Study of the effect of platelet rich plasma (PRP) on structural fat grafting for breast augmentation

Study of the effect of platelet rich plasma (PRP) on structural fat grafting for breast augmentation

Asser A El-Hilaly, MD; Sameh  M El-Taher, MD; Ahmed F El-Sherif, MD;

Mohamed H Zedan, MSc

Departmant of Plastic Surgery, Ain-Shams University, Cairo, Egypt.

Abstract

Introduction: Lipoinjection can be used to give extra-volume during breast enhancement

surgeries and to co"ect various types of depressed deformities of the breast, but certain problems remain as unpredictability and low graft survival which are a major concern in plastic surgery. Different trials and techniques were done for enhancement of the take and vascularity of the fat grafting. Platelet Rich plasma plays an important role in the process of vascularization of the  grafted  fat  due  to  its  high  content  of  Platelet Derived  Growth  Factor(PDGF).

Methods: 20 patients who were candidates for breast augmentation were included in the study and were divided into two groups; one had fat injection with PRP in the breast and the other had breast lipoinjection with Colemantechnique. A questionnaire follow up was designed on Likert scale on grades 0-4 evaluating the volume and fat survival with statistical analysis.

Results: Group B (with PRP) showed overall better results. All patients with PRP showed moderate to good projection post-operatively. 50% of Group B showed no further requirement of secondary procedure. Whereas group A showed moderate to large requirement for secondary augmentation.

Conclusion: The increase in the level of PRP and in turn PDGF during the first days after lipoinjection will enhance the graft vascularity and overall survival, thus there is a need to further studies for standardizing the level of PDGF needed to have better take & results with lipoinjection.

Introduction:

The  transfer  of autologous fat as whole grafts has been performed since 1890s and as injectable grafts since 1920s. However, it is only within the past 20 years that the popularity of autologous fat transfer grafting has gained popularity in the  field of soft tissue augmentation.l

Lipoinjection can be used  to give  extra volume during breast augmentation surgeries and also to correct various types of depressed deformities of the breast, but certain problems still remain, such unpredictability and low rate of graft survival due to partial necrosis of the transferred fat cells.2

Platelet  derived  growth  factors  acts as a very potent mitogen  for mesenchymal cells which include fibroblasts and smooth muscle cells. It also  acts as a chemo-attractant for

neutrophils and   it stimulates collagen and matrix formation.3

It was proved that PDGF signalling plays an important role  in vascular mutation, maturation and remodelling.It has been also shown that expression of PDGF can increase pericyte density in a study done by Gehmert et  al, 2011.4  He proved that  the  capillary network formation  expressed by the adipose progenitor cells  is dependent on PDGF signalling pathway.

The main activating factor found in Plasma rich Plasma(PRP) is PDGF. Gehmert et al has proved that PDGF constitutes the main growth factors  present  in PRP's.4 Previous studies showed that  there  is an increase in the percentage of fat  graft survival and improvement  of the skin quality after the use ofPDGF during soft tissue fat grafting.Breast

enhancement and augmentation occurred with a minimal loss of injectable  fat amount or volume ofbreast.S

The purpose of this study is to report our early experience with breast fat grafts enriched with platelet-rich plasma.

Material and methods:

20 patients underwent lipofilling either with or without PRP (Platelet Rich Plasma) Factor. The study was performed in Ain Shams University Hospitals, from the period of April

2009 to April2011. The patients were divided

into 2 groups:

- Group A: Patients underwent  Lipofilling without PRP.

- Group B:Patients underwent Lipofilling with

PRP.

All patients  passed  our inclusion  criteria:

- Patient that had no aesthetic procedure to the breast ever, with an age ranging from 20 to 50 years old.

- Patient with chronic  illness like DM, malignancies, and systemic immune diseases were in this study, also patients aiming to have huge or bigger  sizes of breast were not included.

- Major asymmetry in breasts and patients with

breast  ptosis  grade  3 where excluded.

Technique:

All patients underwent the procedure under general anathesia.Harvesting of fat from patient is the first step of the procedure after injection of tumescent fluid (1ml adrenaline+500cc ringer solution+lOcc xylocaine 2%). The fluid injected to  fat  aspirated ratio  was  1:1.

