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J Oral Maxillofac Surg71:610-621, 2013

Use of Platelet-Rich Fibrin and Platelet-Rich Plasma in Combination With FatGraft: Which Is More Effective During

Facial Lipostructure?Seied Omid Keyhan, DDS,* Seifollah Hemmat, DDS,†

Amir Ali Badri, DDS, PhD,‡ Arshad Abdeshahzadeh, DDS,§ and

Kazem Khiabani, DDS, PhD�

Purpose: Fat grafts have always represented a challenge in inducing the necessary neoangiogenesis,which results in significant resorption. This study was designed to compare the efficiency of first- andsecond-generation platelet-rich plasmas (PRPs) combined with a fat graft during facial lipostructuresurgery.

Methods and Materials: To address the research purpose, the investigators designed and imple-mented a double-blinded prospective clinical trial. The patients underwent bilateral facial lipostructure,a natural long-lasting method of filling and supporting the face using intricate layers of infiltratedautologous fat. The method involved the use of PRP on 1 side and platelet-rich fibrin (PRF) on the otherside. The study population was composed of all patients presenting to the authors’ department for theevaluation and management of facial contouring in the cheek and cheekbone areas from June 2008through December 2010. The primary predictor variable was the type of combination (PRP/fat orPRF/fat). The outcome variables were the amount of resorption, which was estimated by comparing pre-and postsurgical photographic views, pain, edema, and bruising. The statistical evaluation of the findingswas performed using SPSS software. Parametric tests (t test and Levene test) were used to compare thetreatment efficacy and complications between the groups.

Results: Twenty-five patients (8 men and 17 women) underwent bilateral facial lipostructure surgeryin the cheek and cheekbone areas using PRP and PRF. One year after the operation, a slight estheticasymmetry was noticeable, with greater average resorption on the PRP/fat side.

Conclusions: This first comparative clinical study highlights the value of using concentrated plateletsfor adipocyte grafts. The results suggest that the combination of fat and PRF is more effective than thecombination of fat and PRP in the context of facial lipostructure surgery.© 2013 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 71:610-621, 2013

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at grafts have always represented a challenge innducing the necessary neoangiogenesis, which canesult in significant resorption. The use of a nonreab-orbable, exogenic material such as silicone was in-roduced as early as the 1950s, but was suspendedears later because of harmful effects (migration,ranulomas). Hyaluronic acid fillers and other formu-

Received from the Department of Oral and Maxillofacial Surgery,

Joundishapoor University of Medical Science, Ahvaz, Iran.

*Resident.

†Resident.

‡Assistant Professor.

§General Practitioner, Azad University of Medical Science,

Khorasgan, Esfahan, Iran.

�Assistant Professor.

610

ations are popular, but absorb quickly, and the use ofarge volumes presents cost issues. Facial lipostruc-ure surgery is a natural, long-lasting method of fillingnd supporting the face by using intricate layers ofnfiltrated autologous tissue. This method allows theissues to be sculpted for the 3-dimensional augmen-ation of facial elements, as described by the Ameri-

Address reprint requests and correspondence to Dr Keyhan:

Department of Oral and Maxillofacial Surgery, Joundishapoor Uni-

versity of Medical Science, Emam Khomeini Hospital, Ahvaz, Iran;

e-mail: keyhanomid@ymail.com

© 2013 American Association of Oral and Maxillofacial Surgeons

278-2391/13/7103-0$36.00/0

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KEYHAN ET AL 611

can plastic surgeon Dr Sydney Coleman to address theissue of resorption.

The fat tissue is centrifuged before reinjection,which means it can be sufficiently broken apart with-out damaging the adipocytes to stimulate the newsynthesis of an extracellular matrix and to facilitatecolonization of the graft by endothelial cells. Thiscentrifugation stimulates the preadipocyte cells,which allows for the reconstruction of the graftedtissue. Similar to the Latin expression, destruam etaedificabo—“I destroy and I build up”—Coleman’stechnique requires the decomposition of pre-existenttissue to allow for in situ reconstruction.1-3 Growth-nducing agents to improve the sustainability of adi-ocyte grafts have never really been developed. Therafted adipocytes, being highly differentiated, areot sensitive to the triggers of proliferation likely toe induced by these molecules. The main clinicalrotocols, which allow the use of autogenouslyrowth-inducing agents, generally involve the use of alatelet concentrate.The platelets used in oral, maxillofacial, and plastic

urgery are generally grouped as concentrated plate-et-rich plasma (PRP). According to the literature,

any protocols exist, but all are supported by specificethods originating from fibrin glues, which are not

ncommon in oral and maxillofacial surgery. The clin-cal effects of PRP are not that different from thosesually produced by fibrin adhesives, which suggestshat perhaps a fibrin matrix is more effective thanlatelet cytokines, which are widely distributed inhis biological adhesive. The fibrin matrix has a pro-cient homeostatic effect on any diffuse bleeding ofhe parenchyma and decreases the degree of pain andostoperative edema, which results in improved an-iogenesis.1,4,5

