Microneedling with PRP for Facial Rejuvenation

Currently, facial rejuvenation is likely the most sought out cosmetic modality. Dermatologists and their patients seek an effective, minimally invasive procedure with minimal downtime and side effects with long- lasting results.

Most minimally invasive procedures aim to maintain the overlying epidermis while creating dermal injury; therefore, stimulating wound repair and neocollagenesis. Current minimally invasive techniques include nonablative lasers, radiofrequency, ultrasound, chemical peels, microdermabrasion, injectable fillers, mesotherapy, and microneedling.

Microneedling, or collagen induction therapy, is a minimally invasive skin rejuvenation procedure that involves the use of a device that contains fine needles. These needles are used to puncture the skin at various depths to create a controlled skin injury. Each puncture creates a channel that stimulates neovascularization and neocollagenesis to fill these microscopic wounds.

A variety of microneedling devices exist with needle sizes ranging from 0.1  to 2.5 mm. Outcomes of microneedling vary based on the device, the depth of needle penetration, frequency of needle penetration, and the number of passes.2 The needles traumatically create pores in the dermis, which stimulates the release of growth factors and cytokines.

The growth factors and cytokines in turn stimulate collagen, elastin, and neovascularization.3 Studies have shown that microneedling initiates collagen synthesis, specifically collagens I, III, and VII.4 Needling sessions are typically spaced 4 to 6 weeks apart. Microneedling has minimal side effects and can be used safely in patients with skin types III-VI in addition to patients with a history of melasma.

Microneedling should be avoided in patients with a history of keloid or hypertrophic scarring, inflammatory dermatoses, history of herpes simplex virus in perioral area, or any type of growth in the target area. Absolute contraindications for microneedling include scleroderma, collagen vascular disease, clotting disorders, active infection, and immunosuppression.

El-Domyati et al5 studied 10 patients with 6 microneedling sessions at 2-week intervals and found both clinical improvement and histologic evidence of an increase in type I, III, and VII collagen, newly synthesized collagen, and tropoelastin. There was also a decrease in overall elastin.

Platelet-rich plasma (PRP) is a highly concentrated autologous serum that is rich in growth factors and cytokines such as platelet-derived growth factor, transforming growth factor, insulin-like growth factor, and vascular endothelial growth factor. These growth factors regulate and induce cell migration, attachment proliferation, and differentiation as well as promote extracellular matrix accumulation. PRP and the induction of growth factors has been used specifically in the treatment of bony defects, wound healing, gastrointestinal surgery, and more recently in aesthetic dermatology.

This is a case of microneedling used in conjunction with topical PRP for facial rejuvenation.

Case

A 60-year-old woman with no significant past medical history presented to our office requesting facial rejuvenation (Figure 1A). She desired a minimally invasive technique. After discussing expectations and other treatment modalities including dermal fillers, fractioned laser, chemical peels, and microdermabrasion, the patient selected collagen induction therapy with microneedling in conjunction with PRP.

Methods

The treatment, alternatives, and potential risks were discussed with the patient. EMLA cream was used as a topical numbing agent. Blood was obtained from the patient using a 10-mL syringe containing acid citrate dextrose. The blood was centrifuged for 10 minutes, separating the PRP from the platelet poor plasma.

The PRP was applied to the face immediately prior to and after treatment with the microneedling pen.

The Eclipse MicroPen Elite (Eclipse Aesthetics, LLC) was used at different settings based on anatomic location with an endpoint of eliciting pinpoint bleeding. On the forehead, the needle depth was set to 1.5 mm, the nose and upper lip 1 mm, and on the chin and cheeks 2 mm setting was used. A total of 4 passes with the microneedling pen was used during this session. In addition to microneedling, PRP was injected with subcutaneous blebs of PRP periorally as well as periocularly.

The procedure was well tolerated. Immediately after the session the patient had erythema and pinpoint bleeding. Clinical photos were taken pretreatment (Figures 1A and B) and 4 months after the microneedling session (Figures 2A and B).

Immediate improvement was noted in skin firmness and radiance. The patient noted most significant improvement at the 1 month posttreatment session with improvement of fine lines, skin texture, and hydration as well as subtle skin tightening. Objective improvement was noted in the periocular and perioral areas where fine rhytides became less noticeable as well as midface volumization.

In our experience, PRP used in conjunction with microneedling for facial rejuvenation offers a minimally invasive option for skin types I-VI with minimal downtime and long-lasting effects. Our patient showed improvement after 1 treatment of microneedling with PRP. The patient’s maximum improvement was noted at 1 month.

A proposed mechanism for this optimal outcome may be that the additional growth factors and cytokines from the PRP act synergistically with the already stimulated neocollagenesis secondary to the needling leading to more rapid collagen remodeling.  Although we noted improvement in our patient with just 1 treatment, we would recommend a series of 4 to 6 treatment sessions 1 month apart for a more optimal outcome. Larger patient populations should be studied to further characterize the benefits of PRP with microneedling for facial rejuvenation.

Future applications of microneedling and PRP may include treating surgical scars and acne scars (See related article in the January 2016 issue of The Dermatologist), as well as using microneedling alone to facilitate various medical treatments including photodynamic therapy absorption as well as EMLA absorption.

Dr Lombardi is a fellow at Affiliated Dermatologists in Morristown, NJ.
Dr Lee is a practicing dermatologist and the director of Procedural Dermatology of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologic Surgeons in Morristown, NJ.

Disclosure: The authors report no relevant financial relationships.

References
1. DeHoratius DM, Dover JS. Nonablative tissue remodeling and photorejuvenation. Clin Dermatol. 2007;25(5):474-479.
2. Robinson JK, Hanke W, Sigel DM, et al. Surgery of the Skin: Procedural Dermatology. 3rd ed. New York, NY: Elsevier; 2015.
3. Talakoub L, Wesley N. Microneedling. Dermatology News. January 13, 2015. http://www.edermatologynews.com/specialty-focus/aesthetic-dermatology/single-article-page/microneedling/8ba6cca9162ce6bb3ca06fd7fd358dfa.html.
Accessed March 21, 2016.
4. El-Domyati M, Barakat M, Awad S, Medhat W, El-Fakahany H, Farag H. Microneedling therapy for atrophic acne scars: an objective evaluation. J Clin Aesthet Dermatol. 2015;8(7):36-42.
5. El-Domyati M, Barakat M, Awad S, Medhat W, El-Fakahany H, Farag H. Multiple microneedling sessions for minimally invasive facial rejuvenation: an objective assessment. Int J Dermatol. 2015;54(12):1361-1369.
6. Kim DH, Je YJ, Kim CD, et al. Can platelet-rich plasma be used for skin rejuvenation? Evaluation of effects of platelet-rich plasma on human dermal fibroblast. Ann Dermatol. 2011;23(4):424-431.