia totalis/universalis
• Starts as diffuse and then spreads to involve the
eyebrows and lashes
• Patient loses hair over their entire head and
body
Trichotillomania
• Bizarre-shaped patches
• Negative pull test
Anagen effluvium
• Rapid onset of shedding after a toxin (eg,
chemotherapy)
75
5 / Consultation for the Hair Loss Patient
Treatment planning
Informed consent
Once the type of hair loss is diagnosed, options for
treatment need to be discussed. The following points
are worth considering:
Informed consent is an essential component in every
consultation and covers a variety of considerations that
should be addressed thoroughly with the patient, namely
the following:
• Are there any underlying conditions that need to
be treated?
• Is the patient willing to go on topical or oral therapy
at home?
• Is the patient willing to come to the clinic for treatment and to have blood drawn?
• What are the patient’s financial considerations?
• At least three treatments are usually required. Will
the patient comply?
• Does the patient understand that results will take at
least 12–16 weeks to show and are not guaranteed?
• Is platelet therapy indicated for the patient’s type
of hair loss?
PRP/PRF therapy
PRP/PRF will be most successful if used for the following indications:
•
•
•
•
Male or female pattern hair loss
Diffuse alopecias
Traction alopecia, if follicles are still present
Alopecia areata, but discontinue if no results are
observed after 3 months
Once an agreement has been reached between the
practitioner and the patient, the patient can go ahead
with the informed written consent and be further
scheduled for treatment.
• Treatment options, including the pros and cons of
each, whether they are off-label, and the associated implications
• Why the selected treatment is the most appropriate option
• Realistic expectations posttreatment
• Associated downtime and compliance
• Expected duration of clinical outcome
• Long-term treatment strategy
• Financial implications
If the patient is not an appropriate candidate
for the given treatment, it is important to
decline treating the patient and explain to
them why this is the case.
Documentation
Photographic documentation and clear written documentation of the treatment protocol is crucial. These
should be stored in a safe place, as reviewed in the
previous chapter, and included with the informed
consent of each patient.
Conclusion
This chapter provided an overview of consultation
specific to the hair loss patient. These patients require a
more intimate environment, and proper diagnostics for
the underlying cause of their hair loss is necessary prior
to beginning treatment. A series of simple examination tests, including additional photography, is required
followed by a proper informed written consent.
76
6/
USE OF
PLATELET-RICH
FIBRIN IN FACIAL
ESTHETICS
Richard J. Miron
Yufeng Zhang
Ana Paz
Masako Fujioka-Kobayashi
Catherine Davies
Platelet concentrates have seen a steady rise in use in various fields of
medicine as a natural autogenous source of growth factors derived from
human peripheral blood. While platelet-rich plasma (PRP) was proposed
as a first-generation platelet concentrate over three decades ago, over
the past 10 years, platelet-rich fibrin (PRF) has been introduced as a more
natural platelet concentrate because of its removal of anticoagulants. Its
use has expanded into many fields of medicine, including in facial rejuvenation procedures, because of its superior wound healing capabilities. Over
the years, modifications in centrifugal protocols (known as the low-speed
centrifugation concept) have demonstrated that lower centrifugation
speeds and times lead to an increase in platelets and white blood cells,
which favors higher growth factor release, in vivo vascularization, and tissue
regeneration when compared to PRP. This has been further enhanced utilizing horizontal centrifugation. This chapter reviews the history of platelet
concentrates from PRP to PRF and highlights the recent advancements
made and scientific foundation for these centrifugation protocols leading
to liquid and extended PRF (e-PRF). Finally, the use of PRF in facial esthetics
and facial rejuvenation protocols is presented in the form of an injectable
growth factor complex capable of stimulating tissue regeneration as well
as a platelet concentrate utilized as a topical growth factor solution for
microneedling procedures.
79
6 / Use of Platelet-Rich Fibrin in Facial Esthetics
Acellular plasma (PPP)
Fibrin clot (PRF)
FIG 6-1
Red corpuscles base
Overview of PRF in Medicine
Recent years have witnessed a steady increase in the
use of platelet concentrates to generate supraphysiologic doses of blood growth factors for the regeneration of various human tissues. Their use extends into
multiple fields of medicine, including for the management of osteoarthritic knees, the repair of rotator cuffs,
facial rejuvenation procedures, and the regeneration of
various tissues found in the oral cavity.1 While autogenous PRP was developed as a first-generation platelet
formulation in the 1970s and 1980s,2,3 its incorporation
of anticoagulants such as bovine thrombin has been
shown to slow optimal wound healing.4,5 Naturally,
the first step during wound healing after trauma is the
formation of a blood clot followed by the entrapment
of platelets and leukocytes that initiate wound healing.
Because PRP includes anticoagulants, this clotting
cascade is slightly reduced, leading to less-thanoptimal wound healing. Nevertheless, PRP has been
utilized across multiple areas of medicine as a bioactive regenerative agent that releases growth factors
and cytokines to the surrounding microenvironment.
This has been shown to speed tissue regeneration of
both soft and hard tissues.4,6–12
80
Layers produced after centrifugation of whole
blood. A PRF clot forms in the upper third of
glass tubes after centrifugation.
Due to the reported limitations of PRP, PRF was
proposed with the aim of eliminating the use of anticoagulants within the platelet formulation.13 Because
the anticoagulants are removed, blood naturally clots
during the 8- to 12-minute centrifugation period.
Following centrifugation, three layers are typically
found, including an upper platelet-poor plasma (PPP)
layer, a PRP layer, and a red corpuscle base layer
(Fig 6-1). This second-generation platelet concentrate
differs significantly from previous versions of PRP
because the platelet-rich layer is then able to clot,
forming what is known today as platelet-rich fibrin.
PRF contains a high concentration of platelets and
leukocytes entrapped within a fibrin matrix, thereby
significantly improving not only the host’s immune
system defense against incoming pathogens8,14–18
but also the secretion of growth factors and cytokines responsible for tissue regeneration over time.4,19
The most common growth factors found in platelet
concentrates are platelet-derived growth factor
(PDGF), transforming growth factor β (TGF-β), and
vascular endothelial growth factor (VEGF).4,19 While
each component possesses an individual role in tissue
regeneration, PDGF has since been commercially available as a recombinant growth factor under the trademark name GEM 21S (Lynch Biologics).
Brief History of Platelet Concentrates: From PRP to PRF
A recent systematic review investigating soft tissue
regeneration found that over 20 regenerative procedures have utilized PRF successfully to stimulate
tissue regeneration in various fields of medicine and
dentistry;1,20 7 of these procedures took place in the oral
and maxillofacial region, while the remaining 13 were
medical procedures. In medicine, the most common
use of PRF has been for the successful management
of hard-to-heal leg ulcers, including diabetic foot ulcers,
venous leg ulcers, and chronic leg ulcers.21–25 Furthermore, PRF has been investigated for the management
of hand ulcers26 and facial soft tissue defects;27 for laparoscopic cholecystectomy;28 in plastic surgery for the
treatment of deep nasolabial folds, volume-depleted
midface regions, facial defects, superficial rhytids,
and acne scars;29 for the induction of dermal collagenesis;30 for vaginal prolapse repair31 and urethracutaneous fistula repair;32,33 during lipostructure surgical
procedures;34 as well as in the management of chronic
rotator cuff tears35 and acute traumatic ear drum perforations.36 This chapter is focused on the use of PRF in
facial esthetics.
Brief History of Platelet
Concentrates: From PRP to PRF
While the use of platelet concentrates has recently
gained tremendous momentum as a regenerative
autologous source of growth factors, it is important
to note that their use spans over three decades in
surgery.37 It was originally proposed that concentrated
platelets derived from autogenous sources could be
collected in plasma solutions later to be utilized in
surgical sites to potentially release supraphysiologic
doses of growth factors capable of promoting local
healing.38,39 Further work in the 1990s led to the popular working name platelet-rich plasma.3,11,40 Because
the goal of PRP preparation was to collect the largest
and highest number of platelets, PRP was fabricated
with a protocol lasting over 30 minutes of centrifugation and required the use of anticoagulants to prevent
clotting. The final composition of PRP contains over
95% platelets, cells known to be responsible for the
active secretion of growth factors involved in initiating
wound healing of various cell types, including osteoblasts, epithelial cells, and connective tissue cells.40,41
Following surgical application of PRP, several limitations were observed. The technique and the preparation required the additional use of bovine thrombin or
calcium chloride in addition to coagulation factors,
and these were found to drastically reduce the healing
process during the regenerative phase. Furthermore,
the protocol was technique sensitive, with several steps
that could sometimes last upward of 1 hour, making it
inefficient for everyday clinical purposes. In addition,
because PRP is liquid in nature, in many fields of medicine, a scaffold was required to improve growth factor
release over time. Very recent data has shown that
growth factor release from PRP occurs very early in the
delivery phase, whereas an optimal preference would
be to deliver growth factors over an extended period of
time during the entire regenerative phase.4,42,43
These combined limitations therefore led to the
development of a second generation of platelet concentrates that eliminate anticoagulants, thereby facilitating
formation of a fibrin matrix that incorporates the same
set of growth factors and cells that can be released
slowly over time.44 Furthermore, PRF (which has also
been named leukocyte PRF or L-PRF) contains white
blood cells, which have been shown to be key contributors to wound healing (Fig 6-2). These cells in combination with monocytes, neutrophils, and platelets are
the main players in tissue wound healing and together
are able to further enhance new blood vessel formation
(angiogenesis) and tissue formation.16,45–48
Numerous studies have investigated the regenerative potential of PRF in various medical clinical applications. With respect to tissue engineering, it has long
been proposed that in order to maximize the regenerative potential of various bioactive scaffolds, three
components are essential to improve tissue repair: (1)
a 3D matrix capable of supporting tissue ingrowth, (2)
locally harvested cells capable of influencing tissue
growth, and (3) bioactive growth factors capable of
enhancing cell recruitment and differentiation within
the biomaterial surface. PRF encompasses all three of
these properties, whereby (1) the fibrin matrix serves as
81
6 / Use of Platelet-Rich Fibrin in Facial Esthetics
Cell
types
Provisional
extracellular matrix
• PDGF
• VEGF
• IGF
• EGF
• TGF-β
• BMP-2
Platelet
Leukocyte
• Fibrin matrix
including: fibronectin
vitronectin
Red blood cell
the scaffold surface material; (2) cells including leukocytes, macrophages, neutrophils, and platelets attract
and recruit future regenerative cells to the treatment
sites; and (3) the fibrin acts as a reservoir of growth
factors that may be released over time (10 to 14 days).
These three components are described below.
Fibrin matrix
The removal of anticoagulants from the collected host
blood allows for the formation of a fibrin clot during
the centrifugation process. Naturally, this technology
requires a centrifuge and a collection system present within the office; because anticoagulants are
not utilized, clotting forms rapidly, so centrifugation
must take place immediately after blood collection.
The original PRF protocol was very simple: A blood
sample is collected without anticoagulant in 10-mL
tubes that are immediately centrifuged at about 700g
for 12 minutes. The absence of anticoagulant implies
the activation of most of the blood platelets in contact
with the tube walls and the release of coagulation
cascades within a few minutes. Fibrinogen is initially
82
Bioactive
molecules
FIG 6-2
Natural components of PRF include various cell types (platelets, leukocytes, and
red blood cells), a provisional extracellular matrix 3D scaffold fabricated from
autologous fibrin (including fibronectin
and vitronectin), as well as a wide array
of over 100 bioactive molecules, including most notably PDGF, VEGF, insulin-like
growth factor (IGF), epidermal growth
factor (EGF), TGF-β, and bone morphogenetic protein 2 (BMP-2). (Reprinted with
permission from Miron et al.1)
concentrated in the upper layer of the tube, before the
circulating thrombin transforms it into fibrin. A fibrin
clot is then obtained in the upper middle portion of
the tube, between the red blood cells at the bottom
of the tube and the acellular platelet-poor plasma at
the top (see Fig 6-1).
As previously stated, the success of the technique
is entirely dependent on the speed of blood collection
and its subsequent transfer to the centrifuge. Indeed,
without anticoagulants, the blood samples start to
coagulate and it takes a minimum of a few minutes of
centrifugation to concentrate fibrinogen in the middle
and upper part of the tube when utilizing glass tubes.
Quick handling is therefore the only way to separate
the blood layers efficiently prior to clot formation. By
driving out the fluids trapped in the fibrin matrix, practitioners will obtain very resistant autogenous fibrin
membranes that may be utilized in place of commercially available collagen membranes or other scaffolds
that have been utilized to treat defects such as large
diabetic foot ulcers, skin burns, and soft tissue defects
following surgery.
Brief History of Platelet Concentrates: From PRP to PRF
Major cell types in PRF
Platelets
Platelets are one of the cornerstone cells found in
PRF and the cells that were first collected in previous versions of platelet concentrates (ie, PRP). Interestingly, in PRF, platelets are theoretically trapped
within the fibrin network, and their 3D mesh allows
their slow and gradual release as well as associated
growth factors over time.4
Platelets are constantly being formed in the bone
marrow from megakaryocytes. They are discoidal and
anuclear structures by nature, and their life span is typically in the range of 8 to 10 days. Their cytoplasm contains
many granules whose contents are secreted at the time
of activation. Alpha granules contain many proteins,
both platelet-specific (such as β-thromboglobulin) and
non–platelet-specific (fibronectin, thrombospondin,
fibrinogen, and other factors of coagulation, growth
promoters, fibrinolysis inhibitors, immunoglobulins,
etc), that have been shown to possess many functions during wound healing.49,50 Moreover, the platelet
membrane is a double-layer phospholipid into which
receptors for many molecules are inserted (collagen,
thrombin, etc) and act to improve wound healing.
Activation is fundamental to initiate and support
hemostasis because of aggregation at the injured
site and interactions with the various coagulation
mechanisms.49,50
Leukocytes
Leukocytes are the other major cell type found in PRF,
playing a prominent role in wound healing. In fact, a
major difference between PRF and previous generations of platelet concentrates is that the latter contain
very low quantities of leukocytes, if any at all. The literature related to platelet concentrates often ignores the
importance of leukocytes and monocytes on tissue
wound healing. Several studies have already pointed to
their key role, both for their anti-infection actions and
immune regulation.51–53 Apart from their anti-infection
effect, leukocytes produce large amounts of VEGF
and PDGF, among other growth factors. The number
of white blood cells in PRF has been further improved
with newer centrifugation protocols as discussed later
in this chapter.
Studies from the basic sciences have revealed the
potent and high impact of leukocytes on tissue regeneration.8,18 In addition to releasing growth factors and
playing a large role in immune defense, they also serve
as key regulators controlling the ability of regenerative
agents to adapt and modify to new environments.
Studies have shown that patients receiving PRF
reported less postoperative pain, less need for analgesics, more rapid wound closure, and reduced swelling.54 This is primarily explained by the clotting that
occurs in PRF, which traps cells and growth factors
capable of regenerating tissue in a natural way.
Major growth factors in PRF
Cytokines and growth factors have been observed
to be released in high numbers from platelet alpha
granules following clotting. They are active through
specific cell receptors and play a predominant role in
wound healing. Centrifugation time and speed affect
the density and release rate of growth factors from
PRF clots (see next section). The most commonly
reported growth factors found in PRF include the
following:
• PDGF: As the main growth factors derived from
platelets, PDGFs are essential regulators for the
migration, proliferation, and survival of mesenchymal cell lineages. According to the distribution of
their specific receptors, they are able to induce
stimulation in many cell types. For this reason,
PDGFs play a critical role in the mechanisms of
physiologic healing and have been commercially
available in a recombinant source (rhPDGF-BB)
and FDA approved for the regeneration of various
defects in medicine and dentistry. Interestingly,
PDGFs are naturally produced and accumulated
in high quantities in PRF clots and are considered
one of the most important released molecules over
time from PRF.
• TGF-1: TGF-βs encompass a vast superfamily of more than 30 members known as fibrosis
83
6 / Use of Platelet-Rich Fibrin in Facial Esthetics
FIG 6-3
Histologic observation of leukocytes following centrifugation. Resulting white blood cells have been shown to be contained in the layers between the plasma PRF layer and the red
blood cell clot. This finding demonstrated quite clearly that
the g-force was excessive, necessitating the development
of newer protocols aimed to improve the retention of leukocytes. (Reprinted with permission from Ghanaati et al.58)
agents.55,56 TGF-β1 constitutes the most powerful fibrosis agent among all cytokines and the
growth factor commonly released from autogenous bone during tissue repair and remodeling.56
In simpler terms, it induces a massive synthesis of
matrix molecules such as collagen-1 and fibronectin, whether by osteoblasts or fibroblasts. Thus,
although its regulation mechanisms are particularly complex, TGF-β1 can be considered as an
inflammation regulator through its capacity to
induce fibrous cicatrization.
• VEGF: VEGF was previously isolated as the most
potent growth factor leading to angiogenesis of
tissues.57 It has potent effects on tissue remodeling, and the incorporation of VEGF alone into various bone biomaterials has demonstrated increases
in new bone formation, thereby pointing to its rapid
and potent effects.57
Together these three properties of PRF
membranes—a 3D fibrin matrix, host cells,
and cytokine and growth factor release—
synergistically lead to a fast and potent
increase in tissue regeneration.
84
The Low-Speed Centrifugation
Concept
It is now known that the most important factor for
stimulation is not the amount of growth factors
released but the maintenance of a low and constant
gradient of growth factor delivery to the environment. As the use of PRF has seen a continuous and
steady increase in regenerative medicine, there
has been great interest in determining if the protocols can be optimized by modifying centrifugation
protocols. This hypothesis was derived from the fact
that cells within the original PRF matrix surprisingly
were found accumulated at the bottom of the PRF
matrix or at the bottom of the centrifugation tubes
outside the PRF clots (Fig 6-3).58 To briefly explain
this concept, as centrifugation speed is increased (ie,
the longer centrifugation takes place), or the higher
the relative centrifugal force (RCF) value utilized
(g-force), the more cells move toward the bottom
of the tube. Because PRF is obtained from the upper
layer of centrifugation tubes, it was hypothesized
that lower speeds may be more beneficial for obtaining a higher concentration of platelets, leukocytes,
and growth factors.
Liquid PRF and Heat-Treated PRF
3
*
**
a
— LS-PRF
TGF-β1 accumulated release
over time (pg/mL)
Cell migration
(fold change to control)
— LS+T-PRF
2
#
1
0
Control
PRP
PRF
LS-PRF
b
40,000
--- PRF
**
30,000
**
20,000
10,000
0
15 min 60 min
8h
#
#
#
1d
3d
10 d
FIG 6-4
Cell migration and TGF-β release resulting from the low-speed centrifugation concept over a 10-day period. In general, low-speed
PRF (LS-PRF) significantly demonstrated the greatest ability for cell migration and highest growth factor release. Furthermore, a
reduction in speed and time (LS+T-PRF) further favored additional growth factor release. An asterisk denotes a significant difference, a double asterisk denotes a value significantly higher than all other groups, and a number sign denotes a value significantly
lower than all other groups. (Data from Fujioka-Kobayashi et al.19)
This hypothesis was confirmed by a classic study by
Ghanaati et al, who showed that by decreasing centrifugation speeds, a more optimal formulation of PRF
could be achieved with a higher number of leukocytes
more evenly distributed throughout the PRF matrix.58
It is now recognized that the leukocytes were being
pushed out of the fibrin clots unnecessarily down to
the bottom of centrifugation tubes because of these
high centrifugation speeds and times. More recently,
it has been demonstrated that both centrifugation
speed and time could be reduced to further enhance
growth factor release and cell performance from PRF
(Fig 6-4).19
One of the primary proposed reasons for a slower
release of growth factors over time is the ability of the
fibrin matrix to hold proteins within its fibrin network
as well as contain cells capable of further releasing
growth factors into their surrounding microenvironment.59–63 Therefore, if centrifugation protocols are
optimized to contain more cells (most notably leukocytes), then they will subsequently have the potential
to release more growth factors over a 10-day period
as well as contribute to tissue defense and biomaterial
integration, all factors necessary to further enhance
tissue regeneration.
As centrifugation speeds have been drastically
decreased since the first version of PRF, it has been
observed that should protocols be spun even slower,
a liquid formulation of PRF could be obtained, prior to
clot formation. This new formulation was given the
working name injectable PRF or liquid PRF because
of its hypothesized ability to be injected into defects
or to be combined with other biomaterials, further
improving tissue regeneration. While ongoing research
is underway, this new formulation of liquid PRF has
been shown to contain an increase in leukocytes and
platelets, which have also been detected utilizing
lower centrifugation speeds with a centrifugation
time of 3 to 5 minutes.
Liquid PRF and Heat-Treated PRF
Liquid PRF was developed to act as a regenerative
agent that could be delivered in liquid form by drawing
blood and rapidly processing it in a specific centrifugation tube at a very low speed for an even shorter
centrifugation time (3–4 minutes). Here the objective
was to centrifuge the blood without anticoagulants
or additives yet maintain the ability to separate it into
85
6 / Use of Platelet-Rich Fibrin in Facial Esthetics
FIG 6-5
Newer centrifugation protocols allow production of a liquid
formulation of PRF found in the top 1- to 2-mL layer of centrifugation tubes following a 3- to 5-minute protocol. This liquid
can be collected in a syringe and reinjected into defect sites or
mixed with biomaterials to improve their bioactive properties.
two layers (Fig 6-5). Produced on a horizontal centrifuge with spin cycles of 5 minutes at 300g, liquid PRF
is very rich in cells and growth factors.
This new formulation can be utilized for a variety of
procedures, including knee injections for the management of osteoarthritis, temporomandibular joint (TMJ)
injections for the management of TMJ disorders,
as well as various procedures in facial esthetics to
improve collagen synthesis naturally. The principle
behind liquid PRF remains the same—it contains a
larger proportion of leukocytes and blood plasma
proteins due to the low-speed centrifugation concept.
Because liquid PRF contains the highest proportion of
platelets and growth factors by volume, it remains the
optimal PRF formulation for small-volume injections
such as those used for facial esthetics. Upon injection,
liquid PRF will subsequently clot, facilitating a better
ability to maintain deficient volumes such as those
observed in facial wrinkles (eg, nasolabial folds). It
has been discovered that clotting occurs better with
slightly higher g-forces and/or centrifugation times.
86
FIG 6-6
Layer separation produced on a fixed-angle centrifuge. Note the uneven separation at the junction between the red blood cells and PRF.
Therefore, should the clinician desire to produce a
more dense fibrin scaffold (ie, to fill deeper facial
voids), a heat-treated PRF protocol may be utilized
to extend the resorption of PRF from 2–3 weeks to
4–6 months (extended PRF [e-PRF]). The protocols for
the production of e-PRF are highlighted in chapter 12.
In 2019, a breakthrough article demonstrated that
horizontal centrifugation allowed for better blood
separation than traditional centrifugation methods.64
Because all PRF centrifuges were developed using
fixed-angled rotors, one of the disadvantages was the
accumulation of cells along the outside glass walls
caused by high g-force (Fig 6-6). Furthermore, with
traditional centrifuges, separation cannot occur effectively because larger cells (such as red blood cells)
typically trap and pull smaller platelets to the bottom
of PRF tubes (Fig 6-7). With horizontal centrifugation,
on the other hand, the separation of cell layers is linear
without accumulation of cells along the outer centrifugation tube wall (see Fig 6-7).
Liquid PRF and Heat-Treated PRF
Fixed-angle centrifuge
Fixed-angle
centrifugation
G-force applied
Horizontal
centrifugation
Horizontal centrifuge
G-force applied
Rotor axis
Rotor axis
RCF-min
RCF-max
Due to the fixedangle centrifuge,
cells accumulate in
an angled fashion
RCF-max
RCF-min
Horizontal centrifugation produces
a completely
linear separation
a
b
FIG 6-7
Illustrations comparing fixed-angle and horizontal centrifuges. (a) Following centrifugation on fixed-angle centrifuges, blood
layers do not separate evenly, and as a result, an angled blood separation is observed. In contrast, horizontal centrifugation
produces an even separation. (b) With fixed-angle centrifuges, separation of blood layers based on density is achieved due to
the difference in RCF-min and RCF-max. Note how even at the same RCF-min, the RCF-max on a horizontal centrifuge is much
greater, which favors more effective cell layer separation. Because of the large RCF values (about 200–700g), on a fixed-angle
centrifuge cells are pushed toward the back of centrifugation tubes and then downward or upward based on cell density. These
g-forces produce additional shear stress on cells as they separate along the walls of centrifugation tubes. In contrast, horizontal
centrifugation allows for the free mobility of cells to separate into their appropriate layers based on density, allowing for more
optimal cell separation as well as less trauma/shear stress on cells.
Control
PRP
Liquid PRF
a
FIG 6-8
Cell migration (% of control)
400
b
**
*
300
200
100
0
Control
PRP
Liquid PRF
(a and b) Migration assay of human skin fibroblasts cultured with liquid PRF and PRP after 24 hours. (Scale bars = 100 µm. An
asterisk denotes a significant difference between two groups at P < .05, and a double asterisk denotes a value significantly
higher than all other treatment groups at P < .05.) This assay was performed in triplicate with three independent experiments.
Regenerative potential of PRP vs liquid PRF
In a recent study, dermal skin fibroblasts were cultured
with either liquid PRF or PRP and investigated for their
ability to promote/influence cell viability, migration,
spreading, proliferation, and mRNA levels of known
mediators of dermal biology, including PDGF, TGF-β,
and fibronectin.65 All platelet concentrates were
nontoxic to cells, demonstrating high cell survival.
Skin fibroblasts migrated over 350% more in liquid
PRF when compared to the control and PRP (200%
increase; Fig 6-8). Liquid PRF also significantly induced
87
6 / Use of Platelet-Rich Fibrin in Facial Esthetics
PDGF
6
TGF-β
5
a
**
3
2
*
1
0
3 days
COL1
Relative gene expression
*
2
1
d
0
3 days
FIG 6-9
*
3
*
2
1
0
3 days
7 days
FN1
**
**
4
4
3
*
5
3
b
7 days
6
c
Relative gene expression
4
Relative gene expression
Relative gene expression
**
5
7 days
**
2
*
1
0
3 days
Control
PRP
7 days
Liquid PRF
Expression of regeneration-related and extracellular matrix–related genes of gingival fibroblasts cultured with PRP and liquid
PRF at 3 and 7 days: (a) PDGF, (b) TGF-β, (c) COL1, and (d) FN1. (An asterisk denotes a significant difference between two groups
at P < .05, and a double asterisk denotes a value significantly higher than all other treatment groups at P < .05.) This assay was
performed in triplicate with three independent experiments.
greater cell proliferation at 5 days. While both PRP
and liquid PRF induced significantly elevated cell
mRNA levels of PDGF, it was observed that TGF-β,
collagen-1 (COL1), and fibronectin (FN1) mRNA levels
were all significantly highest in the fluid PRF group (Fig
6-9). Lastly, liquid PRF demonstrated a significantly
greater ability to induce collagen matrix synthesis
when compared to PRP (Fig 6-10). In conclusion, it
was found that liquid PRF has greater regenerative
potential on human skin fibroblasts.65 Furthermore,
because PRF tubes do not contain any additives, it is
further considered a more natural approach to tissue
regeneration, not to mention less expensive for the
clinician.
88
Collecting PRF from peripheral blood
In order to utilize PRP or PRF, it is important to be
familiar with phlebotomy techniques. Because with
PRF a short working time is required, it is advised that
prior to initiating any blood collection, the centrifuge
is set on the appropriate protocol, open and ready for
use (Fig 6-11). Because no anticoagulants are being
utilized, blood collection must occur rapidly (within
90 seconds ideally) and then centrifuged to maximize the regenerative potential of PRF. After blood
collection, blood tubes are added to a centrifuge (Fig
6-12). Following a 3- to 5-minute protocol, the liquid
PRF tubes are removed.
Liquid PRF and Heat-Treated PRF
Control
PRP
Liquid PRF
a
COL1 staining intensity
(% of control)
250
b
*
200
150
100
50
0
Control
FIG 6-10
**
PRP
Liquid PRF
Immunofluorescent collagen type 1 (COL1) staining of skin fibroblasts cultured with PRP and liquid PRF at 7 days. (a) COL1
staining (green) merged with DAPI staining (blue). (Scale bars = 100 μm.) (b) COL1 staining quantification. (An asterisk denotes
a significant difference between two groups at P < .05, and a double asterisk denotes a value significantly higher than all other
treatment groups at P < .05.) This assay was performed in triplicate with three independent experiments.
a
FIG 6-11
(a) Clinical photograph of a BIO-PRF centrifuge. (b) Photograph demonstrating the horizontal centrifugation concept.
The tubes are inserted vertically, but once the device begins
to rotate, the tubes swing out completely horizontally. This
favors better blood cell layer separation with higher platelet
and growth factor concentrations.
b
89
6 / Use of Platelet-Rich Fibrin in Facial Esthetics
a
b
c
d
e
f
h
i
FIG 6-12
Blood collection procedure for PRF. (a) First, a tourniquet is tied about 3 inches above
the elbow. (b) A vein light is then utilized to locate the vein. (c) An alcohol wipe is
used to disinfect the area. (d) A bandage is then typically attached to a nearby location (in this case, the practitioner’s glove) to speed use. (e) The butterfly needle
is then inserted into the vein at a 15- to 30-degree angle and parallel to the vein. (f)
Backflow is observed within the butterfly needle. (g) The collection tubes are then
inserted, and vials of blood are collected. (h) Following blood draw, a bandage is
placed over the puncture site and the butterfly needle removed. (i) Compression is
applied to the puncture site.
g
90
Liquid PRF and Heat-Treated PRF
j
k
FIG 6-12 (cont)
(j) PRF tubes are placed in the centrifuge. (k) Many butterfly needles come with a safety feature locking the needle after use.
When utilizing the liquid PRF formulation, it is important to NOT remove the lids and expose it to oxygen. This
exposure will further speed clotting, and because the
goal is to use liquid PRF as an injectable material, clotting should be
When utilizing the liquid PRF formulaavoided. (If left
tion, it is important to NOT remove the
unexposed to
lids and expose it to oxygen.
oxygen, the PRF
will typically
clot after 20 to 45 minutes, depending on the centrifugation tubes utilized.) Therefore, after centrifugation,
a 21- to 27-gauge needle (ideally 3 inches in length or
longer) is penetrated through the rubber portion of the
lid, and the liquid PRF is aspirated into the syringe (Fig
6-13a). Here it is important to draw up as much as the
liquid PRF as possible, remembering that the greatest
proportion of cells are found at the junction between
the liquid PRF and the red blood cell layer. Figure 6-13b
depicts a syringe filled with liquid PRF that may then
either be used for injections or be added to the skin
layer prior to microneedling.
a
b
FIG 6-13
(a) Collection of liquid PRF with a syringe. Note that the lid
should not be removed, because oxygenation will speed clotting
and reduce the working time of the clinician. (b) Syringe with
collected liquid PRF ready for future facial injection purposes.
91
6 / Use of Platelet-Rich Fibrin in Facial Esthetics
PRF in Facial Esthetics
Until recently, the use of PRF in facial esthetics
paled in comparison to the use of PRP.66,67 In 2010,
Dr Anthony Sclafani performed several studies
investigating the ability of PRF to successfully fill
nasolabial folds.68 PRF has since been proven to
be a safe and effective growth factor concentrate
capable of improving facial rejuvenation. 29 More
recently, PRF has been combined with various
other treatment strategies such as dermal fillers
or nanofat grafting protocols to further improve
tissue regeneration.69,70 PRF has also been shown
to increase hair density in androgenetic alopecia.71
PRF follows the same logic as the previously
utilized PRP in that it acts by stimulating mitogenic activity in cells while being capable of rapidly
improving tissue recruitment of cells. From this
point of view, much literature now supports the
use of PRP in facial esthetics and for hair regeneration. Because of the superior preclinical outcomes
of PRF, its ability to provide a slower and more gradual release of growth factors over time is thought
to further enhance tissue regeneration of facial
tissues, though to date no comparative studies
exists.
Once liquid PRF is drawn into a syringe, it is
important to note that it will clot within 20 to
40 minutes if left in the syringe. Furthermore, if
exposed to oxygen, clotting will occur significantly
more rapidly. From here, PRF may be utilized as an
injectable device either into facial tissues or into
the scalp in a similar fashion as PRP. It may also be
utilized as an autogenous growth factor applied to
the face prior to or after microneedling, in a similar
fashion to PRP in the vampire facelift technique.72,73
It is important to understand that in the field of
esthetic medicine, only plastic tubes are utilized
in order to prevent coagulation into a PRF fibrin
matrix. In medicine and dentistry, the use of PRF
membranes typically favor glass tubes or silicacoated plastic tubes to promote faster clotting. Two
separate formulations of PRF are discussed within
the present chapter: a liquid injectable formulation
92
of PRF termed liquid PRF centrifuged at lower
speeds to maintain cells in the upper layer (300g
for 5 minutes) as well as a more dense e-PRF utilized
as a substitute for fillers (700g for 5 minutes).
These protocols are for a horizontal centrifuge; if
using a fixed-angle centrifuge, lower g-forces are
utilized (typically 60–300g) because of the reduced
distance from the radius at the maximum distance
of the tube (see Fig 6-7b). The main aim of treatment with PRF is to naturally improve the patient’s
cosmetic appearance by providing a natural regenerative therapy. Unlike fillers that simply fill defects,
PRF aims to actually restore and rejuvenate skin.
Specific protocols are described in future chapters, but the treating practitioner should always
remember that liquid PRF contains more cells and
growth factors and can be effectively utilized with
microneedling and for the regeneration of superficial
tissues. e-PRF utilizes a faster centrifugation cycle
and as a result contains more fibrin. This is useful
for filling larger voids such as pronounced nasolabial folds. In general, the growth factor release
from PRF has been observed at up to 10 to 14 days.
Because of the regenerative cycle found in skin, a
typical 14- to 28-day treatment cycle is typically the
initial treatment regimen. The authors recommend
an initial PRF therapy treatment plan with three to
four therapies evenly distributed once a month for
the first 3 to 4 months. Thereafter, maintenance can
be performed every 6 to 12 months as discussed
later in this book.
Liquid PRF therapy with microneedling
A common and effective procedure for facial regeneration is microneedling with a Dermapen (Fig 6-14),
as described in chapter 7. For such procedures, the
treating practitioner aims to deliver small doses of
liquid PRF subdermally via the microneedling tips
from a 0.25- to 2.5-mm depth. The protocol begins
with a layer of liquid PRF (most concentrated in cells
and growth factors) applied topically to the face.
Thereafter, the microneedling device pushes the
topical liquid PRF layer into the skin subdermally.
PRF in Facial Esthetics
a
b
FIG 6-14
(a and b) Topical application of liquid PRF on facial skin surfaces followed by microneedling penetration into the skin.
Following microneedling of the area, another layer
of liquid PRF is applied to fill all the microchannels created via needling (see chapter 7). This 20to 30-minute procedure is generally considered
mechanical skin stimulation. Maintenance is highly
recommended in order to prolong clinical results.
Mesotherapy by syringe injections using
liquid PRF and e-PRF
In this procedure, a needle carrying liquid PRF or e-PRF
is injected more deeply into the skin74 (Fig 6-15), as
described in chapter 8. This has been shown to additionally benefit deeper deficits in skin volume, and
the protocols may be mixed or optimized depending
on the goal (the greater the volume deficit, the more
e-PRF is required). This procedure typically uses both
liquid PRF and e-PRF utilizing varying needle sizes and
gauges, as discussed in chapters 8 and 9. It is also
possible to inject into the same area with both liquid
PRF (which contains a higher concentration of cells
and growth factors) and e-PRF (which favors stability
and the slower and more gradual release of growth
factors), together either simultaneously by premixing
or with subsequent injections into the same area. A
combination approach can also be utilized whereby
liquid PRF is premixed with a facial filler such as hyaluronic acid, as demonstrated in chapter 12. While
this procedure is considered more invasive, causing
more skin damage when compared to microneedling,
the results are more noticeable and superior to lessinvasive procedures. Maintenance is once again highly
recommended to maintain the acquired results.
93
6 / Use of Platelet-Rich Fibrin in Facial Esthetics
a
b
c
d
FIG 6-15
(a to e) Use of liquid PRF for facial injections utilizing differentsized needles. (Courtesy of Dr Ana Paz.) This topic is covered
in great detail in chapter 8.
e
Conclusion
One of the advantages of PRF as a regenerative strategy is that it does not specifically induce the proliferation or differentiation of one specific tissue type.
It can therefore be utilized with many regenerative
strategies either alone or in combination with other
biomaterials for a variety of procedures. Ongoing
94
research continues to investigate the amount of
volume augmentation that can be achieved utilizing
PRF. Furthermore, very recent research has shown that
the plasma layer can additionally be heated and used
thereafter as a much slower-resorbing “filler” when
compared to liquid PRF, for example for lip augmentation (see chapter 12).
References
PRF has proven to be a next-generation autogenous platelet concentrate with a broad future in facial
esthetics. It can be utilized as a completely safe regenerative modality harvested from the patient’s own
blood at lower costs and even higher safety when
compared to PRP. Furthermore, its ability to speed
tissue angiogenesis leads to significant increases
in soft tissue repair. Future avenues of research are
focused at precisely characterizing the exact indications and protocols of PRF that will effectively treat a
greater variety of facial wrinkles and/or defects.
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44. Dohan Ehrenfest DM, Del Corso M, Diss A, Mouhyi J, Charrier
JB. Three-dimensional architecture and cell composition of
a Choukroun’s platelet-rich fibrin clot and membrane. J Periodontol 2010;81:546–555.
