Turkish Journal of Plastic Surgery

CASE REPORT
Year
: 2021  |  Volume : 29  |  Issue : 1  |  Page : 59--61

Fat graft and platelet-rich plasma treatment for localized facial scleroderma


Ali Gokkaya1, Dilek Demirez2, Metin Gorgu1, Ertugrul Karanfil1, Jehat Kizilkan1, Ali Dogan1,  
1 Department of Plastic, Reconstructive and Aesthetic Surgery, Abant Izzet Baysal University, Gölköy, Bolu, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul Bahçesehir University, Istanbul, Turkey

Correspondence Address:
Metin Gorgu
Department of Plastic, Reconstructive and Aesthetic Surgery, Abant Izzet Baysal University, Golkoy, Post Code 14280 Bolu
Turkey

Abstract

Scleroderma is an autoimmune disorder characterized by hardening of the skin on the hands, arms, and face. Immunosuppressors, vasodilators, and physiotherapy are among the treatments for scleroderma. Although these treatments can improve quality of life, the treatment response in locally affected areas may be poor. At present, there is no specific treatment for localized fibrotic skin lesions in scleroderma, although stem cell treatment shows promise for local symptoms. We describe the case of a patient with facial skin symptoms of scleroderma treated with platelet-rich plasma combined with fat grafts rich in stem cells.



How to cite this article:
Gokkaya A, Demirez D, Gorgu M, Karanfil E, Kizilkan J, Dogan A. Fat graft and platelet-rich plasma treatment for localized facial scleroderma.Turk J Plast Surg 2021;29:59-61


How to cite this URL:
Gokkaya A, Demirez D, Gorgu M, Karanfil E, Kizilkan J, Dogan A. Fat graft and platelet-rich plasma treatment for localized facial scleroderma. Turk J Plast Surg [serial online] 2021 [cited 2021 Mar 3 ];29:59-61
Available from: http://www.turkjplastsurg.org/text.asp?2021/29/1/59/305916


Full Text



 Introduction



Scleroderma is an autoimmune, chronic systemic disorder, which is characterized primarily by fibrosis or skin hardening (sclerosis), as well as vascular changes of the skin and auto anticores.[1],[2],[3] Multiple fibrosis and scarring of connective tissue are cardinal symptoms of scleroderma, which is considered a microvascular and immune system disorder.[2],[4],[5]

At present, there is no consensus on the treatment of skin lesions in scleroderma, although adipose tissue injections are frequently the treatment of choice for local symptoms.[1],[2],[3],[4],[5],[6] Recently, platelet-rich plasma (PRP) has been used for scleroderma, in combination with other treatments, including biological treatments.[1] PRP has been applied in plastic surgery and oral and maxillofacial surgery due to its ability to boost a variety of growth factors.[1],[7],[8] A number of studies have investigated the potential of PRP as a regenerative treatment option for nerve damage, tendinitis, osteoarthritis, cardiac muscle injury, bone rejuvenation, and regeneration.[8],[9],[10] Previous in vitro studies demonstrated that PRP had a positive effect on the regenerative potential of mesenchymal stem cells.[1],[9] However, only two studies have examined the potential of a combination of PRP and stem cell-rich fat grafts.[1],[10] We describe the case of a scleroderma patient with facial skin lesions treated with a stem cell-rich fat graft and growth factor-rich PRP.

 Case Report



A 37-year-old female patient consulted our clinic with complaints of wrinkles around the mouth, thinning of facial skin, and cavitation of the nasolabial sulcus [Figure 1] and [Figure 2]. The patient had been diagnosed with scleroderma and followed up for minimal hardening in the lungs. There was a history of rheumatic disorders in the family. Following the diagnosis, the patient had received treatment with six rounds of melphalan (Alkeran, ApoPharma Canada) and prednisolone (Prednisolone, Actavis) combination, azathioprine (Imuran, Glaxo Smith Kline) for 2 years, steroids for 6 months, and mycophenolate mofetil (CellCept, Roche) for 1 year (i.e., in the year before presentation). In our clinic, the patient received a combination of PRP and an autologous fat graft in the perioral region for the treatment of facial skin lesions. The patient received this therapy twice, with 6 months between each application.{Figure 1}{Figure 2}

For PRP preparation, 35 cc of venous blood was drawn from the patient after the administration of an anticoagulant (sodium citrate, 1:9 dilution). PRP was prepared as follows: Plasma was transferred into two empty tubes after a single spin at 180 g × 12 min, followed by a second spin at 180 g × 10 min. The pellet residue was diluted with 2 cc of plasma. Following the double spin, the plasma contained 1,230,000/μl of PRP thrombocytes and 245,000 μl of blood thrombocytes.