The harvesting procedure will be performed by the traditional methods of liposuction using Mercedes cannula of 3mm and 4mm diameter with suction pressure of 200-700mmHg that

can  be  achieved with  syringe system.6

The liposuction areas will be determined according to patient's excess fat and needs. Preparation of fat that will be injected into the breast was done according to Collman's technique6 of fat injection.

Based on Kakudo's7 technique;

-The preparationofPRP of30cc whole blood of patient will be introduced to a centrifuge device (after using of 3cc citrate to prevent

clotting).

- 15 minutes of centrifugation at 3000rpm for

gravitational  separation of whole blood into three fractions: erythrocytes, platelets poor plasma & platelet rich plasma (PRP).

- A total of 3-5cc of PRP will be activated by adding calcium chloride then injected to breast after fat injection through multiple puncture with a syringe 3mm diameter in fashion of 4-5 punctures to each quadrant after dividing  breast  into  4 quadrants. Follow up documentation will be complete with  pre  and post-operative  photographs standardized and taken in three views antero­ posterior, lateral, and oblique with follow up of at least 6 months. All photographs were analysed and placed on a uniform coloured

background.

A questionnaire was developed to evaluate the aesthetic outcome in all patients with their two groups, each page of questionnaire contained pre and postoperative photographs of one patient with the three views mentioned. Each page contained several questions to evaluate the aesthetic outcome and to determine the impression of the viewer and their opinion about the volume of breast, projection and requirement for further augmentation. The answers numerically marked based on 4 points likart  scale  [0 "worst"  & 4 "best"].  This objective /subjective method of analysis was popularised by Moolenburg.8 Page order was randomized, mixing the pre and post-operative pages throughout the survey and completion of the questionnaire was without time limit.

Data management and analysis:

The collected data was revised, coded, tabulated and introduced to a PC using Statistical package for Social Science (SPSS

15.0.1 for windows; SPSS Inc, Chicago, IL,

2001). Data was presented and suitable analysis was done according to the type of data obtained for each parameter.

I.Descriptive statistics:

l.Mean, standard deviation(± SD) and range for parametric numerical data, while median for  non  parametric numerical data.

2.Frequency and percentage of non-numerical data.

ll.Analytital statisth s:

1.Fisher•s exact test: was used to examine the

relationship between two  qualitative

variables when the expected count is less than   S  in  more  than  20%  of  cells.

2. Mann Whitney Test (U test}was used to

assess the statistical  significance of the difference of a non parametric variable between two study groups.

3.Wilcoxon signed rank test was used to assess the statistical significance of the diffmmce of an ordinal variable (score} measured twice  for   the   same study group.

P- value: level of significance

-P>O.OS:Non significant (NS).

-P< 0.05:Significant (S).

-P<O.Ol:Highly significant (HS).

Before(without PRP)

Before(with PRP)

Results:

Personal patient satisfaction was omitted from this study as a form of efficacy analysis. Our analysis relied totally on the statistical

analysis of the  questionnaire. Follow  up Photographs where performed at 6 months post-operatively.

One patient showed signs of minor infection

at the injection  site. He was prescribed  an

antibiotic from  the  quillon group  which resolved the infection withinS days.Six of our patients  showed  signs of ecchymosis post operatively all of which resolved within 10 days without leaving any skin pigmentation

.follow up of the patients was performed for an average of 6 months  and proved to be

uneventful inall cases.

After(without PRP)

After(with PRP)

Bifore

Before (with PRP)

After (with PRP)

After (with PRP)

As for statistical analysis of the questionnaire, the results were all in favour of the patients that were injected with PRP enhanced fat.

Table(1):Descriptionof complll'ison between post-opel'tlliYe cues among the two studygroups

tiS reglll'd expert opinion.

.

There was a statistically significant difference between both groups as regards tbe need for further augmentation. The group with PRPs results showed that 60% (p value 0.015) did not require further intervention while 40

%  (p   value   0.015)  required  further augmentation in the group with fat injection

only.