96
45. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin
(PRF): A second-generation platelet concentrate. Part IV:
Clinical effects on tissue healing. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2006;101:e56–e60.
46. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin
(PRF): A second-generation platelet concentrate. Part I:
Technological concepts and evolution. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2006;101:e37–e44.
47. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin
(PRF): A second-generation platelet concentrate. Part II:
Platelet-related biologic features. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2006;101:e45–e50.
48. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin
(PRF): A second-generation platelet concentrate. Part III:
Leucocyte activation: A new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2006;101:e51–e55.
49. Weibrich G, Kleis WK, Kunz-Kostomanolakis M, Loos AH,
Wagner W. Correlation of platelet concentration in plateletrich plasma to the extraction method, age, sex, and platelet
count of the donor. Int J Oral Maxillofac Implants 2001;
16;693–699.
50. Weibrich G, Kleis WK, Hafner G, Hitzler WE, Wagner W. Comparison of platelet, leukocyte, and growth factor levels in
point-of-care platelet-enriched plasma, prepared using a
modified Curasan kit, with preparations received from a local
blood bank. Clin Oral Implants Res 2003;14:357–362.
51. Kawazoe T, Kim HH. Tissue augmentation by white blood
cell-containing platelet-rich plasma. Cell Transplant
2012;21:601–607.
52. Perut F, Filardo G, Mariani E, et al. Preparation method and
growth factor content of platelet concentrate influence the
osteogenic differentiation of bone marrow stromal cells.
Cytotherapy 2013;15:830–839.
53. Pirraco RP, Reis RL, Marques AP. Effect of monocytes/macrophages on the early osteogenic differentiation of hBMSCs.
J Tissue Eng Regen Med 2013;7:392–400.
54. Bilginaylar K, Uyanik LO. Evaluation of the effects of plateletrich fibrin and piezosurgery on outcomes after removal of
impacted mandibular third molars. Br J Oral Maxillofac Surg
2016;54:629–633.
55. 5Border WA, Noble NA. Transforming growth factor beta in
tissue fibrosis. N Engl J Med 1994;331:1286–1292.
56. Bowen T, Jenkins RH, Fraser DJ. MicroRNAs, transforming
growth factor beta 1, and tissue fibrosis. J Pathol 2013;229:
274–285.
57. Shamloo A, Xu H, Heilshorn S. Mechanisms of vascular endothelial growth factor-induced pathfinding by endothelial sprouts
in biomaterials. Tissue Eng Part A 2012;18:320–330.
58. Ghanaati S, Booms P, Orlowska A, et al. Advanced plateletrich fibrin: A new concept for cell-based tissue engineering
by means of inflammatory cells. J Oral Implantol 2014;40:
679–689.
59. Lekovic V, Milinkovic I, Aleksic Z, et al. Platelet-rich fibrin and
bovine porous bone mineral vs platelet-rich fibrin in the
treatment of intrabony periodontal defects. J Periodontal
Res 2012;47:409–417.
References
60. Panda S, Jayakumar ND, Sankari M, Varghese SS, Kumar DS.
Platelet rich fibrin and xenograft in treatment of intrabony
defect. Contemp Clin Dent 2014;5:550–554.
61. Pradeep AR, Rao NS, Agarwal E, Bajaj P, Kumari M, Naik SB.
Comparative evaluation of autologous platelet-rich fibrin
and platelet-rich plasma in the treatment of 3-wall intrabony
defects in chronic periodontitis: A randomized controlled
clinical trial. J Periodontol 2012;83:1499–1507.
62. Sharma A, Pradeep AR. Treatment of 3-wall intrabony defects
in patients with chronic periodontitis with autologous
platelet-rich fibrin: A randomized controlled clinical trial.
J Periodontol 2011;82:1705–1712.
63. Kumar RV, Shubhashini N. Platelet rich fibrin: A new paradigm
in periodontal regeneration. Cell Tissue Bank 2013;14:
453–463.
64. Miron RJ, Chai J, Zheng S, Feng M, Sculean A, Zhang Y. A
novel method for evaluating and quantifying cell types in
platelet rich fibrin and an introduction to horizontal centrifugation. J Biomed Mater Res A 2019;107:2257–2271.
65. Wang X, Yang Y, Zhang Y, Miron RJ. Fluid platelet-rich fibrin
stimulates greater dermal skin fibroblast cell migration, proliferation, and collagen synthesis when compared to plateletrich plasma. J Cosmet Dermatol 2019;18:2004–2010.
66. Sclafani AP. Applications of platelet-rich fibrin matrix in facial
plastic surgery. Facial Plast Surg 2009;25:270–276.
67. Sclafani AP, Azzi J. Platelet preparations for use in facial rejuvenation and wound healing: A critical review of current
literature. Aesthetic Plast Surg 2015;39:495–505.
68. Sclafani AP. Platelet rich fibrin matrix for improvement of
deep nasolabial folds. J Cosmet Dermatol 2010;9:66–71.
69. Liang ZJ, Lu X, Li DQ, et al. Precise intradermal injection of
nanofat-derived stromal cells combined with platelet-rich
fibrin improves the efficacy of facial skin rejuvenation.
2018;47:316–329.
70. Wei H, Gu SX, Liang YD, et al. Nanofat-derived stem cells
with platelet-rich fibrin improve facial contour remodeling
and skin rejuvenation after autologous structural fat transplantation. Oncotarget 2017;8:68542–68556.
71. Sclafani AP. Platelet-rich fibrin matrix (PRFM) for androgenetic alopecia. Facial Plast Surg 2014;30:219–224.
72. Runels C. CMG facelift. Temple Repair Skin Care 2013;52.
73. Bowes L. Safety considerations for aesthetic nurses administering platelet-rich plasma. J Aesthet Nurs 2013;2:118–122.
74. El Domyati M, El Ammawi TS, Moawad O, et al. Efficacy of
mesotherapy in facial rejuvenation: A histological and immunohistochemical evaluation. Int J Dermatol 2012;
51:913–919.
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7/
BIOLOGY OF
MICRONEEDLING
Erin Anderson
Nichole Kramer
Richard J. Miron
Ana Paz
Catherine Davies
Skin aging is a complex biologic process influenced by many factors, including genetics, cellular metabolism, sun exposure, pollution, stress, and toxins.
In 2005, Fernandes proposed the concept of minimally invasive percutaneous collagen induction, or microneedling. As the term implies, a number
of microneedles (typically 12) are utilized to perform minimally invasive,
nonsurgical, and nonablative therapy of facial tissues. Microneedling relies
on the principle of neovascularization that occurs as a result of minimal
trauma causing rapid neocollagenesis and tissue repair. This is performed
in an automated fashion with a microneedling device—the Dermapen. The
Dermapen is an electrically powered medical device that delivers a vibrating
stamplike motion to the skin, resulting in a series of microchannels. These
channels are then filled with platelet-rich fibrin (PRF), and the device may
also be utilized to “push” a product (in this case, PRF) at specific depths
within skin to faciliate facial rejunevation via autogenous growth factor
release. This chapter reviews the clinical indications and uses of microneedling and provides a protocol depicting its use with PRF.
99
7 / Biology of Microneedling
Breakdown of old/damaged collagen
Production of new/organized collagen
Thickening of skin via autogenous filler
Reduction in imperfections, including scars and wrinkles
FIG 7-1
FIG 7-2
Dermapen microneedling device.
Treatment goals following microneedling. Results may be
seen by the patient 4 weeks after treatment, although it can
take 3 to 6 months for visible results.
Skin Aging
to simply filling them. Microneedling, as indicated
by the term, is defined as the use of needles or
“microneedles” to achieve a therapeutic effect. In
2005, the microneedling technique was proposed
by Fernandes as a minimally invasive, nonsurgical,
and nonablative procedure for facial rejuvenation.5 A
microneedling device (Dermapen; Fig 7-1) is utilized
to create controlled minimal skin injury ranging in
depths from 0.25 to 2.5 mm.6 In brief, the technique
relies on minimal skin damage causing neovascularization, resulting from needle piercing of the stratum
corneum. Thereafter, growth factor release is stimulated and neocollagenesis begins7 (Fig 7-2). This technique is natural in that it does not utilize injectable
materials and instead promotes the local increase in
neoangiogenesis and neocollagenesis via induction
of the natural wound healing cascade.8 Studies have
now demonstrated that the use of microneedling can
substantially thicken the outer epidermis layer as well
as collagen synthesis even 2 years posttreatment in
human skin biopsies (Fig 7-3).9 The Dermapen is an
upgrade from previous archaic dermal rollers, which
had a variety of shortcomings including pressure and
depth penetration, among others. For these reasons,
an automated microneedling device was created.10
Skin aging occurs via two processes: intrinsic aging
and extrinsic aging. Intrinsic aging occurs via intrinsic
factors such as genetics, cellular metabolism, and
hormonal levels as well as extrinsic factors that result
from everyday external stimuli such as exposure to
sunlight, pollution, radiation, chemicals, and toxins.1
Intrinsic aging is often also termed chronological
aging, and it occurs naturally and irreversibly. This
is typically a slow process causing changes in tissue
over time.2 On the other hand, extrinsic aging is related
to controllable factors that result in destruction of
facial tissues as a consequence of repeated exposure
to environmental elements such as ultraviolet radiation (sunlight), pollution, and smoking. These factors
promote the breakdown of collagen and eventually
manifest in wrinkles and other signs of photoaged
skin.3 Two of the most common factors associated
with skin aging are direct sunlight exposure and cigarette smoking.4
For years, individuals have sought ways to minimize
facial aging and, in many cases, reverse it. A prominent avenue and one heavily promoted within this
book is the ability to regenerate tissues as opposed
100
Indications and Contraindications
a
b
FIG 7-3
(a) Preoperative histologic photomicrograph of a burn scar (Masson’s trichrome stain). (b) Histologic photomicrograph of the
same scar obtained 24 months postoperatively. Van Gieson staining showed a considerable normalization of the collagen/elastin
matrix in the reticular dermis and an increase in collagen deposition at 24 months postoperatively, and the collagen appears not
to have been laid down in parallel bundles but is rather in the normal lattice pattern. (Reprinted with permission from Aust et al.9)
Dermapen
Dermapen is an automated and electrically driven
medical device shaped as a pen containing numerous microneedles for one-time use. It is spring-loaded
with an adjustment ring allowing for alteration of the
heights of the microneedles at penetration depths
ranging from 0.25 to 2.5 mm (Fig 7-4). When the
device is utilized, the electrically powered pen delivers
a vibrating stamplike motion to the skin ranging from
1,000 to 5,000 rotations per minute. This creates a
series of microchannels that may later be filled with
various products such as PRF, as discussed later in
this chapter.11
This therapy is a safe skin-resurfacing therapy and
results in minimal damage to the skin. The downtime is usually
approximately
This therapy is a safe skin-resurfacing
24 to 48 hours.
therapy and results in minimal
This method of
damage to the skin.
facial rejuvenation has a much shorter downtime than other comparable methods and a lower risk of side effects such
as hyperpigmentation and scarring (when compared
to lasers, for instance), making it an ideal treatment
FIG 7-4
Illustration of the Dermapen microneedling tip. Note the 12
small microneedles within the tip, which repeatedly penetrate 0.25 to 2.5 mm deep into facial tissues at roughly 1,000
to 5,000 rotations per minute.
choice for all individuals, especially those with thin,
sensitive, or darker skin types (skin types III to VI).5 It
is also effective for smokers and other individuals who
have been exposed to significant external pollutants.12
Indications and Contraindications
Microneedling was originally indicated as a simple
tool to reduce wrinkles, but it has since expanded into
101
7 / Biology of Microneedling
many additional indications. These include various
types of scars, stretch marks (striae rubra), androgenetic alopecia and alopecia areata (with or without
platelet-rich plasma/PRF), pigmentations, and acne.
These are individually addressed later in this chapter.
The contraindications for microneedling have been
reviewed previously by Lichtman et al13 and include
the following:
• Dermatosis like vitiligo, lichen planus, and psoriasis, because trauma leading to koebnerization can
aggravate the dermatosis (Nevertheless, some
authors have used microneedling with topical
latanoprost to treat vitiligo.)
• Blood clotting disorders or patient use of any anticoagulant therapy like warfarin or heparin, because
it can cause uncontrolled bleeding
• Rosacea
• Skin malignancy, moles, warts, and solar keratosis,
because the needles may disseminate abnormal
cells by implantation
• Other chronic skin diseases like eczema
• A history of isotretinoin use within 6 months
• Impetigo or herpes labialis infection on the area
to be treated
• Extreme keloidal tendency
• Chemotherapy or radiotherapy
Local anesthetic cream should be applied to the
face, neck, and décolletage of sensitive patients 30
to 60 minutes before the procedure. Alternatively,
the patient could apply the cream at home an hour
before the procedure. The hands may also be treated
in this way. The skin must be cleansed of any creams
or makeup. Reclean the skin of the areas to be treated
with a disinfectant (Figs 7-5d and 7-5e). Apply a
headband or cap to keep the patient’s hair out of
the treated area.
Application of PRF
Once the face is prepared and clean, the blood is then
collected for the PRF treatment (Figs 7-5f to 7-5j; see
chapter 6). A layer of this PRF is then applied topically to the skin surface (Fig 7-5k). With one hand
slightly stretching the skin, the Dermapen is then
passed over various areas (Figs 7-5l and 7-5m) in a
directional motion following the guidelines shown in
Fig 7-5n. Typically three passes are made on each area
of the face at various recommended depths. Pinpoint
bleeding will typically result.
Following the procedure, the remaining leftover PRF
is then layered on all surfaces of the skin that have
been microneedled (Fig 7-5o).
Postoperative care
Technique with PRF
Preparation
Topical anesthesia with lidocaine and prilocaine are
utilized and applied to the area to be treated (Figs 7-5a
to 7-5c). While various companies market and sell overthe-counter topical creams, the authors recommend
pharmaceutical preparations of topicals. This is achieved
typically utilizing 23% lidocaine and 7% tetracaine
formulations (prepared at a pharmacy via prescription).
Other compounding creams include 20% benzocaine,
8% lidocaine, and 4% tetracaine in a lipobase.
102
The treated area often demonstrates pinpoint bleeding
(see Fig 7-5m), and some superficial bruising may
occur, so a face cooling mask is applied immediately
after treatment (Fig 7-5p). This utilizes a natural hydrogel without any additional drugs or agents. Vitamin
and/or mineral creams (see chapter 11) or low-level
laser therapy (see chapter 10) may be used to improve
wound healing and reduce redness (Figs 7-5q to 7-5s).
Before leaving the office, the patient is presented
with a postoperative instruction sheet. Naturally, the
patient is advised to avoid sun exposure, harsh chemicals, and any cosmetic procedures over the face for
at least 72 hours posttreatment.
Technique with PRF
a
b
c
d
e
f
FIG 7-5
Step-by-step procedure demonstrating microneedling with
PRF. (a and b) Application of exfoliating enzyme-foaming
cleanser for skin disinfection and removal of dead skin cells.
(c) Application of topical anesthetic cream. (d and e) Skin disinfection with 70% alcohol. (f and g) Phlebotomy with a 21G
needle and blood collection.
g
103
7 / Biology of Microneedling
h
i
j
k
l
m
FIG 7-5 (cont)
(h and i) Centrifugation of blood utilizing a horizontal centrifuge (BIO-PRF). (j) Collection of liquid PRF. (k) Topical PRF application for microneedling. (l and m) Microneedling with PRF. Notice the petechiae in the lower right quadrant of the face caused by
microneedling.
104
Technique with PRF
0.25–0.5 mm
0.25–0.5 mm
0.25 mm
0.25–0.5 mm
0.25–0.5 mm
0.5–1.0 mm
0.25–1.0 mm
0.5–1.0 mm
0.5–2.0 mm
0.5–1.0 mm
First pass
(Purple) Treat using the “striping technique” and follow the direction bottom to top.
Start at the bottom of the movement and treat with upward strokes.
Second pass (Blue) Making constant contact, start medially and work laterally from inside toward
the outer face. Pick up the tip from the face at the end of the outer face and then repeat starting from the inside to the outer face. This creates a “striping” movement that
follows protocol.
n
Third pass
(Black) Outward and upward (when treating nose and upper lip on third pass, use
downward strokes as indicated in diagram above).
FIG 7-5 (cont)
(n) Microneedling depth chart. (Courtesy of Dermapen.)
105
7 / Biology of Microneedling
o
p
q
r
FIG 7-5 (cont)
s
106
(o) Application of liquid PRF following microneedling. PRF
enters the microchannels created with the Dermapen, and
autologous growth factors may then be gradually released
over time within the facial tissues. (p) Application of a cooling
and hydrating mask following therapy. (q) Application of vitamin compound. (r) Use of low-level laser therapy to improve
wound healing and reduce redness (see chapter 10). (s) Skin
texture and tone immediately after the procedure. Note the
slight redness, which will disappear within 24 hours.
The Science Behind Microneedling
Complications
The Science Behind Microneedling
Complications of microneedling are almost negligible but may include slight pain postoperatively (rare),
reactivation of herpes simplex virus around the vermilion border, impetigo, and allergic contact dermatitis to
the topical agent utilized. When utilizing PRF, this fully
autogenous agent avoids potential allergic reactions.
While excellent review articles have been written on
microneedling,14–18 this section provides an overview
of the available literature to date on the topic.
In microneedling, the microneedles enter the
skin, causing injury and localized damage. This in
turn causes minor bleeding by rupturing fine blood
vessels. A day after microneedling, keratinocytes
begin to proliferate and release growth factors to
promote collagen deposition by the fibroblasts.
Needling therapy modulates the expression of
several genes in the skin (eg, vascular endothelial
growth factor [VEGF], fibroblast growth factor [FGF],
epidermal growth factor [EGF], and collagen types
1 [COL1] and 3 [COL3]) that promote extracellular
matrix remodeling.19 One particularly useful growth
factor released following microneedling is transforming growth factor β3 (TGF-β3), a growth factor
known to be responsible for a scar-free regeneration
process.20 Furthermore, microneedling induces soft
tissue fibroblast proliferation and collagen and extracellular matrix deposition, reepithelialization, and
angiogenesis.19 This in turn leads to tightening of the
skin, enhanced skin architecture, and improved skin
appearance. A notable increase in collagen and elastin
fibers can be proven 6 months after a microneedling
treatment. Comparative studies between microneedling and intense pulsed light (IPL) laser therapy have
reported a 98% increase in collagen deposition after
microneedling (as opposed to only a 51% increase
with IPL) as well as a significant increase in epidermal tissue thickness (Fig 7-6).21
It is imperative that the treating clinician
utilize high-quality needles. These needle
tips are NOT reusable, even if repeated treatments are performed on the same patient.
Clinical Significance and
Advantages of Microneedling
Several reported advantages have been discussed in
the literature for microneedling13:
• Short healing times compared to other modalities
(typically 24–48 hours)
• Easy-to-master technique
• Can be utilized on all skin types (whereas lasers
and deep peels cannot always)
• Convenient office procedure with minimal overhead cost
• Well tolerated by patients
• Minimal risk of postinflammatory hyperpigmentation or bruising because the needle depth penetrates the skin a maximum of 2.5 mm
107
7 / Biology of Microneedling
1,066.7
a
220
Thickness (µm)
Thickness (µm)
1,333.3
800
*
*
1,600
Control
IPL-treated MTS-treated
*
*
170
120
70
b
Control
IPL-treated MTS-treated
*
*
FIG 7-6
(a) Western blot analysis of type 1 collagen. Expression of the α1 chain of type 1 collagen increased with treatments in the following order: untreated (control), treated with IPL, and treated with a microneedle therapy system (MTS) (P < .05). Levels were
significantly higher after MTS than IPL treatment (P < .05). (b) Caliper-measured skin thickness was analyzed in 54 mice divided
into three groups (18 mice/group): untreated (control), treated with IPL, and treated with an MTS. Values are expressed as means
± standard deviations. The multiple comparison tests showed all pairwise differences (*) between the means. (Reprinted with
permission from Kim et al.21)
Facial rejuvenation
a
Microneedling has most commonly been utilized for
facial rejuvenation procedures.14,15,18,22–27 Preclinical and
clinical studies have demonstrated its ability to reduce
wrinkles and also induce collagen synthesis. Figures 7-7
and 7-8 demonstrate two cases treated with microneedling. Typically, a standard protocol includes three to
four treatments every 14 to 28 days as an initial therapy.
Thereafter, maintenance can be achieved every 6 to 12
months (though studies still demonstrate a positive
effect 24 months postoperative with no maintenance).
Beyond facial rejuvenation, microneedling has been
used in many medical applications, as presented in the
sections that follow.
FIG 7-7
b
108
(a) Clinical photograph demonstrating an older female patient
with pronounced deep facial wrinkles. (b) Results following
four treatment procedures 1 month apart. Note the substantial reduction in depth of each wrinkle postoperatively. (Courtesy of Dermapen.)
The Science Behind Microneedling
a
b
FIG 7-8
(a) Male patient (cigarette smoker) with substantial forehead wrinkles. (b) Following four microneedling treatments, note the
substantial reduction in deep forehead wrinkles. (Courtesy of Dermapen.)
Scars
Several studies have demonstrated the efficacy of
microneedling for scar treatment and revision9,28–33
(Table 7-1 and Fig 7-9). In a first study conducted
by El-Domyati et al, histologic changes induced by
microneedling were observed in 10 patients with atrophic facial scars from acne.29 Following skin biopsies
at baseline and posttreatment, there was a statistically significant increase in the production of collagen
types 1, 3, and 7 by the end of treatment. All patients
reported some level of discomfort and edema at the
treatment site, which resolved within 24 hours. No
other adverse events were noted. Patients collectively
reported a 51% to 60% improvement in scar appearance, 40% to 50% improvement in skin texture, and
80% to 85% overall satisfaction (P = .001) following
six treatment sessions over the course of 3 months.29
Since this first pioneering study, a number of studies have since been reported. In a cohort study by
Majid,30 37 patients were treated with a Dermaroller
and followed over the course of 2 months. Of the 37
patients treated, over 80% reported an “excellent”
treatment outcome, with 94.4% indicating a noticeable reduction in the severity of their scars by at
least one objective grade with no adverse effects.30
A clinical trial by Garg and Baveja investigated the
efficacy of a combination therapy using subcision,
microneedling, and a 15% trichloroacetic acid peel in
the management of 50 patients with atrophic acne
vulgaris scars.31 Overall, 100% of patients had objective improvement in scars by at least 1 grade (some
demonstrating much greater improvements).
Other studies have compared the efficacy of
microneedling to that of lasers. Cachafeiro et al
compared 1,340-nm nonablative fractional erbium
laser therapy with microneedling for the treatment
of 46 patients with facial atrophic acne scars in a
randomized fashion.32 Both groups demonstrated
improvement at 2 and 6 months posttreatment, with
no statistically significant difference between them
(P = .264). One noteworthy difference, however, was
that the microneedling group experienced erythema
for an average of 1 day postoperative, whereas in the
laser group an average of 3 days was needed to return
to normal. Additionally, 13.6% of the patients in the
laser group experienced postinflammatory hyperpigmentation, while none of the patients in the microneedling group observed such an effect.32
109
7 / Biology of Microneedling
TABLE 7-1
Scars treated with microneedling therapy
Authors
(year)
Adjunctive therapy ±
microneedling
Needle
depth
Type
of scar
Study
design
El-Domyati
et al29
(2015)
Dermaroller
1.5 mm
Atrophic acne scars
Prospective clinical study
Majid30
(2009)
Dermaroller
1.5 mm
Atrophic facial scars
Uncontrolled prospective
clinical trial
Garg and
Bajeva31
(2014)
15% trichloroacetic acid
peel and subcision ±
Dermaroller
1.5 mm
Atrophic acne scars
Uncontrolled prospective
clinical trial
Cachafeiro
et al32
(2016)
Nonablative fractional
erbium laser (1,340 nm)
± Dr Roller (Vydence
Medical)
2.0 mm
Atrophic acne scars
Evaluator-blinded
prospective randomized
controlled trial
Dogra et al33
(2014)
Dermaroller
1.5 mm
Atrophic acne scars
Uncontrolled prospective
study
Sharad34
(2011)
35% glycolic acid peels ±
Dermaroller MF8
1.5 mm
Atrophic acne scars
with postinflammatory
hyperpigmentation
Prospective randomized
controlled trial
Aust et al9
(2010)
Topical vitamins A and C ±
Medical Roll-CIT (Vivida)
1.0 mm
Hypertrophic burn scars
Uncontrolled prospective
cohort study
Adapted with permission from Iriarte et al.28
FIG 7-9
a
110
b
(a) Clinical photograph of a patient demonstrating substantial
scarring and color change below
her right eye. (b) Magnification
of the defect area.
The Science Behind Microneedling
No. of
patients
No. of sessions
(interval)
10
6 (2 weeks)
Increase in the mean of collagen types 1, 3, and 7, as well as newly synthesized collagen at the end of treatment (P < .05). There was a decrease in total elastin production. Patients reported an 80% to 85% overall satisfaction (P ≤ .01).
37
4 (4 weeks)
Per Goodman and Baron’s facial scar scale, 94% of patients had a reduction in scar
severity by at least 1 grade. Over 80% of patients assessed their response to treatment as “excellent.”
50
6 (2 weeks)
Per Goodman and Baron’s facial scar scale, 63% with grade 4 improved to grade
2, and 38% improved to grade 3; 23% with grade 3 had full remission, and 68%
improved to grade 2; 100% of patients with grade 2 had full remission.
46
3 (4 weeks)
Both groups demonstrated improvement in the degree of their acne scars, with no
statistically significant difference found between the groups (P = .264).
36
5 (4 weeks)
Significant decrease in mean acne scar assessment score from 11.73 at baseline
to 6.5 after 5 sessions (P < .05). Photographic improvement of 50% to 75% was
observed in the majority of patients.
30
5 (6 weeks)
There was 31% improvement in the microneedling alone group vs 62% improvement
in the microneedling with glycolic acid peels group in regard to skin texture and scar
appearance (P = .001).
16
1–4 (4 weeks)
Reported satisfaction with scar on visual analog scale increased from 4.5 to 8.5
following treatment. Histologic analysis at 1 year showed increase in collagen and
elastin deposition.
Results
FIG 7-9 (cont)
(c and d) Following four sessions of microneedling alone,
note the substantial improvement in scar reduction and
color harmony.
c
d
111
7 / Biology of Microneedling
a
b
d
e
c
FIG 7-10
(a) Visible 2-cm scar below the right chest area following an elective cosmetic procedure. (b) Close-up view of the scar defect pretreatment. (c) Clinical appearance following three passes with microneedling in combination with PRF. (d) Results at 2 months postoperative following two microneedling sessions. (e) Results at 4 months postoperative following four treatments of microneedling with PRF.
Note the substantial improvement and reduction in visible scar tissue.
More recently, clinicians have studied the effects of
microneedling on the skin types of various ethnicities. A
clinical trial by Dogra et al evaluated microneedling for the
treatment atrophic acne scars in an Asian population.33
An objective scar assessment was decreased from 11.73
to 6.5 following five microneedling treatments. Similarly,
in a study with patients of darker pigmented skin in an
Indian population, the use of microneedling combined
with glycolic acid peels for the treatment of acne scars
significantly improved skin texture and scarring with a
reduction in postinflammatory hyperpigmentation. This
was especially observed in the combined approach.34
Microneedling has also been investigated for its efficacy in the treatment of hypertrophic surgical scars,35
and it has proven to be effective for burn patients with
hypertrophic scars.9 However, one area that requires
further research is the evaluation of various-sized
microneedling devices (needle size and depth, microchannels per minute) as well as the frequency and interval between treatments for optimal effects.
In summary, the presented studies demonstrate
that microneedling has comparable efficacy to laser
112
treatments for atrophic facial scars yet are better tolerated and have fewer long-term adverse sequelae.36 Scar
type appears to be a factor affecting clinical response to
microneedling, as icepick scars and deep-seated atrophic
scars responded less favorably to treatment.29 Figure
7-10 demonstrates the improvement of a scar caused
by a routine breast augmentation procedure following
therapy with microneedling and PRF, and Figs 7-11 and
7-12 demonstrate the results of microneedling plus PRF
on difficult-to-treat keloid scars.
Alopecia
Microneedling has been utilized effectively for the
regrowth of hair in alopecia. The efficacy of microneedling in both androgenetic alopecia (AGA) and alopecia areata (AA) has been heavily studied over the past
decade28,37–39 (Table 7-2).
Androgenetic alopecia
In a study of 100 male patients, Dhurat et al found
that combining microneedling with minoxidil was
The Science Behind Microneedling
FIG 7-11 ➤
Keloid scar treatment with microneedling. (a) At baseline,
note the large and obvious demarcation and roughened borders present years after scar formation. (b) Following four
treatments with microneedling, notice the vast improvement
in both texture and color tone.
a
b
a
b
c
FIG 7-12
(a) Keloid scar formation in a 40-year-old woman following biopsy; the scar is 4 cm long. (b) Clinical image following microneedling treatment. Note that the microneedling area is always extended beyond the defect area. (c) Note the clinical improvement
following four treatments at 1-month intervals. It is difficult to reach complete resolution with this scar type.
statistically superior to minoxidil alone.37 Over a
12-week period, a Dermaroller was combined with
5% minoxidil lotion and administered to half of
the participants, with 80% showing moderately or
greatly increased hair regrowth. In the control group
receiving 5% minoxidil alone, only 4.5% of patients
reported greater than 50% improvement.37 Dhurat
and Mathapati then published a follow-up case series
of four men with AGA unresponsive to conventional
treatments.38 In these patients (they were either using
topical minoxidil or oral finasteride), the Dermaroller
was added to their regimen for a period of 6 months.
All four patients noticed increased hair thickness after
1 month, with a reported increase in hair regrowth
between moderate and greatly increased after the
6-month study period.
Alopecia areata
Microneedling has also been proposed as a treatment
option for AA. Chandrashekar et al hypothesized that
the collagen induction therapy offered by microneedling would be a valuable therapeutic strategy to
counter steroid-induced atrophy as well as reduce pain
associated with injections.39 In that study, microneedling was combined with topical corticosteroids.
While only two patients were treated in this study,
both patients reported “excellent” hair regrowth with
no recurrence at the 3-month follow-up.
In summary, while these few clinical studies show
optimism for the use of microneedling in alopecia,
very few studies actually exist. Once again, more data
regarding microneedle depth, needle size, duration
of treatment, and frequency of treatment is needed.
Pigmentary disorders
Several studies have proposed microneedling for the
management of pigmentation affecting darker skin
types including melasma, vitiligo, and periorbital
hyperpigmentation28,40–45 (Table 7-3).
113
7 / Biology of Microneedling
TABLE 7-2
Alopecia treated with microneedling therapy
Authors
(year)
Adjunctive therapy ±
microneedling
Needle
depth
Type of alopecia
Study design
Dhurat et al37
(2013)
5% topical minoxidil ±
Dermaroller
1.5 mm
Androgenetic alopecia
Prospective evaluatorblinded randomized
controlled trial
Dhurat and
Mathapati38
(2015)
5% topical minoxidil
and oral finasteride ±
Dermaroller
1.5 mm
Androgenetic alopecia
Case series
Chandrashekar
et al39 (2014)
0.1% topical triamcinolone ± Dermaroller
1.5 mm
Alopecia areata
Case series
Adapted with permission from Iriarte et al.28
TABLE 7-3
Disorders of pigmentation treated with microneedling therapy
Adjunctive therapy ±
microneedling
Needle depth
Fabbrocini et al40
(2011)
Depigmentation serum ±
Dermaroller CIT 8 in office and
Dermaroller C8 at home
CIT 8: 0.5 mm
Dermaroller C8:
0.13 mm
Melasma
Split-face
prospective
controlled trial
Budamakuntla et al41
(2013)
Tranexamic acid (TA) ±
Dermaroller MS4
1.5 mm
Moderate
to severe
melasma
Randomized
controlled trial
Lima Ede42 (2015)
Depigmentation formula ±
Dr Roller
2.0 mm
Melasma
Retrospective
analysis
Stanimirovic et al43
(2016)
Narrowband ultraviolet B
(NB-UVB) + 0.005% latanoprost
solution ± Dermaroller
1.5 mm
Vitiligo
Split-body
prospective
controlled trial
Sahni and Kassir44
(2013)
Anti-aging serum ± DermaFrac
(Genesis Biosystems)
0.25 mm
Periorbital
melanosis
Case report
Kontochristopoulos
et al45 (2016)
10% trichloroacetic acid peels ±
Automatic Microneedle Therapy
System-Handhold
0–2.5 mm
Periorbital
melanosis
Uncontrolled
prospective study
Authors (year)
Adapted with permission from Iriarte et al.28
114
Pigmentation
disorder
Study design
The Science Behind Microneedling
No. of
patients
No. of sessions
(interval)
100
12 (1 week)
Mean hair counts were significantly greater in the microneedling plus minoxidil group
compared to the minoxidil alone group (91.4 vs 22.2, P = .039); 82% of patients in the
combination group reported greater than 50% improvement vs 4.5% in the minoxidil
alone group.
4
4 (1 week) then
11 (2 weeks)
100% showed +2 or +3 responses on a 7-point standardized scale for hair growth.
Findings were sustained at final follow-up; 75% had subjective improvement in hair
growth > 75%.
2
3 (3 weeks)
100% graded hair regrowth as “excellent” at 3-week follow-up with no recurrence of
AA at 12 weeks.
No. of
patients
No. of sessions (interval)
Results
20
1 in office, 60 at home (daily)
Mean Melasma Area and Severity Index (MASI) score improvement
of 9.9 in the serum plus microneedling group (P < .001) vs improvement from 7.1 in the serum alone group (P < .05).
60
3 (4 weeks)
36% improvement in MASI score in the TA alone group vs 44%
improvement in MASI score in the TA plus microneedling group.
More patients in the combined group had greater than 50%
improvement than in the TA alone group (41% vs 26%).
22
2 (4 weeks)
100% demonstrated “good to very good” results and reported
subjective satisfaction with treatment; 50% of patients maintained
skin lightening at 1-year follow-up.
25
1 session of microneedling plus
latanoprost, 9 sessions of NB-UVB
(3 times per week)
Equal repigmentation observed in paired experimental and control
lesions in 77% of lesions.
1
12 (2 weeks)
Per physician global assessment, there was 50% to 75% improvement
after 4 sessions and 75% to 90% improvement after 12 sessions.
13
1
92.3% had fair, good, or excellent response on physician and
patient global assessments. There was no recurrence at 4 months.
Results
115
7 / Biology of Microneedling
TABLE 7-4
Actinic keratosis treated with microneedling therapy
Authors (year)
Adjunctive therapy ± microneedling
Needle
depth
Torezan et al50
(2013)
Methyl aminolevulinate photodynamic
therapy (MAL-PDT) ± Dermaroller
1.5 mm
Split-face prospective
randomized controlled trial
Spencer and
Freeman51
(2016)
Delta aminolevulinic acid photodynamic
therapy (ALA-PDT) ± Eclipse MicroPen
Elite (Eclipse Aesthetics)
0.5 mm
Split-face, blinded prospective randomized controlled
trial
Bencini et al52
(2012)
MAL-PDT ± Dermaroller MC905
(Alpha Strumenti)
0.5 mm
Uncontrolled prospective
clinical trial
Study design
Adapted with permission from Iriarte et al.28
Melasma
In general, the enhanced transdermal drug absorption
seen with microneedling has achieved better results
when compared to the use of skin lightening agents
alone for the treatment of melasma.40,41,46,47 In a pilot
study on the topic, the use of depigmentation serum
containing 4-n-butylresorcinol and sophora-alpha
(prenylated flavonoids from the roots of Sophora
flavescens) alone was compared to its combination
approach with microneedling.40 It was reported that
the microneedling plus serum group displayed a significant increase in improvement when compared to the
serum group alone. In another study, the combination
of microneedling with sunscreen also led to favorable results in melasma therapy when compared to
sunscreen alone.42
Vitiligo
The efficacy of microneedling for the management
of vitiligo remains unclear. Stanimirovic et al investigated repigmentation of patients with resistant
bilateral symmetric vitiligo by comparing treatment
with narrowband ultraviolet B therapy and topical
0.005% latanoprost solution in combination with a
Dermaroller.43 No statistically significant difference
116
in repigmentation was reported between the groups,
displaying a low level of evidence for the use of
microneedling in this condition.43 Future research is
certainly needed.
Periorbital melanosis
The use of microneedling for the management of
periorbital hyperpigmentation has seen more positive results.44 Kontochristopoulos et al investigated
the use of microneedling in periorbital hyperpigmentation by treating 13 female patients with microneedling followed by 10% trichloroacetic acid peels.45 It
was reported that nearly all (92.3%) patients demonstrated significant improvement according to patient
global assessments. Transient side effects included
mild discomfort, edema, and erythema.
In summary, microneedling has demonstrated promising results for the management of melasma and
periorbital melanosis, most notably for darker-skinned
individuals. Limited data supports its use, however, for
the management of vitiligo. There remains a need for
randomized controlled studies with larger populations
to further explore the potential of microneedling as a
treatment for pigmentation disorders.
The Science Behind Microneedling
No. of
patients
No. of sessions
(interval)
10
1
Average AK clearance was 88.3% overall, but there was no statistically significant
difference in clearance rates between groups. The microneedling group showed
improvement in wrinkles and erythema and had greater improvement for all
measured parameters, including global score (P = 0.01).