Fat grafts were harvested from the periumbilical region under general anesthesia. Then, 15 cc of autologous fat graft combined with 1.5 cc of PRP was injected into the perioral and nasolabial areas. No complications occurred in the postoperative period other than minimal ecchymosis and edema. The patient was followed up at monthly intervals. Improvements in the perioral skin and nasolabial sulcus depths were observed at the 1-month follow-up. At the 2-year follow-up, the results were permanent and satisfactory [Figure 3] and [Figure 4].{Figure 3}{Figure 4}

 Discussion



In recent years, stem cell therapy has been used in many disorders as either an alternative or primary treatment.[1],[11] Adipose tissue is rich in stem cells, endothelial progenitor cells, and immune cells. Adipose tissue contains 100–1000 times more pluripotent cells per cubic centimeter than bone marrow.[11] Therefore, it boosts tissue healing and regeneration. Angiogenic growth factors in adipose tissue have been used to promote wound healing.[1],[11],[12],[13],[14],[15],[16],[17] Previous studies reported that a combination of fat cells and PRP provided greater volume enhancement in breast reconstruction.[1],[7] In addition to improving breast volume, the transferred fat cells had a regenerative effect. The regenerative effect of fat cells is related to the viability of the fat graft and survival with permanent recovery depends on the growth of new veins into the transplanted fat fragments.[1],[14] In terms of its composition, 40%–60% of adipose tissue consists of mature adipocytes. Fat grafts also contain a stromal vascular fraction (SVF), similar to that found in mesenchymal stem cells.[1],[12],[17] Mesenchymal-like stem cells are found within muscle, bone, cartilage, nerve, epithelium, macrophages, and hepatocytes.[15],[16] The SVF contains fibroblasts and CD34 and CD90 membrane markers.[1],[15],[16] It has the ability to secrete collagen, secrete matrix metalloproteinases, and organize the extracellular matrix. The SVF functions as an endothelial progenitor, with potent angiogenic potential.[1] A number of studies demonstrated that reinjected SVF had paracrine-autocrine effects and increased the quality of dermal tissue.[1],[15],[16] In the present case, we did not isolate the SVF and inject it separately.

Serratrice et al. compared treatment outcomes following SVF, PRP, and micro-fat applications in nude mice with sclerosis.[1] A combination of micro-fat and SVF or micro-fat and PRP together significantly reversed dermal and epidermal sclerosis. In the same study, when applied separately, only epidermal sclerosis improved.[1]

In the present case, we harvested fat grafts from subcutaneous tissue using a gentle atraumatic manual aspiration technique described by Coleman.[1],[12],[13] The harvested fat grafts were centrifuged for 3 min/3000 rpm, and the free fat and residue tissue were then separated and removed. We then mixed 15 cc of autologous fat graft with 1.5 cc of PRP and injected it into the nasolabial, lip, and perioral regions. Subsequent follow-up of the patient revealed that the treatment was successful in terms of resolution of localized facial skin lesions. As both fat grafts and PRP are autologous, they are safe, with no rejection reaction and minimal risk. Autologous fat grafts and PRP have rarely been applied in combination.[1] Some experimental and clinical research showed that this combination led to more successful results as compared with those achieved with fat grafts alone.[1],[7] In the present case, the combination of PRP with fat grafts was associated with very satisfactory outcomes in terms of both volume and skin quality. The lifetime of a fat graft in vivo varies, and the graft volume decreases over time. A fat graft receives its blood supply via contact with the recipient region and survives in this way until vascularization occurs. Smaller grafts provide more tissue volume. The graft survival rate using a combination of PRP and fat injections is higher than that of using fat injections alone. The cosmetic outcomes obtained using this combination are also better than those achieved using fat grafts alone, as demonstrated in the present case. The latter may be explained by PRP promoting angiogenesis and regulating the inflammatory response.

