Correction of Depressed Scars with PRP Enriched Fat Graft

INTRODUCTION
Scars are areas of fibrous tissue that replace
normal skin after injury. They results from the
biological process of wound repair in the skin and
other tissues of the body and constitutes a natural
part of the healing process. Scarring is considered
abnormal when the amount of fibrosis is excessive
or suboptimal, as in hypertrophic, atrophic, or
keloidal scars; when it affects normal function;
and when they are disfiguring [1].
Scars on different parts of the body may cause
functional disability and cosmetic disfigurements.
But when the location is on obvious areas as face
or arms the scars need special attention [2].
The selection of autologous graft materials is
accepted as one of the most fundamental media
for use in most soft-tissue augmentation and reconstruction
purposes. Fat grafting affords a medium
that is soft, pliable, and readily available in abundant
stores; can be harvested with minimal morbidity;
has low antigenicity; and lacks risk of
disease transmission [3].
Studies were focused on the effects of enhancing
fat-graft survival by augmenting the biochemical
healing potential of the graft material with the
addition of platelet-rich plasma (PRP) [4].
245
Addition of PRP to fat grafts offers a better
graft survival, a less bruising and inflammation
reaction, and easier application due to liquefaction
effect of PRP [5].
Fat grafts collected by liposuction can be reinjected
subcutaneously for correction of depressed
or irregular areas [6] which is revascularized within
48h. During this time, it is fed by diffused materials
from plasma [7].
PRP maintains a high concentration of bioactive
proteins and growth factors that are shown to
augment tissue repair and regeneration. Results of
researches have suggested that growth factors not
only influence the viability of transferred cells but
also may play a bioactive role in influencing the
differentiation of precursor adipocytes within the
graft into their mature form [8].
In addition to a volumizing effect, the injected
fat has a neoangiogenic effect improving the cutaneous
elasticity. This technique is thus also recommended
for wound healing, scar reduction, radiodermatitis
treatment & correction of acne scars [9].
MATERIAL AND METHODS
The study was performed on 20 patients with
depressed scars of various etiologies in the period
between March 2015 and May 2017 at The Plastic
and Reconstructive Surgery Department, Tanta
University Hospitals.
Patients were treated by autologous fat grafting
mixed with Platelet rich plasma (PRP) and 2 sessions
of PRP prior to fat grafting with 2 weeks apart.
The procedure was done with local or general
anesthesia, according to patient/physician preference.
The abdomen or flanks were chosen as donor
areas depending on patient/physician preference.
Infiltration was performed in the donor site
according to the tumescent technique with a solution
containing normal sterile saline containing
0.05% xylocaine with 1:1,000,000 of epinephrine,
at a ratio of 1ml of solution per milliliter of aspirated
tissue. Manual harvesting using low pressure
vacuum, created by slowly withdrawing the plunger
of a 10ml Luer-lock syringe in a gradual manner.
The fat harvesting was performed with a 3-mmdiameter
blunt tip cannula attached to a 10ml Luerlock
syringe. The aspirate was collected in sterile
tubes to be centrifuged before injection.
The Harvested fat was centrifuged 3 minutes
at 3000 rpm. This method separates fat from substances
that increase degradation, and concentrates
adipocytes and stem cells per milliliter of transplanted
fat.
During the procedure blood was withdrawn
from the patient with citrate phosphate dextrose
(CPD) at a volume ratio of 9 to 1 for anticoagulation.
PRP was produced through centrifugal separation
of whole blood.
After the first centrifugation (2500 rpm, 5
minutes), the blood was separated into plasma and
red blood cells. The red blood cells were removed,
and after a further centrifugation (3500 rpm, 5min)
of the remaining plasma, the bottom layer, which
is rich in platelets and constituted approximately
10% of the total withdrawn blood volume, was
collected for use as PRP. At the time of grafting,
the solution was mixed with 2% calcium chloride
at a volume ratio of 7 to 1 to promote the release
of growth factors from the platelets.
The purified fat by centrifugation was mixed
through a 3-ways connector with PRP.
The fat/PRP mixture was transferred from 10ml
Luer-Lock syringes to 1ml or 3ml Luer-Lock syringes
via a 3-ways connector. It is important to
use smaller syringe, because the fat placement is
more precise. For fat placement, special blunt
cannula (2mm) was connected to the 1 or 3ml
246 Vol. 42, No. 2 / Correction of Depressed Scars with PRP Enriched Fat Graft
syringes. Fat was injected in small parcels and thin
strips in several layers. Before injection, we created
some tunnels in scars, to release fibrotic tissues.
The fat graft is then placed by a withdrawing way.
Patients were dressed in compression garments
that cover the areas that have been suctioned.
Compression garments are generally encouraged
24 hours per day for 4 weeks. Patients were followed
up for scar evaluation concerning texture,
clinical improvement and complications.