When comparing breast symmetry. both groups showed similar results. Group A (without PRP)had a SO%moderate asymmetry while Group B (with PRP) bad 40% moderate asymmetry.These values were not considered statistically  significant  difference.

Table (Z):Description of co1llpf.lf'istm between post-opertlllve cases tm ong the two study

groups t11 ngtud expert opinion (SCORES).

*Mann Whitney tut

...

c:

4

3.6

32

28

2.4

2

1.6

:E

1 .2

0.8

04

0

Post Require augmentation

Post Symmetry    Post Require further

augmentation

Ia without PRPs •With PRPs I

Post Breast projection

Graph (1): Comparison between both groups as regards post-operative results.

As for the projection of the breast; Group

B (with PRP's}showed better projection results

{3.20±.63 SDp value 0.021) which also proved

to be statistically significant when compared

with group A (without PRP's) which showed a mean of2.50±053 SD.

'.

When comparing each group separately Group A showed no significant difference in all questions between preoperative and post­ operative values.This would translate into no or minimal improvement clinically at 6 months post-operative.

*Wilcoxon signed rank test

3

.,

Q..,

2..5

2

Ill  1.5

l.,i

::E    1

0. 5

0

Require augmentation

Symmetry       Require further     Breast projection augmentation

Group 1(without  PRPs)

Io Pre •Post I

Graph (2):Comparlson between pre and post-operative C4Ses among study group A as regard

expert opinion.

In the other group all scores showed a significant improvement in the post-operative values. Improvement was noted inprojection,

symmetry   and  the  need   for   further augmentation.

Tllble (4): Comptll'ison between Pre tmd post-opet'tllheCMes among stlUiy group Bas regard

expert opinion(SCORES).

*Wilcoxon signed rank test

3.5

3

Q..j.

0

'I"l'l

2.5

2

1i  1 5

::E

1

0.5

0

Require augmentation

Symmetry           Require further      Breast projection augmentation

Group 2(with PRPs)

IaPre •Post I

Graph (3):Comparison between pre and post-operative cases anwng study group Bas regard

expert opinion(SCORES).

Discussion:

PRPs are supposedto favour graft viability

both by promoting cell proliferation and favouring new angiogenesis of the ttansphmted fat in the recipient site.This is mainly due to the high content ofPDGFs.

In our hands we experienced a minor improvement in the group using fat enriched PRP at 100/oratio(PRP:Fat 1:9) when c.ompared to graftingalone.Lipoitgectionwith PRPresults showed that90% of the casesshowed moderate to good postoperative projection 6 months post-operative.50 % of cases required minor augmentation while 50% proved to be good enough with the observers.

All results of the cues uti1izing fat alone

showed declined results when compared with the group with PRP. Not only that, but the questionnaire also showed only minor improvement between thepre and postope.rative results in all cases when analysing observer results. Moreover, platelet rich plasma administration led to reduction of the need for secondary grafting.

Salgerllo et al, 20115 investigated the rate of fat necrosis using postoperative breast ultrasound, he concluded that unfortunately a higher rate of liponecrosis was observed in patients treated with PRP enhanced fat, this finding contradicts our results which are in

correspondence with Nakamura et al, 201010 results, they found1hat PRP to fat ratio of 1:4 supports the fat grafting volume and viability by promoting capillary formation in the graft for at least 120 days when compared with fat grafting alone inrats.

Curvally et al, 200911 presented two series of patients treated for facial soft tissue defects using PRP to fat ratio1:2, they concluded that this technique improves adipose tissue maintenance and survival, when compared with fat grafting alone.

The unperidectibilty of fat graft survival has let surgeons worldwide to investigate an alternative technique in fat grafting in order to improve its take. Many approaches have

been proposed in recent years, Coleman's techniques6 remaining the most reliable.