For medicolegal reasons related to blood handling,PRP protocols have not been developed in France.The platelet-rich fibrin (PRF) technique was devel-oped by Choukroun in 2001.6-8 The PRF technique isimple: blood is taken without an anticoagulant from10-mL tube and then centrifuged directly using mod-rate forces (400g). In the center of the tube, a fibrinRF clot is formed; this clot contains most plateletsnd leukocytes in the tube. The clot can be used aslling material; it can be cut into small pieces andixed with a graft (usually with osseous grafts), or it

an be pressed between 2 swabs after removing theerum to preserve the membranes (used in oral sur-ery and tympanoplasties). When mixed with an os-eous graft, the PRF is used to biologically bond therafted particles, and the fibrin matrix leads to vascu-arization of the graft. The mature adipocytes are nothat sensitive to the platelet cytokines, but the incor-oration of fibrin clots to the fat mass allows for

mproved graft vascularization.1,6-8

The purpose of this study was to evaluate first- andsecond-generation PRPs combined with a fat graftduring facial lipostructure surgery The investigatorshypothesized that PRF would be more effective be-cause of its biochemical structure. The specific aim ofthe study was to compare fat resorption between thegroups.

Methods and Materials

To address the research purpose, the investigatorsdesigned and implemented a double-blinded prospec-tive clinical trial. Patients underwent facial lipostruc-ture surgery with the use of PRP on 1 side of the faceand PRF on the other side of the face in combinationwith a fat graft. The treatment side was chosen ran-domly. The study population was composed entirelyof patients who presented voluntarily to the authors’department for the evaluation and management offacial contouring from June 2008 through December2010. To be included in the study sample, patientshad to undergo isolated facial lipostructure surgery inthe cheek and/or cheek bone (malar) areas.

The following patients were excluded as study sub-jects: those who were unwilling to accept risks; thosein whom additional procedures such as a cervicofacialfacelift or blepharoplasty would be necessary; thosein whom similar procedures had been performed pre-viously; those with compromising systemic condi-tions (eg, platelet dysfunction syndrome, criticalthrombocytopenia, hemodynamic instability, septice-mia, a history of local or systemic corticosteroid con-sumption, platelet count �105/IU, hemoglobin level�10 g/dL, and active symptoms of local infection atthe site of the procedure); and those with a history ofaddiction or dramatic weight loss or gain during theprevious month.

The primary predictor variable was the type ofcombination (PRP/fat or PRF/fat). The primary out-come variables were the amount of resorption (whichwas estimated by comparing pre- and postsurgical [1mo and 1 yr later] photographic views), pain,edema, and bruising. Variables such as gender andage had no significant impact on this research be-cause the procedure was performed as part of across-sectional study, and the comparison betweenthe 2 groups was performed under similar condi-tions as in 1 patient.

All the steps of fat harvesting (site and technique),fat preparation, and fat injection techniques werecarried out in all patients by a single clinician accord-ing to the protocols described by Coleman.2,3 Thevolumes of the injected mixtures (PRP/fat and PRF/fat) were equal: 8 mL per cheekbone and 7 mL per

cheek, on average.

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KEYHAN ET AL 613

The types of preparation kits and centrifuges usedfor the PRP and PRF were similar in all patients. Forbetter time management and to ensure the scientificvalidity of the measurements, a single clinician wasresponsible for the preparation of the PRP and PRFand the combination of these platelet concentrates

FIGURE 1. (Cont’d) Schematic view of the photographic analysis.were used: the oral commissure to the lateral cantus; the ala to the trapoint. The first 3 lines determined the ideal location for the malarprocedure and aid the evaluations after surgery. Then, the most pras a reference point, and a perpendicular line was drawn from thiright profile views of each patient. After malar augmentation, the leof the most projected point of the cheekbone area on the profile vieof these differences indicates the amount of augmentation and resouperimposed with the aid of tracing paper. The 5 reference pointshe most projected point of the chin, the radix, and the left and rightrea, the yellow area indicates the remaining fat 1 year after surg

operation. The total amount of augmentation was determined by cmonth after the operation (blue and yellow areas), and the amounviews (blue area). AL, ala; CH, most projected point of the chicommissure; OR, infraorbital rim; R, radix; RLC, right lateral cantu

Keyhan et al. PRF Versus PRP Plus Fat Graft. J Oral Maxillofac S

with harvested fat. For the evaluation of photographic

views with minimal errors, all photographs weretaken in a similar fashion by 1 photographer and atthe same photographic center to identify changesin the cheek and cheekbone areas (Fig 1). To decreasethe effect of postoperative edema during the facialanalysis (Fig 1), the first photographic views were

cheekbone area evaluations in the profile views, 4 reference linese line tangent to the infraorbital rim; and the nasion to the subnasalntation and were used before the injection to mark the site of thepoint of the cheekbone area was determined on the profile viewsto the line connecting the nasion to subnasal point on the left andthe perpendicular line shortened because of anterior displacementis line lengthened incrementally after resorption. The measurement. B, For the cheek area, pre- and postoperative frontal views werer this comparison were the most projected point of the face (nose),

cantus. The red line indicates the preoperative position of the cheekd the blue area indicates the amount of resorption 1 year after theng the preoperative and postoperative views, which were taken 1orption was determined by the correlation of the 2 postoperativeleft lateral cantus; MP, malar projection; N, nasion; OC, oralsubnasal; T, most projected point of the tip (nose); TR, tragus.