19
1
Mean reduction in AK was 89.3% in the microneedling group vs 69.5% in the PDT
alone group (P < 0.05); 87% of patients in the microneedling group had noticeable
cosmetic improvement compared to 11% in PDT alone group.
12
3 (2 weeks)
100% demonstrated a complete response (grade 0, “excellent”) after 3 treatment
sessions; 83% remained without AK at 9-month follow-up.
Results
Verruca
Konicke and Olasz were one of the first to establish the
benefits of microneedling as a means for drug delivery
in verruca by demonstrating a complete cure rate in
three patients after an average of four treatments every
2 to 4 weeks.48 Notably, there was no tissue necrosis as seen with intralesional bleomycin, and patients
reported minimal pain. Comparatively, cure rates range
between 0% and 95% for intralesional bleomycin with
variability attributed to poor infiltration of the lesion.49
Microneedling has therefore been proposed as a viable
option for the treatment of plantar warts by enhancing
the delivery of bleomycin in lesions. More clinical trials
with a much larger sample size remain needed to elucidate the actual role of microneedling.
Actinic keratosis
Patients with actinic keratosis (AK) have demonstrated mixed results following microneedling as
an adjunctive therapy to currently accepted treatments28,50–52 (Table 7-4). In a split-face study, Torezan
et al evaluated the application of methyl aminolevulinate photodynamic therapy (MAL-PDT) compared to
its combination approach with microneedling in 10
patients.50 MAL-PDT combined with microneedling
(Dermaroller) had greater improvement than MAL-PDT
alone for all measured parameters, including photoaging and facial erythema (P = .01 for global score).
Spencer and Freeman utilized topical delta aminolevulinic acid PDT (ALA-PDT) in the treatment of AK
with and without microneedling.51 In their split-face
study, 20 patients with at least four nonhyperkeratotic
AK on each side of the face were randomly assigned
to either microneedling therapy with ALA-PDT or
ALA-PDT alone. A statistically significant improvement was found when microneedling was utilized,
with no additional side effects reported.51 The use of
microneedling for the treatment of AK was also evaluated in 12 organ transplant recipients, with 59 AK
patients unresponsive to classic PDT therapy.52 All
lesions demonstrated a grade 0 (excellent) response
after three sessions and were free of any new AK
lesions for at least 4 months.
In summary, microneedling has shown early promising results as an adjuvant therapy for the treatment
of refractory AK. Nevertheless, large controlled clinical
trials are needed to further evaluate various combination approaches.
117
7 / Biology of Microneedling
Discussion
While wrinkles are not considered a disease, they are
frequently associated with skin aging and undesirable
changes.
Microneedling, also referred to initially as collagen
induction therapy, has been proposed as a minimally
invasive nonsurgical and nonablative procedure for
facial rejuvenation.53 Microneedling is particularly
effective for the management of facial wrinkles of
the periocular and perilabial regions, cheeks, neck,
and décolletage. It has also been shown to stimulate
collagen production by creating microchannels into
the dermis and initiating a repair process. The three
phases of this wound healing process have been well
described by Falanga54:
1. Platelets and neutrophils release growth factors
such as TGF-β, platelet-derived growth factor,
connective tissue activating protein, and connective tissue growth factor, which increases the
production of intercellular matrix.
2. Monocytes then release growth factors to increase
the production of collagen, elastin, and glycosaminoglycans. Five days after injury, a fibronectin matrix forms with an alignment of fibroblasts
that determines the deposition of collagen, which
remains for 5 to 7 years and tightens naturally.
3. Gene and protein expression of collagen, glycosaminoglycans, and growth factors (vascular endothelial growth factor, epidermal growth factor,
fibroblast growth factor) are increased, which are
relevant for skin regeneration.
118
The two most common external factors associated with facial aging—sunlight and cigarette smoking—have been demonstrated to cause premature
skin aging, and both can be at least partially reversed
with microneedling.4 Smoking has been shown to
cause skin damage primarily by decreasing capillary
blood flow to the skin, which in turn creates oxygen
and nutrient deprivation in cutaneous tissues. Peto55
revealed that wrinkle scores were three times greater
in smokers than in nonsmokers. This result was even
more prominently demonstrated in a comparative
study of twins by Okada et al,56 who demonstrated
that facial wrinkles were significantly increased in the
smoking twin when compared with their nonsmoking
counterpart. For these patients (smokers), the use of
PRF is thought to provide additional benefit. Because
one of the main roles of PRF is to promote neoangiogenesis (see chapter 6), this would naturally most
benefit patients with reduced tissue blood flow such
as smokers. Future research is needed to further clarify
the potential of microneedling in smokers.25
It is important to note that to date, most studies
regarding microneedling have been case reports,
case series, or small randomized controlled trials.
For example, microneedling has also been utilized for
the treatment of stretch marks (Fig 7-13), yet very
limited scientific data is available on the topic. Future
large controlled clinical trials exploring the utility of
microneedling are imperative to provide validation
for this therapy. Furthermore, future research aimed
at determining the ideal number of sessions, needle
type, needle depth, and combination with or without adjunctive therapies such as radiofrequency or
bioelectric stimulation (see chapter 12) is needed.
Conclusion
a
b
c
d
FIG 7-13
(a) Clinical image demonstrating substantial and pronounced stretch marks. (b and c) This patient was treated with a combination of liquid PRF and microneedling as well as subcutaneous liquid PRF injection. (d) Note the clinical improvement following
four treatment sessions, though the stretch marks were still apparent and did not reach complete resolution.
Conclusion
This chapter provided an overview of microneedling treatment for facial wrinkles caused by external factors and
presented the Dermapen as an effective medical device
for the treatment of all skin types. The procedure offers
many advantages when compared to other modalities in
that it induces collagen production, resulting in thickening
of skin layers, and has less downtime and fewer potential
secondary complications such as depigmentation.
119
7 / Biology of Microneedling
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55. Peto J. That the effects of smoking should be measured in packyears: Misconceptions 4. Br J Cancer 2012;107:406–407.
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changes caused by smoking: A comparison between smoking and nonsmoking identical twins. Plast Reconstr Surg
2013;132:1085–1092.
121
8/
INJECTION
TECHNIQUES WITH
PLATELET-RICH FIBRIN
Catherine Davies
Ana Paz
Alireza Panahpour
Ana Cristina
Richard J. Miron
This chapter describes injection techniques with platelet-rich fibrin (PRF)
to augment and/or regenerate various facial tissues. The chapter begins
by providing an overview of the possible treatment approaches and then
presents site-specific injection techniques utilizing PRF. These injection sites
include the forehead, temples, periorbital region, nasolabial folds, perioral
region, chin, and jawline. Furthermore, recommendations for needle gauge,
length, and type are presented for each injection site. The specific anatomy
of each facial area is also presented prior to each injection site in order
to maximize learning and minimize potential complications. This chapter
establishes the framework for treatment approaches with PRF presented
in later chapters.
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8 / Injection Techniques with Platelet-Rich Fibrin
PRF Treatment Approach for Facial
Esthetics
Dermal stimulation and augmentation represent the
main facial treatment in esthetic medicine. Treatments primarily use a bioresorbable substance such
as hyaluronic acid. Numerous exogenous fillers may
also be used to obtain a fibrotic response at the dermal
level, resulting in volume augmentation. As biodegradable substances, these exogenous injectables can
have distinct disadvantages. They can cause transient
effects, such as persistent erythema, swelling and
encapsulation, granuloma formation, and sometimes
even chronic or delayed infections. Consequently,
physicians and esthetic dermatologists have sought
an autogenous source for soft tissue augmentation.
Autogenous PRF is an excellent source of growth
factors and fibrin because of its biologic properties and
endogenous origin (see chapter 6). Apart from its wide
applications in medicine, there is substantial clinical
evidence favoring its use in the esthetic field for the
stimulation of the superficial dermis as well as for the
deep layers of the dermis. For superficial stimulation, the
injection must be performed in the superficial dermis,
using a mesotherapy technique in order to enhance the
skin texture, glow, and hydration. When used as a filler,
PRF must be injected into the deep dermis or into the
subdermal tissues in a manner similar to the techniques
commonly used for fillers. This type of PRF application
augments the skin and increases its volume.
Side effects with PRF treatment are minimal but
can include the following:
• Pain in the injected area, headache, or a feeling of
heaviness of the head
• Swelling and redness
• Infection (though PRF is antimicrobial and in theory
minimizes chance of infection compared with
other modalities)
• Skin discoloration or bruising
• Bleeding
• Potential for cross-labeling of samples, which can
lead to serious side effects (eg, severe hypersensitivity reaction and transmission of disease) !
124
There are several contraindications to PRF treatment.
Absolute contraindications include the following:
•
•
•
•
•
•
•
Platelet dysfunction syndrome
Critical thrombocytopenia
Hemodynamic instability
Septicemia
Local infection at the site
Cancer, especially hematopoietic or bone
Patients unwilling to accept the risks
Relative contraindications include the following:
• Consistent use of NSAIDs within 72 hours of procedure
• Corticosteroid injection at treatment site within
1 month
• Systemic use of corticosteroids within 2 weeks
• Use of tobacco
• Recent fever or illness
• Patients who are pregnant or breastfeeding
Pretreatment Considerations
Ergonomics
Proper patient positioning and good lighting are
essential for an optimal treatment outcome and for
the comfort of both the patient and the practitioner.
A fully reclinable, height-adjustable treatment chair
is ideal (Fig 8-1).
Accessories
Certain aids can be used to assist the patient and the practitioner in the planning and treatment phases (Fig 8-2):
• Mirror: A handheld mirror should be used when
discussing treatment objectives and desired
outcomes with the patient.
• Skin markers: Surgical skin markers are useful to
identify key areas for injection.
• Cold packs: Cold packs are useful to manage posttreatment discomfort, pain, and bruising.
Pretreatment Considerations
FIG 8-2
The required tools and accessories are laid out on a sterile
tray prior to the blood draw and procedure.
FIG 8-1
Treatment should take place in a well-lit room, with a fully
reclinable, height-adjustable treatment chair and a good light
source.
FIG 8-3 ➤
A variety of needles (from left to right: 27G, 30G, 30G, 34G)
and cannulas (27G, 25G) for PRF injection.
• Topical anesthesia: A number of topical anesthetic options are available for esthetic treatments.
Always screen patients for any allergies or complications, and do not exceed recommended volumes
per treatment area (eg, 7% benzocaine, 21% to
23% lidocaine, and 7% tetracaine).
• Loupe glasses: Loupe glasses can be used by the
practitioner when doing close-up injections and
are useful to identify and avoid small blood vessels
while injecting.
• Needles and cannulas for injection: Both needles
and cannulas are essential tools for injection of PRF
(Fig 8-3). Each have their advantages and disadvantages based on the areas being treated (Table 8-1).
• Needles and syringes to draw PRF: A long, wide
bore needle (18G to 21G) is useful to draw up PRF
from tubes (Fig 8-4). Luer-Lok syringes are useful
for injecting.
• Stand for PRF: After centrifugation, tubes should
be kept as still as possible. A stable stand to hold
PRF tubes is very useful (Fig 8-5).
• Sharps container: Have your sharps container
close by for every stage of the treatment.
• Permanent marker pen: All blood specimens
must be clearly labeled.
• Vein light: A vein light is useful to identify veins
during phlebotomy as well as in facial areas of
injection.
125
8 / Injection Techniques with Platelet-Rich Fibrin
TABLE 8-1
Cannulas
Needles
Needles and cannulas for injection of PRF
Gauge
Penetration depth
Indications
30–33G
Superficial to medium depth:
intradermal, subdermal
BIO-PRF lift, surface irregularities,
concealment of atrophy-related
deficits, deep mesotherapy
27G (Alb-PRF
requires 25G)
Deep: subcutaneous, supraperiosteal,
supramucosal
Medium-depth augmentation, facial
contouring
18G
Withdrawal of PRF only!
Not for injecting
27G microcannula
Superficial to medium depth:
intradermal, subdermal
Lip surface regeneration mesotherapy,
skin surface regeneration mesotherapy
22–25G
Deep horizontal injections and
mobilization of tissue
Widespread volume projection, tissue
mobilization and homogenization, activation of fibrogenesis, tissue repair
➤ FIG 8-4
A large bore needle (18G) is used for drawing up PRF through
the lid of the tube.
FIG 8-5
A PRF stand is useful in order to stabilize the tube during PRF
withdrawal.
126
Pretreatment Considerations
Tips for successful PRF injections
PRF injections are time dependent!
• All treatment planning and discussions must take
place before blood is drawn.
• All equipment must be ready and in place once
blood is drawn.
• Ensure that the centrifuge is in close proximity to
the patient and switched on.
• After blood withdrawal, insert the tubes into the
centrifuge within 90 seconds.
• The only activity that should be left to complete
after withdrawal of blood is removal of topical
anesthesia from the patient.
• After spin completion, allow the PRF to rest in the
centrifuge for a few seconds before removing the
tubes.
• Once removed from the centrifuge, place the tubes
in a stand to prevent shaking (see Fig 8-5).
• Extract PRF without removing the cap on the tube
(as reviewed in chapter 6) to minimize oxygenation, which will speed clotting.
• Be sure to get the bottommost layer of PRF and
about 0.1 to 0.3cc of the red cell layer.
• Inject PRF into the patient as soon as possible to
avoid clotting.
Types of PRF used for injection
There are two types of PRF that can be used for injection: liquid PRF and Alb-PRF (heated plasma; see chapter 12). For liquid PRF, the horizontal centrifuge should
be used at 300g for 5 minutes. This creates a cell-rich
layer with growth factors (Fig 8-6). For Alb-PRF, the
Bio-Heat (BIO-PRF) protocol is used: 2200 RCF (relative centrifugation force) for 8 minutes with white
tubes. Remove the upper layer and heat at 75°C for
10 minutes, then reconstitute with the cell-rich layer.
This material is used when a higher volume and “filler”
type of effect is needed (Fig 8-7). See chapter 12 for
more information about this new and exciting formulation of PRF.
FIG 8-6
PRF liquid ready for injection.
FIG 8-7
Alb-PRF ready for injection.
Global versus regional approach
Treatment may be approached globally as a method to
improve the general appearance of the skin (BIO-PRF
lift) or with a regional approach whereby each area
is assessed and treated separately (Box 8-1). Optimal
results occur when a combined approach is used. For
same-day treatments, it is advised to always start
with injections requiring the smallest-gauge needles
because time is limited by clotting.
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8 / Injection Techniques with Platelet-Rich Fibrin
BOX 8-1
Global versus regional approach
Global approach (BIO-PRF lift)
“BIO-PRF lift” is a treatment aimed at regenerating the overall quality of the skin using PRF.
This approach usually uses mesotherapy techniques aimed at improving the skin appearance,
elasticity, texture, and homogeneity (face, neck,
décolletage, hands).
Techniques used:
• Collagen induction therapy (CIT)
(see chapter 7)
• BIO-PRF techniques
• Papule
• Nappage
• Deep mesotherapy
• These are best for entire skin of the face,
neck, décolletage, hands, and body skin
(such as knees)
Most techniques are safe and minimally
invasive.
Regional approach (by facial zone)
The techniques performed to volumize and
reshape the skin, thereby augmenting the skin
and/or increasing its volume, may be done per
area following a regional approach. Each area is
addressed separately, and a choice of cannula
vs needle, needle gauge size, and injection technique is specific to each area. An in-depth understanding of the anatomy of each area is needed.
Techniques used:
The regions are addressed by needle or cannula
and varying injection techniques. Areas are
divided into:
•
•
•
•
•
•
128
Forehead
Temples
Periorbital region
Nasolabial folds
Perioral region
Chin and jawline
FIG 8-8
With the BIO-PRF lift, small amounts of PRF are administered
over the entire treatment area.
PRF Global Approach (BIO-PRF Lift)
Findings support the notion that an individual’s
perceived skin health is an important determinant of
attractiveness.1,2 As a result, improving the smoothness of skin and eliminating fine lines irregularities
such as blemishes, wrinkles, uneven pigmentation,
and large pores are a very important part of addressing
the esthetic patient.
In the age of selfies, patients strive for flawless skin more than ever.
The BIO-PRF lift is a treatment aimed at regenerating the overall quality of the skin using
mesotherapy techniques or microneedling to
administer PRF. Mesotherapy was developed by
French physician Dr Michel Pistor3 in the early 1950s
to treat conditions such as rheumatology, sports traumatology, and infectious and vascular diseases. Mesotherapy is an injection and treatment technique now
used in esthetic medicine for various skin conditions.
The benefit of mesotherapy is that small amounts of
PRF are in direct contact with the target tissue, thereby
increasing therapeutic effects.
Various materials can be used for the BIO-PRF lift,
from simple needles to sophisticated automated
PRF Global Approach (BIO-PRF Lift)
TABLE 8-2
Types of mesotherapy injections
Depth
Substance
Description
Intraepidermic
PRF: This technique can be carried
out over the whole treatment area or
focused on the problem areas.
Multiple superficial injections into the
epidermis less than 1 mm in depth
(superficial nappage). This effect is
retarded with minimal to no bleeding, and minimal to no pain. The needle
used is 30G to 32G and 4 to 12 mm in
length. The bevel is directed upward,
but only the bevel goes into the skin.
Superficial intradermal
“papule”
PRF: This technique can be carried
out over the whole treatment area or
focused on the problem areas.
Intrabasal layer injection forming
multiple papules 1 to 2 mm in depth
delivering less than 0.1 mL of PRF per
point. The needle used is 30G and 4 to
12 mm in length. The bevel is directed
upward, creating blanching of the skin
to form a papule.
Deep mesotherapy
PRF or extended PRF (e-PRF): This
technique can be carried out over the
whole treatment area or focused on
the problem areas.
Multipricking technique to depths
of 2 to 4 mm. The effect is semiretarded. The needle used is 30G and 4
mm in length.
injection systems. Whatever the preferred method
of injection, it consists of two successive stages: (1)
preparation of the cutaneous surface prior to injection
and (2) penetration of a small quantity of PRF (Fig 8-8).
PRF injection techniques should be adapted according to indication, pathology, severity of the skin condition, and age of the patient. In general terms, PRF can
be administered using three different techniques of
injection that treat the skin at different levels (Table
8-2): the epidermal level; the superficial intradermal
level, known as papules (Fig 8-9); and the intradermic or subdermal (deep injection). These techniques
serve different purposes because they reach different
depths of the skin. Depending on the patient and the
quality of his or her skin, we should use one, two, or
all three of these techniques.4
FIG 8-9
The appearance of a papule demonstrates good intradermal
technique.
129
8 / Injection Techniques with Platelet-Rich Fibrin
Before treatment can begin, a few steps must be
taken:
• Patient evaluation, history, and examination
• Diagnosis of areas requiring treatment or that
could benefit from treatment
• Setting of goals and discussion of the treatment
plan (ie, the amount of sessions and interval
between them)
• Informed consent
• Patient education: The patient must present for
treatment with clean skin free of makeup or any
creams or lotions. Blood-thinning medication
should be avoided if possible for 10 days prior to
treatment and 4 days postoperatively.
Treatment procedure
1. Local anesthesia: Apply local anesthetic cream
to the face, neck, and décolletage of sensitive
patients 30 to 60 minutes before the procedure.
Alternatively, the patient could apply the cream
at home 1 hour before the procedure. The hands
may also be treated in this way. It is preferable not
to inject local anesthesia because it may have an
inhibiting effect on growth factor signaling due to
pH changes and create additional volume change
prior to injecting the PRF. The procedure is well
tolerated with topical anesthesia.
2. Cleansing: Cleanse the skin of any creams or
makeup remnants. Reclean the skin of the treated
areas with chlorhexidine in water. Apply a headband or cap to the patient’s head to keep hair out
of the treated area.
3. Draw blood and prepare PRF.
4. Draw up PRF: Draw the PRF up into the syringe
and use quickly via one or a combination of the
mesotherapy techniques. It is important to inject
first and then microneedle, as PRF needs to pass
through a small-gauge needle before the clotting
cascade begins.
5. Rub any leftover PRF into the skin.
130
BOX 8-2
Regions of the face
Upper face
• Temples
• Forehead
• Glabella
• Periorbital
• Upper eyelid
• Lateral
canthus
• Tear trough
Midface
• Cheek
• Cheekbone
• Skin
• Nasolabial
folds
Lower face
• Perioral
• Marionette
lines
• Chin
• Jawline
With the BIO-PRF lift, the initial treatment phase
consists of three treatments spaced 1 month apart.
The maintenance phase is then one session every 6
months. Before the patient leaves the office the day of
their first treatment, follow-up appointments should be
scheduled and the patient should be given guidelines
on the suggested course of treatment.
Regional PRF Injections
Regional PRF injections are indicated to augment the
features of patients using minimally invasive injection
and cannula techniques.
PRF is a safe and reliable treatment option for soft
tissue rejuvenation and dermal augmentation, with the
ability to restore lost volume over time. Although it will
not replace dermal fillers in esthetic practice, it is an
effective alternative for patients who might feel they
are too young for dermal fillers or for those who would
prefer a more natural approach. With this approach,
the face is divided into several regions (Box 8-2), and
treatment is customized by region for each patient.
This approach often uses a combination of techniques,
including superficial augmentation techniques, horizontal cannulas, and vertical augmentation.
Understanding Facial Anatomy for Injections
Understanding Facial Anatomy for
Injections
Before planning any regional injections of the face,
it is critical to understand the relevant anatomy of
the underlying structures (see chapter 2). First,
certain areas of the face are at higher risk of unforeseen complications due to underlying structures of
the skin (ie, blood vessels and nerves). Second, one
needs to understand the subtle 3D manifestations of
aging, which reflect the combined effects of gravity,
progressive bone loss, decreased tissue elasticity, and
redistribution of subcutaneous fullness.
It is important for clinicians to understand
and avoid areas at risk of vascular injury AND
to understand and address the underlying
anatomy of aging (by region).
To maximize safety during facial injections, the
authors have outlined six different facial danger zones
(Fig 8-10):
• Glabella: Area of highest risk because the vessels
are small and do not have a good source of collateral circulation.6
• Temple
• Nose angular artery (extension of the facial artery):
Provides blood to the medial cheek, nasal ala and
side wall, and dorsum of the nose. Care should
be exercised when injecting near the alar groove
because excessive compression with large volumes
of material or direct injection into the vessel can
lead to necrosis of the nasal ala, nasal tip, nasolabial fold, and upper lip.7
• Perioral area
• Infraorbital region
• Nasolabial fold
Understanding the vascular “danger
zones”
Certain zones of the face are identified as being at
higher risk for complications following injections due
to the vessels and nerves that lie beneath the skin.5
The most severe potential complication associated
with the use of dermal fillers and volume enhancers
is arterial/venous occlusion, which leads to ischemia,
with subsequent necroIf PRF is combined with any form of
sis of the skin
filler, there is a risk of arterial/venous
and/or vision
occlusion, and all filler safety protol oss. W h i l e
cols should be adhered to.
this is less of a
concern when injecting pure PRF, care must still be
taken not to cause vascular or nerve injury by introduction of the needle or by external compression of
the blood supply by the surrounding PRF or swelling.
It is very important to note that if PRF is combined
with any form of filler, there is a risk of arterial/venous
occlusion, and all filler safety protocols should be
adhered to.
FIG 8-10
The facial arterial/venous system and “danger zones” marked
on a live model.
131
8 / Injection Techniques with Platelet-Rich Fibrin
Bearing in mind the depth and the location of the
vasculature within each zone, practitioners can plan
injections to avoid vascular injury.
Practical tips when injecting near the
“danger zones”
Upper Face
Temple
Anatomy of the temple region
Sound knowledge of facial anatomy, especially the
key arterial and venous structures that are vulnerable to damage, and an understanding of how aging
affects the location of these anatomical structures are
essential when injecting any area of the face. It is also
wise to remember that nerves and vessels may be in
atypical anatomical positions. Each injection entails
some degree of risk, and all of the potential complications should be in the informed consent document
signed by the patient. In addition, the most frequent
and significant adverse events should be discussed
before the procedure.
That being said, there are some specific actions that
can be taken to decrease the potential of complications of this nature from occurring:
The temple is a juncture where four skull bones fuse
together—the frontal, parietal, temporal, and sphenoid bones—forming the temporal fossa (Fig 8-11).
The temporalis muscle covers the expanse of the
temporal fossa. It originates from the coarse surface
of the temporal bone and inserts onto the coronoid
process and inferiorly onto the anterior border of the
mandibular ramus.
The temporalis muscle receives its nervous supply
from the mandibular division of the trigeminal nerve.
The superficial temporal artery lies within the temporoparietal fascia starting at the root of the helix and
travels superficially to above the lateral eyebrow.
• Be aware of the pertinent anatomy outlined in the
danger zones.
• Always aspirate before injecting.
• Inject in a retrograde fashion where possible.
• Use small syringes and inject small aliquots of PRF
at a time.
• Avoid using anesthesia near a vascular bundle,
which may induce vascular spasm, as anesthetics containing epinephrine can mask this vascular
spasm.
• Use the smallest-gauge needle possible to slow
the flow of product.
• Use a cannula where appropriate.
• Pinch/tent the skin to provide more space between
superficial branches of main arteries and to move
away from underlying vasculature.7
• Assess the level of pain during injection.
• Use a vein light to assist in identifying major
vessels.
• Use extreme caution when injecting areas of previous trauma or scarring.
The temporal region has minimal superficial fat. As we
age, atrophy-related loss of the deep temporal fat pad
results in volume loss of the temples (Fig 8-12). This
hollowing leads to a wasted or emaciated appearance,
causing blood vessels that are numerous in this region
to become more visible. Loss of volume in the temple
area can also result in drooping of the eyebrow tail due
to loss of support.
132
Aging of the temple
Anatomical high-risk zones of the
temple !
The superficial temporal artery and vein course in a
superficial plane, giving off a frontal branch that leads
up toward the superior lateral orbital rim, eventually
anastomosing with the supraorbital artery. Thus, deeper
injections are preferred. However, deeper injections risk
injury to the middle temporal vein, which lies just deep
to the superficial layer of the deep temporal fascia8 (Fig
8-13). For these reasons, knowledge of pertinent anatomy is critical to avoid vascular injury when injecting PRF.
Temple
Temporoparietal fascia
(cut fascia)
Temporalis fossa
skull bones
Frontal bone
Superficial temporal vessels
(parietal branch)
Temporalis muscle
Parietal bone
Sphenoid bone
Temporal bone
Superficial temporal vessels
(frontal branch)
Auriculotemporal nerve
branch of CN V3
Temporal branch of CN VII
Zygomatic arch
Coronoid process
Deep temporal nerve
(from mandibular branch of
trigeminal nerve)
FIG 8-11
Anatomy of the temple
region.
FIG 8-12
The temple area may
form hollows (circled) as
volume is lost with age.
133
8 / Injection Techniques with Platelet-Rich Fibrin
Temporoparietal fascia
(cut edge)
Temporal fusion line
Superficial
temporal
vessels
(frontal
branch)
Supratrochlear vessels
Supraorbital vessels
Injection zone
Superior lateral orbital rim
Middle temporal vein (deep to superficial
layer of deep temporal fascia)
Zygomatic arch
External carotid vessels
Temporal branch of CN VII
FIG 8-13
High-risk zones when injecting the temple.
Technique: Vertical supraperiosteal depot technique.
The clinician gathers up the skin with the noninjecting
hand for maximum penetration and pierces the skin at
the thinnest entry point using a 90-degree angle at the
level of the bone. Maintain the tip of the needle on the
bone for a slow injection. Maintain pressure on the area
after injection to prevent bruising.
Safety tips:
• Turn the patient’s head medially to help
highlight superficial veins, which can then
be avoided.9
• Digitally palpate for the pulse of the superficial temporal artery in order to avoid it
completely.
• Use the suggested insertion point.
• Inject on supraperiosteum.
Treatment of temple hollows
Treatment of this region aims to restore volume in the
hollowed temporal region using e-PRF or Alb-PRF with
deep vertical injection at the supraperiosteal level.
134
Substance: Alb-PRF
Entry point: 1 cm up the temporal crest and 1 cm laterally following the supraorbital ridge (Fig 8-14).
Volume: 0.5 mL
Tool: 25–27G needle
Temple
1 cm
1 cm
b
FIG 8-14
a
Treatment steps
1. Apply local anesthetic cream prior to treatment
(optional).
2. Remove makeup and/or anesthetic thoroughly.
3. Disinfect the area.
4. Inject PRF.
5. Massage the injected PRF into the area for even
distribution.
6. Inform the patient about aftercare instructions.
7. Arrange a follow-up appointment.
Combined treatment options
Medical microneedling can be performed in conjunction with PRF injections to maximize the therapeutic
effect. For patients with a wasted appearance, suggest
a nutrient-rich diet.
(a) Preferred point of entry when injecting the temple via a
vertical supraperiosteal depot technique. (b) Safest entry
point for PRF injection into the temple. Avoid visible veins.
Complications
Bruising may occur, because this area is highly vascular. The sentinel vein may become dilated and more
visible for up to 7 days posttreatment.
Practical tips:
• Care should be taken to avoid vessel injury
in this highly vascular region. Vertical
injections should be done at the supraperiosteal plane in the safe zone.
• Patients whose body mass index is too low
are prone to temporal wasting.
135
8 / Injection Techniques with Platelet-Rich Fibrin
Forehead
Aging of the forehead
Anatomy of the forehead region
The combination of fixed glabellar frown lines, fixed
transverse forehead rhytids, a skeletonized supraorbital
rim, and a relative excess of upper eyelid skin is responsible for creating the impression of upper facial aging
(Fig 8-16). Progressive aging brings a loss of subcutaneous fullness to the forehead and accentuates the
underlying anatomical structures. Horizontal forehead
lines are a common esthetic concern, particularly when
they are visible at rest. Expression of emotion such
as surprise alongside photodamage leads to elastotic
changes that result in static forehead wrinkles.
The epicranius muscle consists of the occipitofrontalis
muscle and the temporoparietal muscle. Upon contraction, the epicranius raises the eyebrows, producing horizontal lines across the forehead. There are no deep fat
pads located beneath the epicranius muscle, and the
superficial fat layer is minimal (Fig 8-15).
Epicranius muscle
Occipitofrontalis muscle
Supraorbital artery
Temporoparietal muscle
Supratrochlear artery
Superficial temporal artery
(frontal branch)
Corrugator crease
FIG 8-15
Anatomy of the forehead region.
136
Forehead
Anatomical high-risk zones of the
forehead
The blood supply to the frontalis muscle comes from
the frontal branch of the superficial temporal artery
laterally and the supratrochlear and supraorbital
arteries medially. The supratrochlear artery travels
beneath the corrugator and frontalis muscles, with
the surface landmark being the corrugator crease.
As it courses upward through the frontalis muscle,
the supratrochlear artery becomes more superficial
and is directly beneath the skin. It is this superficial position of the central forehead vessel that may
contribute to reported complication risks. When
placing PRF injections here, the needle needs to stay
very superficial, almost in an intradermal plane, to
avoid injection into the supratrochlear or supraorbital
vessels. When injecting for fine lines in the forehead,
a more superficial plane should again be used to
avoid vascular insult.
Treatment of the forehead
Botulinum toxin type A (Botox, Allergan) treatment
is aimed at smoothing out the horizontal lines on the
forehead that persist at rest, whereas PRF treatment is
FIG 8-16
The aging forehead shows horizontal
lines on expression and at rest.
137
8 / Injection Techniques with Platelet-Rich Fibrin
aimed at regenerating the area, thereby improving fine
lines and rhytids and regenerating volume between
muscle and skin.
Technique: Retrograde linear threading injections
along the forehead lines (intradermal; Fig 8-17). Skin
may be gently compressed by an assistant to accentuate the line.
Direction of needle
when injecting
FIG 8-17
Substance: PRF
Entry point: Inject along horizontal forehead lines.
Retrograde injection of horizontal lines on the forehead using
linear threading.
Volume: Small aliquots per line
Tool: 30G needle; bevel must face upward.
Glabella
Treatment steps
1. Apply local anesthetic cream prior to treatment
(optional).
2. Remove makeup and/or anesthetic thoroughly.
3. Disinfect the area.
4. Inject PRF.
5. Massage the injected PRF into the area for even
distribution.
6. Inform the patient about aftercare instructions.
7. Arrange a follow-up appointment.
Combined treatment options
If the mentalis muscle is overactive, Botox can be
injected. Medical microneedling can also be performed
in conjunction with PRF injections to maximize the
therapeutic effect.
Complications
Bruising may occur.
Practical tip:
Injection of Botox 1 to 2 weeks prior to PRF
treatment creates optimal outcomes.
138
Anatomy of the glabellar region
The glabella is an extremely expressive region and
often expresses negative emotions of disagreement
or unhappiness. The procerus muscle, together with the
corrugator supercilii muscle, draws the medial aspect
of the brow down toward the root of the nose, thus
producing the transverse lines in the glabella. The corrugator supercilii muscle, together with the depressor
supercilii muscle, draws the medial aspect of the brow
medially and down toward the root of the nose, thus
producing the vertical lines in the glabella (Fig 8-18).
Aging of the glabella
In youth, the subcutaneous fullness of the forehead
conceals the muscles of facial expression in the glabellar region. As this fullness between the muscles and
the skin disappears with age, the intrinsic tone of the
glabellar, procerus, and frontalis muscles gives rise to
fixed wrinkles or folds. Contraction of the procerus,
corrugator supercilii, and depressor supercilii muscles
contribute to glabellar lines, which often resemble the
number 11 (Fig 8-19).
Glabella
Procerus muscle
Depressor supercilii muscle
Corrugator supercilii muscle
1
3
2
FIG 8-18
Anatomy of the normal glabella. Frown lines are
caused largely by the contraction of three muscles: (1) procerus, (2) corrugator supercilii, and
(3) depressor supercilii.
FIG 8-19
The aging glabella shows horizontal and
vertical lines.
139
8 / Injection Techniques with Platelet-Rich Fibrin
Superficial temporal
artery (frontal branch)
Supraorbital artery
Supratrochlear artery
Dorsal nasal artery
Ophthalmic artery
Zygomaticotemporal artery
Angular artery
Superficial temporal artery
Optic nerve
Zygomaticofacial artery
Transverse facial artery
Superior labial artery
Facial artery
Infraorbital artery
Internal carotid artery origin
External carotid artery origin
FIG 8-20
Danger zones of the glabellar region.
Anatomical high-risk zones of the
glabellar region !
In multiple reviews, the glabella was the most common
filler injection site leading to visual loss.
Extreme caution should be taken when
injecting any substance into this area.10
The supraorbital, supratrochlear, dorsal nasal, and
angular arteries anastamose in the nasoglabellar
region to form a vascular arcade (Fig 8-20). Intravascular cannulation can create retrograde propagation of
a foreign body to the ophthalmic artery. The arteries
quickly become superficial after exiting the orbit and
closely abut rhytids.
Safety tips:
• Only use intradermal injections—stay
superficial!
• Apply digital pressure during injection
along the rim of the brow to occlude the
supraorbital and supratrochlear vessels to
prevent backflow.
140
Treatment of the glabellar region
The aim of PRF injection in this area is to achieve
a gentle masking effect of the static glabellar lines
(“number 11”). Dynamic glabellar lines are best treated
with Botox 1 week after PRF treatment. Fine rhytids in
the glabellar region can be treated with intradermal
PRF injections (Fig 8-21).
Technique: Serial point injections into glabellar lines,
staying superficial (ie, intradermal). Ask the patient
to frown to accentuate these lines. Apply pressure to
occlude the supraorbital and supratrochlear vessels.
Serial puncture
Static needle
Substance: PRF
Entry point: Multiple small points along the glabellar
lines.
Volume: Small aliquots per line
Tool: 30G needle; bevel must face upward.
Periorbital Region
FIG 8-21
Superficial injections of the glabellar region.
Treatment steps
1. Apply local anesthetic cream prior to treatment
(optional).
2. Remove makeup and/or anesthetic thoroughly.
3. Disinfect the area.
4. Inject PRF.
5. Massage the injected PRF into the area for even
distribution.
6. Inform the patient about aftercare instructions.
7. Arrange a follow-up appointment.
Combined treatment options
If the procerus and corrugator supercilii muscles
are overactive, Botox can be injected 1 week after
PRF treatment. Medical microneedling can also be
performed in conjunction with PRF injections to maximize the therapeutic effect.
Complications
Bruising may occur because this area is highly vascular.
Practical tip:
Injection of Botox 1 to 2 weeks prior to PRF
treatment creates optimal outcomes.
Periorbital Region
Nonsurgical cosmetic treatments in the periorbital
region are becoming more common. However, this is
a complex anatomical region that must be known well
to avoid complications such as chronic lymphedema,
bruising, embolisms, infection, the periodontal pocket
effect, or nodules. Changes in skin thickness, laxity,
hyperpigmentation, and actinic changes also play a
role, so global skin regeneration (such as the BIO-PRF
lift) will contribute positively to the overall improvement. Thin skin or prominent subcutaneous venous
pooling accentuates the periorbital darkening.
141
8 / Injection Techniques with Platelet-Rich Fibrin
Orbicularis oculi muscle
Supraorbital nerve
perforation branch
Supratrochlear nerve
perforation branch
Retro-orbicularis oculi fat pad (ROOF)
Lacrimal nerve perforation branch
Lateral external canthus
Medial limbus of iris
Suborbicularis oculi fat pad (SOOF)
(lateral portion)
Infraorbital nerve
perforation branches
Suborbicularis oculi fat pad (SOOF)
(medial portion)
Area of lacrimal groove
FIG 8-22
Anatomy of the periorbital region.
