Platelet Rich Plasma: Is it Effective in Treatment of Atrophic Scar?

INTRODUCTION
Atrophic scar is the result of decrease collagen
production and matrix formation, that's why many
doctors are convinced that this type of scar is
untreatable due to the damaged skin tissues and
collagen destruction. Histologically, the skin has
reduced thickness and loss of normal architecture
[1].
Several practical questions arise when dealing
with atrophic scar. The desire to have beautiful
and healthy looking scar is considered the most
common question for both genders at any age.
Since scar is the final common outcome of
tissue repair in mammals, the goal is to have fine
un-noticed scar by the mean of reaching a desired
outcome of the healing process [2].
To solve the problem of atrophic scar, many
researchers have proposed various methods of
treatment including, Laser therapy, dermabrasion,
silicon containing products, fillers, skin needling
and surgical scar revision. Each has its benefits
and drawbacks [3].
In the last few years there has been a growing
interest in using platelet-rich plasma (PRP) in the
field of plastic surgery. However, to the authors,
best knowledge, very few publications can be found
available in the literatures that discuss the issue
of using PRP in management of atrophic scar.
Platelet-rich plasma (PRP) which developed
from blood and consists of plasma with a platelet
concentration above the baseline considers one of
the recent methods which are characterized by high
levels of growth factors that enhance wound healing
[4,5].
Platelet-rich plasma (PRP) contains abundant
amount of growth factors that play an important
role in wound healing, through stimulation of
angiogenesis, re-epithelization, matrix formation,
and re-modeling and is chemotactic and mitotic
agents for fibroblasts and endothelial cells. Autologous
PRP injection is a safe process, applicable
even at outpatient clinic, repeatable and reproducible
technique that doesn't require post injection
precautions such as avoidance of sun exposure
which may interfere with patient usual habits like
laser therapy or dermabrasion [6].
The objective of the present study is to study
the effect of autologous PRP injection in improvement
of atrophic scar after scar revision.
PATIENTS AND METHODS
This work was authorized by the ethics committee
of Faculty of Medicine, Assiut University.
This study was carried out to find out the effect of
PRP injection on atrophic scar. Informed consent
from patients or their parents was obtained. This
prospective study was conducted on 20 patients
with atrophic scar in different regions of the body,
who were presented at the outpatient clinic of
plastic surgery department, Assiut university hospital,
in the period from July 2016 to February
2017. Patients were classified into two equal
groups. Group 1 (control), underwent scar revision
only. Group 2 (study), PRP was injected immediately
after scar revision. Followed-up the patients
was at least for six months.
All cases were undergone simple scar revision
under local anaethesia using 2% lidocaine. Inverted
lambert subcutaneous sutures were done using 4/0
Polydioxanone (PDF). We used 6/0 Prolene (monofilament
non-absorbable) in face and 4/0 in limbs
and abdomen to close skin. Stitches were removed
after 5 days in scar face and after 10 days in scars
at the limbs. The patients used topical steroid cream
for 2 weeks, followed by topical silicon containing
ointment twice during the day, and silicon containing
patch during night.
The patient returned weekly for the first month
then monthly for the next 5 months.
For study patients, PRP was immediately injected
intradermal at the edges of the post revision
wound (group II). The platelet rich plasma was
obtained from the patients (autologous) before scar
revision by:
20ml of autologous whole blood is collected
into tubes containing acid-citrate-dextrose (ACD)
and centrifuged at 1000g for 10 minutes in order
to get PRP at the top of the test tube. The PRP is
252 Vol. 42, No. 2 / Platelet Rich Plasma: Is it Effective in Treatment of Atrophic Scar?
further centrifuged at 1500g for 10 minutes in
order to obtain a PC (platelet concentrate) with a
platelet count 4.5 times higher than the baseline,
and platelet-poor plasma (PPP). The PC (platelet
concentrate) is preserved in a sterile container and
then combined with human thrombin (0.2ml per
mL of PC) and calcium gluconate immediately
prior to injection [7]. The 20ml of whole blood
yields 2ml PRP.
Each group was analyzed statistically based on:
• Age.
• Sex.
• Site of the scar.
• Duration of the scar.
• Relation of the scar to lines of relaxed skin
tension.
• Vancouver scar scale pre-operative and 6 months
post-operative (Table 1).
• Patient scar scale pre-operative and 6 months
post-operative (Table 2).
• Physician scar scale preoperative and 6 months
post-operative (Table 2).
• Percent of scar width improvement:
- <25% of scar width improvement means poor
result.
- 25-<50% scar width improvement means fair
result.
- 50-<75% of the scar width improvement means
good result.
- 75-100% of the scar width improvement means
excellent result.
Table (1): Vancouver Scar Scale (VSS) [8].