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photographic views were obtained 1 year after theoperation. The percentage of resorption was esti-mated by comparing the preoperative and postoper-ative photographic views (Fig 1). The amount of aug-mentation was determined by comparing thepreoperative and postoperative views, which weretaken 1 month after the operation (Fig 1). The amountof resorption was determined by comparing the 2postoperative views (Fig 2, 3).

DATA COLLECTION AND ANALYSIS

The results of procedures such as facial lipostruc-ture surgery are difficult to evaluate completely andobjectively. It is also difficult to evaluate the amountof fat resorption without performing pre- and postop-erative magnetic resonance imaging. Therefore, theauthors designed a 2-dimensional facial analysis basedon the profile and frontal photographic views (Fig 1).tatistical evaluation of the findings was performedsing SPSS 16.0 (SPSS, Inc, Chicago, IL). Parametricests (t test and Levene test) were used to comparereatment efficacy and complications between theroups. The significance level of statistical hypothesesas set at .05 (statistically significant).

FAT PREPARATION

The lipostructure surgery was carried out accord-ing to the protocols described by Coleman.1-3 Fatissue was extracted from the inner side of the kneesnd was supplemented with a paraumbilical extrac-ion if necessary (Fig 2). The extraction was per-ormed using a specific aspiration nozzle with a diam-ter of 3 mm and length of 15 cm, with the foam endsnd openings at the 2 sides. A 10-mL syringe wascrewed onto the nozzle. A vacuum was created inhe syringe manually and gradually to avoid theuildup of pressure that could harm the adipocytes.here were multiple drainage tubes to decrease

rauma and bleeding. On average, 60 mL of fat wasxtracted: there were variations among patients basedn the indication and quantity needed for the reinjec-ion. The next step of the purification process in-olved the centrifugation of extracted tissue. The0-mL syringes were sealed using stoppers and placed

n the centrifuge. Centrifugation was carried out for 3inutes at a speed of 3,000 rpm. After centrifugation,

he contents of the syringe were divided into 3 layers.

1. The upper oily sample of adipocytes consistedof triglycerides from the damaged adipocytesand had the lowest density. This part, usuallyeliminated, was kept to humidify the mem-branes with the PRF.1

2. The bottom sample contained primarily blooddebris, which was eliminated when the syringe

was withdrawn. a

3. The middle sample contained the adipocytes,which were grafted.

On average, the graft occupied a volume of 6 mL inthe syringe. After purifying the fat, it was transferredto 1-mL syringes without coming into contact withair.

COMBINATION OF PRP AND FAT

After fat harvesting and processing, the PRP wasprepared with a small volume of blood that had beentaken from a peripheral vein and then centrifuged.Because the secretion of the growth factor beginswith platelet activation, protocols usually use Ca2� toinduce platelet activation and exocytosis of �-gran-

les. Calcium also acts as an essential cofactor forlatelet aggregation.4,5 After activation with CaCl, the

platelet gel was added to the fat tissue within 4 to 5minutes while it remained in the liquid form at a ratioof 1:9 or 1:10. When the PRP is in liquid form, it canbe added easily to the adipose tissue. This approach isrecommended because of the risk of spills when us-ing a 10-mL Luer-Lock syringe (Ahvaz, Khouzestan,Iran) that contains centrifuged fat tissue. Conversely,when the PRP is in solid form, spilling it into a syringecontaining centrifuged fat is difficult because theplunger of the syringe containing the PRP is ham-pered by the strong consistency of the PRP, whichprevents leakage through the needle.4,5

COMBINATION OF PRF AND FAT

To obtain the PRF, 40 to 60 mL of venous bloodwas taken in 4 to 6 tubes without an anticoagulant(10 mL; Vacationer, Becton Dickinson, Texarkana,Texas). These were immediately centrifuged for 10minutes at 3,000 rpm according to the protocoldescribed by Choukroun et al.6-8