Anatomy of the periorbital region
Aging of the periorbital region
The supraorbital region does not contain significant
quantities of superficial fat (Fig 8-22). As such, the
orbicularis oculi muscle lies directly under the skin.
Upon contraction of the orbicularis oculi muscle (eg,
when smiling), radial lines from the lateral canthus
radiate as far as into the cheek itself. Below the
musculature, a deep fat pad is found, known as the
retro-orbicularis oculi fat pad (ROOF). In youth, it
forms the volumizing and supporting soft tissue base
of the supraorbital region.
The suborbicularis oculi fat pad (SOOF) is located
behind the orbicularis oculi muscle and is divided into
a medial portion and a lateral portion. The medial
SOOF extends from the medial limbus of the iris to the
external canthus, while the lateral SOOF runs from the
external canthus to the temporary fat compartment.
The lower limit of the SOOF is the lacrimal groove. The
deep medial cheek fat compartment (DMC) corresponds to the medial edge of the SOOF. The DMC atrophies during aging, making the transition between the
orbital fat compartments more noticeable.
The periorbital region is one of the first areas to be
affected by the aging process (Fig 8-23). There are
many signs of aging in this area, including the appearance of periorbital wrinkles, a deep lacrimal groove, a
visible palpebromalar groove, palpebral bags, excess
skin in the upper eyelid (blepharochalasis), malar bags,
a loss of skin elasticity, and a downward tilt in the
external canthus.
142
Upper eyelid hollows and skin laxity
With age, the ROOF slowly diminishes due to a combination of decreased perfusion alongside tissue atrophy. This results in reduced tissue forces in the entire
complex and leads to visible laxity and sagging in this
region. Below the supraorbital foramen, advancing fat
atrophy leads to supraorbital hollowness.
Lateral canthal lines
The region around the lateral aspect of the eyes
is a dynamic area responsible for communicating
emotions, with the resultant formation of dynamic fine
lines with time. With progressive aging these wrinkles
may become static, which can be a significant esthetic
concern for many patients.
Periorbital Region
a
b
FIG 8-23
(a and b) The aging periorbital region shows palpebral bags and
periorbital wrinkles.
Tear trough deformity and palpebromalar groove
Tear trough deformity is a major concern in a lot of individuals seeking periorbital rejuvenation. A prominent
tear trough deformity is characterized by a sunken
appearance of the eye that results in the casting of a
dark shadow over the lower eyelid, giving the patient
a fatigued appearance despite adequate rest, and is
refractory to attempts at cosmetic concealment. The
tear trough deformity is a natural consequence of the
anatomical attachments of the periorbital tissues.
Anatomical high-risk zones of the
periorbital region !
When filling a tear trough, consideration must be given
to two main arteries: the infraorbital artery and the
angular artery. The infraorbital foramen is easily located
medial to the pupillary line and approximately 1 cm
from the infraorbital rim. The angular artery, a branch
of the facial artery, runs along the inner canthus of
the eye and anastomoses with the supratrochlear and
supraorbital arteries; lesions to these arteries must be
avoided.11 An infraorbital hematoma will increase pressure on soft tissue and may trigger a lymphatic insufficiency and malar lymphedema. An embolism in the
angular artery could have catastrophic consequences
if it causes an occlusion of the ophthalmic artery or
central retinal artery, which could cause a rare but very
serious complication such as blindness.
FIG 8-24
Avoid injections medial to the medial canthus, as they could
cause injury to the infraorbital or angular artery.
Safety tips:
• Use the suggested insertion point.
• Avoid injections medial to the medial
canthus (Fig 8-24).
• Use a cannula.
Treatment of the periorbital region
Most patients require restoration of volume of the
orbit as part of an overall rejuvenation strategy. This
involves addressing upper eyelid hollows and skin
laxity, lateral canthal lines, and tear trough deformity
and palpebromalar groove.
Treatment of lateral canthal lines (crow’s feet)
This treatment is indicated in patients with static
wrinkles or with thinner periorbital skin. The aim of
the treatment is to regenerate the superficial dermal
plane to improve the lateral canthal lines or regenerate
and thicken the skin.
143
8 / Injection Techniques with Platelet-Rich Fibrin
Technique: Serial point injections into lateral canthal
lines at an intradermal level (Fig 8-25).
Serial puncture
Static needle
Substance: PRF
Entry point: Lateral to orbital rim (place finger on
rim); 3–5 injection points per wrinkle.
Volume: Small aliquots per site
Tool: 30–32G needle; bevel up
Treatment steps
1. Apply local anesthetic cream prior to treatment
(optional).
2. Remove makeup and/or anesthetic thoroughly.
3. Disinfect the area.
4. Inject PRF.
5. Massage the injected PRF into the area for even
distribution.
6. Inform the patient about aftercare instructions.
7. Arrange a follow-up appointment.
Combined treatment options
Botox may be administered into the orbicularis oculi
muscle 1 week after PRF injections. Microneedling is
useful in cases of actinic elastosis. In the case of fat
atrophy, injection of fillers or fat augmentation of the
temples and lateral cheeks is recommended.
Complications
This vascular area is prone to bleeding. Use smallgauge needles with the bevel facing upward. Bruising
and swelling may occur.
144
FIG 8-25
Injections for crow’s feet. The skin is gently stretched until
the wrinkle remains just visible, and small aliquots of PRF are
injected intradermally.
Practical tips:
• This area is prone to swelling. Advise the
patient about downtime.
• To accurately inject into these lines,
perform Botox injections 1 or 2 weeks
after PRF treatment. (If done prior, the
lines will not be visible.)
Treatment of tear troughs
The choice between cannula and needle depends
on physician preference, but generally less bruising
and ecchymosis occur with cannulas. The cannula
technique is therefore recommended for filling tear
troughs and palpebromalar grooves.
Periorbital Region
Technique: Deep cannula technique. From the entry
point, resistance to the passage of the cannula should
be noted; the cannula is moved medially, injecting small
amounts in a fan shape using the retrotracing technique (Fig 8-26). The same entry point can be used
laterally for the palpebromalar groove.
Tear trough
Palpebromalar
groove
Orbital rim
Infraorbital
foramen
1–2 cm
a
Substance: PRF or Alb-PRF for deep hollows
Entry point: Located by drawing a line down from the
lateral canthus of the eye to approximately 1–2 cm
below the inferior orbital rim. This is an anatomical safe
zone. From this point of entry, both the tear trough and
the palpebromalar groove can be filled12 (see Fig 8-26a).
Volume: 0.5 mL per side
Tool: 25G 50-mm cannula
Practical tips:
• Injections must be at a supraperiosteal
level of the orbital rim under the defect.
• One should be cautious around the infraorbital foramen.
• Start by treating the midface; this
improves the appearance of tear troughs
and also reduces the risk of complications,
which are difficult to treat.
• Tape the area overnight to reduce postoperative swelling.
• It is preferable to repeat the treatment
after 1 month if more volume is needed.
• It is also advisable not to inject medially in
the inner canthus to avoid lesions to the
angular vessels.
b
FIG 8-26
(a) The insertion point for treatment of the tear trough and
palpebromalar groove is approximately 1 to 2 cm below the
inferior orbital rim. (b) The cannula is inserted into the deep
layer (it should pass through this resistant layer until it reaches the safe supraperiosteal layer). The cannula is then moved
medially, injecting small amounts in a fan shape using the retrotracing technique. The cannula is removed, and from the
same entry point it is reinserted laterally at the supraperiosteal level to fill the palpebromalar groove in a similar way.
145
8 / Injection Techniques with Platelet-Rich Fibrin
Midface
Aging of the cheek
Aging of the lower cheek is characterized by volume
loss and dermal laxity, which makes the underlying
bony structures become more prominent. With aging,
atrophy of the SOOF results in perceived swelling
of the malar fat pad, which is situated more superficially. When the zygomaticus minor and major
muscles contract with facial expressions, especially
when smiling, the area is further projected. The true
buccomaxillary ligament anchors onto the cheekbone; age-related atrophy of the soft tissue base can
enhance skin retraction where the ligament is located
and as a result lead to a visible groove.
The midface consists of the cheek and the nasolabial fold.
Cheek
Anatomy of the cheek
A prominent lateral cheekbone is considered an
attractive and youthful feature of the face. The zygomatic bone forms the most prominent element of
the midface. It is covered with volumizing fat layers,
including deep fat as well as the more superficial fat
layer (Fig 8-27).
SOOF
Zygomatic
prominence
True buccomaxillary
ligament
Zygomatic section
*
Malar fat pad
(superficial)
Medial cheek fat
compartment
*
*
Nasolabial fat
compartment
*
Zygomaticus minor muscle
Zygomaticus major muscle
Nasolabial sulcus
Masseter muscle
*
True buccomaxillary
ligament
Masseteric section
FIG 8-27
* Deep fat compartments
146
Midface anatomy showing the
SOOF and zygomaticus minor and
major muscles.
Cheek
Zygomaticofacial foramen,
nerve, and artery
Zygomatic
prominence
Infraorbital
foramen,
nerve, and
artery
Angular
artery
Transverse
facial artery
Parotid
gland
Zygomaticus
minor muscle
Parotid duct
Zygomaticus
major muscle
Buccal branch
of facial nerve
Buccinator
muscle
Risorius muscle
Masseter
muscle
Facial artery
FIG 8-28
FIG 8-29
Danger zones of the midface.
Draw intersecting lines from the ala of the nose to the tragus
and from the lateral canthus to the corner of the mouth. Deep
supraperiosteal injections can be made in the upper outer
quadrant to volumize and beautify the cheek area.
Anatomical high-risk zones of
the cheek !
When treating this region, one needs to be aware of a
number of areas where there is a potential for damage
of anatomical structures. The blood vessels at risk
include the transverse facial artery, which has a variable course and is at risk in all areas of the cheek. The
zygomaticofacial artery is at risk during cheekbone
augmentation. Finally, the facial artery can be compromised if it is more lateral than anticipated and affected
within the submalar hollowing. In addition, structures that pass through the infraorbital foramen—
an opening in the maxillary bone just below the infraorbital margin—must be considered, including the
infraorbital artery, vein, and nerve. Other structures
at risk in the subzygomatic area include the parotid
gland, parotid duct, and buccal branch of the facial
nerve (Fig 8-28).
Treatment of the cheek area
The aim of treatment in the cheek area is to beautify
the cheekbone region, restore youthful volume to the
anterior cheek, provide lift within the subzygomatic
area, and cause a decrease to the nasolabial fold.
Prior to injections in this area, draw intersecting
lines from the alar groove of the nose to the top of
the tragus of the ear and one from lateral canthus to
the corner of the mouth.13 The upper outer quadrant
is the appropriate injection area for deep supraperiosteal injections to volumize and beautify the cheekbone area (Fig 8-29). Below the line (the sub malar
region) is the appropriate injection area for superficial
injections above the superficial musculoaponeurotic
system (SMAS). Treatment is therefore divided into
injections for cheek volume and injections to improve
skin tone in the submalar region.
147
8 / Injection Techniques with Platelet-Rich Fibrin
To enhance cheek volume
Technique: Vertical supraperiosteal depot technique.
The clinician gathers up the skin with the noninjecting
hand for maximum penetration and pierces the skin
at the thinnest entry point using a 90-degree angle
at the level of the bone (Fig 8-30). The needle is repositioned and advanced slowly below the soft tissue
before material deposition.
FIG 8-30
The noninjecting hand tents the skin during insertion of the
needle.
Substance: Alb-PRF
Entry point: Upper outer quadrant after marking
intersecting lines from the ala of the nose to the
tragus and from the lateral canthus to the corner of
the mouth (see Fig 8-29).
Volume: 0.2 mL per injection point; up to three
points per side.
Combined treatment options
Microneedling and/or laser resurfacing can be
performed in conjunction with PRF injections to maximize the therapeutic effect.
Tool: 27G needle
Treatment steps
1. Apply local anesthetic cream prior to treatment
(optional).
2. Remove makeup and/or anesthetic thoroughly.
3. Disinfect the area.
4. Inject PRF.
5. Massage the injected PRF into the area for even
distribution.
6. Inform the patient about aftercare instructions.
7. Arrange a follow-up appointment.
148
Practical tips:
• Volume may be achieved over time with
multiple sessions.
• Where injection sites overlie bone, the
injections should be deep. Elsewhere in
the cheek, where there is no bony support,
the injections must be superficial.
• Always treat the midface first because
midface augmentation may allow for secondary improvement of the nasolabial fold and
improvement of tear trough hollows.
Nasolabial Folds
To improve skin tone in the submalar region
Technique: Fan technique. A cannula is inserted (Fig
8-31) and slowly slid above the SMAS plane, releasing the filler by means of an anteroretrograde fan
technique.
Fanning
Substance: PRF
Entry point: Below intersecting lines from the ala of
the nose to the tragus and from the lateral canthus
to the corner of the mouth; lateral insertion point.
Volume: 0.5 mL per side
FIG 8-31
A cannula should be used in the cheek area below the line
using a fanning technique with one entry point at a subcutaneous level.
Tool: 22–25G cannula
Treatment steps
1. Apply local anesthetic cream prior to treatment
(optional).
2. Remove makeup and/or anesthetic thoroughly.
3. Disinfect the area.
4. Inject PRF.
5. Massage the injected PRF into the area for even
distribution.
6. Inform the patient about aftercare instructions.
7. Arrange a follow-up appointment.
Combined treatment options
Microneedling and/or laser resurfacing can be
performed in conjunction with PRF injections to maximize the therapeutic effect.
Practical tips:
• Improvement in skin texture and rhytids may
be achieved over time with multiple sessions.
• Care should be taken to avoid injecting
product in the jowls, as this could aggravate the aged appearance.
Nasolabial Folds
Anatomy of the nasolabial fold
The nasolabial fold exists in every human face and
is affected by a variety of muscles involved in facial
expression (Fig 8-32):
•
•
•
•
•
Levator labii superioris alaeque nasi
Levator labii superioris
Zygomaticus minor
Zygomaticus major
Levator anguli oris
The dynamic creasing of skin is most prominent when
the zygomaticus major muscle attaches to the skin.
Aging of the nasolabial fold
With advanced skin aging and soft tissue atrophy, the
folds become visible at rest where the fat-rich buccal
region joins the fat-depleted oral region (Fig 8-33).
149
8 / Injection Techniques with Platelet-Rich Fibrin
Levator labii
superioris alaeque
nasi muscle
Levator labii
superioris muscle
Zygomaticus
minor muscle
Zygomaticus major
muscle
Levator anguli oris
muscle (dash line
phantom)
Risorius muscle
FIG 8-32
FIG 8-33
Muscles involved in facial expression and formation of the
nasolabial fold.
Visible nasolabial fold.
One of the most prominent signs of aging in the face
is deepening and lengthening of the nasolabial folds.
Nasolabial creases are a separate anatomical configuration distinct from nasolabial folds. These creases
are usually fine, superficial wrinkles and are more
common in young patients with thinner skin. They
are usually the result of repetitive muscle movement
and represent actual creases in the skin that overlie
the anchoring musculofascial attachments.14 These
creases, which are skin defects rather than contour
deformities, appear to be epidermal and dermal, not
created by overhanging skin.
Anatomical high-risk zones of the
nasolabial fold !
The nasolabial fold represents a significant danger
zone for augmentation related to the facial artery15
(Fig 8-34). The facial artery has a tortuous course;
the lower two-thirds of the artery travels within the
150
Infraorbital artery
Dorsal nasal artery
Angular artery
Lateral nasal artery
Inferior alar artery
Columellar artery
Superior labial artery
Facial artery
FIG 8-34
Danger zones in treating nasolabial folds.
muscle or deep subcutaneous tissue. It is superficial
in the upper third of the nasolabial fold and ramifies
with the inferior alar artery and lateral nasal artery.
Therefore, deeper injections are safer in this area.
Nasolabial Folds
Safety tips:
• Keep the cannula in constant motion when
injecting into nasolabial folds.
• If using a needle, always stay deep in the
upper third (onto periosteum).
Nasolabial creases (fine lines in the nasolabial area)
require superficial correction (refer to BIO-PRF lift),
whereas deep static folds need volume correction.
Volume correction using PRF aims to reduce visibility
of the nasolabial folds when the patient is at rest.
Technique: Cannula technique in the supramucosal
plane (below muscle).
FIG 8-35
Nasolabial fold injection technique. The cannula is inserted
below the modiolus at the insertion site of the zygomaticus
major muscle.
4. Inject PRF.
5. Massage the injected PRF into the area for even
distribution.
6. Inform the patient about aftercare instructions.
7. Arrange a follow-up appointment.
Combined treatment options
Hyaluronic acid treatment or autologous fat transplantation can be performed in conjunction with PRF injections to maximize the therapeutic effect.
Complications
Overcorrection should be avoided, and bruising and
swelling may occur.
Substance: PRF
Entry point: At insertion point of the zygomaticus
muscle at the modiolus (Fig 8-35).
Volume: 0.3 mL per injection point; up to three
points per side.
Tool: 22–25G cannula
Treatment steps
1. Apply local anesthetic cream prior to treatment
(optional).
2. Remove makeup and/or anesthetic thoroughly.
3. Disinfect the area.
Practical tips:
• Always treat the midface first because
midface augmentation may allow for secondary improvement of the nasolabial fold.
• The distance between the origin of the
nasolabial fold and the tip of the nose, in
a profile view, determines the subjective
impression of aging.
• Several PRF treatments may be necessary
for deeper nasolabial folds.
151
8 / Injection Techniques with Platelet-Rich Fibrin
Lower Face
Perioral Region
Anatomy of the lips
Lips play a key functional role in talking and facial
expression and furthermore can greatly influence an
individual’s level of attractiveness. With an increase in
esthetic demand, there has been a significant increase
in minimally invasive cosmetic procedures related to
the lip and perioral area. Rejuvenation of the perioral region can be challenging because of the many
factors that affect the appearance of this area, such as
repeated muscle movement, loss of the maxillary and
mandibular bony support, and decrease and descent
of the adipose tissue causing the formation of “jowls.”
The orbicularis oris muscle plays a key role in motor
function of the lips. The section of the muscular ring
that lies furthest from the oral aperture can reduce in
size while protruding from the red margin of the lips,
as in the case of whistling. The function of the orbicularis oris muscle is antagonized by the surrounding
muscles of facial expression, which pull the lip corners
of the mouth laterally, upward, or downward, thus
widening the oral aperture.
The blood supply of the lower lip is provided by the
inferior labial artery and that of the upper lip by the
superior labial artery (Fig 8-36).
Columellar
arteries
Orbicularis
oris muscle
Inferior labial
artery
Facial
artery
FIG 8-36
Anatomy of the perioral area showing the orbicularis oris
muscle, inferior labial artery, and superior labial artery.
Aging of the lips
With aging there is a slow, progressive loss of the lip
mass. This results in the corners of the mouth turning
down, giving an expression of negative emotions. In
addition, the vascularity exhibits a loss in volumetric
distribution, giving the lip a dull color (Fig 8-37).
FIG 8-37
The aging lips reflect perioral wrinkles, reduced volume, and
reduced vermilion pigmentation.
152
Inferior alar
artery
Superior
labial artery
Perioral Region
Aging lips are characterized by the following16:
•
•
•
•
•
•
•
•
•
•
•
•
Loss of fullness and projection
Development of rhytids
Reduction in the vermilion border
Inversion of the lower lip
Reduced display of the maxillary teeth
Increased display of the mandibular teeth
Flattening of the cupid’s bow
Flattening of the philtral columns
Lengthening of the cutaneous upper lip
Reduction in the nasolabial angle
Reduction in the mentolabial angle
Reduction of the vermilion pigmentation
Anatomical high-risk zones of the lip
area !
The inferior and superior labial arteries generally lie
deep in the lip between the orbicularis oris muscle
and the mucosa, so injections should be superficial
to avoid these vessels (Fig 8-38).
Safety tips:
• Inject below the vermilion cutaneous
border less than 3 mm deep.
• Stay superficial when injecting medially in
the upper lip.
• When injecting near the commissures, use
a crosshatch technique and apply digital
pressure to avoid the superior labial artery.
Inferior
alar artery
Columellar
arteries
Superior
labial artery
Inferior
labial artery
Facial artery
Mental
artery
Labiomental
artery
Submental
artery
FIG 8-38
Anatomical high-risk zones of the lip area.
Technique: Retrograde linear threading injections
along the perioral lines (intradermal). The skin may
be gently compressed by an assistant to accentuate
the line (Fig 8-39). Begin at the vermilion cutaneous
border and inject intradermally.
Direction of needle
when injecting
Substance: PRF
Treatment of perioral lines
The treatment goal is superficial correction of the
radial lines (smoker’s lines) on the upper and lower lip.
Entry point: Begin at the vermilion cutaneous
border, injecting along the lines.
Volume: Small aliquots per line
Tool: 30G needle, 12 mm
153
8 / Injection Techniques with Platelet-Rich Fibrin
Treatment of lip volume
Full, symmetric lips with upturned corners and a
healthy color are considered esthetically appealing.
The lip is a sensitive area, and thus adequate anesthesia is key to volumizing treatment. Only one point on
either side at the oral commissure is utilized to reach
both the upper lip and the lower lip.
FIG 8-39
The assistant stretches the skin of the upper lip area while the
needle is inserted from the red margin toward the upper lip.
Linear threading is then performed in the perioral lines.
Treatment steps
1. Ask about previous herpes simplex infections and
administer prophylaxis if required.
2. Apply local anesthetic cream prior to treatment
(optional).
3. Remove makeup and/or anesthetic thoroughly.
4. Disinfect the area.
5. Inject PRF.
6. Massage the injected PRF into the area for even
distribution.
7. Inform the patient about aftercare instructions.
8. Arrange a follow-up appointment.
Combined treatment options
Microneedling, nonablative laser therapy, and/or Botox
treatment may be used in conjunction with PRF injections to maximize the therapeutic effect.
Complications
Bruising and swelling may occur, and herpes simplex
virus may recur.
Practical tip:
Environmental issues must be addressed,
such as smoking, sun damage, and poor
dental health and use of straws.
154
Technique: Inject with a needle for the white lip and
a cannula for the red lip.
White lip (needle): Three to four points per line at the
vermilion and the area 2 mm below it. Inject superficially! Avoid the tubercle.
Red lip (cannula): One entry site close to the corner of
the mouth per quadrant of the lips (Fig 8-40). Use a
cannula to place PRF above the muscle.
Philtral columns: Injection superficial due to the position
of the columellar vessels.
Corner of the lips: Inject using a crosshatch pattern
slightly lateral to the insertion of the modiolus. Apply
digital pressure to avoid the superior labial artery.
Cross-hatching
(grid pattern)
Injections are retrograde
and overlapping
Substance:
White lip: PRF
Red lip: Alb-PRF
Entry point: Borders; mark the borders for volume
in line with the external nares. Enter at the vermilion
border, and avoid the tubercle area.
Red lip: One entry site close to the corner of the
mouth per quadrant of the lips.
Mouth corners: Modiolus
Volume:
White lip: Small aliquots
Red lip: 0.3 mL per quadrant
Tool:
Vermilion border: 30G needle, 4 mm (Fig 8-41a)
Red lip: 25G cannula (Fig 8-41b)
Perioral Region
Entry points
FIG 8-40
Entry points for cannula use in red lip.
Treatment steps
1. Ask about previous herpes simplex infections and
administer prophylaxis if required.
2. Apply local anesthetic cream or an anesthetic block
prior to treatment.
3. Remove makeup and/or anesthetic thoroughly.
4. Disinfect the area.
5. Inject PRF.
6. Massage the injected PRF into the area for even
distribution.
7. Inform the patient about aftercare instructions.
8. Arrange a follow-up appointment.
Combined treatment options
Microneedling and/or filler treatment may be used
in conjunction with PRF injections to maximize the
therapeutic effect.
Complications
Bruising and swelling may occur, and herpes simplex
virus may recur.
Practical tips:
• Lips are prone to swelling, so patients need to
refrain from social engagements as necessary.
• Build volume over several sessions to achieve a
natural enhancement gradually.
• For sharply defined esthetic shaping of the lips,
filler materials should be added.
a
b
FIG 8-41
(a) Using a 30G needle to deposit PRF into the border of white
lip. (b) Using a 25G cannula to deposit PRF in a retrograde
fashion is optimal for the red lip region and achieves a uniform
result. A volume of 0.2 to 0.3 mL per quadrant is delivered.
• Ideal lip enhancement should include both
modes of practice (PRF and fillers) to ensure an
optimal esthetic result with long-lasting results.
• Alb-PRF can be used to add additional volume.
• Lip volume usually subsides to about half of the
immediate postoperative volume increase.
155
8 / Injection Techniques with Platelet-Rich Fibrin
Marionette Lines
(Labiomandibular Fold)
Anatomy of marionette lines
Marionette lines arise from the angle of the mouth and
continue downward toward the chin, giving the face a
frustrated, disappointed, and dissatisfied expression.
There are 10 muscles around the perioral area, and they
are built into several layers. At least 7 of them have the
same fixation point called the modiolus, located about
1 cm lateral to the oral commissure. The depressor
anguli oris together with the platysma are muscles
particularly responsible for the downward pulling of
the oral commissures. The most medial border of the
depressor anguli oris has cutaneous insertions forming the labiomandibular ligament. Below the depressor
anguli oris muscle lies the depressor labii inferioris
muscle, which directly connects with the mucosa16
(Fig 8-42).
Modiolus
Depressor
anguli oris
Oral commissure
Platysma
Depressor labii
inferioris muscle
Mental
foramen
Mentalis
muscle
Labiomandibular
ligament
FIG 8-42
Aging of marionette lines
Perioral muscles responsible for marionette lines.
Prominent lines in this area alongside drooping mouth
corners give a powerful negative expression and perception of aging (Fig 8-43). These lines are formed when the
central part of the face loses soft tissue volume as the
fat pads from the lateral parts of the face thin and drop
downward due to changes in the adipose tissue and a
loss of elasticity in the dermis. Together with hyperactivity of muscles such as the depressor anguli oris and the
platysma, this leads to deepening of the marionette lines.
The shadow cast from the more elevated lateral
face to the relatively less elevated medial face causes
the dark line that we notice whenever someone has
nasolabial or marionette lines.
Anatomical high-risk zones of the
marionette area
Beware of the inferior labial branch of the facial artery
and mental branch of the inferior alveolar artery.
FIG 8-43
Drooping mouth corners give a powerful negative expression
and perception of aging.
156
Marionette Lines (Labiomandibular Fold)
Treatment of marionette lines
The aim of treatment is to improve the volume of both
sides of the labiomandibular fold in order to achieve
uniformity and evenness.
Technique: Cannula technique. Inject PRF into the
submucosal area of the marionette line directed toward
the corner of the mouth (Fig 8-44). It may be used in
a fanlike fashion.
FIG 8-44
The cannula is inserted and brought into the submucosal
plane below the perioral muscles. This can be done by starting at the inferior aspect of the marionette line. The cannula is
advanced with gentle mobilizing movements to the superior
portion, close to the corner of the mouth. The practitioner injects 0.2 to 0.3 mL of PRF into the submucosal layer.
Substance: PRF
Entry point: Caudal endpoint of the marionette line
on the chin.
Volume: 0.2 mL per side
Tool: 22–25G cannula
Treatment steps
1. Ask about previous herpes simplex infections and
administer prophylaxis if required.
2. Apply local anesthetic cream prior to treatment
(optional).
3. Remove makeup and/or anesthetic thoroughly.
4. Disinfect the area.
5. Inject PRF.
6. Massage the injected PRF into the area for even
distribution.
7. Inform the patient about aftercare instructions.
8. Arrange a follow-up appointment.
Combined treatment options
Lifting the corners of the mouth also improves marionette lines. Botox can be injected into the depressor
anguli oris muscle 1 week prior to PRF treatment.
Autologous fat augmentation may be used in
conjunction with PRF injections to maximize the therapeutic effect. Cheek, chin, and jawline augmentation
may have a secondary effect and cause improvement
of the marionette shadow.
Practical tips:
• Treat the midface prior to marionette lines.
• Blunt tissue mobilization using the
cannula may reduce marionette lines
further. The cannula allows for mechanical tissue release and fibrogenetic
regeneration.
157
8 / Injection Techniques with Platelet-Rich Fibrin
Chin and Jawline
A well-projected, volumized chin is a key feature of a
youthful, harmonious face. With aging tissue atrophy,
bone regression, and volume loss lead to irregularities
in the chin and contour of the jawline.
Anatomy of the chin
Parotid
The mental complex is influenced by the actions of
the perioral depressor muscles: depressor anguli oris,
depressor labii inferioris, and mentalis muscle. Contraction of the mentalis muscle in combination with the
anchoring system of the ligament leads to an uneven,
irregular, and cobblestone-like chin. Mental, submental,
and mandibular ligaments provide the static retaining
elements of the lower part of the face (Fig 8-45).
Depressor
anguli oris
Depressor labii
inferioris muscle
Mentalis
ligament
Mental
ligament
Mandibular
ligament
Submental
ligament
Platysma
Aging of the chin and jawline
As a general principle, aging causes mandibular
resorption and is associated with hyperactivity of the
mentalis. These factors contribute to a shortened chin,
a less projected lower facial third, and depressions on
the surface of the skin (Fig 8-46); these are initially
seen as shadows but then later progress to surface
irregularities and relative swellings (“golf ball chin”).
Sagging of the jawline is widely attributed to atrophyrelated shrinkage of the surrounding tissues, including
shrinkage of the mandible and displacement of the
maxilla.
FIG 8-45
Anatomy of the chin and jaw.
Anatomical high-risk zones when
injecting the chin and jawline
Jawline
The facial nerve and parotid gland are at risk during shaping of the posterior mandibular ramus, as they are both
deep structures located deep to the SMAS. They can
be avoided by injecting in the subdermal plane. When
injecting in the inferior border of the ramus, be mindful
of the facial artery as it courses along the anterior border
of the masseter. It is palpable at this point and should be
identified and protected prior to injection.
158
FIG 8-46
Sagging jawline and chin in an aging face.
Chin and Jawline
First and second
premolar teeth
Parotid
Buccal branch
of facial nerve
Depressor labii
inferioris muscle
Marginal mandibular
branch of facial nerve
Mentalis
muscle
Cervical branch
of facial nerve
Depressor
anguli oris
Facial artery
Mental foramen,
artery, and nerve
Platysma
FIG 8-47
High-risk zones when injecting the chin and jawline.
Chin
The inferior alveolar artery and nerve exiting from the
mental foramen are the main dangers in this area.
The mental foramen is commonly located between
the first and second premolar teeth and should be
protected from direct injections.
Treatment of the chin
The aim of treatment is to revolumize and recontour
the chin. A youthful jawline is characterized by a
straight line from the chin to the mandibular angle.
The risk of intravascular injection can be
minimized by remaining in the superficial
(subdermal) plane or the deep (periosteal)
planes (Fig 8-47).
159
8 / Injection Techniques with Platelet-Rich Fibrin
Technique: Vertical supraperiosteal depot technique in
the midline of the anterior chin. The labiomental crease
may be injected via the linear threading technique at
dermal level. Supraperiosteal injections are given using
the serial point technique. The needle is inserted at a
90-degree angle and the injection is given superficially
(Fig 8-48).
FIG 8-48
Substance: Alb-PRF
Entry point: The mentalis should be injected in its
inferior portion toward the midline.
Volume: 0.2 mL per injection point; up to three
points.
Tool: 27G needle
Treatment steps
1. Apply local anesthetic cream prior to treatment
(optional).
2. Remove makeup and/or anesthetic thoroughly.
3. Disinfect the area.
4. Inject PRF.
5. Massage the injected PRF into the area for even
distribution.
6. Inform the patient about aftercare instructions.
7. Arrange a follow-up appointment.
Combined treatment options
If the mentalis muscle is overactive, Botox can be
injected. Medical microneedling can also be used in
conjunction with PRF injections to maximize the therapeutic effect.
Complications
Swelling may affect speech for 24 hours.
160
Injections into deficient areas of the chin. Supraperiosteal injections are given using the serial point technique. The needle
is inserted at a 90-degree angle, and the injection is given
superficially.
Practical tips:
• Anterior projection of the chin allows for
correction of the perception of aging in
this area.
• Ask the patient to create an “ooh” sound with
the lips in order to visualize deficient areas.
Treatment of the jawline
The aim of treatment is to create a youthful jawline
characterized by a straight line from the chin to the
mandibular angle. This is achieved by creating a
continuous contour by elimination of the disparity
between the prejowl and jowl area as well as the restoration of the outline of the jawline by the provision of
better support and skin tension.
Chin and Jawline
Technique: Cannula technique. Insert the cannula
along the auricular border of the mandible at a subcutaneous level. The direction of the injection is toward
the chin. Inject into the prejowl sulcus but be careful
not to inject into or worsen the jowl (Fig 8-49); use a
fanning technique if preferred. PRF can also be injected
toward the ear from the same point over the masseter
to restructure the entire area.
FIG 8-49
Mark the prejowl sulcus (avoid adding volume). The cannula
is directed toward the chin in the subcutaneous space.
Substance: PRF or Alb-PRF for deep hollows
Entry point: Along the auricular border of the
mandible.
Volume: 0.5 mL per side
Tool: 22–25G, 50-mm cannula
Treatment steps
1. Apply local anesthetic cream prior to treatment
(optional).
2. Remove makeup and/or anesthetic thoroughly.
3. Disinfect the area.
4. Inject PRF.
5. Massage the injected PRF into the area for even
distribution.
6. Inform the patient about aftercare instructions.
7. Arrange a follow-up appointment
Combined treatment options
Sagging of the jowl can be tightened by radiofrequency, ultrasound, or laser lipolysis. Medical
microneedling can also be used in conjunction with
PRF injections to maximize the therapeutic effect.
Botox may be injected into overactive masseter and
platysma muscles.
Complications
Jaw stiffness may occur for 24 hours.
Practical tips:
• Anesthesia is advisable.
• Several sessions may be needed to build
the jawline.
• Revolumizing the upper and middle thirds
of the face first provides superior volumetric support to the jawline.17
161
8 / Injection Techniques with Platelet-Rich Fibrin
References
1. Matts PJ, Fink B, Grammer K, Burquest M. Color homogeneity
and visual perception of age, health, and attractiveness of
female facial skin. J Am Acad Dermatol 2007;57:977–984.
2. Jones BC, Little AC, Burt DM, Perrett DI. When facial attractiveness is only skin deep. Perception 2004;33:569–577.
3. Pistor M. What is mesotherapy? Chir Dent Fr 1976;
46(288):59–60.
4. Smit R. Bio-skin-gineering: A novel method to focus cutaneous aging treatment on each individual layer of the skin
specifically and precisely. Aesthet Med 2019;5:14–21.
5. Gilbert E, Hui A, Meehan S, Waldorf H. The basic science of
dermal fillers: Past and present. Part II: Adverse events. J
Drugs Dermatol 2012;11:1069–1079.
6. Cohen J. Understanding, avoiding, and managing dermal
filler complications. J Dermatol Surg 2008;34(suppl):
S92–S99.
7. Emer J, Waldorf H. Injectable neurotoxins and fillers: There
is no free lunch. Clin Dermatol 2011;29:678–690.
8. Jiang X, Liu DL, Chen B. Middle temporal vein: A fatal hazard
in injection cosmetic surgery for temple augmentation. JAMA
Facial Plast Surg 2014;16:227–229.
9. Lee JG, Yang HM, Hu KS, et al. Frontal branch of the superficial
temporal artery: Anatomical study and clinical implications
regarding injectable treatments. Surg Radiol Anat 2015;
37:61–68.
162
10. Ozturk CN, Li Y, Tung R, Parker L, Piliang MP, Zins JE. Complications following injection of soft-tissue fillers. Aesthet
Surg J 2013;33:862–877.
11. Ji-Hyun Lee, Giwoong Hong. Definitions of groove and hollowness of the infraorbital region and clinical treatment using
soft-tissue filler. Arch Plast Surg 2018;45:214–221.
12. Guisantes E, Beut J. Periorbital anatomy: Avoiding complications with tear trough fillers. Aesthet Med 2016;2:
73–78.
13. Binder WJ, Azizzadeh B. Malar and submalar augmentation.
Facial Plast Surg Clin North Am 2008;16:11–32.
14. Rohrich R, Rios JL, Fagien S. Role of new fillers in facial rejuvenation: A cautious outlook. Plast Reconstr Surg 2003;
112:1899–1902.
15. Scheuer JF 3rd, Sieber DA, Pezeshk RA, Campbell CF,
Gassman AA, Rohrich RJ. Anatomy of the facial danger zones:
Maximizing safety during soft-tissue filler injections. Plast
Reconstr Surg 2017;139:50e–58e.
16. Rosengaus-Leizgold F, Jasso-Ramírez E, Sicilia NC. The happy
face treatment: An anatomical-based technique for the correction of marionette lines and the oral commissures. J Drugs
Dermatol 2018;17:1226–1228.
17. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum:
Anatomical observations of the jowls in aging: Implications
for facial rejuvenation. Plast Reconstr Surg 2008;121:
1414–1420.
9/
HAIR REGENERATION
WITH PLATELET-RICH
FIBRIN
Catherine Davies
Richard J. Miron
It is currently estimated that over 80 million Americans suffer from hereditary hair loss with an esthetic desire to reverse the condition. While a
number of treatment options have been proposed, one currently utilized
therapy that is minimally invasive and has been shown to be effective at
early onset of hair loss is the use of platelet concentrates. While originally
platelet-rich plasma (PRP) was proposed as a means to halt progressive
hair loss and, in many cases, improve hair density, the advancements in
platelet-rich fibrin (PRF) have further made it possible to utilize platelet
technology without added anticoagulants. This chapter reviews the use of
PRF for hair regeneration and presents the injection techniques required
for its delivery.