Vascularity
Pigmentation
Pliability
Height
Total score
Character of the scar
Normal
Pink
Red
Purple
Normal
Hypopigmentation
Hyperpigmentation
Normal
Supple
Yielding
Firm
Ropes
Contracture
Flat
2-5 mm
>5 mm
Scar characteristic
0123
012
012345
0123
/13
Score
Egypt, J. Plast. Reconstr. Surg., July 2018 253
Low VSS means good result:
Results of the atrophic scars assessments:
• Site of scar:
14 cases (70%) have scar in their face, 4 patients
(20%) have scar in their lower limbs and 2 cases
(10%) have scar in their abdomen. No significant
correlation between site of the scar and the results
could be detected. (Fig. 3).
Table (2): Patient satisfaction scale [9].
Scar Shape
Scar Texture
Scar Color
Itching
Contracture
1
1
1
1
1
Poor
(Grade I)
3
3
3
3
3
Excellent
(Grade III)
2
2
2
2
2
Good
(Grade II)
Improvement Score
Fig. (1): Patient age distribution.
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
Age
Group I Group II
Mean ± SD
Fig. (2): Patient sex distribution.
80
70
60
50
40
30
20
10
0
Group I Group II
% of Sex
Male Female
50 50
40
60
90
80
70
60
50
40
30
20
10
0
% of site of scar
Face Lower limb Abdominal
Fig. (3): Scar site distribution.
Group I Group II
20
0
20 20
80
60
Physician or patient satisfaction scale was assessed
by using a questionnaire of 3-point grade
to assess shape, texture, color, itching and contracture
(total score ranges from 5-15).
• 5-6 patient or physician satisfaction score means
poor result.
• 7-10 patient or physician satisfaction score means
good result.
• 11-15 patient or physician satisfaction score
means excellent result.
The results of study group were identified and
compared with control group according to these
previous criteria.
Statistical analysis:
The statistical software SPSS version 17 was
used for data analysis. The results were expressed
as mean ± SD. The significance level was set as
p<0.05.
RESULTS
This study was conducted on 20 patients who
were presented to plastic surgery clinic, Assiut
University Hospital. Age ranged from 10 to 30
years old with mean age was 22.68±6.75 year old.
45% of cases were males and 55% were females.
Simple scar revision was done for the ten control
patients (group I), and immediate intradermal
injection of PRP was done for the other ten study
patients (group II) after scar revision followed by
once monthly PRP injection at the edges of the
scar for the following five months. Reassessment
of the cases was done six months after scar revision.
Demographic data of the studied cases:
Age ranged from 10-30 years old. The mean
age was 22.68±6.75. Of these 20 patients; 9 were
males while 11 were females. (Figs. 1,2).
• Etiology of the scar:
Post traumatic scar were in 12 patients while
post-operative scar were in 8 cases. (Fig. 4).
254 Vol. 42, No. 2 / Platelet Rich Plasma: Is it Effective in Treatment of Atrophic Scar?
• Vancouver scar scale assessment:
The Vancouver Scar Scale, the most widely
used assessment scale which measures vascularity,
pigmentation, pliability and height.
A- In group I:
VSS ranged from 4 to 9 with a mean 5.9±1.7
pre operatively, while VSS ranged from 3 to 6 with
a mean 4±0.9 post operatively.
B- Group II:
VSS ranged from 4 to 8 with a mean 5.3±1.3
pre operatively, while VSS ranged from 1 to 2 with
a mean 1.6±0.5 post operatively.
There was statistically significant difference
between pre and 6 months post-operative in both
control and study groups, p-value 3).
Table (3): Comparison between control and study groups'
regards VSS pre-operative and six months postoperative.
Pre-operative:
Range
Mean ± SD
After 6 months:
Range
Mean ± SD
4-9
5.9±1.7
3-6
4±0.9
Group I
0.234
<0.001**
p-value
4-8
5.3±1.3
1-2
1.6±0.5
VSS Group II
Table (4): Comparison between control and study groups as
regards VSS 6 months post operative.
VSS after 6-months
p-value
4±0.94
Group I
1.6±0.52
<0.001**
Group II
Fig. (4): Etiology of the scar.
100
90
80
70
60
50
40
30
20
10
0
% of Etiology
Group I Group II
P.T P.O
60 60
40 40
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Group I Group II
Mean ± SD
Fig. (5): Duration of the scar.
80
70
60
50
40
30
20
10
0
% of Relation of scar to
the lines of langer
Group I Group II
70 70
30 30
With Against
Fig. (6): Relation of the scar to lines of Langer.
• Duration of the scar:
Duration of the scar ranged from 1-5 years with
mean 2.5±.8 years. (Fig. 5).
• Relation of the scar to lines of Langer:
Seven patients (70%) in each group have scar
parallel to Linger lines while the remaining 3 cases
(30%) in control and study groups have scar against
Linger lines. (Fig. 6).
