Platelet-Rich Plasma (PRP) in Modern Surgical Practice
The use of Platelet Rich Plasma (PRP) in conjunction with surgical procedures has become more accepted by patients and surgeons in the field of regenerative medicine as we see that patient’s interest in biologically-based treatments increases and that surgeons gain familiarity with the regenerative properties of PRP products. As a result, PRP has become an increasingly common adjunct to surgical procedures.
Purpose of Combining PRP and Surgery
The purpose of this discussion will be to communicate how and when the combination of surgery and regenerative therapies should be implemented, with the hope of standardizing their use when appropriate and ensuring that patients are fully counseled regarding the expected benefits and risks associated with these two approaches together.
Evolution of Surgical Practice
Across the board, surgical practice has evolved significantly due to both procedural and patient outcome expectations. Traditionally, surgeons have focused their efforts on transferring or reconstructing tissue; today, however, there is an opportunity to enhance the biological conditions surrounding the surgical event. Rehabilitative approaches enable both quicker healing and improved graft success, more rapid recovery from surgery, and potentially longer-term positive effects. Thus, combining surgery with regenerative therapies is an opportunity for surgeons to move away from a strictly procedure-driven surgical practice toward a biologically based and holistic approach.
Platelet Rich Plasma (PRP) Overview
PRP is the most frequently used of the regenerative options available to surgeons, and currently, is most widely utilized by office-based surgeons. PRP originates from the patient’s own blood and is then processed to produce a concentrated amount of platelets containing multiple growth factors and cytokines that support the healing of wounds, stimulate the growth of new blood vessels (angiogenesis), and function to facilitate the generation of tissue. The popularity of utilizing PRP is due to the fact that the preparation of PRP is relatively simple, it is considered to be a safe procedure, and it can be performed easily in an office setting. Combining surgical interventions with platelet-rich plasma (PRP) therapy is done on the premise of enhancing the body’s natural repair capacity, therefore enhancing the predictability and quality of surgical outcomes.
Applications of PRP in Hair Restoration
The use of PRP in hair restoration is done in multiple phases; preoperatively, some surgeons use PRP for increased vascularization in the area being treated. Others administer PRP to the harvested graft to provide hydration and protection at the time of graft extraction. In post-operative use, PRP is administered on the grafted area to promote healing and stimulate the earliest stages of hair growth. Each application of PRP addresses a specific biological challenge of hair transplantation, due to a lack of blood supply to the hair follicle during the time between harvest and implantation. PRP applications also utilize multiple growth factors present in the PRP (platelet-derived growth factor [PDGF] and vascular endothelial growth factor [VEGF]) to aid with angiogenesis, repair of cells, and integration of the follicle during the most critical stage.
Other Regenerative Adjuncts
PRP is just one of a number of other regenerative therapies currently being used as adjuncts to surgery. Other modalities include products from extracellular matrix, products derived from stem cells, and adipose-derived regenerative cells (ADRCs). All of these therapies are different in the items being used and the types of repairs that can be achieved with them; however, they all have the main goal of creating the most conducive regenerative environment possible. For hair restoration specifically, there are also studies being conducted using stem cell-rich fractions of either adipose tissue or scalp tissue regarding their nutritive benefits to a follicle, their improvement of the quality of surrounding tissue, and their utility in addressing other negative factors such as inflammation, fibrosis, and decreased vascularization. When these adjunctive treatments are done along with surgery, it is believed that there will be a positive impact on outcomes by addressing both the hair loss and the overall health associated with the scalp.
Mechanism and Rationale
The idea behind merging operating procedures and regenerative medicine is to promote wound healing in patients through the use of both procedures and healing methods together. Trauma can occur in both major and minor surgical procedures, which can impede or hasten the recovery of a patient postoperatively. Problems such as delayed healing, excessive inflammation, and/or poor tissue regeneration can diminish the patient’s cosmetic outcome and satisfaction. Regenerative methods may help modulate the inflammatory response, allowing patients to transition sooner to the repair/remodeling phase of healing, resulting in less postoperative redness, swelling, pain, and extent of time needed out of normal activities.
Graft Health and Survival
Another important consideration when performing hair restoration surgery is the health of the grafts themselves. Although there are new and improved techniques for harvesting and implanting grafts with both the FUE and FUT techniques, graft attrition still presents a problem during the healing process due to ischemia-reperfusion injury, dehydration and/or mechanical trauma/strain that the graft experiences from the time it is harvested until it becomes fully vascularized. PRP and similar procedures are believed to protect the graft and promote early revascularization of the graft by delivering growth factors to the follicular stem cells and dermal papilla cells. Many practitioners report improvements in graft take and visible growth after the use of regenerative adjuncts; however, there are conflicting results in the literature regarding the reproducibility of the benefits of these adjuncts, since clinical studies have not been able to provide consistent benefits across all protocols.