The activation of coagulation and centrifugalforces creates 3 layers in the tube: a red bloodcorpuscle base at the bottom, acellular plasma atthe surface, and a clot of fibrin PRF containingmany platelets in the middle. The PRF clots werecollected using forceps. These were separated fromthe red blood corpuscle base and placed into a cup.The fibrin PRF clot was cut in fragments of 1 to 2mm, which were mixed with the oil sample pro-duced by the fat centrifugation. This mixture wasput into a 1-mL syringe and injected using a nozzle(in line with the tunnelization method of Cole-man2,3) at the principal sites to be grafted beforehe instillation of the purified fat. Once cut andixed, each clot represented an injected volume of

pproximately 1 mL, comprising equal parts fibrinRF matrix and liquid (plasmatic serum and purifieddipocyte sample).1 On average, 4 to 6 clots of PRF

re sufficient to treat a complete face: 6 clots for

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KEYHAN ET AL 615

completing the lipostructure surgery and 4 clots forlipostructure surgery in combination with a cervi-cofacial facelift. A deposition of the PRF before theinjection of the fat grafts was used for preparingand activating the graft site. Based on the tech-niques of Coleman,2,3 the grafted tissue was addedgradually in small amounts with each passage of thenozzle. Cannulas of various forms and lengths were

FIGURE 2. Fat graft, platelet-rich plasma, and platelet-rich fibrin prelatelet-rich fibrin; and D, prepared platelet-rich plasma.

eyhan et al. PRF Versus PRP Plus Fat Graft. J Oral Maxillofac S

used—all with a smooth stump to decrease the risk

of hematoma and with lateral injecting apertures toavoid an intravascular injection. It is important toperform extensive tunneling; all layers were graftedand started at the deepest point, and the incisionswere closed using 6-0 nylon sutures. Pretreatmentof the graft site with the PRF was performed uni-laterally.

On the other side, the PRP/fat was used for the

on procedures: A, Fat harvesting; B, fat centrifugation; C, prepared

13.

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facial lipostructure surgery. There were 2 main sites

616 PRF VERSUS PRP PLUS FAT GRAFT

of injection: the cheekbones and the cheeks. Eachzone received, on average, 8 mL per cheekbone and 7mL per cheek. The postoperative evolution of thepatients was followed for 1 month and 1 year aftersurgery through clinical examination and photo-graphic analysis. This research was approved by thelocal institutional review board and was in compli-ance with the World Medical Association Declarationof Helsinki as it relates to medical research protocolsand ethics.

Results

From June 2008 through December 2010, 25

FIGURE 3. A 32-year-old man A, before and B, 1 year after malaraugmentation. The perpendicular line (white line) is longer beforethan after the malar augmentation (black line).

Keyhan et al. PRF Versus PRP Plus Fat Graft. J Oral MaxillofacSurg 2013.

patients (8 men and 17 women) underwent bilat-

eral facial lipostructure surgery (Coleman method)in the cheek and cheekbone areas using the PRFand/or PRP in combination with a fat graft. Thepatients’ ages ranged from 24 to 69 years (averageage, 45 years).

In this research, the use of PRF and PRP did notrequire retreatment because all but 1 patient wassatisfied with the results (Figs 4, 5). One month afterthe surgery, the average amount of augmentation was7.4 mm (5 to 9 mm) in the PRP/fat group and 7.48mm (5 to 9 mm) in the PRF/fat group (P � .05).

One year after the surgery, the average amount ofresorption was 1.376 mm (0.5 to 3 mm) in the PRP/fatgroup and 0.896 mm (0.5 to 1.5 mm) in the PRF/fatgroup (P � .05). The average percentage of resorp-tion was determined by dividing the average amountof resorption by the average amount of augmentation.This value was higher in the PRP/fat group (18% vs13%; P � .05; Table 1).

Augmentation was performed in the cheekbonearea in 13 patients (52%) and in the cheek area in 12patients (48%). Maximum resorption was observed inthe cheek area in the PRP/fat group (33%); the lowestamount of resorption (10%) was observed in thePRF/fat group. The average amount of resorption wasgreater in the cheekbone area (1.3 vs 0.95 mm;P � .05).

In this study, there was no case of a massive edema,prolonged bruising, or severe pain. Undercorrectionwas the most frequent complication. No significantdifference was observed for gender or age.

Discussion

The purpose of this study was to evaluate first- andsecond-generation PRPs combined with fat graftingduring facial lipostructure surgery. The investigatorshypothesized that the PRF would be more effectivebecause the PRF clot forms a strong fibrin matrix witha complex 3-dimensional architecture and, unlike thePRPs, the Choukroun PRF does not dissolve quicklyafter application. The specific aim of the study was tocompare fat resorption between these groups. Nota-bly, evaluating the 3-dimensional amount of fat re-sorption without performing pre- and postoperativemagnetic resonance imaging is difficult. According tothe present facial analysis (Figs 1, 2) and clinicalevaluation, the degree of resorption was insignificant;there was no massive resorption requiring a second-ary lipostructure, except in 1 case. In the patientswho were treated with the PRP/fat and PRF/fat tech-niques, a slight esthetic asymmetry was noticeable,with more resorption on the PRP/fat side. The aver-age amount of resorption was greater in the cheek-

bone area (range, 10% to 33%).

