Library of Congress Cataloging-in-Publication Data
Names: Davies, Catherine, author. | Miron, Richard J. (Richard John), 1983- author.
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
© 2020 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc
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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
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
Preface
Acknowledgments
Contributors
1 / Introduction to Facial Esthetics and PRF
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
Walter Rozen, Richard J. Miron, and Catherine Davies
4 / Consultation for the Facial Esthetic Patient
Richard J. Miron and Catherine Davies
5 / Consultation for the Hair Loss Patient
Alan J. Bauman, Catherine Davies, and Richard J. Miron
6 / Use of Platelet-Rich Fibrin in Facial Esthetics
Richard J. Miron, Yufeng Zhang, Ana Paz, Masako Fujioka-Kobayashi, and Catherine Davies
7 / Biology of Microneedling
Erin Anderson, Nichole Kramer, Richard J. Miron, Ana Paz, and Catherine Davies
8 / Injection Techniques with Platelet-Rich Fibrin
Catherine Davies, Ana Paz, Alireza Panahpour, Ana Cristina, and Richard J. Miron
9 / Hair Regeneration with Platelet-Rich Fibrin
Catherine Davies and Richard J. Miron
10 / Lasers in Facial Esthetics
Ana Paz, Harvey Shiffman, Miguel Stanley, Catherine Davies, and Richard J. Miron
11 / Skin Care Products and Their Effect on Aging Skin
Geir Håvard Kvalheim, Catherine Davies, and Richard J. Miron
12 / Future Trends in Esthetic Medicine
Carlos Fernando de Almeida Barros Mourão, Delia Tuttle, Ruth Delli Carpini, Scott Delboccio, Richard J. Miron, and Catherine Davies
Index
Facial esthetics has become one of the fastest-growing 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, evidence-based 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.
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.
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.
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.
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!
Erin Anderson
Master Aesthetician
AO Surgical Arts
Salt Lake City, Utah
Director of Education
Dermapen
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
Ruth Delli Carpini, DMD
Private Practice Specializing in Cosmetic Dentistry and Facial Esthetics
Milan, Italy
Masako Fujioka-Kobayashi, DDS, PhD
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, Dr med dent
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
Walter Rozen
Professional Photographer
Venice, Florida
Harvey Shiffman, DDS
Private Practice Specializing in Laser Therapy
Boynton Beach, Florida
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
Richard J. Miron
Catherine Davies
Facial esthetics has become one of the fastest-growing industries in the world. While originally a number of minimally invasive procedures were utilized effectively in facial esthetics (including Botox [Allergan], hyaluronic acids, and polydioxanone [PDO] threads), more recently platelet concentrates have gained momentum because of their more natural regenerative approach. The main advantage of platelet concentrates is that they offer a safe, easy-to-obtain, and completely immune-biocompatible method for the healing or regeneration of aging skin. This differs significantly from previous modalities that aim to act as fillers or paralyzers, which initiate a foreign body reaction once placed within living tissue. As the population continues to age and becomes more concerned with their esthetic appearances, more and more clinicians and practitioners wish to offer patients a natural approach with platelet concentrates and more specifically platelet-rich fibrin (PRF). As trends continue to support minimally invasive esthetic procedures, it is clear that both beginner as well as advanced practitioners seek convenient, safe, and effective therapies. Platelet-rich plasma (PRP) was the first platelet concentrate utilized in facial esthetics because of its supraphysiologic accumulation of platelets and their respective growth factors, known stimulators of tissue regeneration. However, one of its main limitations is its incorporation of anticoagulants, known inhibitors of wound healing. Today, with advancements in centrifugation protocols and centrifugation tube characteristics, it has become possible to utilize a liquid injectable PRF without incorporation of anticoagulants. This formulation has been studied and utilized extensively in various fields of medicine and has become increasingly popular in facial esthetics. This textbook provides a first-of-its-kind introduction to the use of PRF in facial esthetics.