RESULTS
Twenty patients with depressed scars were
included. The epidemiological and clinical features
are listed in Table (1). Patients consisted of 9
women (45%) and 11 men (55%). The average age
was 24.25 (range 6-41). The most common recipient
site was the cheek (40%). Other treatment areas
were the forehead, chin, neck, leg and back area
(in 3, 2, 2, 4 and 1 patients respectively). Fat tissue
donor sites were the flanks and lower abdomen.
The most common etiology was trauma (60%)
while burn was is 6 patients and steroid injection
in 2 patients. The scar was linear in 11 patients
and wide in 9 patients. Patients received an average
of 1.75 fat injections (range 1-3 sessions). Patients
were evaluated clinically with serial photographs.
Two blinded doctors performed clinical assessments
using the following grading scale: 0 = (poor), 1 =
(fair), 2 = (good), 3 = (excellent), and 4 = (complete).
Clinical results are shown in Table (1).
Three patients showed fair results (scale 1), 3
patients showed good results (scale 2), 12 patients
showed excellent results (scale 3) and 2 patients
showed complete resolution (scale 4). There were
no poor results. Postoperative complications of
minimal bruising, pain, edema, and erythema occurred
but rarely persisted more than 72 hours.
Table (1): Patients data.
Grading scale for improvement 0 = (Poor). 1 = (Fair). 2 = (Good). 3 = (Excellent). 4 = (Complete).
123456789
10
11
12
13
14
15
16
17
18
19
20
No.
M/10
F/25
F/31
M/17
M/41
F/6
M/22
F/23
F/36
M/33
F/19
M/22
F/27
M/33
F/34
M/27
F/20
M/15
M/14
M/30
Sex/Age
Cheek
Forehead
Cheek
Chin
Forehead
Cheek
Cheek
Chin
Neck
Forehead
Cheek
Leg
Neck
Cheek
Leg
Back
Leg
Cheek
Cheek
Leg
Scar site
Traumatic
Traumatic
Burn
Traumatic
Traumatic
Steroid injection
Traumatic
Traumatic
Burn
Traumatic
Traumatic
Burn
Burn
Traumatic
Burn
Steroid injection
Burn
Traumatic
Traumatic
Traumatic
Etiology
Linear
Wide
Wide
Linear
Linear
Wide
Linear
Linear
Wide
Linear
Linear
Wide
Wide
Linear
Wide
Wide
Wide
Linear
Linear
Linear
Scar shape
11312211211322323112
Number of injections
33233423134233133313
Result
Egypt, J. Plast. Reconstr. Surg., July 2018 247
Fig. (1): (A) Pre and (B) Post operative views of a post surgical cheek scar.
Fig. (2): (A) Pre and (B) Post operative views of a post traumatic cheek scar.
Fig. (3): (A) Pre and (B) Post operative views of a traumatic scar of the leg.
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Fig. (4): (A) Pre and (B) Post operative frontal views of a post steroid injection cheek scar.
Fig. (5): (A) Pre and (B) Post operative frontal views of a post steroid injection cheek scar.
DISCUSSION
The advent of fat grafting or lipofilling, first
introduced by Neuer in 1893 [10] and popularized
by Coleman [6], has changed the surgical strategy
for soft tissue augmentation. The application of
this technology in patients with scars is a novel
surgical alternative and promises long-term effects
[12]. They are usually implanted into the superficial
layer just beneath the dermis to replace lost tissue
volume and induce collagen production via stretching
of dermal fibroblasts, thus improving skin
texture and thickness [13]. However, the reported
rates of fat cell survival are very variable, may be
due to different techniques of harvesting, processing
and reinjection of fat cells. Recently, the addition
of PRP has been considered very effective to improve
fat intake and survival [14], and several
studies have already demonstrated improvement
of wound healing and fat grafting survival in both
reconstructive and aesthetic cases by using fat
grafting with PRP [15]. Platelet-rich plasma is used
as an additive in various clinical indications [15-
27] including fat grafting. The growth factors
present in platelet-rich plasma stimulate wound
healing [28,29] tissue remodeling, and revascularization
[15] and improve fat graft take [30-32]. Clinical
studies, however, report a large variation of results
[33-35]. Our results confirmed that a combined
approach should be the gold standard to maximize
the outcome in the treatment of atrophic scars. Fat
plus PRP subcutaneous injection can fill the scars
and stimulate self-regeneration, as shown in all
our patients.
Egypt, J. Plast. Reconstr. Surg., July 2018 249
Conclusion:
Scars that involve the cutaneous and subcutaneous
tissues benefit from a combined approach
of fat enriched with PRP that proved to significantly
increase skin and subcutaneous tissue thickness.
All patients, regardless of age, social class or
educational level, are highly motivated to undergo
the procedure because they have not yet found
effective therapy or have not yet undergone treatment.