In a study done by Michalevicz et a1,12 it

was noted1hat vascular smooth musclesrequire mitogens such as PDGF inorder to proliferate, not only that they proved that PDGF is one of the most potent mitogenic factors present in blood serum. PDGF activates fibroblasts and neutrophils, these functions are essential for the processes of inflammation and healing. In relation to self-proliferation, Kakudo et al,

200813 showed that activated PRP contains large amounts of PDGF-f' and Transforming Growth Factor (TGF), and they promoted the

proliferation of human adipose derived stem cells and human dennal fibroblast in vitro. We believe that PDGF-a,p are the most essential growth factors present in PRP.

Adipose tissue angiogenesis  is a complex process that  involves many  steps  such  as basement membrane breakdown, angiogenic remodelling, and vessel stability. Giusti et al,

200914 concluded that PDGF plays an integral

role  for  promoting angiogenesis in human endothelial cells.

Hu et al15 showed a negative effect on the

proliferation of oral cells when  using  high concentrations ofPRP, however Patiel et al16 contradicted Hu's study and documented that collagen synthesis improvement was  dose dependent. Thus in short saying a higher PRP to fat ratio would prove a better overall result.

We  believe that  a ratio 1:9 in fat injection with  PRP would prove to sufficient in improving fat survival, not only sufficient, but also feasible to achieve in order to reach a ratio1:2, we would require a minimal of200cc of blood per breast. In our study we required an average of 225cc of fat per breast in order to reach a sufficient volume. Our requirements ofPRP utilizing 1:9 ratio was 25cc ofPRP per breast.

Our  questionnaire was  performed at  6 months postoperative interval, it showed that the group utilizing PRPs had better projection and overall result. This indicates that PRP's or its  active ingredient PDGF  improves fat survival and overall result.   Salgarello  et al,

20115 in a similar study showed no difference

between two groups of fat transfer one of which utilizing PRP 10%.

We believe that primary take of fat results in increasing the longevity & results, therefore, in increasing factors aiding in neovascularization but should be administrated within the first week of the graft.

There are other factors that should be studied

in order to reach a standardized  protocol for fat injection in the breast  in order  to reach reliable outcome & results.

Conclusion:

In conclusion we believe that the increase of PDGF levels during the flrst 10 days of adipose tissue transfer enhances both take &

fat survival. Also PDGF levels stabilization to a standard  value  should  be studied  further.

All clinical trials concerning adipose tissue transfer in order  to correct  human  volume deficiencies aim to improvement of fat survival

& standardization to reach reliable outcomes.

References:

1- Peer LA: The neglected "free fat graft": Its behaviour and clinical use. AmJ Surg1956;

92: (40).

2- Billings Jr E, May Jr Jw:Histological review and  present status of free  fat  graft autotransplantation in plastic and reconstructive surgery. Plast Recost Surg

1989; 88 (22): 368-381.

3- Rudkin,  Geoge  H, Timothy A: Growth factors in surgery.Plast Reconst Surg 1996;

97 (2): 469-476.

4- Geghmert S: Angiogenesis: The  role of PDGF on adipose tissue derived stem cells. Clinical                        Hemorheology    and Microcirculation  2 011;  48:    5-13.

5- Salganello M, Visconti G, Rusciani A:

Breast fat grafting with platelet rich plasma: A comparative  clinical study and current state of art. Plast Reconst Surg 2011; 127 (6): 2176-2185.

6- Coleman  RS: Facial  augmentation with structural fat grafting.  Clin Plastic Surg

2006; (33): 567-577.

7-  Kakudo: Platelet rich plasma: The importance of separation and concentration. Plast Reconst Surg 2009; 123 (3): 1135-

1136.

8- Moolenburg SE, Mureau MA, Hofer SO: Validation of a questionnaire assessing patient's aesthetic and functional outcome after  nasal  reconstruction: The  patient NAFEQ-score. PlastReconst Aesthet Surg

2009; 62 (5): 656-662.

9- Likert R:A technique for the measurement of attitudes. Archives of pschycology 1932;

140: 1-55.

10-Nakamura S, Ishihara M, Takikawa M, et al: Platelet-rich plasma  (PRP) promotes survival of fat-grafts in rats. Ann Plast Surg

2010; 65: 101-106.

11-Cervelli V, Gentile  P, Scioli  MG, et al: Application of platelet rich plasma in plastic surgery: Clinical  and in vitro evaluation.