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KEYHAN ET AL 617

At the end of 4 weeks, a significant percentage(approximately 10%) of patients presented withedema and approximately 6% with bruising. In thepresent study, there was no case of massive edema,severe pain, or prolonged bruising. Indeed, the de-posit of a fibrin matrix in the grafted areas allows

FIGURE 4. A, A 26-year-old woman before isolated bilateral facplatelet-rich fibrin (right). B, One year postoperatively, the half trealatelet-rich plasma. L, left; R, right.

eyhan et al. PRF Versus PRP Plus Fat Graft. J Oral Maxillofac S

FIGURE 5. A, A 24-year-old woman before isolated bilateral faciaplatelet-rich plasma (right). B, One year after surgery.

Keyhan et al. PRF Versus PRP Plus Fat Graft. J Oral Maxillofac Surg 20

improved angiogenesis and thus superior vascular andlymphatic drainage; the risks of bruising and edema alsomay be decreased. Undercorrection was the most fre-quent complication, perhaps due to an underestimationon the part of the surgeon at the time of the interventionor an excess adipocyte-mediated resorption.

structure surgery (cheek area) with platelet-rich plasma (left) andh platelet-rich fibrin appears rounder than the side treated with the

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In transfusion medicine, platelet concentrates orig-inally were used for the treatment and prevention ofhemorrhage caused by severe thrombopenia, whichoften is caused by medullar aplasia, acute leukemia, orsignificant blood loss during long-lasting surgeries.The standard platelet concentrate for transfusion isdenoted as PRP. The use of blood-derived products toseal wounds and stimulate healing started with theuse of fibrin glues, which were first described 40years ago and are made of concentrated fibrinogen(polymerization induced by thrombin and calcium).9

Currently, fibrin glues prepared from human plasma,such as Tisseel (Baxter, Deerfield, IL), are usedwidely. Autologous fibrin glues are considered thebest choice to avoid the risk of contamination, buttheir use remains very limited because of the com-plexity and cost of the production protocols.10 Con-sequently, the use of concentrated platelets to im-prove healing and replace fibrin glues, as firstdescribed by Whitman et al,11 has been exploredonsiderably during the previous decade.11 Platelets

contain large quantities of key growth factors, such asplatelet-derived growth factor-AB, transforminggrowth factor-�1, and vascular endothelial growthactor, which can stimulate cell proliferation, matrixemodeling, and angiogenesis. The use of theserowth factors to enhance healing is an interestingption, but commercial interests might obscure a lackf true clinical benefits in some cases. Indeed, theseoncepts have spurred commercial exploitation withhe development of a wide range of preparation pro-ocols, kits, and centrifuges.

Most of these products were called PRP, the sameame as the original transfusion platelet concentrate,hich does not allow for a distinction among theifferent systems and protocols. All available PRPechniques have some points in common: blood isollected with an anticoagulant just before or during

Table 1. GROUP STATISTICS: AVERAGE AMOUNT OFFAT RESORPTION AFTER 1-YEAR FOLLOW-UP

Group n Mean SD SEM P Value

ugmentation (mm)PRF � fat graft 25 7.5 1.2 0.2 .823PRP � fat graft 25 7.4 1.3 0.2

Resorption (mm)PRF � fat graft 25 0.9 0.3 0.6 .000PRP � fat graft 25 1.4 0.5 0.1

Abbreviations: PRF, platelet-rich fibrin; PRP, platelet-richplasma; SD, standard deviation; SEM, standard error of themean.

Keyhan et al. PRF Versus PRP Plus Fat Graft. J Oral MaxillofacSurg 2013.

urgery and is immediately processed by centrifuga- t

ion. The time for platelet concentrate preparation isariable but is always completed within 1 hour.The first centrifugation step is designed to separate

he blood into 3 layers: red blood cells are found athe bottom, acellular plasma (platelet-poor plasma) isn the supernatant layer, and a “buffy coat” layer ofoncentrated platelets appears between. The nextteps vary in the numerous protocols but are an at-empt to discard the red blood cell layer and thelatelet-poor plasma to collect only the buffy coat

ayer. The platelet concentrate obtained is applied tohe surgical site with a syringe, with the combinationf thrombin and/or calcium chloride (or similar fac-ors) to trigger platelet activation and fibrin polymer-zation. The Choukroun PRF is the latest version ofhis protocol; blood is collected without the use of annticoagulant and centrifuged immediately. A naturaloagulation process then occurs and allows for theasy collection of a leukocyte-rich clot, without theeed for any biochemical modification of the blood;hat is, no anticoagulant, thrombin, or calcium chlo-ide is required. This open-access technique is theimplest and the least expensive protocol developedhus far. However, some confusion is likely becauseifferent suppliers use a similar nomenclature forheir distinct products (such as Vivo Stat PRF (Den-ark) and Fibrinet Platelet-Rich Fibrin Matrix, Cas-