VSS six months post-operative showed highly
significant improvement in the group treated with
PRP compared to control group (Table 4).
• Response of atrophic scar to treatments according
to patient scar assessment scale:
Group I:
Patient scar assessment scale ranged from 5 to
9 with a mean 7.9±1.2, pre operatively, while 6-
months post-operative, patient scar scale ranged
from 8 to 11 with a mean 9.7±0.9.
Group II:
Patient scar assessment scale ranged from 7 to
9 with a mean 8.2±0.6, pre operatively, while 6-
months post-operative, patient scar scale ranged
from 11 to 14 with a mean 12.3±1.1.
Egypt, J. Plast. Reconstr. Surg., July 2018 255
There was statistically significant difference
between pre and 6 months post-operative in both
control and study groups, p-value 5).
This table shows that physician assessment scar
scale showed significant improvement in cases of
group II in comparison with those of group I.
• According to improvement of scar width:
Pre and post op. measurements of scar width
were taken and the percent of improvement of scar
width was calculated for each group:
- Group I: Percent of improvement of scar width
ranged from 10-40% with Mean ± SD 26.5±11.6.
- Group II: Percent of improvement of scar width
range from 50-70% with Mean ± SD 61±7.4.
There was statistically significant difference
between pre-operative and post-operative in groups
I and II (Table 9).
Table (5): Comparison between control and study groups
regards Patient Scar Assessment scale pre-operative
and six months post-operative.
Pre-operative:
Range
Mean ±SD
After 6 months:
Range
Mean ±SD
5-9
7.9±1.2
8-11
9.7±0.9
Group I
0.401
<0.001**
p-value
7-9
8.2±0.6
11-14
12.3±1.1
Patient Scar Group II
Assessment scale
Table (6): Comparison between control and study groups
regards Patient Scar Assessment scale 6 months
post-operative.
Patient Scar Assessment
scale 6 months post-operative
p-value
9.7±0.95
Group I
12.3±1.06
<0.001**
Group II
Table (7): Comparison between control and study groups
regards Physician Scar Assessment scale preoperative
and six months post-operative.
Pre-operative:
Range
Mean ±SD
After 6 months:
Range
Mean ±SD
7-10
9±1.1
9-12
10.4±1.1
Group I
0.633
<0.001**
p-value
8-11
8.9±1
11-14
12.4±1.2
Physician Group II
scar scale
Table (8): Comparison between control and study groups
regards Physician Scar Assessment scale 6 months
post-operative.
Physician scar Assessment
scale 6 months post-operative
p-value
10.4±1.07
Group I
12.4±1.17
<0.001**
Group II
Table (9): Comparison between control and study groups
regards Percent of improvement of scar width 6
months post-operative.
Percent of improvement
of scar width:
Range
Mean ± SD
10-40
26.5±11.6
Group I
<0.001**
p-value
50-70
61±7.4
Group II
Table (10): Comparison between control and study groups
regards percent of improvement of scar width six
months post-operative, according to relation of
scar to lines of Langer.
With
Against
28.57±9.88
21.67±16.07
Group I
<0.001**
0.003**
p-value
64.29±5.35
53.33±5.77
Group II
Patient assessment scar scale showed significant
improvement in cases of group II in comparison
with those of group I.
There was statistically significant difference
between control and study groups, p6).
• Response of atrophic scar to treatments according
to physician scar assessment scale:
Group I:
Physician scar assessment scale ranged from 7
to 10 with a mean 9±1.1 pre-operative. While 6-
months post-operative, it ranged from 9 to 12 with
a mean 10.4±1.1.
Group II:
Physician scar assessment scale was ranged
from 8 to 11 with a mean 8.9±1, pre-operative,
while 6-months post-operative, it ranged from 11
to 14 with a mean 12.4±1.2.
There was statistically significant difference
between pre and 6 months post-operative in both
control and study groups, p-value 7).
256 Vol. 42, No. 2 / Platelet Rich Plasma: Is it Effective in Treatment of Atrophic Scar?
There was statistically significant improvement
of scar width in PRP group compared to control
group post-operative in atrophic scars regardless
with or against Langer lines but the improvement
was better in scars parallel than against Langer
lines (Table 10).
Fig. (7): Male patient 30 years old have post traumatic scar at the left check parallel to lines of Langer, since 1y. (A) Preoperative,
(B) Immediately after scar revision, (C) 6-months post-operative shows about 20% improvement of the
width of the scar, no improvement of color of the scar and poor patient satisfaction.
Clinical Cases:
(A) (B) (C)
Fig. (8): Male patient 25 years old
have post traumatic forehead scar parallel
to lines of Langer since 5y. (A)
Pre-operative, (B) 6-months postoperative
showing 60% improvement
of the scar width, flattening of the
depression of the scar and excellent
patient satisfaction.