165
9 / Hair Regeneration with Platelet-Rich Fibrin
PRF Injections to Treat Hair Loss
In recent years, PRF has gained the attention of doctors
due to its ability to rejuvenate skin and hair. PRF has
been observed in clinical cases to promote hair growth,
reverse hair loss, and enhance hair thickness (Fig 9-1).
PRF is used to treat nonscarring alopecia. The procedure is generally safe, tolerable for the patient, and
can result in only mild irritation
PRF is used to treat
afterward. No serious allergic
nonscarring alopecia.
reactions have been reported
concerning the administration
of PRF for hair rejuvenation. Patients should sign a
consent form before undergoing any treatment.
Goals of treatment
• Restore local microcirculation via vasodilators
• Provide growth factors and fibrin to the affected area
• Slow the programmed process of follicular
involution
• Stimulate the hair’s environment with a needling
effect
• Psychologic effect
• Complement other treatments (hair care, medication, etc):
– Adjunct to surgery (before, immediately after,
and later)
– Adjunct to other hair treatments such as
polydioxanone (PDO) threads
FIG 9-1
Clinical image of the head and scalp. Note that male pattern
hair loss can occur in various patterns, so adequate diagnosis
is essential (see chapter 5).
• Mark out each area to be injected with optimal
positioning.
• Make sure the scalp can be reached from all angles.
• Prepare everything before withdrawing blood,
because time is limited once the PRF preparation
is ready.
Anesthetizing the Scalp
PRF injection is a minimally invasive procedure that should be performed under aseptic
conditions.
Adequate anesthesia of the scalp is necessary to make
PRF treatment as painless as possible for the patient.
In most cases, topical anesthetic creams are sufficient, but occasionally regional anesthesia is required.
Tips for treatment
Topical anesthesia
• Ask the patient to shampoo and detangle their hair
prior to each session.
• The patient must not apply any product to the hair
such as wax, gel, or hair spray.
• Take excellent before and after photographs.
• Comb through the area prior to injection.
166
Various anesthetic solutions and creams have been
developed and approved for the anesthesia of intact
skin. They have proven to be most advantageous in
patients who do not want to have an injection. Topical anesthesia should be applied well ahead of time
(approximately 30 minutes) and covered with an
Anesthetizing the Scalp
Ophthalmic nerve, V1
Supraorbital nerve
Supratrochlear nerve
Trigeminal nerve
(Cranial nerve V)
Cervical plexus
Maxillary nerve, V2
Third occipital nerve
Zygomaticotemporal nerve
Greater occipital nerve
Mandibular nerve, V3
Temporomandibular nerve
Minor occipital nerve
Auriculotemporal nerve
FIG 9-2
Greater auricular nerve
Sensory innervation of the scalp. Lateral view
of the head depicting the course of superficial
trigeminal and cervical nerve branches.
occlusive dressing, which should be fully removed
before the procedure begins.
A combination of products is often used. For example, it is possible to formulate BLT creams (benzocaine,
lidocaine, and tetracaine) in a pharmacy compounded
stronger than the typical over-the-counter 7% BLT. A
commonly used formulation is 7% benzocaine, 21%
tetracaine, and 7% tetracaine. It is generally recommended that clinicians speak to their local compounding
pharmacy about alternative options with stronger formulations. Furthermore, topical creams can also contain
epinephrine to increase their potency. Such examples
include 4% lidocaine, with epinephrine 1:1000, and 0.5%
tetracaine or 2.5% lidocaine and 2.5% prilocaine.
added to both 1% and 2% solutions. The time from injection to onset of anesthesia with lidocaine is approximately
60 to 90 seconds, and the effects of lidocaine typically last
20 to 30 minutes (or up to 2 hours if mixed with epinephrine). The maximum dose of lidocaine in adults is 300 mg
(3–4 mg/kg in children); when mixed with epinephrine,
the maximum dose is 500 mg (7 mg/kg).
Anesthesia of the scalp requires a very superficial
injection. All injections should be performed under sterile conditions and administered with the smallest needle
possible in an effort to cause the least pain. A 25G needle
is an excellent choice for administration of anesthesia.
Regional scalp block
Nerve supply of the scalp emanates from the trigeminal nerve (fifth cranial nerve) as well as the cervical
plexus. The forehead is innervated by the supraorbital
and supratrochlear nerves (branches of V1). The vertex
and lateral region of the scalp receives its nerve supply
from the V2 and V3 divisions (zygomaticotemporal,
and temporomandibular and auriculotemporal nerves,
respectively). The posterior scalp is innervated by the
occipital and greater auricular nerves. All of these
nerves become superficial above an imaginary line
drawn from the occipital protuberance to the eyebrows,
passing along the upper border of the ear (Fig 9-2).
Subcutaneous injections should be short-acting and
mixed with a vasoconstricting agent to help control
bleeding. An added benefit of vasoconstriction is prolongation of the anesthetic action through decreased blood
flow from the site of infiltration; it is this mechanism that
increases the maximum doses of anesthetic medication.
The most commonly used short-acting subcutaneous
anesthetic agent is lidocaine, which can be given as 1%
or 2% mixtures. It is not necessary to use longer-acting
agents for PRF injections. Epinephrine 1:1000 should be
Innervation of the scalp
167
9 / Hair Regeneration with Platelet-Rich Fibrin
FIG 9-3
FIG 9-4
Clinical photograph of an anterior scalp block.
Clinical photograph of a posterior scalp block.
Anesthetizing the anterior scalp
Anesthetizing the posterior scalp
Anterior scalp anesthesia requires an ophthalmic
nerve block. The nerves of the ophthalmic branch,
including the supraorbital, supratrochlear, and infratrochlear nerves, are all anesthetized at the supraorbital notch, a point where they exit the skull. The
supraorbital notch can be easily palpated on the ridge
of the upper orbital bone in line with the patient’s pupil
when looking straight ahead (Fig 9-3). The procedure
is as follows:
Posterior scalp anesthesia requires a greater and
lesser occipital nerve block (Fig 9-4).
For greater occipital nerve anesthesia, the procedure is as follows:
1. Insert a 25G needle attached to a syringe at the
supraorbital notch.
2. Carefully aspirate.
3. Inject between 1 and 3 mL of anesthetic slowly.
4. Use finger pressure on the underside of the superior orbital bone to prevent the anesthetic from
draining into the upper eyelid.
168
1. Palpate the occipital protuberance and mastoid
process.
2. Find the point ¹⁄³ the distance medially to the
mastoid process along this line and insert the needle.
3. Carefully aspirate to ensure that the needle tip is
not in the occipital artery.
4. Inject 0.5 mL of anesthetic.
To anesthetize the lesser occipital nerve, do the
following:
1. Remove the needle from the skin and move 3 cm
laterally and 1 cm caudally.
2. Insert the 25G needle and aspirate to prevent
intra-arterial injection.
3. Inject another 0.5 mL of anesthetic in a semicircular pattern.
Techniques for PRF Injection
FIG 9-5
FIG 9-6
Clinical photograph demonstrating the nappage technique
with a 45-degree needle angle.
Clinical photograph demonstrating the point-by-point injection technique with a 90-degree needle angle.
Techniques for PRF Injection
Two techniques may be used to administer PRF into the
scalp to treat alopecia: the nappage technique and pointby-point injections. In both techniques, PRF should be
withdrawn from the PRF tube into a Luer-Lok syringe
and used as soon as possible, before clotting occurs.
Equipment needed
•
•
•
•
•
•
•
Luer-Lok syringe
Withdrawal needle
Mesotherapy needle: 30G × 4 mm
Gloves
Gauze
Disposable comb
Antiseptic solution spray
Nappage technique
The nappage technique was developed by Dalloz
Bourguignon. With this technique, multiple superficial
intradermal injections (2–4 per second) are performed
every 2 to 4 mm over the entire treatment area at
a 45-degree angle from the skin surface (Fig 9-5).
The needle penetrates to a depth of 2 to 4 mm while
constant unchanging pressure is applied to the piston
of the syringe.
During the treatment phase, the patient has one
session every 30 days for three months, with evaluation after 1 year. Thereafter the maintenance phase
comprises one session every 6 months.
Point-by-point injection technique
With the point-by-point injection technique, multiple
deep intradermal injections are performed at depths
between 1.5 and 4 mm (see Fig 9-9e). For each square
centimeter of the treatment area, 0.1 mL of PRF is
injected, with no papule formation. The needle is
inserted at 90 degrees (Fig 9-6). Injections are given
vertically along parted hair at a distance of 1 cm apart.
During the treatment phase, the patient has one
session every 4 to 6 weeks for a total of three sessions,
with evaluation after 1 year. Thereafter, the maintenance phase comprises one session every 6 months.
169
9 / Hair Regeneration with Platelet-Rich Fibrin
a
b
c
d
e
f
g
FIG 9-7
Step-by-step protocol using liquid PRF injections and low-level laser therapy. (a) Materials needed for hair procedure. (b) Disinfection with 70% alcohol for phlebotomy. (c) Blood collection. (d) Scalp disinfection with 70% alcohol. (e) Blood centrifugation
using a horizontal-angle centrifuge at 700g for 5 minutes. (f) Collection of liquid PRF from plastic tubes. (g) Mixing of liquid PRF
with some procaine anesthetic.
Follow-up
Clinical Cases
Treatment response should be assessed at
months 3, 6, and 12, but the patient should
only expect to see maximal results at month 12.
Figure 9-7 demonstrates the step-by-step protocol
used for hair restoration. Following adequate disinfection, PRF is collected and injected locally in 1-cm
170
Clinical Cases
h
i
j
k
FIG 9-7 (cont)
(h and i) Hair injections with a 4-mm 32G needle. (j) Low-level laser therapy utilizing an 8-minute alopecia program (ATP38, Biotech Dental). (k) Photographs before treatment (left) and after the third treatment session (right). Notice after 3 months that some hair growth is
already evident. (Case courtesy of Dr Ana Paz.)
a
b
c
FIG 9-8
Clinical photographs demonstrating microneedling of the scalp with PRF (a and b) as well as injections (c). Typically, injections
are favored and more commonly used than microneedling.
areas in all places demonstrating hair loss. Typically,
additional bordering injections are also performed
to prevent further hair loss. Note that microneedling
can also be performed (Fig 9-8); however, based on
results from numerous clinicians practicing in the field,
it typically has not been associated with any additional
171
9 / Hair Regeneration with Platelet-Rich Fibrin
a
c
b
d
e
FIG 9-9
(a and b) Clinical photographs demonstrating obvious hair loss in a 35-yearold male patient. (c to e)
Subdermal injections were
performed once a month for
3 months. Note the entirety
of regions covered. (f and g)
Note the vast improvement
in hair growth 3 months
postoperatively. (Part f courtesy of Dr Yuriy May.)
f
g
benefit when compared to injections alone. Figures
9-9 to 9-11 demonstrate additional cases of success
with liquid PRF. In all of these clinical cases, noticeable
hair growth occurred with pleasing esthetic outcomes.
172
Conclusion
While the use of PRF for hair regrowth has only begun,
case series and studies are continuously ongoing and
will further improve the field as well as offer better
long-term documented results.
Conclusion
a
b
FIG 9-10
Photographs before (a) and 6 months after (b) one session of PRF treatment. (Case courtesy of
Dr C. Baard.)
a
b
FIG 9-11
(a) Male patient demonstrating noticeable hair loss. (b) Substantial early hair regrowth 6 months
after follicular unit extraction surgery with PRF pretreatment for 7 days. The follicles were soaked
in PRF during surgery. Note the excellent esthetic outcome.
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LASERS IN FACIAL
ESTHETICS
Ana Paz
Harvey Shiffman
Miguel Stanley
Catherine Davies
Richard J. Miron
The use of lasers for facial esthetics has a long history dating back to the
1960s. While originally clinical procedures and indications were limited to
ablative therapies, over the past decade technologic advancements have
expanded the applications of lasers in clinical practice. Today, over 150
commercially available lasers exist on the market for various indications,
including scar revisions, pigmented lesions, vascular lesions, hair removal,
facial resurfacing, facial rejuvenation, fat ablation, and laser lipolysis. This
chapter provides an in-depth overview of the current state-of-the-art technology and provides specific indications and guidelines regarding the use
of lasers in facial esthetics.
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Introduction to Lasers in Facial
Esthetics
Facial esthetics has rapidly progressed from a
primarily experimental discipline of medicine into a
multibillion-dollar industry. While lasers were once
experimentally utilized for scar revisions and medically related facial disorders, today they are more
commonly utilized for esthetic procedures aimed at
improving facial appearance and restoring/maintaining a youthful look (facial rejuvenation). As a result,
a plethora of new devices have been proposed, each
with specific protocols, wavelengths, and/or clinical
recommendations. This increase in product development, along with an increase in protocols, laser types,
wavelengths, and competing products, has created a
mass of confusing information with respect to product differences and clinical indications. This chapter
aims to provide an overview of the different laser
types available in the field of facial esthetics as well
as their specific clinical indications and protocols.
While new and exciting developments in the laser
field will certainly continue to evolve exponentially
in the coming years, this chapter provides an up-todate overview of laser therapy in facial esthetics and
summarizes the wealth of knowledge available to date
on the topic.
History of Lasers in Facial Esthetics
The use of lasers for facial esthetic procedures began
in the 1960s when dermatologist Leon Goldman
utilized a ruby laser with the goal of improving skin
texture.1 Goldman’s first experimental use of lasers left
minor scarring, and modifications were made thereafter to produce enhanced results while avoiding potential skin damage.2 Years later, a new concept called
selective photodermolysis was developed by R. Rox
Anderson and John A. Parrish that consisted of using
a laser system capable of selectively targeting a single
layer with the aim of minimizing tissue damage.3 This
concept gave rise to the development of tunable dye
lasers, which selectively target the hemoglobin in red
176
blood cells and are therefore capable of removing skin
marks4 such as telangiectasias.
Carbon dioxide (CO2) lasers were the first ablative
laser used for skin resurfacing, which was originally
developed by Thomas B. Fitzpatrick.2 Despite early
promising results, a long healing period resulted
because full reepithelialization was necessary following therapy. Nevertheless, the technique observed
satisfactory results and encouraged industrial development of new laser alternatives with a more focused
and precise energy application creating less intensive
side effects.5
In the 1990s, the erbium-doped yttrium aluminum
garnet (Er:YAG) laser was introduced, demonstrating a positive role in skin resurfacing, especially for
mild skin pigmentation, facial wrinkles, and acne
scarring.6 Although both CO2 and Er:YAG lasers have
demonstrated their efficacy, several challenges were
also reported, including lengthy recovery periods,
possible scar tissue, and risk of infection as a result
of deepithelialization. More recently, nonablative fractional lasers have been developed with much shorter
recovery periods.7
Furthermore, while low-level laser (or light) therapy
(LLLT) was discovered in the late 1960s, only recently
have these lasers been introduced for dermatologic
applications.8 Light-emitting diode (LED) devices have
also been introduced with the aim of reducing many of
the concerns related to laser safety and the need for
trained personnel to operate them; these devices are
considered a more modern, low-risk, and noninvasive
approach to laser treatment.7
Biologic Activity of Lasers on
Skin Cells
Wound healing of skin tissues
Skin is the largest organ in the human body, accounting for 16% of the total body weight, and represents
the body’s interface with the external environment.
This cutaneous organ covers the surface of the body
and is composed of two layers originating from two
Biologic Activity of Lasers on Skin Cells
Hair shaft
Sweat pore
Eccrine sweat gland
FIG 10-1
Skin layers including the epidermis, dermis, and
subcutis/hypodermis. Note the various tissues
found throughout the layers.
Epidermis
Dermis
Arrector pili
muscle
Hair root
Subcutis/
hypodermis
Hair follicle
Hair follicle receptor
(root hair plexus)
Adipose (fat) tissue
Vein
Artery
Sebaceous (oil) gland
different germinal leaflets.9 The epidermis is the
surface epithelial tissue derived from the cutaneous
ectoderm. The dermis is the deeper layer, consisting of dense, unformed connective tissue derived
from the mesoderm.10,11 The network of embryonic
connective tissue, or mesenchyme, derived from the
mesoderm forms the connective tissue of the dermis
(Fig 10-1). Below and in continuity with the dermis is
the hypodermis, which is not considered part of the
skin but keeps it attached to underlying organs.9,10 The
main role of the skin is to protect against physical,
chemical, and infectious agents, as well as prevent
excessive elimination of water by evaporation. It also
functions as a temperature-regulation system: Sweat
glands secrete fluid to cool the body while the hairs
and underlying layer of fat insulate against the cold.11
During wound healing caused by tissue trauma, a
series of vascular, cellular, and biochemical events
occur that are responsible for replacing dead or
damaged cells with healthy cells.12 This repair process
is not completely regenerative; while wound closure
by scar tissue restores dermal integrity, hair follicles
and other dermal appendages may be lacking in larger
defects, leading to a disorganized pattern of collagen
deposition and reduced tissue resistance.12,13
Wound repair can be divided into three main phases:
(1) the inflammatory phase, (2) the proliferative phase
(including reepithelialization, matrix synthesis, and
neovascularization), and (3) the maturation phase14
(Fig 10-2). The tissue repair process begins with an
inflammatory phase, which, initially, involves the
formation of a clot through platelet activation, red
blood cells, and fibrin brought on by bleeding. The
clot also provides a defense barrier against potential
contamination. Tissue injury and recruitment of these
cells positively influences the secretion of several key
tissue-promoting mediators, including growth factors,
serotonin, adrenaline, and complement factors, among
others. This phase lasts roughly 3 days and is vitally
important for the healing process (see Fig 10-2).
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10 / Lasers in Facial Esthetics
Blood clot
Fibroblast
Macrophage
Fibroblasts proliferating
Subcutaneous fat
Freshly healed
epidermis
Freshly healed
dermis
Scrub
Blood vessel
Bleeding
Inflammatory
Proliferative
Remodeling
FIG 10-2
The typical phases found during wound healing including the inflammatory phase, proliferative phase (including reepithelialization, matrix synthesis, and neovascularization), and maturation phase.
The proliferative phase is characterized by the
formation of granulation tissue, consisting of a fibroblast capillary bed, macrophages, a weak arrangement of collagen, fibronectin, and hyaluronic acid.
This phase is composed of three important events: (1)
neoangiogenesis, which is the process of formation
of new blood vessels necessary to maintain the healing environment of the wound; (2) fibroplasia, which
consists of the appearance of fibroblasts at the site of
inflammation that will synthesize the collagen responsible for the sustentation and tensile strength of the
scar; and (3) epithelialization, which begins within
the first 24 to 36 hours and continues throughout the
healing phases. Epithelialization involves a sequence
of changes in wound keratinocytes: separation, migration, proliferation, differentiation, and stratification.
Thus, the extracellular matrix rapidly replaces the clot
deposited in the wound bed soon after the trauma,
with the main focus being to restore continuity of the
damaged tissue all while functioning as a framework
for cell migration.15
178
In the final maturation phase, wound contraction
reduces the amount and size of the disordered scar.15,16
During this stage, the scar tissue formed is remodeled, and the collagen fibers are reorganized with the
aim of increasing tissue strength and decreasing scar
thickness and deformity. The maturation of the wound
begins by the third week and lasts the entire remaining
life span of the wound.16
While the biologic process of wound healing has
been extensively studied, various research groups
have further demonstrated the effectiveness of light
stimulation in the functional and esthetic rehabilitation of the skin.7,8,12,17–23 Lasers are attractive therapeutic medical devices because they have the ability
to target localized regions or layers of the skin by
modifying the fluence rate, time, and spatial parameters. Because of the precise control over these
parameters in modern laser therapy devices, the
distribution of radiant energy and/or heat can be
controlled favorably to activate thermal, mechanical, and/or chemical processes.7
Biologic Activity of Lasers on Skin Cells
Basics of laser biologic activity
While the aim of this chapter is not to go into extensive detail over laser biology, a basic understanding is
necessary to carry out efficient laser treatment.20 Laser
is an acronym for Light Amplification by Stimulated
Emission of Radiation, which articulates precisely how
light is produced. Thus, the term reflects the crucial role
of the process of stimulated emission for the quantum
generators and amplifiers of coherent light.9,10 Laser
is an electromagnetic radiation with its own characteristics that differ from common light: It has a single
wavelength, with its waves propagating coherently in
space and time, carrying in a collimated and directional
way high concentrations of energy9 (Fig 10-3).
Electromagnetic radiation is a wave that propagates
itself in space resulting from the interaction of electric and magnetic fields. It is classified according to
the wavelength (∆), which is the distance between
two consecutive crests of the wave. The frequency
is the number of waves per unit time or contained in
the unit of length. The elementary unit of rem (radiation dosage) is the photon. According to quantum
mechanics, this is both wave and particle. The electromagnetic spectrum consists of a variety of wavelengths: gamma rays, X-rays, ultraviolet (UV), visible
light, infrared, microwave, and radio waves. Each has
various practical or clinical applications.
The extent of the interaction between lasers and
biologic tissue is usually determined by factors related
to the laser and by the optical characteristics of each
tissue.10 However, the literature is controversial regarding the effects of lasers in these processes, and it is
difficult to identify specific laser effects because many
factors and variables modify the effect on tissues.11,12
These factors are related to the optical properties
(reflection coefficient, absorption, and scattering)
and the thermal properties (thermal conductivity
and thermal/heat capacity) of the tissue as well as
the wavelength, the applied energy, the peak power,
the focused area (power and energy density), and the
laser light exposure time.13,14
In comparison to a light beam, a laser beam is
ordered because the target unit is an impulse to a
Laser source
Totally reflector
mirror
Laser beam
Laser medium
Partially reflector mirror
FIG 10-3
Illustration of a laser.
single direction, configuring to a stimulated emission.
This is well described in the following statement by
Jawad et al: “An excited atom may emit radiation in
advance if a photon from another similar atom passes
through it. The emission will occur during this passage,
and the new wave train will be incorporated into the
exiting wave train, increasing its length and increasing
its amplitude in the region in which the two coincide.”20
Understanding the fundamentals of laser emission
allows for the recognition that lasers have particular
properties: high collimation of its beam, the possibility
of providing high densities of radiation potency (considered a consequence of the high collimation of its beam),
and a high degree of monochromaticity of its radiation.12
Laser light features
Unlike sunlight and incandescent light that are
chaotic and emit radiation in all directions and in the
entire wavelength spectrum, laser light has different
characteristics:
• Coherent: The waves are in the same phase in
time and space.
• Monochromatic: They have the same wavelength
(pure light of the same color).
179
10 / Lasers in Facial Esthetics
n
tio
c
fle
Re
ng
eri
att
Sc
n
180
o
pti
sor
Ab
When a laser beam reaches a biologic tissue such as
the skin, the continuous source of photons can be
reflected, transmitted, scattered, or absorbed13 (Fig
10-4). The photons that do not penetrate the tissue
are reflected, while the photons that do penetrate
the tissue are divided into one of three paths and are
either absorbed, scattered, or transmitted.14 In biologic
tissue, water molecules or macromolecules such as
proteins and pigments mainly cause absorption. The
absorption of infrared light can be attributed to water
molecules, whereas UV and visible light are absorbed
by proteins and pigments.15 The absorbed portion of
on
ssi
Laser light interaction with tissues
i
sm
Usually medical lasers are named by the active
means or the injurious means. In relation to the
physical state, the laser mean can be (1) gaseous, (2)
liquid, (3) solid, or (4) free-electron. Gaseous lasers
can be atomic, ionic, or molecular. Gaseous lasers are
the most common and the oldest. They consist of a
mixture of gases. Examples of gaseous lasers include
CO2, argon, copper vapor, and helium-neon (HeNe). A
dye laser is an example of a liquid laser. Solid lasers can
be of two types: (1) doped insulators (crystals: ruby,
neodymium) and (2) semiconductors (eg, diode). In
the neodymium-doped YAG (Nd:YAG) laser, the laser
means consists of yttrium, aluminum, and garnet crystals. The excimer laser is a free-electron laser.
n
Tra
• Collimated: The waves have the same direction;
the light is parallel, not divergent, narrow, concentrated, and 1 mm in diameter.
• High-intensity light: Because it is monochromatic,
it can interact intensively with certain substances
and little with others. Because it is emitted in the
form of a highly collimated beam, it can be directed
with great precision for significant distances. This
is the reason why it is used routinely in satellite
technologies to measure distances (eg, accurately
measuring distances between the Earth and the
moon). In addition, laser light can be collected by a
lens and focused onto a small circle, which allows a
significant increase in energy per unit area.
FIG 10-4
Laser light that reaches the skin surface can be either reflected, transmitted, scattered, or absorbed.
the laser radiation can produce photothermal and/or
photochemical effects depending on the wavelength
of the laser radiation and nature of the tissue16:
• Photothermal effect: The high-energy laser is
absorbed by the tissues, generating heat that
causes destruction to the tissue (eg, CO2 laser).
• Photodisruption: A shock wave from the vibration
causes explosion and fragmentation of the target
tissue, resulting in mechanoacoustic and photoacoustic effects (eg, a Q-switched laser).
• Photoablation: Direct breakage of molecular bonds
by high-energy UV photons (eg, excimer laser).
• Plasma ablation: Induced ablation through the
ionization of molecules and atoms when plasma
formation is obtained (eg, Nd:YAG laser).
• Photochemical effect: Photodynamic therapy
(PDT) or photochemotherapy. It is based on the
administration of a photosensitizing substance,
which is selectively captured by tumor (or other)
cells and, under the action of a light source of
certain characteristics, causes toxic products that
damage the neoplastic cells, inducing their death.
This light source can be a laser.
Biologic Activity of Lasers on Skin Cells
In recent years, phototherapy by lasers has gained
popularity as a biostimulatory method for tissue repair
by increasing local circulation, cell proliferation, and
collagen synthesis.9 Low-power laser or LLLT is an
example of photobiomodulation using infrared red
light, which has been shown to accelerate the wound
healing process for postoperative surgical wounds and
treatment of ulcerated lesions.7,23,24
Several clinical studies have evaluated phototherapy for the treatment of scars and tissue repair.
One limitation remains the array of laser application
therapies differing in the type of laser and dosimetry
used (wavelength, power, intensity).20,25 Despite the
frequent and growing use of lasers, the ideal dose of
energy is a question frequented by many researchers
and clinicians. There is therefore a need for further
research and randomized controlled clinical studies
evaluating the ideal laser conditions for each clinical indication; ongoing research is continuously
underway.7,12,25
Laser photobiostimulation
The absorption of laser light by tissues can occur by
four methods: photochemical, photothermal, photomechanical, and photoelectric. Because of the large
number of clinical effects these processes cause,
they can be subdivided according to their clinical
application.19 During photochemical absorption,
biomodulation can occur, which is the effect of laser
light on molecular and biochemical processes that
normally occur in tissues, such as wound healing and
bone repair. Laser phototherapy has a wavelengthdependent ability to modify cell behavior in the absence
of significant heat.26 The dispersion of laser light in the
tissue is naturally very complex, because the components
of the tissue influence the dispersion of light.20,26
It has been demonstrated in several in vitro and
in vivo studies that laser photobiomodulation at the
cellular level stimulates the cytochrome C oxidase
(CCO) photoreceptor, resulting in an increased
metabolism and energy production. Consequently,
an increase in oxidative mitochondrial metabolism
occurs, which then initiates a cascade of cellular
reactions that modulate biologic behavior such as
angiogenesis, macrophage and lymphocyte activity, fibroblast proliferation, collagen synthesis, and
mesenchymal cell differentiation, among others, thus
accelerating the wound repair process.19,26,27
LED photobiostimulation
LED emission is different from lasers, which produce
stimulated and amplified emission of radiation.28 The
increase in collagen deposition after LED irradiation
was documented in fibroblast cultures and also in
human models in third-degree cicatrizing burn models
and in human bolus lesions. There is evidence that
light produced by LEDs, at the same biostimulatory
wavelengths as previous studies with lasers, has similar biochemical effects.29,30 The mechanism associated with the cellular photobiostimulation by LLLT is
not yet fully understood; nevertheless, there is some
indication that the mechanism involved is similar to
laser, with the absorption of light by the CCO present
in the mitochondrial membrane28–30 and perhaps also
by photoacceptors found in the plasma membrane of
cells.29 As a consequence, a cascade of events takes
place in the mitochondria, leading to biostimulation of
various processes.29 It has been hypothesized that the
absorption of light energy can lead to photodissociation of inhibitory nitric oxide from CCO9,31 producing
the enhancement of enzyme activity, electron transportation, mitochondrial respiration, and adenosine
triphosphate (ATP) production.32–37 In turn, LLLT can
modify the cellular redox state, which induces the activation of numerous intracellular signaling pathways
and also modifies the affinity of transcription factors
concerned with cell proliferation, survival, tissue
repair, and regeneration. In skin rejuvenation, LLLT
helps to increase collagen production by enhancing
fibroblast activity, decreasing apoptosis, improving
vascular perfusion, and synthesizing wound healing
growth factors including platelet-derived growth
factor (PDGF), basic fibroblast growth factor (bFGF),
and transforming growth factor β (TGF-β).28,29,38,39
Although LLLT has a variety of clinical applications, some limitations have also been reported to be
181
Near infrared: 800–835 nm
Dermal papilla of
hair follicle
Fat of subcutis
Red: 610–775 nm
Arrector pili
Yellow: 580–600 nm
Sebaceous gland
Blue: 450–470 nm
Dermo-epidermal junction
UV: 350 nm
Dermal-epidermal
junction
Eccrine gland
Green: 510–540 nm
10 / Lasers in Facial Esthetics
FIG 10-5
Light penetration into
the skin.
associated with its use.39 First, its cellular and molecular mechanism remains unclear.40 Secondly, there
are no established parameters regarding wavelength,
irradiance or power density, pulse structure, coherence, polarization, energy, fluence, irradiation time,
contact versus noncontact application, and repetition
regimen.41,42 It must always be considered that high
dosimetric parameters can lead to tissue damage and
lower ones can result in reduced treatment effectiveness. It is also important to have an appropriate characterization of the patient’s skin before application of
LLLT; an appropriate dose of light must be considered
for each skin pigmentation or particular application.7
Furthermore, suitable removal of makeup and oily
debris is mandatory as with the other modalities to
allow convenient penetration of the light source.
Therapeutic effects of lasers
The therapeutic effect of lasers varies according to wavelength; pulse duration; size, type, and depth of the target;
and interaction between the light emitted by the laser and
the determined target. The main targets of medical lasers
are natural pigment, external pigment, intracellular water,
and amino acids and nucleic acids. Natural and external
pigments are called chromophores. Chromophores are a
182
group of atoms that give color to a substance and absorb
light of a specific wavelength in the visible spectrum. The
skin chromophores are oxyhemoglobin and deoxyhemoglobin, melanin, carotenes, water, and proteins (Fig 10-5).
Proteins and water are not absorbed in the spectrum of
the visible and theoretically should not be called chromophores, but in practice they are organic molecules
that absorb rem so they are considered chromophores in
general, even if they absorb UV or infrared light.
Most organic molecules absorb UV light via strong
absorption of the proteins in this area of the spectrum. Oxyhemoglobin has an absorption peak between
490 and 595 nm corresponding to green and yellow
(Fig 10-6). Deoxyhemoglobin is absorbed at 770 nm.
The methemoglobin that results from the transformation of hemoglobin after heating the blood has a
preferential absorption at 1,000 nm. Melanin has a
very broad absorption in the optical spectrum, but it
slowly decreases from UV to infrared with a maximum
of around 530 nm. Water absorption predominates at
wavelengths exceeding 1,800 nm and peaks around
2,940 nm (Er:YAG laser setting). Water adsorption is
much lower when utilizing the Nd:YAG laser, which
allows for a deeper-penetrating laser that typically
generates more heat (see Fig 10-6). It is important to
note that there is no wavelength that allows a laser
Clinical Indications for Laser Treatment
Nd:YAG (1,064 nm)
Er:YAG (2,940 nm)
Absorption
Water
Hydroxyapatite
Desoxythemoglobin
Oxythemoglobin
Melanin
500
FIG 10-6
1,000
1,500
2,000
Wavelength (nm)
2,500
3,000
Absorption of organic molecules according to laser wavelength.
FIG 10-7
Demonstration of an LLLT device (ATP38) being utilized on a
patient following esthetic treatment.
to reach a chromophore in a completely specific fashion. The optical window chosen is only as selective as
possible for the target tissue, hence the importance
of cooling systems that cool the epidermis and the
surface dermis and thereby enhance the selectivity
of the thermal action at the level of a deeper target.43
LLLT
There are more than 200 different types of LLLT devices
on the market, mostly utilized for hair growth and pain
regulation. ATP38 (Biotech Dental) is a painless and
noninvasive concept that follows the tissue biostimulation technique of LLLT, which includes a light program
for facial esthetics (Fig 10-7). This technology is the
only one that combines a spectrum between 450 and
835 nm. The blue light corresponds to a wavelength
of 400–450 nm and stimulates oxygen formation and
gives an antibacterial and healing effect that is efficient
in acne and in dermatosis. The green light corresponds
to 480 and 530 nm; these light wavelengths aid the
oxygenation and hydration of the skin and are effective
against skin stress and fatigue as well as in treating skin
pigmentation. The amber light (570–530 nm), whose
colors vary between yellow and brown, stimulates the
hormonal and immune system as well as the nerve
system. The red light corresponds to a wavelength
of 630–700 nm, and its penetration stimulates blood
circulation and improves fibroblast activity. This cellular
action also helps with collagen and elastin regeneration,
which acts on wrinkles and scars. The infrared light
corresponds to wavelengths greater than 800 nm and
allows penetration up to 4–5 cm in the target tissues.
Because various wavelengths and frequencies exist,
it is important to respect the manufacturer’s distance
between the patient and laser during its use. This
light acts for the process of pain and has an antiinflammatory, anti-infectious, and healing effect useful
for skin rejuvenation and in hair growth stimulation.
More evidence is needed to prove the efficacy of this
laser in the facial esthetic field.
Clinical Indications for
Laser Treatment
In today’s market there are about 60 different companies manufacturing over 150 different laser apparatuses for facial esthetic application (Fig 10-8). These
lasers are typically classified based on their laser type,
wavelength, and clinical application, with the majority
having more than one application.
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10 / Lasers in Facial Esthetics
a
b
FIG 10-8
FIG 10-9
Various commercially available lasers in today’s market. They
range in size, type, and laser wavelength, among other things.
Atrophic surgical scar on the face (a) that showed clinical improvement including reduction in depth after two treatments
with ablative fractional CO2 laser at settings of 40 mJ per
pulse, 30% coverage, and 0.05 kJ total energy delivered at
each session. (Reprinted from Reddy et al49 with permission).
Scars
and flattening of keloidal scars.40–54 Results, however,
were transient, scar recurrences were common, and
several studies were criticized for lacking outcome
definitions and adequate follow-up. The excision and
vaporization of hypertrophic scars and keloids using a
continuous-wave CO2 laser has demonstrated similar
recurrences within 1 year and a high level of recurrence
between 6 and 12 months postoperatively.55,56 Another
disadvantage of CO2 lasers is that they can aerosolize
diseases such as hepatitis B and C, HIV, and other
viruses. For this reason, these lasers fell out of favor.
The pulsed dye laser (PDL) (585 nm) was already
effective in the treatment of port-wine stains, telangiectasias, and other vascular lesions in the 1990s. Clinical
studies revealed that the 585-nm flashlamp-pumped
PDLs could be utilized to clinically improve hypertrophic
and keloidal scars. It demonstrates improvements in
scar vascularity, color, height, texture, and pliability.57,58
The exact mechanism by which the PDL reduces scarring remains unclear. Possible implicated mechanisms
are laser-induced tissue ischemia (by destruction of
the microvasculature) leading to collagenesis, collagen
fiber heating with dissociation of disulfide bonds and
A scar results from the culmination of the complex
processes of wound healing. Scars are usually formed
following a surgical treatment, trauma, or even acne,
and they are difficult to eradicate. Two of the main
characteristics of scars are fibroblastic proliferation
and excessive collagen deposits. A wide range of
nonsurgical (eg, pharmacologic, mechanical pressure,
silicone gel dressings), surgical (eg, cryotherapy, excision), and laser therapies (CO2, pulsed dye, fractional
ablative, and nonablative lasers) have been used with
variable success, with ongoing research needed to
achieve an optimal treatment modality.44–48
Laser treatment of hypertrophic and keloidal scars
started with CO2, argon, and Nd:YAG lasers (Fig 10-9).49
Apfelberg et al reported promising initial findings
using argon lasers; however, subsequent reports failed
to confirm these findings, with universal keloid recurrences in the study groups.50,51 The use of the continuouswave Nd:YAG laser (1,064 nm), which selectively
inhibits collagen production based on in vivo and in
vitro studies, also initially demonstrated softening
184
Clinical Indications for Laser Treatment
FIG 10-10
(a and b) Acne scars before and
after phototherapy with a laser.
(Reprinted from Tenna et al63
with permission.)
a
subsequent collagen realignment, and mast cell factors
affecting collagen metabolism.54
Barolet and Boucher have investigated the application of LLLT as a prophylactic method to modify the
wound healing process in order to avoid or attenuate
the formation of hypertrophic scars or keloids.59 In this
study, CO2 lasers were evaluated and compared with
the results of near-infrared (NIR)-LED 805 nm at 30
mW/cm2 and 27 J/cm2. Significant improvements in
the NIR-LED–treated versus the control scar were seen
in all efficacy measures, and no significant treatmentrelated adverse effects were reported.59
In summary, a variety of studies have demonstrated
improvement when using lasers in scar treatment.
