Platelet-Rich Growth Factor for Lip and Perioral Rejuvenation: A Case Study on “The Kiss Shot”

INTRODUCTION
Loss of lip volume is part of the aging process. With the increase of aesthetic demands and medical-grade products, there has been a significant increase in minimally invasive cosmetic procedures (MICPs) related to the lip and perioral area. The use of platelet-rich plasma (PRP) aesthetic rejuvenation therapy is a recent development. When we examine the etiology of volume-loss aging, we see there is a slow progressive loss of the differential mass in general.¹ This includes thinning of the epidermis. In addition, the vascularity exhibits a loss in volumetric distribution.² This manifestation does not occur exclusively in the stratified squamous epithelium of the face. Aging also impacts the lips, one of the most aesthetic areas of the face.³ The lip and perioral aging manifests clinically in the lips as sharp demarcated lines around the lips in zone A (smoker lines), and the loss of vascularity and volume in the prolabium zone B (Figure 1).⁴

Lip rejuvenation, by definition, relates to the general reversal of age-related manifestations. This is in contrast to the aesthetic shaping of the lips using filler materials. Ideal lip enhancement should include both modes of practice to ensure an optimal aesthetic result with long-lasting results. Most cell-mediated growth and anatomical regeneration can be initiated with PRP stimulation in the intended area, which initiates a healing and rejuvenation cascade that involves transforming growth factor-beta, platelet-derived growth factor (PDGF), insulin-like growth factor, vascular endothelial growth factor, epidermal growth factor, and fibroblastic growth factors. These cytokines are the building blocks of regeneration and are found up to 5 times their normal values in PRP therapy.⁵

The following case study illustrates the application of PDGF in regards to strategic application and regenerative therapy of the lip and perioral tissue.

CASE REPORT
A 44-year-old female presented with a history of severe actinic scarring around her lips, with generalized loss of lip volume in zones A and B (Figure 2). In addition, the lip and perioral area presented with sun damage commonly seen in semitropical states like Florida.

Rejuvenation and volumizing procedures were discussed with the patient. The consultation also covered the positive and long-lasting results of revitalization and lip contouring using a combination of PRP and hyaluronic acid-based fillers. Three consecutive treatments in 4-week intervals were suggested for optimal aesthetic foundational results.

Figure 1. Gordon Lip Classification.	Figure 2. Preoperative photo. (Note the scarring and general volume loss.)
Figure 3. Microneedling zone A stratified squamous, which facilitates transepidermal and dermal absorption of topical platelet-rich plasma (PRP) and initial low-level wound insult for repair initiation.	Figure 4. Injection of PRP into zones A and B, segments 1 to 6.
Figure 5. Topical application of PRP with mediated microneedling into zone A only. Note: Needling into zone B causes undue swelling and bruising.	Figure 6. Topical application of membranous clot of platelet-poor plasma for 10 minutes into the heavier lines.

Figure 7. Notice the volume increase in segments 1 to 6 and zone B. In addition, there is a significant change in overall tissue color and consistency in both zones A and B, segments 1 to 6.

Preparation of the PRP
Harvesting of PRP is done via blood drawn from the cubital fossa area. An amount of 32 mL was harvested and centrifuged at 450 gravitational forces (g) for 9 minutes using the BTI Endoret system. Visual manual separation of PRP was carried out. The platelet-poor plasma (PPP) was separated out to be prepped for topical placement. The PRP was extracted and activated with calcium chloride for injection and topical injection.⁶ Using the Gordon Classification Methods, the lip and perioral area and midface were selected for rejuvenation.

Subjective aesthetic grading systems used included pre- and postoperative volumetric assessment and wrinkle reduction. Digital photography was used to record the preoperative and postoperative clinical presentation. Using the Gordon Lip Classification, the PRP was discreetly placed into recorded areas of prolabium and stratified squamous epithelium of the lips proper. The classification method allows a recorded and communicative method of placement. In addition, areas of resolve can be subjectively analyzed using descriptive properties relating to wrinkle severity, natural geometric forms, and resultant height of contours.⁷

Clinical Protocol
This 44-year-old female presented with Fitzpatrick skin type 2. The preparation for this procedure included cleaning zones A and B with chlorhexidine wipes.⁸ The local anesthesia administered included modified infra-orbital and mental blocks using carbocation with no (zero) epinephrine. PRP was injected into segments 1 to 6, zones A and B, using a 30-gauge needle (Figures 3 and 4). Care was used not to insult underlying muscular and vascular anatomy associated with the thin prolabium of zone B. The targeted plane for injection of PRP was directly beneath the prolabium and superior to orbicularis oris. An amount of 0.1 cc was used for each segment, 1 to 6, in zone B. Using a 30-gauge needle and a fan technique, injection of PRP was carried out in zone A. Placing of the PRP was immediately below the reticular dermis. Microneedling was then carried out above injected areas of zone A (Figure 5).^9,10 This was finished up with topical application of PRP administered in a slow massaging motion for a period of 5 minutes for maximum absorption.

The harvested PPP was laid in the BTI Endoret plasmatherm oven set at 37°C for 20 minutes. The resultant membranous coagulant was then placed on zone A, segments 1 to 6 (Figure 6), for further desorption and saturation of dermis. This was removed when visible desiccation of the membrane was evident at approximately 5 minutes.