 Conclusions



PRP, combined with a fat graft, is a suitable, convenient, innovative treatment option for local symptoms in systemic sclerosis. The fat used in the graft is autologous and widespread in the body. It can also be easily harvested, and the fat injections can be easily administered under local anesthesia. In addition, postoperative healing is rapid. Although the treatment has no effects on systemic symptoms of scleroderma, it is effective against localized lesions, especially on the face. Therefore, the treatment has a positive impact on the quality of life of the patient. This was a single case study, and success was determined using subjective rather than objective measures. These caveats aside, we propose that a combination of fat graft and PRP can offer satisfactory results in the treatment of local symptoms of scleroderma.

Informed consent

The patient signed an informed consent form.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Serratrice N, Bruzzese L, Magalon J, Véran J, Giraudo L, Aboudou H, et al. New fat-derived products for treating skin-induced lesions of scleroderma in nude mice. Stem Cell Res Ther 2014;5:138.
2Abraham DJ, Varga J. Scleroderma: From cell and molecular mechanisms to disease models. Trends Immunol 2005;26:587-95.
3Gabrielli A, Avvedimento EV, Krieg T. Scleroderma. N Engl J Med 2009;360:1989-2003.
4Kahaleh MB. Raynaud phenomenon and the vascular disease in scleroderma. Curr Opin Rheumatol 2004;16:718-22.
5Sakkas LI, Platsoucas CD. Is systemic sclerosis an antigen-driven T cell disease? Arthritis Rheum 2004;50:1721-33.
6Ould Ali D, Hautier A, Daumas A, Andrac-Meyer L, Bardin N, Magalon G, et al. Bleomycin-induced scleroderma in nude mice can be reversed by injection of adipose tissue: Evidence for a novel therapeutic intervention in systemic sclerosis. J Clin Exp dermatol Res 2012;3:-164.
7Magra M, Maffulli N. Nonsteroidal antiinflammatory drugs in tendinopathy: Friend or foe. Clin J Sport Med 2006;16:1-3.
8Everts PA, Hoogbergen MM, Weber TA, Devilee RJ, van Monftort G, de Hingh IH. Is the use of autologous platelet-rich plasma gels in gynecologic, cardiac, and general, reconstructive surgery beneficial? Curr Pharm Biotechnol 2012;13:1163-72.
9Rubio-Azpeitia E, Andia I. Partnership between platelet-rich plasma and mesenchymal stem cells: In vitro experience. Muscles Ligaments Tendons J 2014;4:52-62.
10Gentile P, Orlandi A, Scioli MG, Di Pasquali C, Bocchini I, Curcio CB, et al. A comparative translational study: The combined use of enhanced stromal vascular fraction and platelet-rich plasma improves fat grafting maintenance in breast reconstruction. Stem Cells Transl Med 2012;1:341-51.
11Aust L, Devlin B, Foster SJ, Halvorsen YD, Hicok K, du Laney T, et al. Yield of human adipose-derived adult stem cells from liposuction aspirates. Cytotherapy 2004;6:7-14.
12Coleman SR. Long-term survival of fat transplants: Controlled demonstrations. Aesthetic Plast Surg 1995;19:421-5.
13Coleman SR. Structural fat grafting: More than a permanent filler. Plast Reconstr Surg 2006;118:108S-20.
14Nguyen PS, Desouches C, Gay AM, Hautier A, Magalon G. Development of micro-injection as an innovative autologous fat graft technique: The use of adipose tissue as dermal filler. J Plast Reconstr Aesthet Surg 2012;65:1692-9.
15Nakagami H, Maeda K, Morishita R, Iguchi S, Nishikawa T, Takami Y, et al. Novel autologous cell therapy in ischemic limb disease through growth factor secretion by cultured adipose tissue-derived stromal cells. Arterioscler Thromb Vasc Biol 2005;25:2542-7.
16Miyahara Y, Nagaya N, Kataoka M, Yanagawa B, Tanaka K, Hao H, et al. Monolayered mesenchymal stem cells repair scarred myocardium after myocardial infarction. Nat Med 2006;12:459-65.
17Karaaltin MV, Akpinar AC, Baghaki S, Akpinar F. Treatment of “en coup de sabre” deformity with adipose-derived regenerative cell-enriched fat graft. J Craniofac Surg 2012;23:e103-5.