ade Medical Enterprises, UK).Three main sets of parameters are necessary for a

lear classification of platelet concentrates. The firstet of parameters relates to the preparation kits andentrifuges used. The size of the centrifuge (parame-er A1), the duration of the procedure (parameter2), and the cost of the device and kits (parameter3) are significant factors when considering the re-etitive use of these techniques in daily surgical prac-ice. The ergonomics of the kit and the complexity ofhe procedure (parameter A4) are also key parame-ers, because complex procedures are in danger ofeing unusable or potentially misused, leading to ir-eproducible results. For these reasons, automatedystems have been developed and are commerciallyvailable. These parameters define the practical char-cteristics of each technique. The second set of pa-ameters relates to the content of the concentrate.he final volume of usable concentrate (parameter1) depends on the initial blood harvest and canefine the potential clinical applications of a prepara-ion protocol. The efficiency in collecting plateletsparameter B2) and leukocytes (parameter B3) andheir preservation throughout the entire process (pa-ameter B4) define the basic pharmacologic relevancef the product and indicate its potential applications.he third set of parameters relates to the fibrin net-ork that supports the platelet and leukocyte concen-

rate during its application. The density of the fibrin

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KEYHAN ET AL 619

network is determined mainly by the concentration ofthe fibrinogen (parameter C1) during preparation.12

Most protocols lead to the creation of a low-densityfibrin gel, which allows for convenient surgical appli-cation but lacks a true fibrin support matrix. In con-trast, a high-density fibrin network means that theplatelet concentrate can be considered a biomaterial,and the fibrin matrix itself might have potential heal-ing effects.13 The fibrin polymerization process (pa-rameter C2) needs to be evaluated, taking into ac-count the ratios between fibrinogen and thrombinconcentrations and the biomechanical properties ofthe final fibrin network. Fibrinogen is activated bythrombin, which initiates polymerization into fibrin.However, the fibrin fibrillate can be assembled in 2different biochemical architectures: by condensed te-tramolecular or bilateral junctions or by connectedtrimolecular or equilateral junctions.12 Bilateral junc-ions are created by a drastic activation and polymer-zation with, for example, high thrombin concentra-ions. This process leads to a dense network ofonofibers similar to a fibrin glue, which is not par-

icularly favorable to cytokine enmeshment and cel-ular migration. In contrast, a low level of physiologicbrin polymerization yields a larger percentage ofquilateral junctions, which allows for the establish-ent of a flexible fibrin network with a multifiber

ssembly that can support cytokine enmeshment andellular migration.14 Moreover, this organization pro-

vides elasticity to the fibrin matrix comparable to thatof a solid biomaterial. Fibrinogen collection efficiencyand polymerization type define the material charac-teristics of the concentrate. Using these sets of param-eters, actual available methods can then be classifiedin 4 main categories, depending on the pharmaco-logic (B parameters) and material (C parameters) char-acteristics of the obtained product: pure PRP, leuko-cyte-rich PRP, pure PRF, and leukocyte-rich PRF (orChoukroun PRF). In each category, the concentratecan be produced by different processes (A parame-ters) through the use of a fully automatized setup ormanual protocols.

New issues have arisen for the selection of the mostappropriate face rejuvenation methods. There aremany publications on the use of fat grafts in plasticsurgery. Guerrerosantos et al15 reported the use of fatissue in patients affected by Romberg syndrome andacial defects. Based on the degree of facial tissueepression, they separated their cases into 4 types.or types 1 and 2, they used only fat grafts; for typesand 4, they used a combination of cartilage and

one graft, free dermis fat graft, or galeal flaps, de-ending on the case. The authors also recently re-orted some interesting cases treated with rhytido-lasty combined with pursing plication suspension

utures and lipoinjection. This combination of proce-

ures provides a 3-dimensional esthetic improvementn contour and volume, has a short convalescence andecovery time, and offers less risk for complications,specially those cases involving the facial nerve.16

Currently, the lipostructure technique is an alterna-tive to the mid-facelift, augmentation malarplasty, oraugmentation genioplasty with prostheses. Lipostruc-ture evolved from lipofilling and is better known asthe Coleman technique.2,3

Notably, platelets isolated from peripheral bloodare an autologous source of growth factors. Whenplatelets, in a concentrated form, are added to graftmaterials, the outcome is more predictable. PRP is aneasily accessible source of growth factors that sup-port bone and soft tissue healing. The use of PRP inplace of recombinant growth factors has several ad-vantages: growth factors obtained from platelets notonly have their own specific effect on tissues, but alsointeract with other growth factors, resulting in theactivation of gene expression and protein produc-tion.17-19 Therefore, the properties of PRP are basedon the production and release of multiple growth anddifferentiation factors at platelet activation. These fac-tors regulate and stimulate the healing process, andthey play an important role in regulating cellular pro-cesses such as mitogenesis, chemotaxis, differentiation,and metabolism.20-22 In general, platelet concentratesre blood-derived products used for the prevention andreatment of hemorrhage due to serious thrombopenia.RP is an autologous modification of fibrin glue, whichas been described and used in various applicationsith apparent clinical success. PRP obtained from