The patient underwent 2 consecutive treatments as described above with approximate 4-week intervals between treatments.

Clinical Outcome
The patient reported the presence of significant volume in the lips (zone A, segments 1 to 6) for approximately 3 days. Then the volume subsided to about one half of the immediate postoperative volume increase. This reported swelling and then decrease in swelling was also present after the second treatment. Clinical review saw significant dermal enhancement, which consisted of dermal thickness, associated with zone A. Rejuvenation and tightening of zone A was also clinically evident. Zone B demonstrated a remarkable postoperative enhancement in tonicity, thickness and color, changing from a dull pink to a richer red. There was also a distinct reduction in associated sun damage around zone A (Figure 7).

CLOSING COMMENTS
The evidence is building related to the clinical practicality of PRP therapy in conjunction with wound healing and aesthetic rejuvenation. Optimal results manifest at 3 months.11 Most studies^12-15 have concentrated on the facial skin in general and or isolated age-related areas; for example, the nasiolabial folds. It is important for this author to convey that PRP is not filler in the applicable sense of today’s jargon. Instead, PRP should be considered a foundational prep for full facial rejuvenation not limited to the integumentary system. Studies show promising overall improvement in muscle tissue vascularity and neuronal rejuvenation.

References

1. Glogau RG. Systemic evaluation of the aging face. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. Edinburgh, Scotland: Mosby; 2003:2357-2360.
2. Suter-Widmer J, Elsner P. Age and irritation. In: van der Valk PGM, Maibach HI, eds. The Irritant Contact Dermatitis Syndrome. Boca Raton, FL: CRC Press; 1996:257-262.
3. Gordon RW. Age grouping to optimize augmentation success. Dent Today. 2010;29:128-131.
4. Martini F. Fundamentals of Anatomy & Physiology. 6th ed. San Francisco, CA: Benjamin Cummings; 2004.
5. Chen F-M, Liu X. Advancing biomaterials of human origin for tissue engineering. Prog Polym Sci. 2016;53:86-168. 
6. Gordon R. Vermilion Dollar Lips. St. Petersburg, FL: Vermilion Dollar Publications; 2007.
7. Mautner K, Malanga GA, Smith J, et al. A call for a standard classification system for future biologic research: the rationale for new PRP nomenclature. PM R. 2015;7(suppl 4):S53-S59.  
8. Edmiston CE, Krepel CJ, Spencer MP, et al. Preadmission application of 2% chlorhexidine gluconate (CHG): enhancing patient compliance while maximizing skin surface concentrations. Infect Control Hosp Epidemiol. 2016;37:254-259.
9. El-Domyati M, Barakat M, Awad S, et al. Multiple microneedling sessions for minimally invasive facial rejuvenation: an objective assessment. Int J Dermatol. 2015;54:1361-1369.
10. Lee HJ, Lee EG, Kang S, et al. Efficacy of microneedling plus human stem cell conditioned medium for skin rejuvenation: a randomized, controlled, blinded split-face study. Ann Dermatol. 2014;26:584-591.
11. Yuksel EP, Sahin G, Aydin F, et al. Evaluation of effects of platelet-rich plasma on human facial skin. J Cosmet Laser Ther. 2014;16:206-208.
12. Zheng C1, Zhu Q, Liu X, et al. Improved peripheral nerve regeneration using acellular nerve allografts loaded with platelet-rich plasma. Tissue Eng Part A. 2014;20(23-24):3228-3240.
13. Li H, Hicks JJ, Wang L, et al. Customized platelet-rich plasma with transforming growth factor ß1 neutralization antibody to reduce fibrosis in skeletal muscle. Biomaterials. 2016;87:147-56. Epub 2016 Feb 17.
14. Cianforlini M,Mattioli-Belmonte M, Manzotti S, et al. Effect of platelet rich plasma concentration on skeletal muscle regeneration: an experimental study. J Biol Regul Homeost Agents. 2015;29(4 Suppl):47-55.
15. Kim DH, Je YK, 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.

Dr. Gordon, after graduating from Marquette School of Dentistry, attended the University of Nebraska-Lincoln periodontal residency and oral surgery internship at Winn Army Hospital Georgia in the Army Dental Corps. He concentrated his work at State University of New York at Buffalo as an assistant professor in the department of orthodontics and in the subfield of ortho-facial aesthetics. He also is a recipient scholar of the K30 scholarship at the department of dermatology, University of Southern Florida School of Medicine, for his research in dermal fillers. His private practice is limited to ortho-facial aesthetics, which is the study and practice of ideal clinical facial aesthetic phenomenology. He is the author of 3 books that specialize in the art and science of lip and facial augmentation as well as numerous peer-reviewed articles on facial aesthetics. Vermilion Dollar Lips was the first book written on lip augmentation and was inducted into the ADA library. His second book is Cupid’s Bow. His most recent book, PhenoEsthetics, is the first comprehensive aesthetic diagnostic and treatment-planning method for minimally invasive cosmetic procedures. He lectures internationally and can be reached at drlips@me.com.

Disclosure: Dr. Gordon reports no disclosures.