Aging of the skin is an inevitable process that gradually occurs as we get older1,2 (Fig 1-1). Several factors have been associated with this process, including both genetic and environmental factors.3 Exposure to sun, pollution, and various chemicals have been known to cause skin and/or DNA damage, speeding the aging process.3 A number of changes to the skin may occur as a result, including skin atrophy, telangiectasia, fine and deep wrinkles, yellowing (solar elastosis), and dyspigmentation.3 Furthermore, poor diet, lack of exercise, caffeine intake, smoking, and drug use are additional factors known to speed the aging process.4
FIG 1-1
The process of skin aging. With age, facial features tend to sag, with a volume shift downward of facial tissues.
One key element certainly important for overall health and particularly skin attractiveness is hydration. Dehydration of the skin may lead to epithelial cell apoptosis and flaky skin complexion. From this standpoint, skin dehydration is a major risk factor for skin aging, and many topical applications, including hyaluronic acid creams, are geared toward water retention as a modality to prevent dryness of the skin. Aging skin is also related to a number of obvious demarcations of the face (see chapter 2). Depressions in the corners of the mouth, cheeks, forehead, eyebrows, eyelids, and nose are all associated with aging5 (Box 1-1; see Fig 1-1). Based on visible differences that occur with aging, a variety of treatment options have been proposed to favor a more youthful appearance, but hydration is a key feature.
As the body ages, it undergoes many changes that directly impact the physiology of human tissues, resulting in lower cellular activity.6 These changes include a loss in density, increases in fat storage, and lower production of collagen. A reduction in collagen synthesis as well as its associated increase in collagen degradation both have apparent disadvantages leading to a net loss of facial volume, resulting in skin folds and wrinkles7 (see chapter 2). Based on these changes associated with aging, several years ago it was proposed that platelet concentrates could be utilized in facial esthetics to improve collagen synthesis and restore facial volume.8–10 The main function of platelet concentrates is to increase recruitment and proliferation of cells and to further speed revascularization/blood flow toward defective areas. Many advancements have been made since the first-generation platelet concentrate—platelet-rich plasma (PRP). Several devices and isolation kits have since been fabricated based on the concept of isolating platelets for regenerative purposes, eliminating the inclusion of anticoagulants and speeding the preparation protocols. This second-generation platelet formulation, termed platelet-rich fibrin (PRF), has formed the basis for more than 600 scientific publications on the topic and has now extended into the field of facial esthetics. This textbook addresses this topic in detail and introduces the concept of PRF as a safer, more effective regenerative platelet concentrate that is 100% natural and thereby prevents a foreign body response.
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.
While various protocols and injectable materials have been proposed in facial esthetics, patients generally seek more natural regenerative approaches with the shortest possible downtime. In addition, medicine has gradually and naturally progressed toward more minimally invasive procedures. Today, many different agents and biomaterials can be utilized to accomplish this task, including Botox, fillers (eg, silicone, calcium hydroxyapatite, polymethyl methacrylate, hyaluronic acid products, hyaluronic acid + calcium hydroxyapatite, polylactic acid), various laser therapies at different wavelengths/intensities, and polydioxanone (PDO) threads.15–21 These products and modalities have been made popular by extensive marketing and celebrity endorsements and have been demonstrated to be successful in various esthetic procedures to improve cosmetic appearance (Box 1-2).
Importantly, however, these techniques heavily rely on normal protective mechanisms of the epidermis, which can be altered or disrupted following their use. The use of Botox, for example, has shown secondary effects that may cause a cascade of reactions with potential consequences.22 Botox causes temporary denervation and relaxation of muscles by preventing the release of the neurotransmitter acetylcholine at the peripheral nerve endings.23 Clinicians generally recommend repeated injections every 6 months or so to maintain the facial appearance, but these injections may lead to secondary effects associated with an increased granular layer or thinning of the epidermis as a result of a foreign body reaction to this material.24,25 Other reported secondary effects include cases of muscle paresis including muscle weakness, brow ptosis, upper and/or lower eyelid ptosis, lateral arching of the eyebrow, double or blurred vision, loss or difficulty in 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.
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 natural- looking 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.
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. 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.
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)
Therefore, the ability to offer a more natural, autologous concentrate of growth factors derived from 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.
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