utologous blood is used to deliver growth factors inigh concentrations to the sites of bone defects or aegion requiring augmentation.17 The clinical effectsf PRP are similar to those usually produced by fibrindhesives, which suggests that a fibrin matrix may beore effective than platelet cytokines, which can

istribute widely throughout this biological adhesive.t has a proficient homeostatic effect on any diffuseleeding of the parenchyma and decreases pain andostoperative edema, resulting in improved angiogen-sis.1,4,5 The Choukroun PRF protocol is a simple and

free technique developed in France by Choukroun etal. The product can be considered a second-genera-tion platelet concentrate because the natural concen-trate is produced without any anticoagulants or jelli-fying agents. Venous blood is collected in dry glasstubes and centrifuged at low speed (Process Protocol,Nice, France). In the absence of anticoagulants, plate-let activation and fibrin polymerization are triggeredimmediately.

The PRF clot forms a strong fibrin matrix with acomplex 3-dimensional architecture, in which mostplatelets and leukocytes from the harvested blood are

concentrated.6-8,22 When pressed between 2 pieces of

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620 PRF VERSUS PRP PLUS FAT GRAFT

gauze, the PRF clot becomes a strong membrane, andsome applications of this autologous biomaterial havebeen described in oral,6 maxillofacial,7,23 ear, nose,nd throat,8 and plastic7 surgery.

Unlike the PRPs, the Choukroun PRF does not dis-solve quickly after application; instead, the strongfibrin matrix is remodeled slowly in a manner similarto the formation of a natural blood clot. Platelets andleukocytes are collected with high efficiency with theuse of this method, and leukocytes are preservedthroughout. However, platelets are activated duringthe process, which leads to a substantial embeddingof platelet and leukocyte growth factors in the fibrinmatrix.24,25 This method allows for the production of

large quantity of leukocyte-rich PRF clots simultane-usly using a specific centrifuge that takes 8 tubes orny modified laboratory centrifuge, which makes itossible to produce even more clots for larger surger-

es. Another advantage of this method is its low costnd the great ease of the procedure, which allows forhe rapid production of many concentrates by naturaleans, that is, without the use of chemicals or unnat-

ral conditions. The quality and stability of the grafthrough time are the most difficult factors to controlecause significant resorption (reaching 50% to 70%)an occur. The first in vitro studies highlighted ancceleration in the proliferation of preadipocytes putn contact with a PRF membrane.8 If the plateletcytokines can help accelerate the cicatrization, thedeposit of a cicatricle fibrin screen will affect theincorporation of the grafted tissue. The presence of afibrin membrane charged with platelets and leuko-cyte cytokines is therefore the best chemotactic fac-tor and is supported by the proliferation of endothe-lial cells. The rapid neovascularization of graftedtissue is a major factor affecting cellular survival thatalso limits tissue resorption. The Coleman techniqueis performed predominantly using small fat tissue de-posits: if the graft is too large, it cannot be vascular-ized and ultimately shrinks. It is important to considerthat fibrin is an excellent trap for the original circu-lating cells and the immune cells, which ultimatelyresults in improved immunization of the purifiedgraft.1 The results of the Coleman procedure are sub-ective and operator dependent. The results are rathernforeseeable, and the graft’s stability rate after 3onths has varied in the literature. The use of PRF/fat

ombined with PRP/fat and 2-dimensional facial anal-sis allowed the stabilization of the present results,lthough it is difficult to report complete and desir-ble results objectively unless systematic magneticesonance imaging is performed or 3-dimensionalcan technologies are used.

The quality and stability of the graft through timere the most difficult factors to control because

ignificant resorption (reaching 50% to 70%) can

ccur. This first comparative clinical study de-cribes the utility of concentrated platelets in pa-ients receiving adipocyte grafts. The PRF is a plate-et concentrate and can be produced quickly andasily at minimal cost using only a natural bloodlot without biochemically modifying the blood.he present results appear to indicate that a PRF/fatombination is more effective than a PRP/fat com-ination, although more studies might be needed.he major disadvantages of PRF/fat compared withRP/fat are the lack of a fibrin PRF clot and theifficult injection technique. With this knowledgef the extended utility of surgical additives contain-

ng fibrin in maxillofacial plastic surgery, biomate-ials that facilitate cicatrization such as PRF and PRPill be used more broadly in the future, even if it is

till necessary to carry out further studies to vali-ate the associated indications.26

References1. Braccini F, Dohan DM: The relevance of Choukroun’s platelet

rich fibrin (PRF) during facial aesthetic lipostructure (Cole-man’s technique): Preliminary results. Rev Laryngol Otol Rhi-nol (Bord) 128:255, 2007