More randomized controlled trials are needed to evaluate each modality comparatively, especially considering that pathologic scars remain a clinical challenge.
Advanced research programs are required in order to
improve laser systems and protocols specific to scar
history, scar type, and scar functional morbidity.
Acne
The pathogenesis of acne vulgaris has not yet been
clarified; nevertheless, there are four events that characterize the pathology: follicular hyperconification,
increased sebum secretion effected by the androgenic
hormone secretions, colonization of Propionibacterium
acnes, and inflammation.60 P acnes plays a key role
by acting on triglycerides and releasing its cytokines,
b
which in turn trigger inflammatory reactions and alter
infundibular keratinization.60 Topical and oral medications such as topical antibiotics, topical retinoids,
benzoyl peroxide, alpha hydroxy acids, salicylic acid, or
azaleic acid are current treatment modalities for acne
vulgaris. In severe cases, systemic antibiotics such as
tetracycline and doxycycline, oral retinoids, and some
hormones are indicated to counteract microcomedone
formation, sebum production, P acnes colonization,
and inflammation.61 Adverse effects and/or inadequate
response to acne treatment remain big challenges.
Phototherapy (light, lasers, and PDT) has been
considered a therapeutic modality to treat acne
vulgaris, having fewer side effects when compared
to other treatment options62,63 (Fig 10-10). It has
been reported that exposure to sunlight can be
effective because sunlight decreases the androgenic
hormones in sebaceous glands. Nevertheless, there
is an unwanted side effect of exposure to UVA and
UVB rays.64
Visible light in phototherapy, especially blue and red
light, has also been applied in acne treatment.65 Phototherapy for acne is capable of producing reactive free
radicals that lead to bacterial destruction.66 Studies have
demonstrated that red light can reduce the sebum secretion and alter keratinocyte action, reducing inflammation
as well, due to its modulating cytokine effect64–67 (see Fig
10-10). Studies demonstrate that LLLT using red to NIR
spectral range (630–1,000 nm) and nonthermal power
(less than 200 mW) alone or in combination with other
185
10 / Lasers in Facial Esthetics
treatment modalities (blue light) has positive results for
the treatment of acne vulgaris.60–68 It is also noteworthy that phototherapy led to greater improvement in
inflammatory lesions when compared to comedones.60,68
Atrophic scarring as a result of cystic acne is another
concern derived from acne.69 This topic was discussed
in the previous section on scars.
Vascular lesions and hemangiomas
Telangiectasias and erythema in the facial area are
some of the most common complaints of facial esthetic
patients. These lesions can occur due to the skin aging
process, photodamage, or as a result of conditions like
rosacea. Laser therapy has therefore been proposed as a
solution to treat these types of lesions. The main objective to cure these vascular malformations and hemangiomas is to target oxyhemoglobin within the vessels and
destroy the pathologic vasculature. Protecting the light
absorption by epidermal melanin is also a secondary
challenge in this therapy.70 A variety of lasers can be
applied to target the chromophore oxyhemoglobin, but
the PDL is generally preferable.71 After PDL treatments,
blood vessels were observed to contain agglutinated
erythrocytes, fibrin, and thrombi. It was observed that
these damaged vessels were replaced by normalappearing vessels 1 month after treatment.72 The best
results for port-wine stain therapy were reported to
be accomplished by the use of PDL with cryogen cooling.73,74 The application of PDT and nonablative therapies was also reported to have positive results against
hereditary hemorrhagic telangiectasia.25
Pigmented lesions
To effectively treat pigmented lesions, a good diagnostic and histopathologic classification of the lesion is
necessary. With this information, the lesion can effectively be categorized according to the depth of the
target pigment distribution: epidermal, dermal, or a
combination of both.75 Epidermal pigmented lesions
include lentigo, café-au-lait macule (CALM), ephelis
(freckle), junctional nevus, nevus spilus, and seborrheic keratosis. Dermal pigmented lesions include
186
a
b
c
d
FIG 10-11
(a and b) Clinical photographs taken before and after treatment of a pigmented lesion with PRF and laser therapy. (c and
d) High-magnification view of areas of the skin before and
after treatment.
blue nevi and nevi of Ota or Ito. Pigmented lesions
with both an epidermal and a dermal component
include melasma, Becker nevus, compound nevus,
and congenital nevus. For some pigmented lesions,
the target is melanosomes in keratinocytes, whereas
in most cases it is melanosomes in melanocytes or
the whole melanocyte76 (Fig 10-11).
Clinical Indications for Laser Treatment
a
b
FIG 10-12
(a and b) Skin pigmentation before and after treatment with lasers and PRF.
The success of Q-switched lasers in the realm of
pigmented lesions is based on the ability of these lasers
to selectively target melanosomes situated within
melanocytes and keratinocytes. The melanosomespecific damage is due to the absorption of highenergy, nanosecond laser pulses.77–79 Long-pulsed
lasers in the millisecond domain can also be used to
target epidermal and dermal pigment found in larger
clumps, such as those in nested melanocytes or
confluent melanin in the epidermis.80
Epidermal lesions are more easily treated because
there are more treatment options due to their superficial location; virtually all injuries confined to the
epidermis heal without scarring. The 532-nm (frequencydoubled Nd:YAG) and 694-nm (ruby) wavelengths are
the most appropriate for epidermal lesions, followed
by the 755-nm (alexandrite) and, least effective, the
1,064-nm wavelength (long-pulse Nd:YAG). The
shorter wavelengths are particularly useful because
their greater melanin absorption best targets the
superficial melanin in keratinocytes and melanocytes.
Furthermore, lesions with less melanin such as lighter
lentigines, freckles, or CALMs can still be effectively
targeted. Longer-pulsed pigment-specific lasers and
ablative and nonablative fractional photothermolysis
lasers are also capable of treating epidermal pigmentation, even though fractional photothermolysis would be
used more efficiently in the context of a diffuse epidermal pigmentary aberration.43 Deeper lesions require
the longer wavelengths of 694, 755, and 1,064 nm for
better depth of penetration. Q-switched ruby, alexandrite,
and Nd:YAG lasers should also be effective in removing
deep dermal melanocytes, as long as the lesion does not
extend into the subcutaneous fat layer.81–84
Pigmented lesions are often treated for esthetic
reasons. When choosing the therapeutic means for an
optimal esthetic result, minimal risk must be the goal.
Selective targeting of pigment-containing cells is the
way to achieve the best results (Fig 10-12). Patients
should follow sun-protection measures in order to avoid
the risk of hyperpigmentation. If hyperpigmentation
is noted within the healing irradiated sites, hydroquinone therapy should be used two times per day until
it resolves. Avoidance of sun exposure and use of a
sunscreen with UVA/UVB protection is recommended.
If hypopigmentation does occur, it often resolves spontaneously with time. If not, the excimer laser or other
narrow-band UV source may be utilized. In the rare
event of adverse sequelae such as scarring, it is best
to implement early treatment with the PDL.43
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10 / Lasers in Facial Esthetics
The role of fractionated photothermolysis in improving certain types of pigmented lesions is forthcoming,
and the potential use of picosecond lasers also holds
promise for the treatment of pigmented lesions.85
Further research evaluating these newer laser parameters is needed to obtain a higher percentage of
successful outcomes.
Skin rejuvenation
Laser resurfacing is a field that has evolved over the
past 30 years. The CO2 laser, which produces infrared light with a 10,600-nm wavelength, was the first
laser to be applied for cutaneous resurfacing. Because
water represents 70% of the total volume of the skin
and the CO2 laser’s wavelength is strongly absorbed
by water, this laser was initially considered an ideal
tool for superficial ablation of the skin. However, early
on the CO2 laser was used in a continuous-wave mode
with a tissue dwell time that was well above the thermal relaxation time of the superficial skin (1 ms). This
resulted in the generation of excessive nonspecific
thermal damage, which clinically translated into high
rates of scarring and pigmentary disturbances.86
Given the complications encountered with CO2 laser
resurfacing, clinicians began looking for an alternative
ablative resurfacing laser. Ideally, this would be a laser
system capable of carrying out considerably greater
ablation with a significantly reduced residual zone of
nonspecific thermal damage. The arrival of the Er:YAG
laser in the mid 1990s made it possible for clinicians
to successfully substitute the CO2 laser.87
While the CO2 laser creates a zone of thermal injury
up to 200 µm in depth, leading to prolonged erythema
and slower recovery times, the Er:YAG laser (with a
pulse length of approximately 250 ms) has advantages such as relatively quick recovery times, less
erythema, higher light absorbance, and the production
of less thermal injury with each pass (approximately
50 µm).88,89 Nevertheless, slightly decreased clinical
efficacy is also associated with the Er:YAG laser.90
Due to the prolonged time of recovery and possible complications associated with ablative lasers,89
nonablative lasers started to be utilized more routinely
188
for this indication because they can selectively heat
dermal tissues, protecting the epidermis from significant thermal injury and therefore reducing possible
complications and/or recovery times.89,91,92 Nonablative rejuvenation techniques preserve the integrity of
the epidermis by stimulating the production of collagen in the dermis. They are indicated for rejuvenation
of aged skin as well as prophylaxis.
Nonablative lasers are infrared lasers that act
by stimulating collagen neosynthesis, without the
destruction of the epidermis, in a method called
subsurfacing. The laser has to penetrate 100–400
µm to reach the dermal-epidermal junction pigment,
where the collagen and the vessels of the dermis are
located. The absorption of light by the water causes
photothermal effects and consequently an inflammatory response that stimulates fibroblastic activity.
The epidermis is protected by cooling, which may be
obtained by a jet of cryogenic gas or by direct contact
of the skin with a sapphire window inserted in the
handpiece.93 The lasers used in nonablative rejuvenation are the following: Nd:YAG 1,064 nm and 1,320
nm; diode 1,450 nm; erbium 1,540 nm; Q-switched
Nd:YAG 1,064 nm; krypton/Nd:YAG 532 nm; PDL 595
nm; and intense pulsed light (IPL).
Several vascular lasers such as the PDL and the
krypton/Nd:YAG laser have been used for skin rejuvenation.93,94 This is because platelet activation and
laser-induced cytokine release in the blood vessels activates the fibroblasts and induces collagen synthesis,
resulting in a firming action. In addition, they act on
the vascular and pigment component of photoaging.
Infrared lasers act by remodeling the dermis and stimulate the production of collagen and elastic fibers.95–97
Fractional ablation is the latest development in
cutaneous rejuvenation. It was first introduced by
Manstein et al in 2004.87 The laser radiation is emitted
by optical microfeigs that act in columns surrounded
by a hyperthermic zone. This technique is less invasive
than ablative techniques and allows a faster recovery
than unfractionated rejuvenation.98,99 Treatments can
be repeated every 3 to 4 weeks. On a case-by-case
basis, the treatment area and the energy density
of microbundles can be adapted. The depth of skin
Clinical Indications for Laser Treatment
penetration depends on the energy and wavelength of
the laser beam. This treatment can be performed with
a fractionated erbium 1,540-nm laser, and it generally
does not require anesthesia. It causes erythema and
moderate edema for 3 days. Fractional ablation can
be used on all phototypes and in all anatomical areas
and has lower complication rates when compared to
many other procedures used for facial rejuvenation.
The most common complication are acneiform eruptions and herpes simplex infections. Postinflammatory
hyperpigmentation is rare but more frequent in high
phototypes. This type of laser treatment has indications for the improvement of wrinkles, acne scars,
surgical/traumatic scars or burns, and stretch marks,
among others.100–102
Low-level LED therapy is a newer nonthermal,
nonablative laser treatment for skin that uses an
LED as the source. This type of therapy has demonstrated promising results in improving wrinkles and
skin laxity.103–111 In animal studies, it has been reported
that LLLT can increase the production of collagen and
bFGF.112,113 It has also been reported that LLLT is able
to increase microcirculation and vascular perfusion
on skin, increase expression of PDGF and TGF-β1,
and inhibit apoptosis.112,113 In 2007, Lee et al reported
that the amount of collagen was increased following
different combinations of LED phototherapy, leading
them to surmise that LED therapy may induce wound
healing that contributes to new collagen synthesis.114
In another clinical study performed by Weiss et al,
300 patients received LED therapy alone, and 600
patients received LED therapy in combination with
a thermal-based photorejuvenation procedure.106
The data showed that 90% of the patients who
received LED therapy alone reported a softening of
skin texture and a reduction in roughness and fine
lines. Patients in the combination group reported a
prominent reduction in posttreatment erythema and
an overall impression of increased efficacy with the
additional LED treatment,106 which could be attributed
to the anti-inflammatory effects of LLLT.115,116 Another
split-face single-blinded clinical study using LLLT on
skin texture and appearance of individuals with aged/
photoaged skin demonstrated that while more than
90% of individuals had a reduction in rhytid depth and
surface roughness, 87% of the individuals reported
that they experienced a reduction in the Fitzpatrick
wrinkling severity score.117
Laser fat ablation and laser lipolysis
The use of lasers in fat ablation permits lipolysis on a
mesoscopic scale, which is suitable for use in the face.
The first reported instance of laser fat ablation was
via CO2 laser.114 The technique became known as laser
lipolysis and has since been more frequently utilized
with Nd:YAG and diode lasers as a primary light source.
Laser lipolysis was shown to be safe and minimally
invasive (requiring only a small incision), while causing
desired skin retraction. Furthermore, laser lipolysis
caused thermal damage in the fat that led to better
hemostasis and wound healing, less surgical trauma,
and faster recovery compared to traditional surgical
liposuction.25,118
Hair removal
In 1996, Grossman et al described hair removal with
a laser by selective photothermolysis of hair follicles
using a normal-mode ruby laser. As with other laser
therapies, novel laser sources were thereafter introduced.119 The target is the melanin pigment present
in the hair bulbs. The purpose is to destroy the bulb
that leads to permanent epilation. Only the bulbs that
are in the anagen phase are destroyed. In the catagenic and telogenic phase, the hair gradually detaches
itself from the bulb. For this reason, the melanin chromophore cannot serve as a selective leader to atrophied target cells. The duration of the pillar cycle is
different in intermediate hair and terminal hair, so the
duration and percentage of hair in the anagen phase
varies from one zone to another. The ideal duration of
treatment is that of the pillar cycle, so the intervals
between the sessions should be 2 to 4 months, with
longer times for thicker hair. The darker and thicker
the hair, the more effective the treatment. White hairs
do not respond to the laser. Between sessions, the
hair should not be pulled out. After 15 days, it will
189
10 / Lasers in Facial Esthetics
fall out spontaneously. This treatment is indicated in
cases of hirsutism, hypertrichosis, Becker hamartoma,
folliculitis (traumatic, decalvant, hidrosadenitis), pili
incarnati of the black race (via Nd:YAG laser), and for
other facial esthetic purposes. There are no studies
to support the concept that lasers can improve the
evolution of hidradenitis suppurativa.53–55 Laser treatment of hairy nevi is not recommended because of
the risk of damage to nevitic cells whose evolution
is unpredictable.56
Pulsed lasers are used but have a longer pulse duration than Q-switched lasers. The wavelengths of these
lasers are between 600 and 1,100 nm, which is the
optimum optical window because the competition
between melanin and other cutaneous chromophores
is reduced. Appropriate lasers include alexandrite 755
nm; 800-nm diode; ruby 694 nm; Nd:YAG 1,064 nm
pulse length; IPL 500–1,200 nm; and alexandrite
combination 755 nm + Nd:YAG 1,064 nm. The explanation for the choice of wavelength and this pulse
duration lies in the competition between follicular
melanin and melanin in the epidermis for the absorption of energy of determined wavelength. The higher
the wavelength, the lower the probability of being
absorbed by the melanin of the epidermis because
the radiation penetrates deeper into the dermis. To
obtain a selective photothermolysis of the hair follicle, the radiation must penetrate at least 3 mm. In
the high phototypes IV to VI, only the lasers diode
800 nm and Nd:YAG 1,064 nm are recommended. The
diode laser is more effective, but the Nd:YAG laser is
safer due to its higher wavelength, meaning it is less
absorbed by the epidermis. In light skin, the alexandrite laser is the most effective, followed by the diode
laser and finally the Nd:YAG. The first two are also the
best tolerated. A recent comparative study among
the various lasers used in epilation did not show any
benefit of the combined alexandrite + Nd:YAG laser
compared to the alexandrite laser. The IPL achieves
very similar results to the alexandrite laser, and the
new-generation devices can also be used in the high
phototypes. The long-pulse ruby laser would theoretically have the ideal wavelength for pigmented hair
epilation but is usually marketed in the Q-switched
190
form rather than in the long-pulse form, the only one
effective in the destruction of hair follicles.57 These
lasers are coupled with cooling systems to prevent
injury to the epidermis and accumulation of heat
therein. The ambient temperature should be 19°C to
21°C. Treatment of supracilia and mucosa is contraindicated. Sun exposure should be avoided 1 month
before and 1 month after treatment. Therapy is also
contraindicated for patients taking photosensitizing
drugs, isotretinoin within the previous 6 months, or
beta-carotene, as well as in patients using self-tanning
agents. Diseases associated with photosensitization
such as lupus and polymorphous light rash contraindicate IPL but not lasers. This is because lupus is
triggered mostly by UVB (280–320 nm) radiation,
and to a lesser extent by UVA (320–400 nm) radiation, but especially by visible light (400–800 nm).
Infrared radiation is not harmful.58,59 A diode laser
epilation study was published that concluded it to be
safe in patients on isotretinoin medication. There are
currently portable IPL devices and diode lasers for
do-it-yourself epilation. The opinion of dermatologists
and experts in the field in relation to these apparatuses
is not consensual.
Pregnancy is always a contraindication for
laser therapy.
Laser therapy in facial esthetics with PRF
The traditional indications for using lasers in facial
esthetics include advancing age and lifestylerelated loss of facial volume, reduction in elasticity,
and dryness of skin, all caused by a loss of collagen.
While these were once the primary indications, more
commonly today many patients wish to use laser
therapy as a means to maintain a youthful look by
stimulating collagen synthesis. Furthermore, patients
may benefit from laser therapy knowing that its use
does not include agents or products being injected
into the body.
The Smoothlase, Necklase, and Liplase protocols
(Fotona) have been developed as mainly intraoral
Clinical Indications for Laser Treatment
FIG 10-13
Image demonstrating the clinical use of a Fotona Lightwalker for intraoral skin
rejuvenation.
a
b
c
FIG 10-14
Use of the Smoothlase application (Fotona) for nasolabial folds. Seven treatments were performed, once every 21 days. (a) Preoperative photograph. (b) Clinical photograph taken at 30 days following treatment. (c) Clinical photograph at 42 months following treatment with no touch-up therapies performed in between. Note that the patient should have received updated treatments
but still demonstrates a visible difference nearly 4 years posttreatment.
laser rejuvenating procedures, using both the Er:YAG
and Nd:YAG wavelengths to tighten skin and improve
elasticity, skin tone, and texture in a minimally invasive
manner (Fig 10-13). First, the Nd:YAG laser preheats
the tissues to 40°C , followed by the Er:YAG laser
using a proprietary “Smoothmode” pulse technology
(Fotona). Smoothmode is a burst of pulses offered in
quick succession to create deep heating, conversion,
and immediate tightening of collagen. The patient in
Fig 10-14 has not had subsequent follow-up procedures for nearly 4 years yet maintains a relative gain in
skin volume 42 months after initial treatment. Figure
10-15 also demonstrates a patient following the standard protocol. Note the immediate visible results 30
days after the treatment regimen.
Liplase was created to address the rapid increase in
primarily female demand for restored and/or plumper
lips. This technique is an Er:YAG-only technique where
stimulation of the patient’s own collagen formation
is observed and can last 6 to 12 months. While fillers
remain the top material utilized for such procedures,
more natural approaches utilizing PRF and/or lasers
191
10 / Lasers in Facial Esthetics
a
b
c
FIG 10-15
Clinical photographs before and after five treatments with Smoothlase intraoral applications with Necklase. During these five treatments, three times the laser was applied to enhance lip volume (Liplase). Treatments were performed every 21 days. The final
treatment involved a light fractal peel (Er:YAG). (a) Preoperative photograph. (b) Photograph 30 days after the fifth treatment. Note
the noticeable change in skin tightening and reduction in skin laxity. (c) Final view 30 days after the fractal peel.
FIG 10-16
a
b
a
b
Use of an Er:YAG laser in Smoothmode
pulse technology (Liplase). (a and b)
Clinical photographs before and only 10
minutes after one procedure. Note the increase in upper lip volume.
c
FIG 10-17
(a to c) Change in lip dimensions after several treatments with an Er:YAG laser in Smoothmode pulse technology. Note the increase over time in lip volume. These increases may be maintained 6 to 12 months after therapy.
have been proposed. Figures 10-16 and 10-17 demonstrate two cases that were treated with lasers alone,
avoiding the use of artificial materials. This laser can
be used to create a larger cupid’s bow and/or plump
certain lip deficiencies or defects. Touch-ups are
required every 6 to 12 months.
In 2017, the “Dr. Acula’s Facial,” or the Dracula technique, was proposed as a novel therapy whereby the use
of PRF was combined with extraoral laser microchanneling. First, the laser penetrates the skin and creates
microchannels 0.5 to 1 mm deep, when the pulsing is
varied with the Fotona Er:YAG laser. Once the laser is
192
utilized on the skin, a coating (mask) of liquid PRF is
applied to the face (Figs 10-18 and 10-19). Typically,
two to three treatments are necessary for the desired
results. Similar to traditional microneedling, the laser
also stimulates new collagen formation and tightening
of existing collagen to contribute to facial rejuvenation
and improved elasticity, minimizing surface lines, wrinkles, and sagging and improving moisture and color
of the skin. Figure 10-20 demonstrates a step-by-step
series of clinical photography whereby PRF was utilized
for facial rejuvenation followed by LLLT therapy.
Clinical Indications for Laser Treatment
a
b
c
d
e
FIG 10-18
Results of the Dracula treatment (laser + PRF) after 30
days. (a) Preoperative photograph. (b) First the face is prepared for laser microchanneling.
(c) Then the liquid PRF is applied
as a topical for 30 minutes. (d)
The liquid PRF is removed. (e)
Clinical photograph 30 days after treatment. Note the tightening of the skin and reduction in
skin wrinkles following only one
treatment.
a
b
c
d
FIG 10-19
Use of laser microchanneling
(Necklase) with PRF. (a) Preoperative photograph. (b and c)
Photographs immediately after
the laser procedure. Notice the
small lumps that are formed on
the skin surface. (d) Clinical photograph 30 days after treatment.
193
10 / Lasers in Facial Esthetics
c
a
b
d
g
e
f
h
FIG 10-20
Step-by-step protocol for combined PRF treatment with LLLT. The use of LLLT has been shown to decrease postoperative swelling and
redness following PRF treatment. (a) Initial clinical situation. (b) Cleaning the skin with foaming cleanser and skin disinfection with
70% alcohol. (c) Collecting blood in PRF plastic tubes. (d) Production of liquid PRF following centrifugation. (e) Collecting liquid PRF
into 1-mL syringes. (f) Exchange of needle depending on the injection type. (g) Micropapular injections with 4-mm 32G needle.
(h) Application of liquid PRF for mesotherapy with microneedling.
194
Clinical Indications for Laser Treatment
i
j
k
l
m
n
o
FIG 10-20 (cont)
(i) Microneedling the liquid PRF into the skin. (j) Skin redness
and petechiae following microneedling. (k) Application of a
hydrating mask to cool and rehydrate the skin posttreatment.
(l and m) Use of ATP38 laser application in “Fade out wrinkles
and fine lines” mode. (n to p) Before and after photographs in
frontal, right-side, and left-side views.
p
195
10 / Lasers in Facial Esthetics
Conclusion
While laser therapy was once considered a treatment
option with high morbidity, today various lasers can be
utilized with favorable outcomes and minimal recovery periods. In the coming years, additional comparative studies will surely provide new guidelines with
optimized systems and protocols for various clinical
indications. Furthermore, a growing area of future
research has been on combination approaches for
facial rejuvenation with lasers and other modalities
that may further optimize final outcomes.
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95. Goldberg DJ, Rogachefsky AS, Silapunt S. Non-ablative laser
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face and neck using a combined diode laser and radiofrequency technology. Dermatol Surg 2005;31:1695–1699.
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11 /
SKIN CARE
PRODUCTS AND
THEIR EFFECT ON
AGING SKIN
Geir Håvard Kvalheim
Catherine Davies
Richard J. Miron
Posttreatment skin care is a crucial step aimed at enhancing the clinical
results following facial esthetic procedures. This field specifically has rapidly
ballooned into a multibillion-dollar-per-year industry with thousands of
skin care products and formulations now available. The medical provider
is therefore encouraged to better understand the field so they can further
optimize long-term outcomes of esthetic procedures such as platelet-rich
fibrin (PRF) injection. In general, skin care products usually only penetrate
8% into the skin. When microneedling is performed, penetration can reach
up to 80% to 90% depth penetration for up to 72 hours. The application
of ideal skin products not only helps to stimulate and regenerate skin cells,
improving their collagen synthesis, but may also modulate the inflammatory
response posttreatment, thereby significantly reducing patient downtime.
This chapter aims to discuss leading medical research centers devoted to
improving skin care with various extracts that are able to better promote
wound healing. Specifically, Norwegian scientists who spent decades studying the harsh artic climate discovered that a specific mushroom (chaga)
surviving these northern climates carried potent and powerful antioxidants
capable of drastically reducing oxidative damage by as much as 80% within
an hour. Following years of research on the topic, these novel extracts have
since been formulated within skin care products (Čuvget). This chapter
presents research on the topic and further provides a better understanding
of skin care products utilized after PRF treatment.
201
11 / Skin Care Products and Their Effect on Aging Skin
Skin Rejuvenation
Our modern way of living has given us the opportunity
to live longer and healthier lives. At the same time,
however, the sun is stronger, we live more stressful
lives, and we are exposed more than ever before to
external factors that suppress our skin health and
promote skin aging. Medical esthetic skin treatments
have therefore seen significant growth over the years,
and a vast majority of these treatments are aimed to
rejuvenate the skin by imposing controlled damage
(such as laser therapy or microneedling).
Because controlled damage on the skin causes a
certain degree of inflammation, it has been demonstrated that a specific skin care regimen may reduce
the “downtime” required for healing, improve the
esthetic results, and ultimately give the patient a
better experience. This chapter demonstrates how
specific ingredients delivered via topical skin care
products can create a synergistic effect with PRF posttreatment. Each of the ingredients is briefly introduced
along with its role in skin care and maintenance.
The biologic effects of initiating a potent skin care
posttreatment regimen are based on three core steps:
1. Activating Langerhans cells and reducing inflammation caused by controlled damage
2. Stimulating the epidermal rejuvenation processes
3. Enhancing epidermal protection from extrinsic
aging factors
Step 1: Activating Immune Cells and
Reducing Inflammation
Controlled damage on the epidermal layer of the skin will
trigger a cascade reaction, eventually resulting in skin
rejuvenation. Clinical trials have concluded that immediately after treatment of the epidermis, a combination of
immune-modulating agents and potent antioxidants will
result in both a short- and long-term advantage, favoring
healing and minimizing downtime post-therapy.
Over the past decade, scientists at the University
of Tromsø in Norway have developed world-leading
202
competence on biologic properties of Arctic extracts.
The hypothesis was that because the Arctic environment
represents one of the harshest and coldest climate conditions on the planet, and because species found in this
area have developed extreme protection mechanisms as
an adaptation, a better understanding of their biologic
behavior could lead to breakthrough research for medical
applications. In 2014, after investigating thousands of
extracts, the research team discovered that a specific
extract concentrated from a mushroom called chaga
(trademarked Čaga) led to potent would healing properties as highlighted throughout this chapter.
Arctic Čaga extract
Arctic Čaga extract has its origin from a rare species of
parasitic fungus growing on the bark of genus Betula
trees in the northern parts of the world. It has a rich
background in folk medicine as tinctures and tea to aid
the immune system and suppress infections.
The Arctic Čaga extract is produced from the conk
(shelf) of wild Nordic chaga fungus. It contains a
rich composition of bioactive compounds including polysaccharides, beta-glucans, and polyphenols
that in skin care formulations are designed to reduce
the “downtime” after invasive esthetic treatments,
because they contain potent levels of antioxidants. In
fact, ancient medicine from the Norwegian indigenous
people have called it the “mushroom of immortality”
and the “diamond of the forest.” Various preparations
of Čaga, including Čaga tea, have been used in the past
to treat complicated diseases and immune disorders.
Over the years, scientific focus has been directed
toward this unique extract and its potential health
benefits and/or application for new treatments in the
fight against various diseases. The skin care company
Čuvget has since adopted its formulation in its vitamin
ampules, as discussed later in this chapter.
Antioxidant properties
Research conducted by Fenola demonstrated that the
Arctic Čaga extract scored extremely high in their antioxidant analysis scores (ORAC value over 250,000;
Change in epidermal volume (%)
1 week
% μg of Čaga extract per
mL in the test solution
Step 1: Activating Immune Cells and Reducing Inflammation
100
62
53
34
22
20
0
L
Q
1
0.5
0.25
–
180
160
140
120
100
80
60
40
20
0
IVA
+
Control
FIG 11-1
FIG 11-2
Arctic Čaga extract (blue) CAA efficacy (percentage of presupplied reactive oxygen species left after treatment) measured against known antioxidant compounds. L, luteolin; Q,
quercetin. (Data from Dr Jeanette Hammer Andersen/ScandiDerma, 2014.)
Skin interface after 1 week of treatment with Čuvget IVA vs control.
(Data from Dr Catherine Booth/Epistem/ScandiDerma, 2014.)
FIG 11-3
(a and b) Note the 50% increase in epidermal volume with Čuvget IVA, which
clinically translates to a reduction in fine
lines and wrinkles. (Study performed by
ScandiDerma in collaboration with Epistem Ltd, unpublished.)
a
b
ScandiDerma unpublished research, 2016). The Arctic
Čaga extract exhibits a very potent antioxidative
effect on a skin keratocyte model where the cellular
antioxidative assay (CAA) analysis was performed to
investigate antioxidative efficacy. Several studies have
reported a dramatic reduction of oxidative damage up
to 80% observed within 60 minutes (Fig 11-1).
smoother appearance with an even distribution of
skin cells as a result of an improved epidermal performance. Histologic evaluation of the LSEs also demonstrated a significantly larger surface volume compared
to the control (Fig 11-3).
Living skin equivalents
Another important aspect following any facial esthetic
treatment is the management of inflammation after
the procedure. Therefore, products and ingredients
developed to modulate the immune system following
therapy may lead to faster healing and shorter healing periods. The Arctic Čaga extract contains a rich
and natural concentration of beta-glucans, with the
key target of activating the Langerhans cells. Langerhans cells are the modulators of the skin because they
The Čuvget Instant Vitamin Ampoules (IVA) have been
tested on living skin equivalents (LSE) to evaluate
the performance and increase in epidermal volume
following 1 week of culture. The conclusion from this
study demonstrated a significant 50% increase of
the epidermal volume when compared to the control
(Fig 11-2). The skin surface also showed a significantly
Immunomodulating properties
203
11 / Skin Care Products and Their Effect on Aging Skin
serve as the control center managing crucial biologic
processes. These cells are well known as protective
cells (“magistrate cells”) residing in the upper layers
of the skin and protect against both invading microorganisms and other skin damage. Beta-glucans have
vast documentation1,2 and have been shown to do the
following:
• Increase renewal of skin cells (rejuvenation)
• Stimulate the production of collagen and other
growth factors of the skin
• Repair skin cells damaged by ultraviolet (UV) rays
• Optimize the normal processes of human skin via
the Langerhans cell
Additional important epidermal
antioxidants
Sodium ascorbyl phosphate – Vitamin C
Sodium ascorbyl phosphate (SAP) is an important
antioxidant that is crucial for the synthesis of collagen
and restraining the oxidation of lipids. The stability of
vitamin C derivatives like SAP has been significantly
improved in recent years. It is absorbed by the skin
layer and quickly decomposes into vitamin C to exert
its physiologic action. SAP has better stability because
it shows lower photosensitivity and heat sensitivity
than vitamin C. Its stability in water is also much higher
than that of vitamin C. SAP has antiradical effects and
can suppress oxidative stress that causes aging.3
Tocopherol acetate – Vitamin E
Vitamin E is the major naturally occurring lipid-soluble
antioxidant protecting skin from the adverse effects
of oxidative stress. Many studies document that vitamin E occupies a central position as a highly efficient
antioxidant, thereby providing possibilities to decrease
the frequency and severity of pathologic events in
the skin.3
Panthenol – Vitamin B5
After absorption into the skin, panthenol is transformed
into pantothenic acid (vitamin B5). The pantothenic
acid is considered to be essential for the normal
204
function of the epidermis. In cases of disturbances
of the epidermis, the requirement for this substance
increases significantly. Topical panthenol acts like a
moisturizer, improving stratum corneum hydration,
reducing transepidermal water loss, and maintaining
skin softness and elasticity. Activation of fibroblast
proliferation, which is of relevance in wound healing,
has been observed both in vitro and in vivo with panthenol. Beneficial effects of panthenol have been observed
in patients who have undergone skin transplantation,
scar treatment, or therapy for burn injuries and different
dermatoses. Pantothenic acid has also been shown
to increase levels of cellular reduced glutathione.
Increased levels of glutathione have been shown to
play a role in the protective effect of pantothenic acid
against peroxidative damage of cell membranes.4
Step 2: Stimulating Epidermal
Rejuvenation
Clinical studies have demonstrated that treating the
skin with a complex of collagen-inducing therapies
and protective ingredients will enhance the effects
of PRF. Therefore, a stimulating serum is the basis
of many esthetic creams developed to target fibroblast activity and induce collagen synthesis. Several
active ingredients are carefully formulated to stimulate epidermal rejuvenation as highlighted below.
Lingonberry stem cell extract – Lingostem
Arctic berries have been known to contain a high
concentration of polyphenols that protect cells from
reactive oxygen species (ROS).5 A research project in
collaboration with the University of Tromsø, the Norwegian Institute of Bioeconomy Research, and the Technical Research Centre of Finland concluded that Arctic
lingonberry leaves contain potent antioxidant properties. Stem cell extract is obtained from lingonberry
(Vaccinium vitis-idaea), which is rich in polyphenols
and traditionally used by the indigenous people of the
north for its antioxidant healing properties. Lingostem
(Centerchem) is a formulation of lingonberry stem cells
Step 2: Stimulating Epidermal Rejuvenation
FIG 11-4
Thirty-two volunteers between 40 and 60
years old with signs of photoaged skin were
given the active formula of 1.5% Lingostem
on one half of the face and one forearm,
while a placebo was used on the other half
of the face and the other forearm. Volunteers applied the extract twice daily for 28
days. Note the repairing effect of the cream
on eye contour wrinkles at 28 days.
Day 0
Day 28
BOX 11-1
Results of 20 volunteers using 1% Juvenessence twice daily for 28 days
In vivo on crow’s feet
• Firmness: +25%
• Elasticity: +20%
In vivo on the cheeks
• Hydration: +19%
• Skin texture improvement: +12%
Self-evaluation
• Depth of wrinkle has decreased:
80%
• Skin is more hydrated: 85%
• Skin is smoother: 85%
• Skin texture has improved: 80%
Self-evaluation
• Skin texture has improved: 85%
• Skin is more hydrated: 70%
• Skin is firmer: 90%
• Skin is better toned: 85%
designed to prevent and reverse photoaging, mimicking one of nature’s solutions to fight damaging effects
of solar radiation in plants. Clinical studies with the
same concentration as applied in the Čuvget Stimulating Serum show a 37% reduction in the number of
wrinkles after 28 days of use (Fig 11-4).
a 30% improvement in skin firmness on day 14 and
80% improvement in skin firmness on day 28. In the
end, Beta-Glucan M performed 60% better than the
placebo and 100% better than the untreated area at
day 28 (ScandiDerma, unpublished research, 2016).
Alaria exculenta extract – Juvenessence AD
Beta-Glucan M
Beta-Glucan M (McKinley), also called sodium
carboxymethyl beta-glucan, is the sodium salt of a
carboxymethyl ether of beta-glucan. It is commonly
used as a binding agent and rheologic modifier in
personal care formulations. It is known to soothe irritated skin, support the skin’s own antioxidant activity,
protect the skin from environmental damage, and help
the skin retain moisture. In one study, the application
of a placebo emulsion counteracted the photoaging
process of the skin slightly. The incorporation of only
0.04% Beta-Glucan M into the same emulsion led to
Juvenessence AD (Seppic) is the only all-natural active
ingredient (Alaria exculenta extract) to specifically
target progerin, the age-accelerating protein. Its
unique pathway helps boost cellular activity leading
to significant increases in skin firmness and elasticity
after only 4 weeks. Juvenessence AD is oil soluble,
preservative free, and compliant with Ecocert and
Cosmos. Clinical studies with a similar concentration
as applied in the Čuvget Stimulating Serum showed
a significant improvement in skin firmness and elasticity after 28 days of use (Box 11-1; ScandiDerma,
unpublished research, 2016).
205
11 / Skin Care Products and Their Effect on Aging Skin
Before treatment
FIG 11-5
After 28 days
0 mm
After only 1 month, SYN-TC
showed significant improvement in skin smoothness (+9.1%).