Patient Awareness and Expectations
With so many people able to access the internet, the amount of information available to consumers has increased significantly; as such, there are more patients who have researched their options prior to surgery. As a result, patients are becoming more and more inclined to seek less invasive or damaging forms of treatment, such as regenerative therapies. Regenerative medicine is especially enticing for hair restoration due to the advent of regenerative medicine’s exciting capabilities. Surgeons must make a clear distinction that these regenerative therapeutic modalities are adjuncts to surgery (complementary/collateral), not replacements (stand-alone). In making this distinction, surgeons must ensure that their patients have reasonable and achievable expectations before surgery.
Clinical Evidence and Limitations
As with most things in the new and developing area of regenerative therapy, the current clinical data supporting platelet-rich plasma (PRP) and other regenerative therapies is variable. Preparation techniques, concentration of platelets, activation processes, and timing of application can all affect the outcome of the patient’s response to regenerative therapies. In addition, the majority of newer regenerative products do not have strong clinical data supporting their effectiveness, and the mechanism by which they produce intended outcomes is under investigation. Thus, the efficacious use of these therapies will, for the most part, continue to be based on the surgeon’s experience, adherence to protocol, and provision of patient education.
Practical Implementation in Surgical Workflow
When incorporating regenerative therapies into the surgical workflow, practical considerations must be taken into account. Careful planning must be implemented to ensure that blood collection, processing, and delivery are performed in a manner that does not disrupt the flow of the surgical procedure. Staff must also be well-trained in the preparation, handling, and safety of the regenerative therapies. Patients also need to be assessed individually for suitability as candidates for regenerative therapies, as not every patient is a suitable candidate. Each patient’s treatment plan should be developed on an individual basis, with clinical judgment being the basis for determining the treatment plan rather than a cookie-cutter approach.
Timing and Postoperative Applications
Timing of the regenerative therapies is not limited to the day of surgery. There may also be a benefit to receiving PRP sessions postoperatively, as this practice may assist with further tissue remodeling and hair growth for several weeks or months following surgery. This understanding corresponds to the fact that surgical results continue to be developed well after the surgical procedure has ended. Providing ongoing biological assistance throughout the recovery phase may improve the amount of hair, its thickness, and aesthetic improvement.
Ethical Considerations
Ethics surrounding regenerative medicine are equally important. The marketing of regenerative medicine is prevalent; however, results will be overstated in order to provide what patients want. That being said, surgeons should not perform regenerative medicine procedures by presenting them as guarantees of improved surgical results. Being open and honest about the current scientific evidence and known effectiveness of the different procedures, the known limitations of each procedure, and cost limitations will help sustain the patients’ trust and maintain ethical principles in providing surgical care.
Broader Implications for Surgical Practice
More globally, regenerative medicine in surgery reflects a paradigm shift away from delivering surgery as an isolated event and considering the patients’ cellular environment, ability to heal, and long-term tissue health as part of a larger continuum of care. The information learned from hair restoration may translate to regenerative therapies across other surgical specialties, such as orthopedic, plastic, and reconstructive procedures.
Cost and Access Considerations
The cost and access to regenerative therapies are another significant barrier to the use of these options. These additional therapies add to the overall cost of the surgery, as most insurance companies do not cover the costs (in cosmetic surgeries, this is especially true). Therefore, the surgeon must explain the use of these adjunctive therapies (in addition to justifying the use) while presenting alternative therapies, as well as being sensitive to the financial position of the patient when determining if to include these additional therapies in their treatment plan. By explaining that regenerative therapies are purely optional enhancements of surgery and not required adjuncts, the patient can make an informed choice based on their preference.
Future Directions in Regenerative Medicine
In the future, ongoing research into responding and standardizing the preparation and reporting of PRP data will help clarify ideal usage/responsiveness of PRP and will substantiate ongoing clinical data in PRP use. As we utilize regenerative medicine in practice, it will be essential for surgeons and their teams to stay current in not only the available literature pertaining to PRP and regenerative medicine but also on the emerging data regarding the use of these therapies, to provide the best patient care possible.
Conclusion
In conclusion, by appropriately combining the use of PRP and other regenerative therapies with the practice of surgery, this represents a significant shift in today’s practice of modern surgical procedures. Assuming PRP and regenerative therapy are each used correctly and their usages are transparently discussed, the patient’s ability to recover, ability to maintain a graft, and potential for aesthetic enhancements can be greatly enhanced by the use of these therapies. When properly incorporated into surgical skill, regenerative medicine may serve as an additional tool for surgeons to provide their patients with the expected outcomes that are possible with biologically informed medicine in contemporary surgical practice.