2. Coleman SR: Facial augmentation with structural fat grafting.Clin Plast Surg 33:567, 2006

3. Coleman SR: Structural fat grafting, in Nahai F (ed): The Art ofAesthetic Surgery: Principles and Techniques. St Louis, MO,Quality Medical Publishing, 2005, pp 289-363

4. Marx ER: Platelet-rich plasma: A source of multiple autologousgrowth factors for bone grafts, in Lynch SE, Genco RJ, Marx RE(eds): Tissue Engineering, Applications in Maxillofacial Surgeryand Periodontics. Hanover Park, IL, Quintessence Publishing,1999, pp 71-82

5. Cervelli V, Palla L, Pascali M, et al: Autologous platelet-richplasma mixed with purified fat graft in aesthetic plastic sur-gery. Aesthetic Plast Surg 33:76, 2009

6. Choukroun J, Diss A, Simonpieri A, et al: Platelet-rich fibrin(PRF): A second-generation platelet concentrate. Part IV: Clin-ical effects on tissue healing. Oral Surg Oral Med Oral PatholOral Radiol Endod 101:e56, 2006

7. Choukroun J, Diss A, Simonpieri A, et al: Platelet-rich fibrin(PRF): A second-generation platelet concentrate. Part V: Histo-logic evaluations of PRF effects on bone allograft maturation insinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod101:299, 2006

8. Choukroun JI, Braccini F, Diss A, et al: Influence of platelet richfibrin (PRF) on proliferation of human preadipocytes and tym-panic keratinocytes: A new opportunity in facial lipostructure(Coleman’s technique) and tympanoplasty? Rev Laryngeal OtolRhinol (Bord) 128:27, 2007

9. Matras H: [Effect of various fibrin preparations on reimplanta-tions in the rat skin]. Osterr Z Stomatol 67:338, 1970

0. Gibble JW, Ness PM: Fibrin glue: The perfect operative sealant?Transfusion 30:741, 1990

1. Whitman DH, Berry RL, Green DM: Platelet gel: An autologousalternative to fibrin glue with applications in oral and maxillo-facial surgery. J Oral Maxillofac Surg 55:1294, 1997

2. Mosesson MW, Siebenlist KR, Meh DA: The structure andbiological features of fibrinogen and fibrin. Ann N Y Acad Sci936:11, 2001

3. Clark RA: Fibrin and wound healing. Ann N Y Acad Sci 936:355, 2001

4. van Hinsbergh VW, Collen A, Koolwijk P: Role of fibrin matrix

in angiogenesis. Ann N Y Acad Sci 936:426, 2001

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15. Guerrerosantos J, Guerrerosantos F, Orozco J: Classificationand treatment of facial tissue atrophy in Parry-Romberg disease.Aesthetic Plast Surg 31:424, 2007

16. Guerrerosantos J: Evolution of technique: Face and neck liftingand fat injections. Clin Plast Surg 35:663, 2008

17. Carlson ER: Bone grafting the jaws in the 21st century: The useof platelet-rich plasma and bone morphogenetic protein. AlphaOmegan 93:26, 2000

18. Sánchez AR, Sheridan PJ, Kupp LI: Is platelet-rich plasma theperfect enhancement factor? A current review. Int J Oral Max-illofac Implants 18:93, 2003

19. Landesberg R, Moses M, Karpatkin M: Risk of using platelet-richplasma gel. J Oral Maxillofac Surg 56:1116, 1998

20. Garg AK: The use of platelet-rich plasma to enhance the suc-cess of bone grafts around dental implants. Dent ImplantolUpdate 11:17, 2000

21. Wiltfang J, Terheyden H, Gassling V, et al: Platelet rich plasma (PRP)vs. platelet rich fibrin (PRF): Comparison of growth factor contentand osteoblast proliferation and differentiation in the cell culture.

Report of the 2nd International Symposium on Growth Factors (Sy-Fac 2005). Implantodontie 14:121 (abstract), 2005

22. Dohan DM, Choukroun J, Diss A, et al: Platelet-rich fibrin (PRF):A second-generation platelet concentrate. Part I: Technologicalconcepts and evolution. Oral Surg Oral Med Oral Pathol OralRadiol Endod 101:E37, 2006

23. Diss A, Dohan DM, Mouhyi J, et al: Osteotome sinus floorelevation using Choukroun’s platelet-rich fibrin as graftingmaterial: A one-year prospective pilot study with micro-threaded implants. Oral Surg Oral Med Oral Pathol OralRadiol Endod 105:572, 2008

24. Dohan DM, Choukroun J, Diss A, et al: Platelet-rich fibrin (PRF):A second-generation platelet concentrate. Part II: Platelet-re-lated biologic features. Oral Surg Oral Med Oral Pathol OralRadiol Endod 101:e45, 2006

25. 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 concen-trates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod101:e51, 2006

26. Dodson TB: A guide for preparing a patient-oriented research

manuscript. Oral Surg Oral Med Oral Pathol Oral Radiol Endod104:307, 2007