The effect was further pronounced after 2 months (+12.2%).
1 mm
Peptides – SYN-TC
Synthetic tripeptide and tetrapeptide (eg, SYN-TC
[DSM]) are other key ingredients added to facial care
products due to their ability to significantly increase
the amount of stable and homogenous collagen facilitating smooth skin. Clinical studies of SYN-TC with the
same concentration as applied in the Čuvget Stimulating Serum showed a significant improvement of
skin smoothness and firmness after 28 days of use
(ScandiDerma, unpublished research, 2016). 3D imaging confirmed significant reduction of visible signs of
aging (Fig 11-5).
45
40
Transmittance (%)
35
30
25
20
15
10
5
Step 3: Multilayer Protection and
Rejuvenation
0
250 266 282 297 313 328 359 374 389 405 420 435 450
Wavelength (nm)
Invasive treatments trigger rejuvenation but also
expose the skin to damaging external environmental
effects. A multilayer protection giving the epidermis
an optimal layer against external exposure is therefore needed. The Čuvget Protective Day Cream is
designed to immediately aid the several epidermal
layers through combining UVA and UVB protection
with potent ingredients that improve the performance
of cell membranes and scavenging ROS (Fig 11-6).
Omega-3 – Omegatri
Cell membranes are composed of phospholipids and
other membrane lipids, with membrane proteins
interspersed. The composition and properties of the
206
FIG 11-6
It is demonstrated that the Čuvget Protective Day Cream
holds an actual SPF of 37. A synergistic effect of the potent
active ingredients combined is documented to boost the daytime protection by 85%, as the cream has an original formulation with a broad-spectrum SPF of 20. (Study performed by
BioNest and Daiso/ScandiDerma, unpublished, 2017.)
membrane lipids, including the fatty acid building
blocks, will influence cell function and membrane
behavior. Cell membranes with an optimal fatty acid
composition including an appropriate amount of
omega-3 will help keep the appropriate flexibility and
hydration of the tissue, and, for skin cells, thus keep
Step 3: Multilayer Protection and Rejuvenation
FIG 11-7
SEG-FO
Omega-3 stimulates collagen production
and is known for its anti-inflammatory
properties. Several studies show how
polyunsaturated fatty acids are able to
significantly improve skin healing within
20 days. (Reprinted with permission from
Shingel et al.6)
SEG-OO
Day 10
Day 0
the skin soft and protect against dryness. The moisturizing effects of omega-3 are essential. Recent studies
have shown that a diet low in essential fatty acids
(which applies to about 99% of the US population) can
lead to dry skin and premature wrinkles. Boosting the
intake of fatty acids will improve smoothness and radiance of the skin. To keep skin cells moist and strong,
sufficient intake of omega-3 is strongly recommended.
Omega-3’s effects on skin include the stimulation of
tissue repair6 (Fig 11-7) and the enhancement of collagen production.7 Excess collagen deposits occurring
in keloid formation, on the other hand, are inhibited by
omega-3, and oral as well as local supplementation of
omega-3 is recommended for the treatment of keloids.
This is linked to the ability of omega-3 to modulate
inflammation, including skin inflammation.8
The variety of positive effects of omega-3 will altogether help keep the skin healthy and strong, enabling
it to withstand stress caused by external and internal factors. The preventive and reparative effects of
omega-3 give reason for recommending omega-3
cream for relaxing and repairing skin that is damaged.9
Typically omega-3 is delivered via encapsulation in
facial creams. The cyclodextrin will change some of
the properties of the omega-3 by improving its stability and solubility in aqueous media,10 and it will also
improve the permeability of the substance through
Day 20
the skin.11 The Omegatri technology is an awardwinning encapsulation technique developed to
promote epidermal uptake and stabilize the omega-3
oils to ensure optimal performance and stability.
Arnica
Another important component is arnica. Its activity is
mainly due to the sesquiterpene lactone and flavonoid
content of arnica inflorescences. Animal experiments
revealed that helenalin and dihydrohelenalin exerted
anti-inflammatory effects by inhibiting prostaglandin
production through the blockade of the prostaglandinsynthase enzyme. Such anti-inflammatory effects
were reinforced by carotenoids and flavonoids.
Flavonoids also strengthen the anti-inflammatory
properties of sesquiterpene lactones. A homeopathic
product (Traumeel S) containing Arnica montana and
other plant extracts and minerals was tested in a rat
model of inflammation. It was found that its main
mechanism of action was associated with a significant decrease in systemic interleukin-6 levels. An
open multicenter clinical study revealed that twicedaily application of an arnica-containing gel to 79
patients suffering from knee osteoarthritis for 3 to 6
weeks significantly reduced joint pain in most of the
cases, and the product was well tolerated in 87% of
207
11 / Skin Care Products and Their Effect on Aging Skin
Skin thickness (mm)
2.0
1.5
Negative control
Positive control
Retinol
Chaga
1.0
FIG 11-8
Effect of chaga extract supplementation on skin thickness and
wrinkle formation after repeated exposure to UV irradiation.
0
0
3
7
Weeks
10
12
the cases.12 Therefore, arnica extract is highly recommended in formulations of cosmetic products for
sensitive and/or irritated skin and to stimulate general
blood circulation.
Arctic Čaga extract – UV protection
Chronic exposure of the skin to UV radiation is known
to induce a multitude of harmful effects such as skin
thickening, wrinkle formation, inflammation, and even
carcinogenesis. This has been shown to arise from
a continuous oxidative stress state from excessive
generation of ROS from exposure to UV irradiation,
which ultimately leads to cell apoptosis events and
breakdown of collagen and thus to the aforementioned
undesired morphologic changes in the skin.
Chaga extracts contain a considerable amount
of melanin-type polyphenolic pigment compounds
that offer a good amount of UV-scattering and UVabsorbing qualities in addition to the power to scavenge free radicals after exposure to UV radiation. This
has been demonstrated through in vivo skin models
where chaga has been demonstrated to have remarkable potential at reducing and almost completely
suppressing the UV-induced skin thickening and wrinkle
formation, when applied topically after repetitive exposure to UV radiation, comparable to that of high-concentration retinol13 (Fig 11-8).
208
ˇ
Application of Cuvget
Skin Care
Products
The standard set of post-procedure skin care products
comes with various products each designed to help
maintain the hydration of skin, modulate the immune
response, improve collagen synthesis, and protect
against external factors (Fig 11-9).
Step 1: Exfoliating Foaming Cleanser
The Exfoliating Foaming Cleanser is used to cleanse
and exfoliate the skin twice per day, in the morning
and evening. One pump of the cleanser is utilized
and massaged in the palm of the hand before applying it to the face, neck, and décolletage (Fig 11-10).
The potent enzymes must be allowed to work for a
2-minute period before rinsing off the cleanser with
water and gently patting the skin dry with a clean
towel. It provides immediate and gentle exfoliation
in a pH-friendly formulation for gentle but effective
cleansing (Table 11-1).
ˇ
Application of Cuvget
Skin Care Products
Exfoliating Foaming
Cleanser
Instant Vitamin
Ampoules
Stimulating
Serum
Protective Day
Cream
Renewal Night Cream
Apply evening after
the Exfoliating Foaming
Cleanser, Instant Vitamin
Ampoules, &
Stimulating Serum
Apply morning & evening Apply morning & evening Apply morning & evening Apply morning after
after Exfoliation Foaming after the Instant Vitamin the Exfoliating Foaming
Cleanser
Ampoules are absorbed Cleanser, Instant Vitamin
Ampoules, & Stimulating
Serum
FIG 11-9
Čuvget 24-hour protocol.
TABLE 11-1
Key ingredients in Čuvget Exfoliating Foaming
Cleanser
Keratoline
Cleansing
X
Hydration
X
Moisturization
X
Exfoliation
X
Rejuvenation
X
Revitalization
Radiance/glow
a
b
FIG 11-10
(a) Čuvget Exfoliating Foaming Cleanser. (b) Cleanser being
applied to the face.
AntiOXA
Complex
X
X
Antioxidant effect
X
Skin soothing
X
209
11 / Skin Care Products and Their Effect on Aging Skin
TABLE 11-2
Key ingredients in Čuvget IVA
Anti-aging
Arctic
Čaga Max
Saturated
Caplex
X
X
Collagen care
X
a
Hydration
Moisturization
Rejuvenation
X
X
Revitalization
Radiance/glow
X
Antioxidant effect
X
X
UV protection/
photoaging
X
X
Barrier function
X
X
Skin soothing
b
FIG 11-11
(a) Čuvget IVA. (b) A single dropper is applied to all areas of
the face and neck.
Step 2: IVA
Step 3: Stimulating Serum
Immediately after cleansing the skin, a single dropper of the IVA liquid should be applied on all areas of
the face and neck. IVA contains a rich cocktail of a
combination of Arctic Čaga, one of the most potent
epidermal antioxidants (Fig 11-11 and Table 11-2).
Thereafter, one pump of the Stimulating Serum is
applied. Stimulating Serum focuses on total collagen care and maintaining a healthy skin matrix.
The product is composed of extracts from stem cells
of Arctic berries, marine extracts with potent peptides,
as well as beta-glucans. In combination, these intense
ingredients have shown to uniquely reduce the signs
of aging. The serum creates an optimal environment
and performance of the skin’s matrix, leaving the skin
surface perfectly smooth and younger looking, with
improved radiance and glow (Fig 11-12 and Table 11-3).
210
ˇ
Application of Cuvget
Skin Care Products
FIG 11-12
(a) Čuvget Stimulating Serum. (b) Serum being applied
to the face.
a
b
TABLE 11-3
Key ingredients in Čuvget Stimulating Serum
BetaGlucan M
Anti-aging
Algae
extract
Lingostem
X
Anti-wrinkle
X
Collagen care
X
Hydration
X
Moisturization
SYN-TC
X
X
Exfoliation
Rejuvenation
X
Antioxidant
effect
X
UV protection/
photoaging
X
Barrier function
X
Skin firmness
X
Skin
nourishment
Radiance/glow
X
X
X
X
211
11 / Skin Care Products and Their Effect on Aging Skin
TABLE 11-4
Key ingredients in Čuvget Protective Day Cream
Arctic
Čaga
Omegatri
Anti-wrinkle
Collagen care
Arnica
MFE
Rhizome
RE
X
X
Lingonberry
E
X
Hydration
X
Moisturization
X
FIG 11-13
Čuvget Protective
Day Cream.
Rejuvenation
X
X
X
X
Revitalization
Radiance/glow
X
Antioxidant
effect
X
Skin soothing
UV protection/
photoaging
X
Barrier function
X
Skin
nourishment
X
Puffiness
X
The final step involves the application of either the
Protective Day Cream (in the morning) or the Renewal
Night Cream (in the evening). Once again, a single pump
is utilized and the cream is applied evenly on the skin.
X
X
X
Step 4: Protective Day/Renewal
Night Cream
X
X
Dark circles
Age spots
212
X
X
The Protective Day Cream is the ultimate product
against daytime free radical exposure and skin aging.
It is based on research using the finest extracts of
Arctic origin (Fig 11-13 and Table 11-4), in particular
a unique complex of omega-3 technology and plantbased Arctic Čaga extract.
Conclusion
TABLE 11-5
Key ingredients in Čuvget Renewal Night Cream
Arctic
Čaga
Squalane
Arnica
MFE
Rhizome
RE
Anti-aging
X
Anti-wrinkle
X
Collagen care
FIG 11-14
Čuvget Renewal
Night Cream.
X
X
X
Hydration
X
Moisturization
Rejuvenation
Ubiquinone
X
X
X
X
Revitalization
Radiance/
glow
X
Antioxidant
effect
X
X
X
Skin soothing
Barrier
function
X
X
X
Skin firmness
X
X
Skin
nourishment
X
Dark circles
X
Puffiness
X
The Renewal Night Cream is a unique combination
of Arctic plant extracts that focus on stimulating night
repair of the skin cells and barrier functions (Fig 11-14
and Table 11-5). The cream improves hydration and
skin elasticity and reduces the signs of fine lines and
wrinkles. The Renewal Night Cream will stimulate skin
repair and work against both extrinsic and intrinsic
aging to ensure optimal skin rejuvenation.
Conclusion
This chapter reviewed important research on skin care
products, providing the treating practitioner with a
better understanding of the various components and
ingredients that formulate their mixtures. Posttreatment skin care is a crucial step aimed at enhancing
the clinical results following facial esthetic procedures
213
11 / Skin Care Products and Their Effect on Aging Skin
and a pivotal additional component following therapy with PRF, microneedling, or laser therapy. The
application of highly researched skin products not
only helps to stimulate the production of collagen
synthesis but may also modulate the inflammatory
response posttreatment, thereby significantly reducing patient downtime. Specifically, the application of
Čuvget products during and after the use of PRF has
been demonstrated to activate Langerhans cells and
thereby modulate the inflammatory process, stimulating the epidermal rejuvenation.
References
1. Arlian LG, Morgan MS, Neal JS. Modulation of cytokine expression in human keratinocytes and fibroblasts by extracts
of scabies mites. Am J Trop Med Hyg 2003;69:652–656.
2. Persaud R, Re T. The impact of the skin’s innate immunity
by cosmetic products applied to the skin and scalp. In: Dayan
N, Wertz PW (eds). Innate Immune System of Skin and Oral
Mucosa. Hoboken: Wiley, 2011:275–279.
3. Briganti S, Picardo M. Antioxidant activity, lipid peroxidation
and skin diseases. What’s new. J Eur Acad Dermatol Venereol
2003;17:663–669.
214
4. Ebner F, Heller A, Rippke F, Tausch I. Topical use of dexpanthenol in skin disorders. Am J Clin Dermatol 2002;3:427–433.
5. Wang SY, Feng R, Bowman L, Penhallegon R, Ding M, Lu Y.
Antioxidant activity in lingonberries (Vaccinium vitis-idaea
L.) and its inhibitory effect on activator protein-1, nuclear
factor-κB, and mitogen-activated protein kinases activation.
J Agric Food Chem 2005;53:3156−3166.
6. Shingel KI, Faure MP, Azoulay L, Roberge C, Deckelbaum RJ.
Solid emulsion gel as a vehicle for delivery of polyunsaturated
fatty acids: Implications for tissue repair, dermal angiogenesis and wound healing. J Tissue Eng Regen Med 2008;
2:383–393.
7. Hankenson KD, Watkins BA, Schoenlein IA, Allen KGD, Turek
JJ. Omega-3 fatty acids enhance ligament fibroblast collagen
formation in association with changes in interleukin-6 production. Proc Soc Exp Biol Med 2000;223:88–95.
8. McDaniel JC, Belury M, Ahijevych K, Blakely W. Omega-3
fatty acids effect on wound healing. Wound Repair Regen
2008;16:337–345.
9. Schwartz S. Lotion sickness: Are your cosmetics making you
ill? South China Morning Post. 26 May 2009.
10. Singh M, Sharma R, Banerjee UC. Biotechnological applications of cyclodextrins. Biotechnol Adv 2002;20:341–359.
11. Matsuda H, Arima H. Cyclodextrins in transdermal and rectal
delivery. Adv Drug Deliv Rev 1999;36:81–99.
12. Alonso J. Tratado de Fitofármacos y Nutracéuticos. Barcelona: Corpus, 2004:178–182.
13. Joo JI, Kim DH, Yun JW. Extract of chaga mushroom (Inonotus
obliquus) stimulates 3T3-L1 adipocyte differentiation. Phytother Res 2010;24:1592–1599.
12 /
FUTURE TRENDS IN
ESTHETIC MEDICINE
Carlos Fernando de Almeida Barros Mourão
Delia Tuttle
Ruth Delli Carpini
Scott Delboccio
Richard J. Miron
Catherine Davies
The field of esthetic medicine has certainly seen widespread and rapid
growth over the past decade. Since that time, platelet-rich fibrin (PRF) has
certainly become a popular treatment modality because of its completely
natural and regenerative approach. Today, several new strategies have been
proposed as means to further increase regeneration of facial defects. These
new trends aim to restore the patient’s lost tissue as opposed to simply
“filling” the skin with an artificial substance. Novel strategies include the
use of adipose tissue, stem cells, heating of plasma, bioelectric stimulation,
and various combination therapies. This chapter briefly discusses each of
these regenerative approaches and provides insight on the future of the field.
217
12 / Future Trends in Esthetic Medicine
Limitations of PRF
Recent years have witnessed the trend of patients
favoring less invasive procedures and more
natural prodIt is always important to remember
ucts. It is always
that every biomaterial introduced
important to
into the body will initiate at least
remember that
in part an inflammatory response,
every biomateand more natural products like PRF
rial introduced
minimize this inflammatory response,
into the body
favoring patient safety.
will initiate at
least in part an inflammatory response, and more
natural products like PRF minimize this inflammatory
response, favoring patient safety.
While PRF is certainly effective at reducing facial
wrinkles such as nasolabial folds and “restoring” the
patient’s appearance back to a more youthful look,
because of its short half-life (10–14 days), it is not
effective for certain filler therapies like lip overaugmentation, since genetically the lips were designed
to be a certain size. Instead, facial fillers like hyaluronic acid in combination with PRF have been more
commonly utilized for such procedures. By utilizing
a Luer-Lok connector, it is possible to mix the two
substances, thereby improving the biocompatibility
of certain foreign biomaterials. PRF can be utilized in
combination with many products in the facial field.
Furthermore, recent novel breakthrough research in
blood-derived growth factors have found methods
to extend the resorption period of PRF by heating
plasma.
and proliferation.3,4 PRF then provided a new advantage
in that a fibrin mesh could be obtained, thereby favoring a slower release of growth factors. Protocols and
research in this field focused primarily on increasing
the cellularity within the fibrin mesh or attempting
to improve the distribution and production of growth
factors within their formulation. However, while different protocols for autogenous platelet concentrates are
often suitable for specific clinical applications, limitations in the stability of this fibrin mesh may compromise their applicability to esthetic procedures that
demand improved stability.5,6
Recently, a novel technique was developed with
these blood byproducts whereby the plasma is heated
to create denatured serum albumin, with a working name
Alb-PRF. Simply stated, by heating and denaturing albumin, new hydrogen and disulfide ligations in the enzymes
are created, favoring a larger tridimensional structure
and effecting drastic changes in its resorption properties,
thereby leading to improved stability (Fig 12-1). This in
turn creates a biologic filler or “Bio-Filler” derived entirely
from whole blood, with extended resorption properties
allowing the material to last up to 6 months as opposed
to 2 weeks. While albumin is the most abundant human
plasma protein, responsible for more than 50% of the
total protein present in the bloodstream, it is important to
note that during denaturation, collected growth factors
and cells also lose their activity and undergo apoptosis
at high temperatures. Therefore, a new protocol had to
be developed following heating to reintroduce cells and
growth factors back into the Alb-PRF.
Protocol to produce Alb-PRF
Heating of Plasma
Since the use of platelet concentrates first began three
decades ago, the goal has always been to concentrate
natural autogenous growth factors to stimulate tissue
regeneration.1,2 For years, any improvements or newly
developed techniques were focused on obtaining higher
or better concentrations of collected growth factors
and/or cells. First, platelet-rich plasma provided documented evidence for the stimulation of cell recruitment
218
First, peripheral blood is collected in 9- to 10-mL tubes
(Fig 12-2a) and placed in a horizontal centrifuge at 2000g
for 8 minutes (Fig 12-2b). After processing, it is possible
to observe separation of blood layers into plasma and
the remaining decanted red cells. Then 2 to 4 mL of the
platelet-poor plasma (PPP) is collected with a syringe
(Fig 12-2c), while the other blood portions (buffy coat,
liquid PRF, and red blood cells) are left at room temperature (20°C). The syringe containing PPP is then inserted
into a specialized heating device (Bio-Heat, BIO-PRF) to
Heating of Plasma
Denaturation of proteins
Extreme
environments
(temperature, pH)
disrupt protein shape
and function.
Normal protein
Denatured protein
FIG 12-1
Process of protein denaturation. The heating of plasma modifies its secondary structure, creating new hydrogen and disulfide
ligations in the enzymes. This process guarantees more stability.
a
b
c
d
FIG 12-2
Step-by-step clinical protocol for the production of Alb-PRF. (a) Venipuncture and blood collection. (b) Centrifugation. (c) Collection
of the serum plus PPP after centrifugation. (d) Introduction of the PPP into the Bio-Heat device at 75°C for 10 minutes.
produce the albumin gel (Fig 12-2d). After 10 minutes at
an operating temperature of 75°C, the syringe is then
removed and allowed to cool to room temperature and
ideally protected from ambient light. Figure 12-2e demonstrates the noticeable color change between the Alb-PRF
and standard liquid PRF.7 Thereafter, the albumin gel and
the liquid PRF are mixed together by passing back and
forth between syringes using a female-female Luer-Lok
connector (Figs 12-2f and 12-2g). The substances should
be passed back and forth between syringes a minimum
of 10 times to allow for adequate mixing. Thereafter, the
Alb-PRF can be utilized as an injectable filler with concentrated growth factors and cells (Fig 12-2h). A 1.5-inch 23G
needle is recommended (under local anesthesia). Smaller
needles are difficult to allow for subcutaneous injections.
219
12 / Future Trends in Esthetic Medicine
e
f
g
h
FIG 12-2 (cont)
(e) Clinical differences in color between the liquid PRF (top) and the albumin gel (bottom) after heating. (f) A Luer-Lok mixer
device is attached to both the liquid PRF and the albumin gel syringes. (g) Mixing of the liquid PRF and albumin gel back and forth
to create Alb-PRF. (h) Alb-PRF ready for use. Note the ability to inject out of a syringe following adequate mixing.
In vivo studies
Several developmental phases of the Alb-PRF were
undertaken in order to expand the resorption properties
of PRF (extended PRF or e-PRF). In a recent research
project, subcutaneous injections into nude mice were
performed to evaluate the resorption properties of the
material over time. In each animal, one side was injected
with PRF alone, whereas the contralateral side was
injected with Alb-PRF. Figure 12-3 demonstrates a study
animal 21 days postoperatively; note the large bump
remaining on the side injected with Alb-PRF (almost no
degradation), whereas the liquid PRF side is completely
resorbed. Figure 12-4 demonstrates the Alb-PRF after
14 and 21 days. Note that no inflammatory reaction or
infection was observed in either case, and by day 21 it
is possible to further observe neovascularization. Mice
have extremely rapid metabolisms, so a 21-day period
without much resorption signifies that the product will
last months in humans due to the differences in metabolic speeds.
220
FIG 12-3
Nude mouse demonstrating a lump on the dorsal tissue 21
days after injection of Alb-PRF. On the contralateral side, liquid PRF was injected and fully resorbed after 21 days.
a
b
FIG 12-4
(a and b) Subcutaneous Alb-PRF still present in nude mice after 14
and 21 days, respectively. No inflammatory reaction or infection
was observed at either time point. After 21 days, it is also possible
to observe the neovascularization occurring around the Alb-PRF.
(Photographs courtesy of Prof Monica Calasans-Maia and team.)
Adipose Tissue Grafting
FIG 12-5
(a and b) Clinical photographs before and after Alb-PRF injections in
the lips. Note the augmentation and
ability to inject with a 23G needle.
(Photographs courtesy of Dr Giselle
Hoffmann.)
a
Clinical application
In all aspects, the injections of Alb-PRF are identical to
those presented throughout this book (and identical
to filler injections; Fig 12-5). The advantage with this
procedure is that the results of injection will last on
average 6 months as opposed to only a few weeks for
PRF alone. The technique is very new, and it is clear
that much further study and follow-up are required to
better understand both the regenerative properties
of Alb-PRF as well as its resorption properties following repeat injections. It certainly opens an entire new
field of platelet-derived concentrates, and future work
in this field remains ongoing to further improve the
resorption properties of Alb-PRF.
Adipose Tissue Grafting
Another strategy commonly utilized in facial esthetics
is the use of fat tissue grafting. Once again, the use
of fat tissue is autogenous, so results do not elicit a
foreign body reaction. The first successful fat graft
was reported by Neuber in 1893 for the correction of
facial scarring. Although the results seemed initially
b
favorable, the long-term outcome was less optimal
due to inadequate survival of the transplanted fat. To
improve survival outcome, a systematic procedure
was developed by Sydney Coleman aimed at improving the survival of cells by careful handling of the
fat during harvesting, purification, and grafting. The
Coleman technique is still widely used today in plastic
surgery practice. Further studies done by Zuk et al in
2001 and 2002 showed that lipoaspirate contains a
mesenchymal stem cell (MSC) population comparable to that isolated from the bone marrow, thereby
expanding opportunities in multiple fields.8,9
The process typically involves three steps: adipose
harvesting, processing, and implantation. During fat
harvesting, subcutaneous fat is aspirated through a
cannula and collected for later reuse as a graft. The
adipose-derived cell sources for regenerative therapy are rapidly showing promise in dermatology and
esthetic rejuvenation because of their ease of harvesting and readily available sources in the human body.
In 2009, the American Society of Plastic Surgeons
Task Force on Autologous Fat Grafting determined that
autologous fat grafting (AFG) was a safe procedure
with a relatively low rate of complications. This consensus opinion unleashed a wave of popularity as plastic
221
12 / Future Trends in Esthetic Medicine
a
b
FIG 12-6
Preoperative (a) and postoperative (b) lateral views of a
33-year-old woman who underwent AFG of the face. The preoperative photograph demonstrates flattening of the lower
forehead with an open nasofrontal angle and an appropriately
rotated nasal tip. The postoperative photograph, obtained 1.6
years following the procedure, shows improvement in forehead contour. The patient received 3 cm3 of fat in the nasofrontal region only. Note reduction in the nasofrontal angle
(from 134.3° preoperatively to 130.5° postoperatively) and no
change in tip rotation. (Courtesy of Drs Andrew N. Kornstein
and Jeremy S. Nikfarjam.)
surgeons discovered the procedure’s efficacy in a wide
variety of cosmetic and reconstructive indications.
In recent years, AFG has become a widely accepted
and utilized technique in the field of plastic surgery
due to its application in soft tissue augmentation and
its regenerative effects on local tissue such as reversal of hyperpigmentation, softening of hypertrophic
scars, increased local vascularity, and improvement of
radiated tissue.10 AFG has been helpful in treating the
volume-deficient aging face11 and can easily be injected
following subcutaneous laser therapy (Fig 12-6).
Adipose-derived stem cells and cellassisted lipotransfer
In 2006, the research team led by Yoshimura et al12
published an article in which they described a method
222
of supplementing the lipoaspirate used for fat grafting with progenitor cells found in adipose tissue,
adipose-derived stem cells (ASCs). They termed this
process cell-assisted lipotransfer (CAL). The rationale
behind this technique is that aspirated adipose tissue
(lipoaspirate) is generally poor in progenitor cells,
which is a contributing factor to poor survival in vivo.
ASCs aid in the retention of fat grafts because they are
able to differentiate into new adipocytes, replacing a
portion of the adipocytes that succumb to apoptosis
due to hypoxic or physical stress. Current research is
focused on the combined use of fat tissue grafting
with stem cells as well as with PRF to improve the
revascularization of grafts and potentially improve
the viability of cells following grafting.
Hyaluronic Acid with PRF
Hyaluronic acid (HA) is the most commonly utilized
filler in facial esthetics; most lip augmentation procedures are performed with HA. Interestingly, a new
technique was developed and designed to further
improve the biocompatibility of facial fillers by
combining HA with PRF. By mixing the two together
prior to injection, it theoretically becomes possible
to improve the biocompatibility and regenerative
potential of the HA. Figure 12-7 demonstrates a case
whereby HA was premixed with PRF and subsequently
utilized as a facial filler.
Injectable Poly-L-Lactic Acid and
Polydioxanone Threads
Polydioxanone (PDO) threads were introduced some
years ago as a means to augment volume into the
deeper layers of the skin. Once introduced, these
threads produce instant skin lifting through mechanical effects, collagen stimulation, and neovascularization to improve skin texture, fine lines, and elasticity,
tightening the skin by contracting fat tissue. About
6 months after the procedure, the PDO threads have
been shown to resorb through simple hydrolysis.13
Injectable Poly-L-Lactic Acid and Polydioxanone Threads
a
b
c
d
FIG 12-7
(a and b) Mixing of liquid PRF with HA. (c) Application of the
PRF+HA in the upper lip with cannula. (d) Application of the
PRF+HA in the upper lip using a needle. (e) Application of the
PRF+HA in the forehead.
e
Figure 12-8 demonstrates a case whereby PDO threads
were combined with PRF to reach a very pleasing
esthetic outcome.
Poly-L-lactic acid (PLLA) was introduced as a
biocompatible synthetic biodegradable polymer
composed of irregularly sized (40–63 micron) salt
microparticles of the alpha hydroxy acid family. It
bears the advantage that the resorption properties
allow it to last much longer, upwards of 18 months. It
was first approved in Europe as a filler material in 1999
and was approved by the FDA for treatment of immunosuppressed patients. The product is presented in the
form of a lyophilized powder containing nonpyrogenic
mannitol, which increases the lyophilization process,
sodium croscarmellose as a suspending agent to
maintain uniform distribution of acid particles after
reconstitution, and microparticles of PLLA.14
The injectable PLLA acts as a tool for facial expansion, stimulates fibroblasts, and confers volumetric
changes. This tissue reaction is known as a foreign
body giant cell reaction, occurring for up to 9 to 12
months after its injection, eventually being eliminated in up to 18 months. Also, the production of
collagen that occurs as the PLLA degrades produces
223
12 / Future Trends in Esthetic Medicine
a
b
d
f
c
e
g
h
FIG 12-8
(a to c) Preoperative photographs of an 18-year-old woman with severe facial acne. (d and e) Treatment with PDO threads plus
PRF to promote blood supply. (f to h) Clinical photographs 1 year posttreatment. Notice the excellent healing outcomes and facial
harmony.
224
High-Intensity Focused Ultrasound
the observed changes in volume and esthetic benefit.
Product degradation occurs through nonenzymatic
hydrolysis in lactic acid monomers that are metabolized to CO2 or H2O or incorporated into glucose.
Subcutaneous injections of PLLA can be made
in the zygomatic and temporal regions, nasolabial
sulcus, labiomental grooves, marionette lines, chin,
and mandibular contour in adult patients who are
not pregnant or lactating. The lips and nose should
be avoided, and injections in the periorbital and
perioral regions should be made with caution by an
experienced practitioner. Any regions that have been
treated with polymethyl methacrylate (PMMA) are
completely contraindicated for the use of PLLA. Use
of nonsteroidal anti-inflammatory drugs (NSAIDs),
anticoagulants, aspirin, or vitamin E and chronic
use of corticosteroids are contraindications for the
procedure; if the drug can be discontinued, there is
no adverse effect or subclinical response. The interval
of the sessions must respect the minimum time of
40 days.
Microfocused Ultrasound for Lifting
Microfocused ultrasound is a treatment that has been
developed to provide a facelift effect by noninvasive
and nonsurgical means. This technology uses heat to
improve facial sagging. Ultrasound waves can reach
and warm the deeper layers of the skin, which causes
the contraction of collagen. The energy is focused at a
point below the surface of the skin and concentrated
in an area of about 1 mm3 per point. This increase
in temperature produces small aspects of thermal
coagulation to a depth of up to 5 mm in the deeper
layers of the skin, without damaging the more superficial layers.15
In addition to tissue coagulation, the application of
heat promotes the denaturation of collagen fibers in the
fatty tissue below the skin, located near the muscles
of facial expression, as well as in the deeper portion
of the dermis. This process leads to the contraction of
these fibers and stimulates the formation of new collagen at the site.16 This has been suggested to cause an
immediate facelift effect after treatment and lasts
several months, with its peak around the 4th or 5th
month, a period in which collagen production is at its
highest stage, resulting in flaccidity.
Its main indication is mild to moderate sagging, both
facial and body, in individuals who are not prepared to
perform a surgical facelift. Only one annual session is
indicated, but in cases of more pronounced sagging,
the procedure can be done with a shorter interval at
every 6 months. It can be made on the face, neck,
eyes, hands, and perioral wrinkles as well as the belly,
inner thigh, buttocks, abdomen, and knees, with an
entirely satisfactory result.
High-Intensity Focused Ultrasound
Various treatments have been proposed for the
management of facial wrinkles and laxity due to
aging, including chemical peels, microdermabrasion,
fractional laser, and radiofrequency, but to date no
ideal treatment therapy exists.17 The high-intensity
focused ultrasound (HIFU) is a new tool with increasing popularity that is excellent for facial wrinkles and
a resulting loss of elasticity due to aging.
White et al was the first group to report the HIFU
technique in 2008.18 The transcutaneously delivered intense ultrasound (IUS) energy was produced
to target the facial superficial musculoaponeurotic
system (SMAS) to produce discrete thermal injury
zones in the SMAS. The IUS handpiece contains a
transducer that has two functioning modes: imaging
(which is used to image the region of interest before
the therapeutic ultrasound exposures) and treatment
(which is the mode that delivers a series of higherenergy ultrasound exposures). In treatment mode,
the transducer delivers a series of precise ultrasound
pulses along a linear path. The handpiece is designed
to mechanically slide in a straight line to deliver a
series of ultrasound exposures. For each series of
exposures, the following source conditions can be
varied: power output, exposure time, length of exposure line, distance between exposure zones, and time
delay after each exposure.
225
12 / Future Trends in Esthetic Medicine
FIG 12-9
(a) Noticeable hair loss in a
19-year-old man. (b) Following
monthly PRF treatment for 3
months combined with semiweekly bioelectric stimulation
treatment for 3 months. Notice the substantial hair regrowth and pleasing esthetic
outcome at 6 months.
a
b
HIFU was approved by the FDA in 2009 for use
in brow lifting. Currently, it is being used for facial
rejuvenation, lifting, tightening, and body contouring. The principle of HIFU is to induce cellular damage
and volume reduction of the target area selectively
by means of coagulation; this is accomplished by
generating instant microthermal lesions through the
accumulation of high-frequency ultrasound beams
at the specific tissue site without any damage to the
epidermis and adjacent issue.
Bioelectric Stimulation
The regenerative properties of bioelectric stimulation
have also received much attention. More recently, a team
of researchers have been able to create very specific
and short wavelength bands that are geared toward the
specific stimulation of single genes. In essence, with
a very specific frequency, one can specifically upregulate single genes such as vascular endothelial growth
factor (VEGF).19 This allows for the delivery of specific
growth factors at specific times. This patented technology can be utilized on skin to stimulate the specific
upregulation of elastin, followed by collagen and plateletderived growth factor, all delivered in sequential order.
226
Furthermore, it is possible to specifically bioelectrically
stimulate PRF prior to its use (Fig 12-9). Future research
is ongoing in this exciting field.
Plastic Surgery in Combination
with PRF
It is important to note that plastic surgery remains
the gold standard for many surgical procedures aimed
at drastic facial appearance change. That being said,
PRF can be combined with all medical procedures
to improve healing, reduce scarring, and favorably
lower potential infections and complications postoperatively. PRF can
PRF can be combined with all
also be utilized
medical procedures to improve
as an adjunct
healing, reduce scarring, and favorto surgery to
ably lower potential infections and
improve skin
complications postoperatively.
texture with
microneedling
postoperatively. Figure 12-10 demonstrates a successful case whereby a group of professionals collaborated
to offer a patient a combination treatment including
a facelift, PRF, and dental restorations.
Plastic Surgery in Combination with PRF
a
b
c
d
FIG 12-10
(a and b) A 65-year-old woman with severe dental and facial deficiencies resulting from poor
oral hygiene and chronic smoking. Following a reconstructive teamwork approach, the patient
was recommended to rebuild her teeth using ceramics (laboratory work performed by Ryan
Megaw, CDT) and periodontal plastic surgery including crown lengthening (performed by Dr Delia Tuttle). PRF treatment, a face and neck lift, as well as a chemical peel (phenol) were utilized in
combination to improve her facial esthetics (performed by Dr Kelly O’Neil). Prior to and after her
facial lift procedure, PRF was utilized with microneedling to improve blood supply and stimulate
collagen production (performed by Dr Delia Tuttle). (c and d) Facial esthetics after treatment
reflecting the significant changes achieved.
227
12 / Future Trends in Esthetic Medicine
a
b
FIG 12-11
(a) Woman in her mid 40s with pronounced marionette lines, deep nasolabial folds, and an
overall aged facial appearance. (b) Final outcome following three treatments with 100% natural
approaches including laser therapy (Smoothlase), microneedling with PRF, and Alb-PRF injections. (Case performed by Dr Scott Delboccio.)
Combination Approaches with
Lasers, Microneedling, and PRF
This textbook presented many new technologies that
enhance facial rejuvenation and repair. While many
were presented in individual chapters as standalone
therapies, many of the approaches act via different
methods and/or on different tissues and together may
be utilized in combination approaches. Figure 12-11a
presents a woman in her 40s with pronounced marionette lines, deep nasolabial folds, and an overall aged
facial appearance. While laser therapy would typically
require four to five treatments and microneedling with
PRF would certainly smooth fine line and wrinkles,
such cases are typically performed utilizing combination approaches. This woman was treated with three
228
laser therapy treatments including Smoothlase therapy (Fotona) in combination with microneedling with
PRF. During the third appointment (evenly spaced 1
month apart), the novel Alb-PRF protocol with e-PRF
resorption properties was used for her marionette
lines, nasolabial folds, as well as within her midface
region to augment volume. Note the final outcome 1
month after therapy (Fig 12-11b). There was a clear and
definite reduction in wrinkles and a dramatic overall
improvement in facial appearance. Such combination therapies utilized in this case were entirely 100%
natural. The future field aims to further study which
combination approaches are most effective to favor
better facial rejuvenation while minimizing the use of
chemical/synthetic additives as highlighted throughout this textbook.