(A) (B)
Fig. (9): Male patient 27 years old with post traumatic scar face since 2.5y
(A). The scar was divided into 2-parts; vertical part (arrow I) was treated as
control group and transverse part (arrow II) was treated by intradermal injection
with PRP after scar revision. (A) & (B) are pre-operative, (C) is fifth days postoperative
(for removal of stitches), (D) 6-months post-operative, although scar
II (PRP group) is against Langer line but it shows significant improvement
than scar I (control group) which parallel to Langer lines.
(A) (B) (C)
(D)
Egypt, J. Plast. Reconstr. Surg., July 2018 257
DISCUSSION
Despite many modern techniques use to improve
scars, there is still a need for other new methods
to improve the atrophic scars results after their
surgical revision. One of the promising new methods
is injection of PRP to improve the clinical
appearance of atrophic scar.
Quite recently, considerable attention has been
paid to use autologous platelet-rich plasma (PRP)
for a wide variety of surgical applications, particularly
in cosmetic surgery.
Few studies were conducted for assessing the
effect of intradermal PRP injection on improvement
of non-acne – atrophic scars.
The purpose of this study is to evaluate the
efficacy and safety of intradermal autologous platelet-
rich plasma (PRP) injection in improvement of
atrophic scar.
Several publications have been appeared in
recent years documenting that autologous PRP has
minimal scar tissue formation or serious side effects
[10].
The results of this study are in good agreement
with other studies which have shown that PRP
clinically improve the appearance of atrophic scar
which indicate minimal scar tissue formation, with
no significant adverse effect.
Platelets contain large stores of growth factors
and the effectiveness of PRP is based on these
growth factors such as PDGF, EGF, and TGF that
have an important role in matrix and new healthy
tissue formation, and stem cells proliferation
[11,12,13].
The data obtained from this study shows significant
improvement of clinical appearance of
atrophic scar as regard Vancouver scar scale, patient
assessment scar scale, physician assessment scar
scale and percent of improvement of scar width,
after intradermal injection of PRP following revision,
compared to surgical revision only. This may
be due to high contents of platelets in PRP which
release growth factors that promote cellular proliferation,
matrix formation and collagen production.
Hence it directs the issue of decreased collagen
synthesis (mechanism of atrophic scaring).
On a split-face, randomized clinical trial is
conducted by Faghihi et al., in 2016 [14] to study
the efficacy of autologous platelet-rich plasma
combined with fractional ablative carbon dioxide
resurfacing laser in treatment of facial atrophic
acne scars, He conclude that patients, satisfaction
is higher on the side of the face that is treated with
the combination of PRP and fractional ablative
CO2 laser than on the side that is treated with
fractional ablative CO2 laser only.
Lee et al., reported [15], that patients who receive
ablative fractional carbon dioxide laser combined
with intradermal platelet-rich plasma injection on
one half of the face have significant improvement
in clinical appearance of scar and erythema is
improved faster than the other side which receive
fractional carbon dioxide laser combined with
intradermal normal saline injection.
The findings from the present study support a
previously accepted hypothesis that there are higher
patients and physicians' satisfaction and clinical
improvement of atrophic scar after injection of
PRP following surgical revision than revision only
but we did not use laser.
Spiridaskin et al., reported [16] that using platelet
derived growth factor (PDGF) enhances the healing
process of pilonidal sinus and shorten patients,
recovery period. On contrary, Litmath et al. [17]
reported that, there is no significant effect of using
autologous platelet rich gel on healing of complicated
wounds on high risk patients. In contrast to
some reports in the literature, the results from the
presenting study show significant improvement of
uncomplicated atrophic scars in completely fit
patients who are injected by PRP compare to control
patients.
The results of this study are in good agreement
with other studies [18] which have shown that
second, third, and fourth decade are the common
age seeking for scar revision.
We didn't meet any limitation during the study
as PRP is easy obtainable, applicable and safe
repeatable maneuver.
The next stage of our research will be studying
the effect of intradermal PRP injection on atrophic
scar without revision.
We also recommend further studying the effect
of PRP injection on other types of scars and the
effect of its injection at subcutaneous instead of
intradermal level. We also recommend further
studying the histological point of view beside the
clinical results to know the exact mechanism by
which the PRP improves the appearance of scar.
Our study suggests that injecting a recent wound
with PRP will result in desirable outcome of wound
healing and scaring.
258 Vol. 42, No. 2 / Platelet Rich Plasma: Is it Effective in Treatment of Atrophic Scar?
Conclusion:
From the research that has been carried out, it
is possible to conclude that intradermal injection
of autologous PRP in an atrophic scar after its
revision could be considered as a promising option
for atrophic scar management as it improves wound
healing process and decreases scar tissue formation
that appears in the improvement of clinical appearance
of the scar.