References
Conclusion
While many new techniques and protocols are being
developed, one must always aim to use high-quality
products and protocols based on evidence-based practice. Many of the above-mentioned technologies are new
and exciting but experimental. Future clinical studies
comparing and evaluating different technologies remain
pivotal to further provide recommended guidelines to
the practicing clinician. Nevertheless, the field is still
extremely exciting, with many new trends coming down
the pipeline.
References
1. Miron RJ, Zucchelli G, Pikos MA, et al. Use of platelet-rich
fibrin in regenerative dentistry: A systematic review. Clin
Oral Investig 2017;21:1913–1927.
2. Miron RJ, Fujioka-Kobayashi M, Hernandez M, et al. Injectable
platelet rich fibrin (i-PRF): Opportunities in regenerative
dentistry? Clin Oral Investig 2017;21:2619–2627.
3. Wang X, Wang Y, Bosshardt DD, Miron RJ, Zhang Y. The role
of macrophage polarization on fibroblast behavior—An in
vitro investigation on titanium surfaces. Clin Oral Investig
2018;22:847–857.
4. Miron RJ, Dham A, Dham U, Zhang Y, Pikos MA, Sculean A. The
effect of age, gender, and time between blood draw and start
of centrifugation on the size outcomes of platelet-rich fibrin
(PRF) membranes. Clin Oral Investig 2019;23:2179–2185.
5. Dohan DM, Choukroun J. PRP, cPRP, PRF, PRG, PRGF, FC…
How to find your way in the jungle of platelet concentrates?
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2007;103:305–306.
6. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo
SA. Platelet-rich plasma: From basic science to clinical applications. Am J Sports Med 2009;37:2259–2272.
7. Mourão CFAB, Gheno E, Lourenço ES, et al. Characterization
of a new membrane from concentrated growth factors associated with denaturized Albumin (Alb-CGF) for clinical
applications: A preliminary study. Int J Growth Factors Stem
Cells Dent 2018;1:64–69.
8. Zuk PA, Zhu M, Mizuno H, et al. Multilineage cells from human adipose tissue: Implications for cell-based therapies.
Tissue Eng 2001;7:211–228.
9. Zuk PA, Zhu M, Ashjian P, et al. Human adipose tissue is a
source of multipotent stem cells. Mol Biol Cell 2002;13:
4279–4295.
10. Atiyeh BS. Nonsurgical management of hypertrophic scars:
Evidence-based therapies, standard practices, and emerging
methods. Aesthetic Plast Surg 2007;31:468–492.
11. Kornstein AN, Nikfarjam JS. Fat grafting to the forehead/
glabella/radix complex and pyriform aperture: Aesthetic and
anti-aging implications. Plast Reconstr Surg Glob Open
2015;27:e500.
12. Yoshimura K, Shigeura T, Matsumoto D, et al. Characterization of freshly isolated and cultured cells derived from the
fatty and fluid portions of liposuction aspirates. J Cell Physiol
2006;208:64–76.
13. Suh DH, Jang HW, Lee SJ, Lee WS, Ryu HJ. Outcomes of
polydioxanone knotless thread lifting for facial rejuvenation.
Dermatol Surg 2015;41:720–725.
14. Schierle CF, Casas LA. Nonsurgical rejuvenation of the aging
face with injectable poly-L-lactic acid for restoration of soft
tissue volume. Aesthet Surg J 2011;31:95–109.
15. Fabi SG, Goldman MP. Retrospective evaluation of microfocused ultrasound for lifting and tightening the face and
neck. Dermatol Surg 2014;40:569–575.
16. Chan NP, Shek SY, Yu CS, Ho SG, Yeung CK, Chan HH. Safety
study of transcutaneous focused ultrasound for non-invasive
skin tightening in Asians. Lasers Surg Med 2011;43:366–375.
17. Illing R, Kennedy JE, Wu F, et al. The safety and feasibility of
extracorporeal high-intensity focused ultrasound (HIFU) for
the treatment of liver and kidney tumours in a Western population. Br J Cancer 2005;93:890–895.
18. White WB, Liu Z. Non-linear alignment of El Niño to the 11-yr
solar cycle. Geophysical Research Letters 2008;35:doi:
10.1029/2008GL034831.
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aspects and future perspectives. Semin Cell Dev Biol
2009;20:543–556.
229
Index
Index
Page references followed by “f” denote figures, “t” denote tables, and “b” denote boxes.
A
Acetylcholine, 4
Acne/acne scars
atrophic, 110t–111t, 112, 184f, 186
description of, 57
laser treatment for, 185–186, 185f
microneedling for, 110t–111t, 112
pathogenesis of, 185
polydioxanone threads for, 224f
Actinic elastosis, 144
Actinic keratosis, 116t–117t, 117
Acupuncture, 3
Adenosine triphosphate, 181
Adipose tissue grafting, 221–222
Adipose-derived stem cells, 222
AFG. See Autologous fat grafting.
Aging skin. See Skin aging.
Alaria exculenta extract, 205, 205b
Alb-PRF
clinical applications of, 221, 221f, 228,
228f
description of, 127f, 218
in vivo studies of, 220, 220f
liquid platelet-rich fibrin versus, 220f
in periorbital region, 145
protocol for producing, 218–219, 219f
in temple, 134
Alopecia
androgenetic, 22, 92, 112–113,
114t–115t
differential diagnosis of, 64
microneedling for, 112–113, 114t–115t
scarring, 75b
traction, 75b
Alopecia areata, 75b, 76, 113, 114t–115t
Alopecia totalis/universalis, 75b
Alpha granules, 83
Anagen effluvium, 75b
Anagen phase, of hair growth, 21, 22f
Androgen(s), 22
Androgenetic alopecia, 22, 92, 112–113,
114t–115t
Angiogenesis
platelet concentrates for, 25, 95
platelet-rich plasma for, 95
Angular artery, 131, 143
Anticoagulants, 1, 80
Antioxidants, 204
Apex nasi, 11f
Archiving of photographs, 41
Arctic Čaga extract, 202–203, 203f, 208
Arnica, 207–208
Arrector pili muscle, 20, 21
230
ASCs. See Adipose-derived stem cells.
ATP38, 183
Atrophic acne scars, 110t–111t, 112, 184f,
186
Autologous fat grafting
facial esthetics uses of, 221–222, 222f
for marionette lines, 157
B
Basic fibroblast growth factor, 181
Benzocaine, lidocaine, and tetracaine
creams, 167
Beta-glucans/beta-glucan M, 204, 205
bFGF. See Basic fibroblast growth factor.
Bioelectric stimulation, for hair loss,
226, 226f
BIO-PRF centrifuge, 89f
BIO-PRF lift, 128–130
Blepharochalasis, 10f
Blood assessment, 54
Blood centrifugation, 80, 80f
Bluish skin, 57
Bone(s)
aging effects on, 23
of face, 12f
Botox
description of, 1
forehead applications of, 137–138
muscle denervation and relaxation
caused by, 4
recommendations for, 4
safety of, 5, 5b
secondary effects of, 4
Brow lifting, high-intensity focused
ultrasound for, 226
Brow positioning, 45f
Brownish skin, 57
Bulla, 57, 57f
Burn scars
illustration of, 101f
microneedling for, 110t–111t
4-Butylresorcinol, 116
C
Café-au-lait macules, 186–187
CAL. See Cell-assisted lipotransfer.
CALMs. See Café-au-lait macules.
Camera, 30–32, 30f–32f
Cannula technique
in jawline, 161
in marionette lines, 157, 157f
in nasolabial folds, 151
Cannulas, 125, 125f, 126t
Canon Veos-SLR/Hair photography
package, 70, 70f
Carbon dioxide lasers
description of, 176, 184
skin resurfacing uses of, 188
Catagen phase, of hair growth, 21, 22f
Cell-assisted lipotransfer, 222
Cellular antioxidative assay, 203
Centrifugation
description of, 80, 80f
fibrin clot formation from, 82
horizontal, 86, 87f, 89f
illustration of, 104f
leukocytes from, 84f
low-speed centrifugation concept, 79,
84–85
Centrifuge, horizontal, 87f, 89f, 92, 104f,
127
Cheek
aging of, 146
anatomy of, 146, 146f
high-risk zones of, 147, 147f
platelet-rich fibrin injections in, 146–
149, 146f–149f
treatment of, 147f–148f, 148–149
Chin
aging of, 158, 158f
anatomy of, 158, 158f
high-risk zones in, 159, 159f
intravascular injection in, 159
platelet-rich fibrin injections in, 158–
161, 158f–161f
treatment of, 159–160
vertical supraperiosteal depot
technique in, 160
Chromophores, 181, 189
Chronological aging, 100
Club hairs, 21
CO2 lasers. See Carbon dioxide lasers.
Cold packs, 124
Collagen-1, 88, 89f, 108f
Collagen induction therapy. See
Microneedling.
Collagen synthesis, 2
Columella, 11f
Consultation
clarifying of patient expectations at,
52–53
considerations for, 52
hair loss treatment. See Hair loss,
consultation for.
informed consent for, 61
Index
initial, 44t, 44–53, 45f–52f
lifestyle factors, 54
manual assessment, 58, 58f–59f
medical examination, 54
Merz full esthetic scale, 44, 44t,
45f–52f
one-on-one, 52
overview of, 43
psychologic assessment, 54
summary of, 61
treatment planning from, 60
visual examination, 54, 55f, 56t, 57f
Corrugator supercilii muscle, 138
Cross-sectional trichometry, 67–68,
68f–69f
Crow’s feet. See Lateral canthal lines.
Čuvget skin care products
application of, 208–213, 209f–213f,
209t–213t
Exfoliating Foaming Cleanser, 208,
209f, 209t
Instant Vitamin Ampoules, 203, 203f,
210, 210f, 210t
Protective Day Cream, 206, 206f, 212,
212f, 212t
Renewal Night Cream, 212–213, 213f,
213t
Stimulating Serum, 210, 211f, 211t
24-hour protocol for, 209f
Cytochrome C oxidase, 180
Cytokines, 83–84
D
Deep cannula technique, 145
Deep medial cheek fat compartment,
142
Dehydration, of skin, 2
Delta aminolevulinic acid photodynamic
therapy, 117
Deoxyhemoglobin, 182
Depressor anguli oris, 156
Dermal fillers
blindness associated with, 5
complications of, 131
description of, 1, 4f
lip augmentation uses of, 4f
platelet-rich fibrin and, 130, 218
safety of, 5, 5b
Dermal papilla, 21
Dermapen, 92, 93f, 99, 100f, 101, 119
Dermis, 19, 177, 177f
Digital compact cameras, 30f
Digital reflex cameras, 30f
Dihydrohelenalin, 207
DMC. See Deep medial cheek fat
compartment.
Documentation
consultation, 58, 59f
esthetic treatments, 59f
photography, 28, 35–41
“Dr. Acula’s Facial,” 192, 193f
Dracula technique, 192, 193f
Drooping mouth corners, 156f
Dry skin, 57
Dye laser, 180
E
Efflorescence, 57, 57f
Electromagnetic radiation, 179
Electromagnetic spectrum, 179
Embolism, angular artery, 143
Epicranius muscle, 136
Epidermis
anatomy of, 19, 21, 177, 177f
lesions of, 187
rejuvenation of, 204–206, 205f
Epithelialization, 178
e-PRF, 92–93 129t, 220
Ergonomics, 124, 125f
Er:YAG lasers, 176, 182, 188, 192
Esthetic medicine. See also Facial
esthetics.
procedures in, 5b, 5–6
specialties included in, 5
unesthetic features treated with, 4b
Excimer laser, 180
Excoriation, 57, 57f
Exfoliating Foaming Cleanser, 208, 209f,
209t
Extrinsic aging, of skin, 100
Eyebrow ptosis, 10f
F
Face
aging of, 10f, 10–11, 23, 24f, 118
anatomy of, 10–19, 131–132, 10f–19f
arteries of, 15–16, 15f–16f
blood supply to, 15–16, 15f–16f
bones of, 12f
bony prominence assessment, 58f
deep fat distribution in, 14, 14f, 23
demarcations of, 2
fat distribution in, 14, 14f
features of, 53
functions of, 10
innervation of, 17–18, 17f–18f
measurement landmarks for, 11f
muscles of, 13, 13f
regions of, 130b
skeleton of, 12f
subcutaneous fat of, 14, 14f, 24f
superficial fat distribution in, 14, 14f
vascular “danger zones” of, 131–132,
131f–132f
veins of, 15–16, 15f–16f
Facial artery, 150
Facial esthetics
adipose tissue grafting, 221–222
autologous fat grafting, 221–222,
222f
consumer demand for, 6
growth of, 1
inflammation control after, 203
lasers for, 176
Merz scale, 44, 44t, 45f–52f
microfocused ultrasound for, 225
platelet-rich fibrin in, 92–93, 93f–94f,
124
Facial expression
lines caused by, 60t
muscles of, 150f
Facial nerve, 18
Facial rejuvenation
biomaterials for, 3–5
microneedling for, 108, 108f–109f
traditional methods for, 3
Facial scars, 110t–111t. See also Scar(s).
Female pattern hair loss, 75b
Fibrin clot, 82
Fibrin matrix, 82, 85
Fibrinogen, 82
Fibroblasts, 87f, 178f
Fibronectin, 88
Fibroplasia, 178
Fibrosis agents, 83–84
Fitzpatrick classification, 54, 55f, 56t
Fixed-angle centrifuge, 87f
Flash light, 33, 35f
Flavonoids, 207
Forehead
aging of, 136, 137f
anatomy of, 136, 136f
botulinum toxin type A treatment
of, 137
high-risk zones of, 137
liquid platelet-rich fibrin and
hyaluronic acid injection in, 223f
Merz esthetic scale for, 45f
platelet-rich fibrin injections in, 136–
138, 136f–138f
retrograde linear threading injections
in, 138, 138f
Forehead lines, 10f, 136, 137f–138f
Fotona Lightwalker, 190, 191f
Fractional ablation, 188–189
Fractional photothermolysis, 187–188
Frontalis muscle, 137
G
Gaseous lasers, 180
Glabella
aging of, 138, 139f
anatomy of, 11f, 138, 139f
frown lines in, 139f
as high-risk area, 131
high-risk zones of, 140, 140f
platelet-rich fibrin injections in, 138–
141, 139f–141f
serial point injections in, 140
Glabellar lines, 10f, 48f, 139f
231
Index
Glogau classification, of photoaging,
54, 56t
“Golf ball chin,” 159
Greasy skin, 57
Greater occipital nerve anesthesia, 168
Growth factors. See also specific growth
factor.
microneedling release of, 107
platelet release of, 118
in platelet-rich fibrin, 80, 83–84
H
Hair
function of, 20–22
growth cycle of, 21–22, 22f
layers of, 21
loss of, 22
structure of, 20–22
Hair follicle, 20, 20f
Hair loss
bioelectric stimulation for, 226, 226f
case studies of, 170–172, 170f–173f
consultation for
cross-sectional trichometry, 67–68,
68f–69f
documentation, 70–74, 76, 70f–74f
examination, 64, 67f–74f, 67–75
forms, 65f–66f, 73f–74f
hair pull test, 67, 67f
hair tug test, 67, 67f
history-taking, 64, 65f–66f
informed consent, 71, 76
laboratory investigations, 75
photographic documentation,
70–74, 76, 70f–74f
privacy issues, 64
scalp examination, 67, 67f
treatment planning after, 76
trichoscopy, 70, 70f
differential diagnosis of, 75, 75b
female pattern, 75b
goals for, 166
indications for, 76
Ludwig scaling system, 72, 72f
male pattern, 75b
nappage technique for, 169, 169f
Norwood scaling system, 72, 72f
point-by-point injection technique,
169, 169f
prevalence of, 63–64, 165
scalp
anesthesia of, 166–168, 167f–169f
anterior, 168, 168f
biopsy of, 72
examination of, 67, 67f, 69f
innervation of, 167, 167f
photographic documentation of,
71, 71f
posterior, 168, 168f
regional block of, 167
232
topical anesthesia of, 166–167
summary of, 172
techniques for, 169–170, 169f–170f
type of, 75b
Hair Mass Index, 68, 68f
Hair pull test, 67, 67f
Hair removal, using lasers, 189–190
Hair tug test, 67, 67f
Hair zones, 21
HairCheck, 69f
Hands, 51f
Healing, wound. See Wound healing.
Helenalin, 207
Hemangiomas, 186
Hereditary hemorrhagic telangiectasia,
186
HIFU. See High-intensity focused
ultrasound.
High-intensity focused ultrasound,
225–226
High-intensity light, 180
History taking
for facial esthetics consultation, 54
for hair loss consultation, 64, 65f–66f
HMI. See Hair Mass Index.
Horizontal centrifugation, 86
Horizontal centrifuge, 87f, 89f, 92, 104f,
127
Hyaluronic acid
description of, 1
liquid platelet-rich fibrin with, 222,
223f
platelet-rich fibrin with, 151, 222, 223f
skin dehydration prevention uses of, 2
Hypertrophic scars
laser treatment for, 184
microneedling for, 110t–111t
Hypodermis, 19, 177, 177f
I
Immune cells, 202
Indirect flash light, 33, 35f
Inferior alveolar artery, 159
Inflammation, 203
Informed consent, 61, 71, 76
Infraorbital artery, 143
Infraorbital foramen, 143
Infraorbital hollowness, 52f
Injectable platelet-rich fibrin, 85. See
also Platelet-rich fibrin injections.
Intrinsic aging, of skin, 100
J
Jawline, 50f
aging of, 158, 158f
high-risk zones in, 158, 159f
platelet-rich fibrin injections in, 158–
161, 158f–161f
sagging of, 158
treatment of, 160–161
Jowl, 160, 161f
Juvenessence AD, 205, 205b
K
Keloid scars
laser treatment for, 184
microneedling for, 112, 113f
Keratinocytes, 107, 178, 187
Krypton/Nd:YAG laser, 188
L
Langerhans cells, 19, 203
Laser(s)
acne scars treated with, 185–186,
185f
biologic activity of, 176–183
carbon dioxide, 176
classification of, 180, 182–183, 184f
in combination therapy, 228, 228f
dye, 180
epidermal lesions treated with, 187
Er:YAG, 176, 182, 188, 192
facial esthetics uses of, 176
fat ablation uses of, 189
gaseous, 180
hair removal uses of, 189–190
hemangiomas treated with, 186
history of, 175–176
illustration of, 179f
indications for, 183–195, 184f–188f,
191f–195f
krypton/Nd:YAG, 188
lipolysis uses of, 189
low-level laser therapy. See Low-level
laser therapy.
microneedling versus, 109
Nd:YAG, 180, 182, 184, 187, 190
nonablative, 188
photobiostimulation uses of, 180
phototherapy uses of, 180–181
pigmented lesions treated with,
186f–187f, 186–188
platelet-rich fibrin and, in facial
esthetics, 190–192, 191f–195f
pulsed dye, 184, 186, 190
Q-switched, 187, 190
scars treated with, 184–185,
184f–185f
skin rejuvenation uses of, 188–189
solid, 180
sun exposure after treatment with,
190
sunscreen use after, 187
therapeutic effects of, 181–182
tissue interactions, 180
vascular lesions treated with, 186
wound healing uses of, 176–178
Laser light, 179–181
Index
Latanoprost sodium, 116
Lateral canthal lines, 10f, 46f, 142
LED devices. See Light-emitting diode
devices.
Lens, 30–32, 30f–32f
Lesser occipital nerve anesthesia, 168
Leukocyte(s), 80, 83, 84f
Leukocyte platelet-rich fibrin, 81, 82f
Lidocaine, for regional scalp block, 167
Lifestyle factors, 54
Light-emitting diode devices
description of, 176
photobiostimulation uses of, 181–182
skin rejuvenation uses of, 189
Lighting, 33, 34f–35f
Lingonberry stem cell extract, 204–205,
205f
Lingostem, 204–205, 205f
Lip(s)
aging of, 152–153
anatomy of, 152, 152f
augmentation of, dermal fillers for,
4f, 94
blood supply to, 152
corner of, 154
Er:YAG laser treatment of, 192f
fullness of, 47f
high-risk zones of, 153, 153f
liquid platelet-rich fibrin and
hyaluronic acid injection in, 223f
perioral lines, 153–154, 153f
platelet-rich fibrin injections in, 152–
156, 152f–155f
volumizing treatment of, 154–155,
155f
wrinkles around, 49f
Liplase, 191–192, 192f
Lipolysis, 189
Liquid platelet-rich fibrin
Alb-PRF versus, 220f
centrifugation protocols for, 86f
clinical uses of, 86
clotting of, 86
collection of, 91f, 104f
description of, 1
development of, 85–86
facial filler with, 93
hair loss treated with, 170f
horizontal centrifugation, 86
hyaluronic acid with, 222, 223f
illustration of, 127f
low-level laser therapy with,
170f–171f, 192, 194f–195f
mesotherapy by syringe injections
using, 93, 94f
microneedling with, 92–93, 93f, 106f,
195f
protocols for, 92
regenerative potential of, 87f, 87–88
syringe injections of, 93, 94f
topical application of, 93f
Living skin equivalents, 203
LLLT. See Low-level laser therapy.
Local anesthesia, 130
Loupe glasses, 125
Lower face, platelet-rich fibrin injections
in, 152–161, 152f–161f
Low-level laser therapy
acne vulgaris treated with, 185–186
devices, 183, 183f
history of, 176
limitations of, 181–182
liquid platelet-rich fibrin with,
170f–171f, 192, 194f–195f
photobiostimulation uses of, 181–182
skin rejuvenation uses of, 189
Low-speed centrifugation concept, 79,
84–85
L-PRF. See Leukocyte platelet-rich fibrin.
Ludwig scaling system, 72, 72f
Luer-Lok connector, 218, 220f
Luer-Lok syringes, 125
M
Macule, 57, 57f
Male pattern hair loss, 75b
MAL-PDT. See Methyl aminolevulinate
photodynamic therapy.
Mandibular nerve, 17
Marionette lines
aging of, 156, 156f
anatomy of, 156, 156f
combination therapy for, 228, 228f
high-risk zones, 156
illustration of, 10f, 46f
platelet-rich fibrin injections in, 156–
157, 156f–157f
treatment of, 157, 157f
Matrix metalloproteinases, 20
Maxillary nerve, 17
Medical examination, 54
Megakaryocytes, 83
Melanin, 182, 189
Melanocytes, 19–21
Melanosomes, 186
Melasma, 114t–115t, 116
Mental foramen, 159
Mentalis muscle, 158
Merz full esthetic scale, 44, 44t,
45f–52f, 58
Mesenchymal stem cells, 221
Mesenchyme, 177
Mesotherapy, 128, 129t
Methyl aminolevulinate photodynamic
therapy, 117
Microfocused ultrasound, 225
Microneedling
acne scars treated with, 110t–111t, 112
actinic keratosis treated with,
116t–117t, 117
advantages of, 107
alopecia treated with, 112–113,
114t–115t
in combination therapy, 228, 228f
complications of, 107
contraindications for, 101–102
definition of, 100, 118
depth chart for, 105f
Dermapen for, 92, 93f, 99, 100f, 101,
119
description of, 3, 99
facial rejuvenation uses of, 108,
108f–109f
growth factors released after, 107
indications for, 101–102
keloid scars treated with, 112, 113f
lasers versus, 109
liquid platelet-rich fibrin with, 92–93,
93f, 106f, 195f
melasma treated with, 114t–115t, 116
neovascularization, 99
periorbital melanosis treated with,
114t–115t, 116
pigmentary disorders treated with,
113–116, 114t–117t
platelet-rich fibrin with
in cheek, 148
description of, 102, 103f–106f,
128–129, 129b
in forehead, 138
for hair loss, 171f
in jawline, 161
in lips, 155
in temple, 135
scars treated with, 109–112, 110t–112t
science of, 107–117
skin penetration with, 201
stretch marks treated with, 118, 119f
summary of, 118
treatment goals after, 100f
verruca treated with, 117
vitiligo treated with, 114t–115t, 116
Midface, platelet-rich fibrin injections in,
146–151, 146f–151f
Minimally invasive procedures
statistics regarding, 6f
types of, 1
Mirror, 124
MMPs. See Matrix metalloproteinases.
Monocytes, 118
Muscles, of face, 13, 13f
N
Nappage technique, 169, 169f
Nasolabial creases, 150
Nasolabial folds
aging of, 149–150
anatomy of, 10f, 32f, 149, 150f
combination therapy for, 228, 228f
high-risk zones of, 150f, 150–151
laser treatment of, 191f
233
Index
platelet-rich fibrin injections in, 149–
151, 150f–151f
Smoothlase application for, 191f
Nasolabial lines, 48f
Nd:YAG lasers, 180, 182, 184, 187, 190
Neck
elastosis of, 10f
Merz esthetic scale for, 51f
Neck lines, 10f
Needles, for platelet-rich fibrin, 125,
125f–126f, 126t
Neoangiogenesis, 118, 178
Neovascularization, 99
Neutrophils, 118
Nodule, 57, 57f
Nonscarring alopecia, 166
Norwood scaling system, 72, 72f
Nose, 131
O
Omega-3, 206–207, 207f
Omegatri, 206–207, 207f
Ophthalmic artery, 140
Ophthalmic nerve, 17
Oral commissures, 49f
Orbicularis oculi muscle, 142, 152
Oxyhemoglobin, 182
P
Palpebromalar groove, 143, 145f
Panthenol, 204
“Papule,” 129f, 129t
Paralyzers, 1
Patient expectations, 52–53
PDGF. See Platelet-derived growth
factor.
PDL. See Pulsed dye lasers.
PDO threads. See Polydioxanone
threads.
Peptides, 206, 206f
Periocular lines, 10f
Perioral lines, 153–154, 153f
Perioral region, 152–156, 152f–155f
Periorbital melanosis, 114t–115t, 116
Periorbital region
aging of, 142f, 142–143
anatomy of, 142, 142f
high-risk zones of, 143
lateral canthal lines, 142–143, 144f
palpebromalar groove, 143, 145f
platelet-rich fibrin injections in, 141–
145, 142f–145f
tear troughs, 143–144, 144f
upper eyelids, 142
Peripheral blood, platelet-rich fibrin
collection from, 88–91, 89f–91f
Philtral columns, 154
Photoablation, 180
234
Photoaging, Glogau classification of,
54, 56t
Photochemical effect, 180
Photodisruption, 180
Photodynamic therapy, 117, 180–181
Photographs
archiving of, 41
in hair loss consultation, 70–74, 76,
70f–74f
taking of, 35
Photography
background of, 29, 29f
camera, 30–32, 30f–32f
documentation series, 28, 35–41
facial esthetics use of, 29
functions of, 28
general requirements for, 28–29
lens, 30–32, 30f–32f
lighting of, 33, 34f–35f
marketing of, 41
Phototherapy
acne vulgaris treated with, 185
description of, 180–181
Photothermal effect, 180
Photothermolysis, fractional, 187–188
Phototrichogram, 67
Pigmentary disorders. See also specific
disorder.
laser treatment for, 186f–187f,
186–188
microneedling for, 113–116, 114t–117t
Plasma ablation, 180
Plasma heating, 218
Plastic surgery, 226, 227f
Platelet(s), 80, 83, 118
Platelet concentrates
advantages of, 1, 6
angiogenesis promotion by, 25, 95
centrifugal protocols for, 79
function of, 2
growth factors in, 80–81
history of, 81–84
medicinal uses of, 80–81
platelet-rich plasma, 1
Platelet-derived growth factor, 80, 83,
181
Platelet-poor plasma, 218
Platelet-rich fibrin
advantages of, 3, 53, 94
Alb-PRF. See Alb-PRF.
angiogenesis promotion by, 25
application of, 102, 103f–106f
autogenous, 124
cells in, 83
clot formation, 80f, 91
collection of, from peripheral blood,
88–91, 89f–91f
in combination therapy, 228, 228f
components of, 82f
contraindications for, 124
definition of, 3
dermal fillers and, 130, 218
description of, 1
drawing up, 125, 126f, 130
e-PRF, 92–93 129t, 229
facial esthetics use of, 92–93,
93f–94f, 124
facial rejuvenation uses of, 92
formation of, 80
goals of, 5
growth factors in, 83–84
half-life of, 218
heat-treated, 85
history of, 81–84
hyaluronic acid with, 222, 223f
injectable, 85
laser microchanneling with, 193f
laser treatment and, 190–192,
191f–195f
leukocytes in, 81, 82f, 83
limitations of, 218
liquid. See Liquid platelet-rich fibrin.
low-level laser treatment and,
194f–195f
matrix of, 82
mechanism of action, 92
medicinal uses of, 80–81
plastic surgery with, 226, 227f
platelet-rich plasma versus, 95
platelets in, 83
postoperative care, 102, 106f
preparation of, 102, 103f–106f
side effects of, 124
technique with, 102, 103f–106f
treatment protocol for, 44, 60
types of, 127, 127f
ulcers treated with, 81
Platelet-rich fibrin injections
accessories for, 124–125, 125f–126f
BIO-PRF lift, 127–130, 128b–129b, 129f
complications of, 131
ergonomics for, 124, 125f
global approach, 127–130, 128b, 129b,
129f
hair loss treated with. See Hair loss.
intraepidermic, 129t
mesotherapy, 128, 129t
needles for, 125, 125f–126f, 126t
platelet-rich fibrin types for, 127, 127f
pretreatment considerations for,
124–125, 125f–126f
regional
cheek, 146–149, 146f–149f
chin, 158–161, 158f–161f
description of, 127, 128b
forehead, 136–138, 136f–138f
glabella, 138–141, 139f–141f
jawline, 158–161, 158f–161f
lateral canthal lines, 142–143, 144f
lips, 152–156, 152f–155f
Index
lower face, 152–161, 152f–161f
marionette lines, 156–157, 156f–157f
midface, 146–151, 146f–151f
nasolabial folds, 149–151, 150f–151f
perioral region, 152–156, 152f–155f
periorbital region, 141–145,
142f–145f
tear troughs, 143–144, 144f
temple, 132–135, 133f–135f
upper face, 132–145, 133f–145f
vascular “danger zones” of face,
131–132, 131f–132f
superficial intradermal “papule,” 129f,
129t
tips for, 127
topical anesthesia for, 125
Platelet-rich fibrin stand, 125, 126f
Platelet-rich plasma
advantages of, 3
autogenous, 80
composition of, 81
description of, 1
history of, 81–84
limitations of, 81
platelet-rich fibrin versus, 95
regenerative potential of, 87f, 87–88
PLLA. See Poly-L-lactic acid.
PMMA. See Polymethyl methacrylate.
Point-by-point injection technique, for
hair loss, 169, 169f
Polydioxanone threads, 1, 222–223, 224f
Poly-L-lactic acid, 222–223, 225
Polymethyl methacrylate, 225
Posttreatment skin care. See Skin care
products.
PPP. See Platelet-poor plasma.
PRF. See Platelet-rich fibrin.
PRFEDU facial esthetic photographic
documentation series, 36, 39f–40f,
41
Procerus muscle, 138
Propionibacterium acnes, 185
Protective Day Cream, 206, 206f, 212,
212f, 212t
PRP. See Platelet-rich plasma.
Psychologic assessment, 54
Pulsed dye lasers, 184, 186, 190
Punch biopsy, of scalp, 72
Pustule, 57, 57f
Q
Q-switched lasers, 187, 190
R
Reactive oxygen species, 20, 203f, 204,
208
Recombinant human platelet-derived
growth factor-BB, 83
Red lip, 154, 155f
Relative centrifugal force, 84
Rem, 179
Renewal Night Cream, 212–213, 213f,
213t
Retrograde linear threading injections
in forehead, 138, 138f
in perioral region, 153
Retro-orbicularis oculi fat pad, 142
rhPDGF-BB. See Recombinant human
platelet-derived growth factor-BB.
ROOF. See Retro-orbicularis oculi fat
pad.
ROS. See Reactive oxygen species.
S
Scalp
anesthesia of, 166–168, 167f–169f
anterior, 168, 168f
biopsy of, 72
examination of, 67, 67f, 69f
innervation of, 167, 167f
photographic documentation of, 71,
71f
posterior, 168, 168f
regional block of, 167
topical anesthesia of, 166–167
Scar(s)
acne. See Acne/acne scars.
atrophic, 110t–111t, 112, 184f
burn
illustration of, 101f
microneedling for, 110t–111t
formation of, 184
hypertrophic, 184
keloid
laser treatment for, 184
microneedling for, 112, 113f
laser treatment for, 184–185,
184f–185f
microneedling for, 109–112, 110t–112t
Scarring alopecia, 75b
Sebaceous glands, 20–21
Selective photodermolysis, 176
Serial point injections, 140
Sharps container, 125
Shedding, 64
Skin
aging of. See Skin aging.
anatomy of, 176–177
bluish, 57
brownish, 57
color of, 56f, 57
dehydration of, 2
dry, 57
efflorescence of, 57, 57f
ethnic differences in, 19–20
external factors that affect, 57
Fitzpatrick classification of, 54, 55f,
56t
functions of, 19
greasy, 57
hydration of, 58f
laser resurfacing of, 188–189
layers of, 19
light penetration into, 181f
manual assessment of, 58, 58f–59f
omega-3’s effects on, 207
reddening of, 57
rejuvenation of, using lasers, 188–189
smoking effects on, 118
structure of, 19
texture of, 57
ultraviolet radiation exposure, 208
wrinkles of, 58, 60t
yellowish, 57
Skin aging
changes associated with, 2, 3b, 19–20
characteristics of, 2f, 2–3, 19–20
chronological, 100
ethnic differences, 19–20
extrinsic, 100
factors associated with, 2, 20, 99
healing or regeneration of, 1
intrinsic, 100
treatment options for, 2–3
Skin care products
Alaria exculenta extract, 205, 205b
antioxidants, 204
Arctic Čaga extract, 202–203, 203f,
208
arnica, 207–208
beta-glucan M, 205
Čuvget. See Čuvget skin care
products.
description of, 201
lingonberry stem cell extract, 204–
205, 205f
omega-3, 206–207, 207f
peptides, 206, 206f
SYN-TC, 206, 206f
Skin markers, 124
Skin rejuvenation, 189, 202
Skin snap test, 58, 58f
SMAS. See Superficial
musculoaponeurotic system.
Smoker’s lines, 153
Smoking, 118
Smoothlase, 190–191, 191f–192f
Snap test, 58, 58f
Sodium ascorbyl phosphate, 204
Sodium carboxymethyl beta-glucan, 205
Soft tissue nasion, 11f
Solid lasers, 180
SOOF. See Suborbicularis oculi fat pad.
Stimulating Serum, 210, 211f, 211t
Stratum corneum, 19
Stretch marks, 118, 119f
Subcutaneous tissue, 19, 60t
Subnasale, 11f
235
Index
Suborbicularis oculi fat pad, 142, 146
Subsurfacing, 188
Sun exposure, 2
Sunscreen, 187
Superficial intradermal “papule,” 129t
Superficial musculoaponeurotic system,
14, 147, 158, 225
Superficial temporal artery, 132, 134f
Supraorbital artery, 132
Supraperiosteal injections, 147f, 160f
Supratrochlear artery, 137
SYN-TC, 206, 206f
T
Tear troughs, 143–144, 144f
Telangiectasias, 186
Telogen effluvium, 75b
Telogen phase, of hair growth, 21, 22f
Temple
aging of, 132, 133f
anatomy of, 132, 133f
high-risk zones in, 134f
hollows formation in, 133f, 134–135
vertical supraperiosteal depot
technique in, 134, 135f
Temporal fossa, 132
Temporalis muscle, 132
Terminal hairs, 20
Testosterone, 22
TGF-b1. See Transforming growth
factor-b1.
TGF-b3. See Transforming growth
factor-b3.
236
Tinea capitis, 75b
Tissue regeneration, 83
Tocopherol acetate, 204
Topical anesthesia, 125, 166–167
Traction alopecia, 75b
Transforming growth factor-b1, 83–84,
85f, 181
Transforming growth factor-b3, 107
Traumeel-S, 207
Treatment planning, 60, 76
Trichion, 11f
Trichometry, cross-sectional, 67–68,
68f–69f
Trichoscopy, 70, 70f
Trichotillomania, 75b
Trigeminal nerve, 17, 167
U
Ulcer, 57, 57f, 81
Ultrasound
high-intensity focused, 225–226
microfocused, 225
Ultraviolet light, 180, 182, 187
Ultraviolet radiation, 20, 100, 208
Upper eyelid hollows, 142
V
Vascular endothelial growth factor, 80,
84, 226
Vascular lesions, 186
VEGF. See Vascular endothelial growth
factor.
Vein light, 125
Vellus hairs, 20
Verruca, 117
Vertical supraperiosteal depot technique
in cheek, 148
in chin, 160
in temple, 134, 135f
Videodermoscopy, 70
Visual examination, 54, 55f, 56t, 57f
Vitamin B5, 204
Vitamin C, 204
Vitamin E, 204
Vitiligo, 114t–115t, 116
W
Wheal, 57, 57f
White lip, 154, 155f
Wide-angled lens, 32
Wound contraction, 178
Wound healing
description of, 80
lasers for, 176–178
leukocytes’ role in, 83
phases of, 118, 177–178, 178f
Wrinkles, 49f, 58, 60t
Y
Yellowish skin, 57
Z
Zygomatic bone, 146
Zygomaticofacial artery, 147
Zygomaticus muscle, 146, 146f